Dental Implants Bring Quality Back to Life

What is a dental implant?

A dental implant is a small titanium fixture that serves as the replacement for the root portion of a missing tooth. Dental implants can be used to replace a single lost tooth or many missing teeth.

Improved Appearance
When teeth are missing an ongoing shrinkage of the jawbone occurs making the face look older. Dental implants can slow or stop this process.

What are the Benefits of Dental Implant Therapy?

Eliminates the pain and discomfort of full removable or partial dentures.

Implant supported replacement teeth are like natural teeth because they are anchored securely to your jawbone.

Confidence & Convenience

Who is a candidate for dental implants?

Adequate bone in your jaw is needed to support the implant(s) along with healthy gum tissues that are free of periodontal disease.

Are dental implants successful?

Documentation studies have proven the effectiveness and long lasting results of dental implants. Good oral hygiene is one of the most critical factors to insure the health of your dental implants.

Part 1

permucosal extension (PME)

Abutment for cement retention

abutment for screw retention

Abutment for attachment

Analogs
Analogs may represent an abutment for screw retention, an implant body (left), and/or an abutment for attachment (right).

Fixed restorations have three categories: FP-1, FP-2, and FP-3

FP-1 is ideal FP-2 is hypercontoured FP-3 replaces the gingival drape

with pink porcelain or acrylic

The difference between FP-2 and

FP-3 most often is related to the maxillary high lip position during smiling or the mandibular lip position during sibilant sounds of speech. FP-2 and FP-3 restorations often require more implant surface area support by increasing implant number or size or by adjusting design considerations.

Removable restorations
RP-4 prostheses have complete implant support anterior and posterior. In the mandible the superstructure bar often is cantilevered from implants positioned between the foramens. The maxillary RP-4 prosthesis usually has more implants and little to no cantilever. An RP-5 restoration has primarily anterior implant support and posterior soft tissue support in the maxilla or mandible. Often fewer implants are required and bone grafting is less indicated

A tooth exhibits more vertical movement than an implant. This may result in higher occlusal loads on the implant, whether or not it is connected to the natural tooth, when in a mouth with both implants and teeth.

Occlusal Considerations for Implant-Supported Prostheses

light occlusal force heavy bite force

The premaxilla loses 40% to 60% bone width within 3 years

after the loss of teeth. The implant surgeon often has difficulty inserting implants when augmentation does not restore the region before implant placement.

Maxillary Teeth Dimensions

Type of Teeth Mesiodistal Mesiodistal Faciolingual Faciolingual Mesiodistal Crown (mm) Cervix (mm) Crown (mm) Cervix (mm) CEJ (2 mm)

Central incisor Lateral incisor Cuspid First bicuspid Second bicuspid First Molar Second molar

8.6 6.6

6.4 4.7

7.1 6.2

6.4 5.8

5.5 4.3

7.6
7.1 6.6

5.6
4.8 4.7

8.1
9.2 9.0

7.6
8.2 8.1

4.6
4.2 4.1

10.4
9.8

7.9
7.6

11.5
11.4

10.7
10.7

7.0

IMPLANT SELECTION

Implant Size Selection Criteria in Posterior Maxilla

1.5 mm from adjacent

tooth 3 mm from adjacent implant 4 mm diameter minimum, for posterior maxilla

The minimum mesiodistal dimension

for two standard 4-mm diameter implants is 1.5 mm + 4 mm + 3 mm + 4 mm + 1.5 mm = 14 mm.

d = 1.5mm +DZ + 3mm +DY + 3mm +DX + 1.5mm

Existing Occlusal Vertical Dimension

The minimum crown height space for a fixed restoration is 8 mm

The abutment should be at

least 5 mm for cement retention. The margin of the crown should be at least 2 mm above the crestal bone level to allow the connective tissue and junctional epithelial attachment zones. At least 1 mm occlusal clearance should be left for an occlusal metal restoration (2 mm for porcelain).

The ideal mesiodistal distance

between an implant and

a tooth is 1.5 mm or more and 3 mm between each implant. B, If bone loss occurs on the implant, the horizontal dimension of the defect is less than 1.5 mm.

 PROTECTION OF THE PROSTHESIS

CEMENT-RETAINED VERSUS SCREW-RETAINED

IMPLANT FIXED PROSTHESES

The primary advantage of a screwretained prosthesis (right) is retrievability.

CEMENT-RETAINED VERSUS SCREWRETAINED IMPLANT FIXED PROSTHESES

Retrieval of the cement-retained fixed prosthesis
Protection of the implant

ADVANTAGES OF CEMENTRETAINED IMPLANT PROSTHESES

Passive Casting

TABLE 23-1 RESCAN

A 50 m misfit may require the implant to move within the bone 200 m before the casting fits passively

dimensional change in impression material , stone, metal wax

A. The dimensional change of

the stone die in this picture is 0.06% shrinkage of the impression material and 0.06% expansion of the stone. This is clinically acceptable. B, The male die does not fit accurately into the female stone model. The dimensional change in this picture represents a 0.2% shrinkage of the impression material and the same stone expansion as in A.

Axial Load
The ideal occlusal load on an

implant prosthesis is directed over the implant body and is accomplished easily with a cemented prosthesis (f). When a screw hole is placed to retain the restoration, the primary occlusal contact often is located on the buccal cusp in the mandible (fn), which is an offset load that magnifies the force applied to the implant component interfaces (and the fixation screw), fi, Buccal; L, Lingual.

The ideal primary occlusal contacts

The ideal primary occlusal contacts for posterior single-tooth implant restorations that are cement retained is directly over the top of each implant, which is usually positioned under the central fossa. When the implants are splinted together, the occlusal contacts may include the marginal ridges, which are between the most distal and mesial implant (right). The diagram on the left is for a screw-retained restoration that is splinted together. The occlusal contacts are usually between the implants. Offset loads to the buccal contact are not indicated, since they will increase the moment force.

Esthetics and Hygiene Occlusal Material Fracture Access Fatigue In the anterior regions of the mouth a screw-retained restoration requires a different implant body position than a cement-retained restoration. As a result, a facial porcelain ridge lap is required. This makes the cervical sulcus of the implant inaccessible for hygiene.

Abutment screws fatigue and are prone to fracture. The abutment crown crevice is not sealed completely, and bacteria may proliferate within the components. Because the environment often has low oxygen tension, the bacteria may be anaerobic organisms that contribute to foul odor and periimplant disease.

1.
2. 3. 4. 5. 6. 7.

Esthetics and Hygiene Occlusal Material Fracture Access Fatigue Progressive Loading Abutment-Crown Crevice Cost and Time

Low-profile retention 2. Reduced moments of force 3. Risk of cement in the sulcus

1.

A screw-retained device is more resistant to tensile forces compared with a cemented abutment inferior to 5 mm in height. Therefore overdenture bars are often screw retained. The lower-profile bar provides greater space for denture tooth placement and greater bulk of acrylic to reduce fracture risks.

One-piece Vs. Two-piece Abutments

Two categories of abutments are used for cemented restorations. The one-piece abutment (far left) may be used in multiple restorations when the implant bodies are within 20 degrees of ideal. The two-piece abutments may be used for single teeth, angled implants, and with laboratory transfers or for custom abutments.

retaining screws. The head of the torque wrench is released at a preset torque level.

Advantages and Disadvantages of One-Piece Abutment for Cement

Advantages
No torque wrench needed Stronger No screw loosening Easy complete seating No need to retighten under

Disadvantages
Only for multiple

restoration Less expensive Thicker walls to allow great freedom of preparation

abutments Not for single-tooth restoration Not for angled abutments Weaker to fracture

A one-piece abutment for cement retention

is threaded into the implant body and bypasses the antirotational hexagon component.

two-piece abutment for cement retention

In the two-piece abutment for cement retention the abutment engages the antirotational features of the implant body platform and the abutment screw that fixates the components into position.

Advantages and Disadvantages Of Two-Piece Abutment for Cement: Single-Tooth Implants

Advantages
Antirotational under shear

Disadvantages
Screw loosening Abutment loosening under

forces Angled abutments

restoration Torque and countertorque devices needed for preload Proper seating with radiograph must be checked Thinner walls limit freedom of preparation

A hemostat holds the abutment in position to the implant body. A 30N/cm torque wrench is seated into the abutment screw and rotated. B, The head of the torque wrench bends at the approximate torque value. The hemostat stops the rotation force on the screw, loading the implant-to-bone interface with a rotational force, because the abutment engages the hexagon of the implant body

Angled abutments are similar to a two-piece abutment system ranging from 15 to 30 degrees

The UCLA abutment concept permits the laboratory to custom fabricate the abutment

The combination of metal and plastic components offers several advantages. With the plastic component, customizing the shape of the abutment on the implant body transfer impression is easy. The metal coping ensures a high precision at the implant platformabutment connections.

Disadvantages of Anatomical Abutments

Precise location of implant body and hexagon is

needed. Two-piece abutment is needed. Facial and lingual overcontours need to be eliminated. A "subgingival ridge lap" is created. Margin is difficult to capture if intraoral impression is made.

A custom abutment with pink porcelain added to the subgingival region is fabricated to enhance the cervical esthetics

The custom abutment and crown are seated. The subgingival pink porcelain is advantageous in situations in which the soft tissues are thin and the grayish color of the titanium abutment may affect the esthetic outcome

Caries and Abutments

Because caries is the most common complication of crowns on the natural teeth, guidelines indicate that the crown margin not only should be supragingival but also should be placed on enamel. This not only facilitates access for hygiene but also decreases the risk of caries, since enamel is more resistant to decay.

Factors Affecting Abutment Retention Taper Surface area Height Resistance form Surface texture Path of insertion

The taper of an implant abutment affects the amount

of retention. The amount of retention is significantly reduced for tapers greater than 20 degrees. This concept is more relevant for implant abutments because of their reduced diameter (usually 4 or 5 mm).

The greater the diameter of the abutment, the greater the retention. Larger-diameter implant abutments have greater retention than narrow-diameter implants.

Abutment Taper Abutment Height Abutment Surface Area Shear Forces Resistance and Abutments Abutment Surface Texture

Abutment Height
A, When a crown receives a lateral force, it tends to rotate upward on one side of the implant. The arc of rotation is related to the diameter of the implant. The height of the abutment should be greater than the arc of rotation. A wider implant abutment requires greater height than a smaller-diameter implant to resist these lateral forces. B, The arc of rotation may be decreased when directional grooves are prepared into the abutment. Therefore when abutment height is questionable, the addition of vertical grooves decreases the risk of uncementation

In a cantilevered prosthesis, tensile forces are applied on the crown farthest from the cantilever. The height of this implant abutment should be greater than the arc of displacement of the prosthesis because compressive forces to the cement seal are placed on the abutment above the arc of displacement. Buccolingual directional grooves decrease the rotation arc and place compressive forces within the grooves.

The two implants replacing the canine and first premolar have minimal abutment height and will receive lateral forces. Vertical directional grooves parallel to the path of insertion of the prosthesis will decrease the risk of uncementation.

Shear Forces
The crown on a tapered

implant abutment (left) may have several paths of insertion or removal. This places the abutment more at risk of an uncemented restoration. A directional groove (right) limits the path of insertion or removal.

 Directional grooves and

flat surfaces reduce the arc of displacement and increase the compressive forces rather than shear forces on the cement seal. These concepts are most important for a cantilevered restoration.

 Mesial and distal

directional grooves decrease tensile forces on a prosthesis subjected to offset loads. These offset loads more often are applied on the facial aspect of maxillary and mandibular restorations. B, Buccal; L, lingual.

Abutment Surface Texture

 When the path of insertion is

similar to the forces of mastication, sticky food may place shear and tensile forces on the restoration and contribute to uncemented prosthe-ses. The implant body should receive a long-axis load to reduce crestal stress. A path of insertion different from the occlusal force direction is selected to decrease the shear loads to the cement seal from sticky foods. Angling the path anteriorly facilitates preparation of the abutment and seating of the restoration.

| NON PARALLEL ABUTMENTS

When the abutment

angle needs a correction of less than 20 degrees, a straight abutment may be used and prepared intraorally (one-piece or two-piece abutment) or in the laboratory (using an implant body transfer impression and a twopiece abutment).

One-piece abutments for cement were placed on these two implant bodies. The distal implant is angled buccally.

A high-speed handpiece is used to prepare the abutment and correct the path of insertion.

 When the implant body

is between 15 and 35 degrees from ideal, a prefabricated two-piece angled abutment may be used to improve the path of insertion.

 The cervical region of an

angled abutment is often larger in diameter to increase the metal thickness on the side of the abutment screw hole. This portion of the abutment is placed subgingivally but may become exposed after gingival recession.

 Copings are cemented

over the abutments. These copings are prepared in the laboratory to create a common path of insertion for the prosthesis.

 A reverse conical

abutment is wider at the top than the abutment connection to the implants.

 The reverse conical

abutment is inserted into the angled implant body and prepared to be parallel to the ideal implant position.

 A two-piece custom

angled abutment may be fabricated in the laboratory using a transfer impression of the implant body.

 The maxillary first molar had

a buccal furca exposed. The knife-edge preparation reduced the furcation undercut and decreased the risk of pulpal exposure.

 In the interproximal region of

lower anterior teeth, a knifeedge preparation may be indicated, especially when the incisal edge is wide and the cervical region is narrow in diameter.

 The facial position of two of

these implant abutments requires a chamfer preparation to provide greater room for porcelain.

Option 1 (Indirect) Option 2 (Indirect) Option 3 (Direct)

Steps in Direct and Indirect (Prosthesis) Fabrication Techniques

Steps in Direct and Indirect (Prosthesis) Fabrication Techniques

Option 1 (Indirect)
the dentist makes an implant body impression with an

indirect or direct impression transfer coping.

Option 2 (Indirect)

Clinical 1 Remove healing abutment. Place indirect impression transfer. Take alginate impression. Remove independent impression transfer. Replace healing abutments. Laboratory 1 Connect independent impression transfer and implant body analog. Reposition in impression. Pour the impression. Fabricate open custom tray. Clinical 2 Remove healing abutments. Place direct impression transfers with hexagon; confirm seating with radiograph. Make impression (polyether or polyvinyl siloxane). Unscrew direct impression transfer through tray. Remove impression. Replace healing abutments. Obtain opposing model, bite registration, and face-bow registration. Laboratory 2 Connect implant body analog to direct impression transfers in impression. Pour model in die stone. Mount opposing with bite and face-bow. Select and prepare all abutments.

Option A
Remove healing abutments. Position final

Option B
Remove healing abutments.

abutments with jig. Confirm seating with radiograph. Torque abutments to 30 N-cm. Metal work try-in. Radiograph to verify fit. Take bite registration. Remove all abutment. Replace healing abutments. Laboratory 3 Remount model to new bite. Finish prosthesis. Clinical 3 Remove healing abutments. Seat abutment with jig. Torque to 30 N-cm. Seat final prosthesis; deliver prosthesis.

Position final abutment with jig. Confirm seating with radiograph. Metal work try-in. Radiograph to verify fit. Take bite registration. Make pick up impression. Deliver temporary restoration. Pour pickup impression. Remount impression. Finish prosthesis. Remove temporary restoration. Radiograph to verify fit.

The permucosal extensions are unthreaded from the implant bodies

 A two-piece indirect

impression transfer, which engages the hexagon of the implant body, is designed with undercuts to maintain it in proper position and prevent its movement while the impression is poured.

 The two-piece indirect

impression transfer copings are threaded into position. A radiograph is obtained to confirm proper seating of the components.

Small bubbles or voids are usually not relevant for indirect impression transfer impressions as long as the transfer undercuts are engaged securely in the impression and the component is maintained securely

An impression is made of the three implant bodies and of the four natural teeth prepared on the contralateral side

 The component to the far left is

an abutment screw; next is a two-piece abutment for cement retention assembled with the abutment screw; next is a ball abutment transfer screw; next is the ball transfer screw assembled with a two-piece abutment; next is an implant body analog; far right is the ball transfer screw assembled with a two-piece abutment and the implant body analog. These last components are reinserted into the final impression before pouring the stone model.

 The implant analogs are

reinserted into the impression, and the laboratory places a resilient material around them to represent the soft tissue around the implants.

 The cast is separated

from the model, and the two-piece abutments for cement retention are inserted into the body analogs of the implant. A marking pen is used to transfer the tissue height onto the abutment.

 The resilient soft tissue

replica is removed from the master cast. A surveyor/handpiece is used to prepare the abutments parallel to each other. A flat side on each abutment and a knifeedge margin are common features.

 The master model is

complete with the soft tissue replica and the prepared abutments seated on the implant body analogs.

 The laboratory may wax

the substructure of the final restoration directly on the prepared abutments.

 61

Castings are obtained for the natural teeth and implant abutments.

 The implant abutments

are connected together with an acrylic jig to assist in intraoral seating of the abutments in the proper position.

 At the next patient visit,

a try-in for the metal casting on the teeth is performed.

 The acrylic jig helps seat

the laboratory-prepared abutments intraorally before adding the abutment screws.

 The metal try-in for the

implant prosthesis is performed.

 With metal try-in for the

teeth and the implant prosthesis in place, a bite registration is obtained.

 A bite registration is

made over the metal castings. The laboratory evaluates this registration and compares it to the occlusal index obtained after the impressionmaking appointment.

 At the third

appointment, the prosthesis is delivered. The acrylic index used to reinsert the abutments also may be used to countertorque the abutments while the torque wrench tightens the abutment screws to 30 N-cm.

 The final restoration is

completed. The chair time for the indirect method of implant restoration was shorter than for the natural teeth because no intraoral abutment preparation or transitional prosthesis fabrication was required.

 The final prostheses are

delivered. An indirect implant prosthesis fabrication on the patient's right and conventional direct procedure on the left natural teeth were selected.

 The implant prosthesis is

cement retained, and a heavy bite is used for the occlusal adjustment with primary occlusal contacts in the central fossae.

 The natural three-unit

fixed prosthesis and crowns are delivered following a conventional protocol.

transferring the implant body position in a working cast (Option 1 or 2) has several advantages:
1. The impression requirements are less demanding because small

bubbles or voids do not affect abutment transfer and margins are not important to record. 2. If an angled abutment is required, the laboratory may choose the right component. A custom abutment may be fabricated (e.g., for a short crown height when a greater

diameter would help with retention). As a result, less inventory is required in the doctor's office. 3. The laboratory can fabricate the transitional prosthesis on the model. 4. A framework may be fabricated directly on the implant abutments, allowing for a more accurate margin fit. 5. Chair time is decreased because the preparations, metal work, and transitionals are fabricated by the laboratory.

Disadvantages of the laboratoryassisted approach include the following:

1. One-piece implant abutment transfers may not be timed or transferred accurately. When an impression is made and the abutments are first removed and inserted into a laboratory model, the rotation of the implant analog may be different by several degrees than in the implant body in the mouth, precluding the use of one-piece abutments. 2. A two-piece abutment post system should be used in the laboratory transfer because thread timing is more exact; however, this may mean long-term complications such as abutment screw loosening. A system with excellent precision is needed. 3. No fixed transitional prosthesis is used to load the bone gradually during fabrication of the metal framework. This increases the risk of early bone loss or early implant failure. This risk can be alleviated by delivering a temporary prosthesis on a temporary abutment with the added disadvantage of increased chair time and laboratory cost. 4. The laboratory decides on the margin location and preparation style. 5. The laboratory cost is increased. 6. The casting is made directly on the implant post and may fit the abutment so accurately as to produce a nonpassive casting.

Option 3 (Direct)
One-piece straight

abutments for cement retention are inserted into the implant bodies If within 15 degrees of each other, the abutments are prepared intraorally with a #703 crosscut fissure bur under copious irrigation

In the posterior three implants, first-stage cover screws are exposed. The cover screws are removed with an ASA screwdriver and a 0.035- inch hexagonal driver (BioHorizons Dental Implants).

The one-piece abutments for cement retention are threaded into the implant bodies with an ASA screwdriver and a 0.050-inch hexagonal driver

 A torque wrench is used

to tighten the one-piece abutments. The torque applied is transferred to the implant body.

 The crown height space

is evaluated. A 2-mm clearance is necessary for porcelain-fused-tornetal restorations with porcelain oclusal surfaces. These 8-mm abutments are too high.

 The abutments are

reduced in height with a high-speed handpiece and carbide bur with a copious amount of irrigation. Parallelism also is achieved.

 The abutment height is

reduced for a porce-lainfused-to-metal restoration.

 A coarse diamond high-

speed handpiece is used to roughen the surface and increase the retention of the cemented restoration.

 A final impression is

made of the abutment, similar to the direct procedure with natural teeth.

 A transitional restoration

is made. When in soft bone, the restoration is left out of occlusion. Occlusal contacts then are incorporated on the transitional restoration at the metal try-in appointment.

 Stone dies are used for

the direct fabrication procedure with implants. The small-diameter posts may break off when the impression is separated from the cast. Several techniques are of benefit to minimize this complication.

Definitive Cementation
A groove may be placed in

the preparation or the casting to act as an additional spacer or vent for the cement. Another method to reduce film thickness is the timing of the prosthesis insertion. Film thickness may increase by 10 iim or more for every additional 30 seconds, once the cement is properly mixed.

As a result, although most

definitive cements may exhibit a cement thickness between 10 and 25 ^m,

Zinc oxide/eugenol
excellent seal
lowest compressive strength high solubility

often is used as a transitional cement at the initial

delivery of the prosthesis addition of EBA modifier increases the compressive strength, almost to the value of polycarboxylate cement

Zinc polycarboxylate
Zinc polycarboxylate cement may adhere to teeth

because it chelates the calcium ions does not adhere to a gold casting or to a titanium abutment post The working time is 50% shorter than zinc phosphate cement This is a problem when cementing multiple abutments

Glass ionomer
Glass ionomer cements may adhere to enamel or

dentine and release fluoride for an anticariogenic effect. Their properties for luting fixed restorations to natural teeth are excellent. However, their performance as luting agents on metallic abutments has raised controversy

Composite resin
Composite resin cements have the highest compressive

and tensile strengths of all cements, 5 times greater than zinc phosphate.121'124'130 When these cements are used in implant dentistry, the intent is to not remove the restoration in the future. . Unlike polycarboxy-late cement, the excess cement should be removed before final setting; otherwise, a rotary bur may be required to eliminate any excess.