Tissue punch implant access: close or not?

D) abutment placement (healing, temporary or permanent)

I have done hundreds with hole only. If you're 100% sure of your bone in ALL 5 DIRECTIONS. Post op is easier than a filling for the patient. I will ALWAYS use my largest punch to ensure not to take any tissue down with the implant threading.

Sorry , i forget to include---I will put a healing cap or a very low temp abut. at the time of placement and let the tissue migrate .

I would agree with Joe above except I would caution that before doing a punch determine if it would be advantageous to add to the width of attached mucosa. It almost always is. If so cut a flap that you can move to the side where you need more attached mucosa, put on a healing cap and sew the tissue down. If it doesn't approvimate over the exposed bone entirely no worries - it will granulate in. It is always best to try to get the greatest width of attached mucosa around an implant you can. Punch technique is rarely applicable in thin tissue types.

I like to reflect a small flap to see where I am drilling and that there is no cortical plate perforation or if any bone augmentation needed. I don't use tissue punches anymore at implant exposure but I reflect the attached tissue, this preserves keratinized tissue. A cortical perforation or thin bone doesn't show up on a panorex or periapical and probable happens more often than we think with these blind procedures. However I would answer the question quite simply with nothing is needed in such a small area to allow the tissue to heal over or a short healing head can be placed. I will only do a punch type technique in a guided case but I still like to reference depth with a small flap, it is easy to become disoriented and one can get into trouble with a lingual perforation. I like to be sure where I place the osteotomy and it is not that big of a deal to raise a small flap.

I feel u can leave it open or u can place healing cap. both are acceptable.

thank you everyone! my concern about placing a healing abutment and/or temp has been potential accidental "loading" of the implant early on via mastication. from what i understand, immediate loading of implant retained complete dentures is inadvisable, so i assumed Id play it safe with implant retained crowns, as well.

Stop doing punch, please! Preserve the gingiva!

Tissue Punch Technique can be advantageous, as they are (quick to perform, quick to heal, less post op. discomfort & pain & possibly less costly) However, a 1.5mm-to-2mm of bone needed around the planned fixture head on all directions i.e. availability of a good bone volume in addition to a good bone quality. This can be confirmed from 3D scan after clinical assessment. Ridge mapping technique may be employed to determine the thickness of the mucoperiosteum overlying the alveolar bone. The technique can also be used with a CT scan where a radio-opaque marker has been placed on the mucosal surface.

I will do you one better. For those cases that don't require an APF, I use a round diamond on a handpiece to shape the tissue to the form of the healing abutment. No need for extra punches, stocking, replacing, dull.... etc. It let's you center the implants perfectly and no need for surgical guides. If the torque is sufficient, which if you're placing into mature bone it normally is, you place a healing abutment. Otherwise leave open and it will cover on its own. Don't sweat the small stuff