Jan Lindhe. Clinical Periodontology

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IMPLANTS IN THE LOAD CARRYING PART OF THE DENTITION • 967

Fig. 41-79. Occlusal configuration of a three-unit metal-Fig. 41-80. The oral aspect of that same prosthesis fea-

ceramic implant restoration designed for transversaltures the decisive elements related to the transverse

screw-retention. Note the absence of any interferencescrew-retention: improved esthetics, no weakening of

due to screws on the occlusal aspect of the restoration.the ceramo-metal design. The screw-access channels

are completely protected by the metal framework.

Fig. 41-81. Clinical 5-year follow-up of this three-unitFig. 41-82. Palatal view of the transverse screw-re-

implant restoration. No significant changes can be no-tained implant prosthesis after 5 years of clinical serv-

ticed on the occlusal surface. ice. The screw-access channels are blocked out by a

temporary material.

Fig. 41-83. Preoperative radiograph of the patient's

Fig. 41-84. Five-year follow-up radiograph of the same

maxillary right posterior segment, revealing a tooth-

quadrant, now restored with a three-unit transverse

borne long-span FPD which had failed after four years

screw-retained metal-ceramic implant suprastructure.

of function due to loss of retention and subsequent

Note that the distal retainer of the original tooth-borne

damage on the mesial abutment.

FPD could be maintained.

968 • CHAPTER 41

tually avoided due to now adequate conditions for a

cemented suprastructure.

Transverse screw-retention

When it comes to screw-retained posterior implant

restorations one should not forget the option of trans

verse screw-retention (Figs.

41-79

41-84).

This spe-

cific technical approach leaves the occlusal surface of

the restoration free from any screw and permits the

design of a screw-access channel on the oral aspect,

featuring a metal protection on the entire circumfer-

ence of the perforation (Fig.

41-80).

These two factors

improve significantly both the overall mechanical re-

sistance and the esthetic appearance. Furthermore, the

metal protects the surrounding porcelain during re-

moval and tightening of the transverse screw and

thereby prevents the induction of fissures prone to

subsequent propagation and ultimately leading to ce-

ramic fractures. One has to be aware, however, that

from a purely technical and economic point of view,

transverse screw-retained restorations require addi-

tional, more complex components and advanced tech

nical skills, and are more expensive. On the other hand

the distinct advantages should in the long-term

clearly outweigh these inconveniences in numerous

clinical situations.

Abutment-level impression versus implant

shoulder-level impression

Most of the leading implant systems currently offer

the possibility of taking impressions either at the level

of a previously inserted abutment or at the level of the

implant shoulder itself (Figs.

41-85

and

41-86).

The

former approach is mostly indicated if the patient

does not wear a removable temporary prosthesis and

in the case of optimally – "restoration-driven" –

placed

implants, comprising accessibility of the im

plant

shoulder, point of emergence from the soft tis

sue,

implant axis, interarch distance and overall easy

access for use of simple "pop-on" plastic transfer cop-

ings. As shown later, a clear preference is given

cemented suprastructures under such simple,

straightforward conditions. In fact, the clinician is

only required to keep a limited stock of components,

i.e. cementable titanium abutments of various heights

and injection-molded impression copings, in his of-

fice. Whenever the clinical situation deviates notably

from the previously described conditions, one may

consider taking an impression directly at the level of

the implant shoulder. For that approach, only transfer

copings have to be available in the dental practice. In

fact, the patient is leaving the office after the impres-

sion session exactly as he came in, i.e. with the same

cover screw and with the same unaltered temporary

prosthesis. The technician will then – after master

model fabrication and articulator mounting – select in

the laboratory the most appropriate secondary com-

ponents and ultimately deliver the finished restora-

tion together with the respective supporting abut-

ments.

Cemented multiple-unit posterior implant

prostheses

In recent years, an increasing trend towards cemented

posterior implant restorations, using either temporary

or permanent luting agents, could be observed. The

associated original paradigm, indicating that main-

taining "retrievability" was one of the fundamental

advantages of implant-borne suprastructures, permit

ting reintervention, modification and/or extension at

any time, has been lately challenged by parameters

such as increased clinical and technical simplicity,

low-maintenance design of the restorations and supe

rior cost effectiveness. The more implants are utilized

in clinical situations where conventional FPDs would

also be easily possible, but where the latter have be-

come second choice, the more the sites are favorable

for this type of therapy and the more these implants

come close to the characteristics currently termed as

"restoration-driven". Parallel to this improved mas-

Fig. 41-85. Example of a typical mandibular master

model, derived from an impression at the abutment

level, comprising four colour-coded implant-abutment

analogues.

Fig. 41-86. Example of a typical mandibular master

model, derived from an impression at the implant

shoulder level, comprizing three colour-coded implant

analogues.

IMPLANTS IN THE LOAD CARRYING PART OF THE DENTITION • 969

Fig. 41-87. Occlusal view of the mandibular right poste

rior quadrant with three implants that had been placed

according to a single-step transmucosal surgical proto

col.

Fig. 41-88. In accordance with the available interoc-

clusal space, adequately dimensioned solid abutments

are selected, inserted and subsequently tightened to 35

Ncm in view of a cemented suprastructure.

Fig. 41-89. With the solid abutments in place, the inter

implant parallelism is confirmed. Note the easily

acces

sible implant shoulders which will facilitate the

ing impression and restorative procedures.

tering of the three-dimensional implant positioning,

secondary components such as abutments that are

optimally designed for subsequent cemented restora-

tions have been developed, in combination with aux-

iliary parts such as simplified impression copings,

laboratory analogues and burn-out patterns. A typical

clinical example of the treatment of an extended tooth

bound posterior segment by means of implants and a

subsequently cemented suprastructure is presented in

Figs. 41-87 to 41-94. Three screw-type implants have

been inserted according to a single-step transmucosal

(non-submerged) surgical protocol, leading 8 weeks

after implant installation to a clinical situation which

is well suited for a restorative procedure similar to the

one traditionally used in the context of natural tooth

abutments. More particularly, all of the involved im-

plant shoulders are easily accessible (Figs. 41-87 to

41-90) for restorative procedures and later for mainte

nance, and the surrounding peri-implant mucosa

healing and tissue maturation has occurred simulta-

neously with implant osseointegration, both being

key factors in facilitating prosthetic procedures. Fur-

thermore, the superficially located interface between

implant shoulder and suprastructure or abutment will

Fig. 41-90. Prefabricated injection-molded, self-center

ing impression copings and related color-coded posi

tioning cylinders are inserted prior to impression tak

ing with a stock tray.

Fig. 41-91. The completed master model comprises

color-coded aluminum implant analogues.

reduce the length of suprastructure leverage and by

this the resulting bending moments. Under the as-

sumption that presurgical site analysis and, derived

from that, prosthetic treatment planning has predict-

ably led to an optimal implant positioning, the result

ing implant prosthesis should almost by definition

feature a gradually increasing, flat axial emergence

970 • CHAPTER 41

Fig.

41-92.

Based on prefabricated burn-out patterns,

the final metal-ceramic restoration has been completed.

Note the continuous flat axial emergence profile of the

individual elements.

Fig.

41-94. The radiographic control confirms both suc

cessful osseointegration of the involved implants and

accurate marginal adaptation of the suprastructure.

profile, adequate embrasures and overall design and

occlusal characteristics similar to those advocated for

tooth-borne FPDs (Figs.

41-92

41-94).

Angulated abutments

It is not infrequent that all of the parameters defining

an optimal three-dimensional implant position cannot

be readily reached. Under such conditions the clini-

cian has basically three options. Either a bone aug-

mentation procedure is undertaken, or a conventional

tooth-borne prosthesis is chosen, or one evaluates

carefully whether a minor positional compromise can

be considered acceptable. The related parameters

have to be objectively pondered prior to taking the

respective decision together with the duly informed

patient. The heaviness of a so-called "site-develop-

ment" procedure (e.g. lateral or vertical bone augmen

tation or anterior sinus floor elevation) should defi-

nitely be put in direct relation with the expected bene

fit. This approach in some instances allows signifi-

cantly invasive procedures to be avoided. Particularly

in situations where only the implant axis interferes

Fig.

41-93.

The clinical occlusal view of the cemented

four-unit implant prosthesis composed by premolar

sized segments.

with an otherwise optimal implant positioning, the

subsequent use of angled abutments may still lead to

largely acceptable treatment outcome (Figs.

41-95

41-98).

In other terms, there appears to exist some

limited room for sometimes considering a slightly "

bone-driven" instead of a purely "restoration-driv

en"

implant placement in order to render implant

therapy

bearable for a given individual patient.

Angled abutments, encompassing various inclina-

tions and dimensions, are currently part of the arma-

mentarium of most of the leading implant systems.

They are frequently used and compatible with both a

cementable or a screw-retained suprastructure design.

High-strength all-ceramic implant

restorations

Additional options, such as milled titanium frame-

works as infrastructures for metal-ceramic prostheses

or high-strength all-ceramic restorations, have also

become recently available in the context of posterior

implant restorations. Some of these approaches are

based on computer-assisted design and computer-as

sisted machining (CAD/CAM) technology. As im-

plants and their secondary components are mostly

industrially produced or machined, and as their re-

lated dimensions and tolerances are well defined, they

appear particularly well-suited to this kind of technol

ogy. In this context, and in order to explain the par-

ticular interest associated with this type of technology,

it has to be underlined that using either the same metal

(i.e. c.p. titanium) or no metal at all for the suprastruc

ture fabrication, would be highly preferable. The still

widely spread high-gold containing porcelain-fused-

to-metal alloys is primarily utilized due to its superior

casting ability.

It would go beyond the scope of this textbook to

describe in detail the current evolution in the field of

CAD/CAM systems in general and to their impact on

implant dentistry in particular. A representative clini-

cal example, however, is given in Figs.

41-99

41-105.

IMPLANTS IN THE LOAD CARRYING PART OF THE DENTITION • 971

Fig. 41-95. Lateral view of a master model comprising

implant level analogues in the right mandibular poste

rior sextant. Angulated abutments have been

selected

to correct a too distal implant axis.

Fig. 41-96. The corresponding occlusal aspect visual

izes the amount of axis correction achieved.

Fig. 41-97. Using an appropriate index, the two angu

lated abutments are transferred intraorally and sub

sequently tightened to 35 Ncm with a torque

wrench.

All-ceramic implant suprastructures are still preferred

as single-unit restorations, primarily for purely tech-

nical reasons.

Orthodontic and occlusal considerations

related to posterior implant therapy

As one increasingly strives for the best possible bio-

logical, functional and esthetic integration of a given

implant restoration in the pre-existing dentition,

three-dimensional preoperative site analysis is of

paramount importance. It is not infrequent that this

subsequently calls for a pluridisciplinary approach

termed "site development", which may also include

presurgical orthodontic therapy (Figs. 41-106 to 41-

119). The objective is clearly to create local conditions

that are best suited for the type of therapy chosen. If

implants are to be involved, the local bone and soft

tissue anatomy as well as the mesio-distal and oro-fa

cial distances of a given edentulous segment have to

comply optimally with the respective most appropri-

ate implant dimensions. Quite often mesio-distal gap

dimensions have to be optimized orthodontically and

neighboring roots aligned, so that they will not inter-

Fig. 41-98. Clinical occlusal view of the cemented two

unit metal-ceramic implant restoration.

fere with "restoration-driven" implant positioning.

Site development in the broad sense of the term com-

prises also parameters associated with intermaxillary

relationships such as occlusal plane, interarch space

and occlusal guidance during mandibular excursions.

As osseointegrated implants do provide excellent an-

chorage for orthodontic appliances (Melsen & Lang

2001), and thus can significantly contribute to the

efficacy and simplicity of such a treatment, one may

also consider implant insertion prior to orthodontic

therapy. This, however, requires a meticulous preop-

erative analysis and precise three-dimensional im-

plant positioning, anticipating perfectly the ideal lo-

cation with respect to the final treatment objective.

When it comes to occlusal considerations related to

posterior implant restorations, one should note that

most of the relevant literature available to date is

addressing eventual effects of occlusal loading on the

various components of the implant-abutment-supras

tructure complex (Bragger 1999, 2001, Bassit et al.

2002, Wiskott et al. 2002). In fact, a variety of recom-

mendations are derived from such studies, including

various occlusal restorative materials, type and me-

chanical characteristics of different abutment to im-

972 • CHAPTER

Fig. 41-99. Mandibular right posterior segment, featur-

Fig. 41-100. Master model including the stone die of the

ing a full-coverage preparation on the non-vital second

prepared premolar and the two implant analogues.

premolar and two implants equipped with solid abut-

ments in the area of the missing first molar.

Fig. 41-101. Three respective aluminous oxyde copingsFig. 41-102. Clinical try-in of the high-strength porce-

have been fabricated according to the PROCERA® tech-

lain infrastructures.

nique.

Fig. 41-103. Vestibular view of the cemented final all-ce-Fig. 41-104. The 1-year radiographic follow-up dis-

ramic restorations.

plays sufficient radio-opacity of the all-ceramic sub-

strate to evaluate the marginal adaptation of the three

single-unit restorations.

Fig. 41-105. Occlusal view of the two posterior implant-

borne premolar-sized suprastructures and the tooth-

supported ceramic restoration on the second premolar.

IMPLANTS IN THE LOAD CARRYING PART OF THE DENTITION • 973

Fig. 41-106. Right lateral view of a 19-year-old female

Fig. 41-107. A similar situation regarding interarch dis-

patient, congenitally missing all four permanent maxil-

tance is present on the patien

s left side.

lary premolars. One can note both an inadequate

mesio-distal gap width and a reduced interarch dis-

tance.

Fig. 41-108. The corresponding radiograph underlines

the need for additional orthodontic therapy prior to the

insertion of an implant in order to optimize the gap

width and the interradicular distance.

Fig. 41-109. Although to a lesser degree, presurgical or-

thodontic therapy is also indicated on the maxillary left

posterior segment.

Fig. 41-110. The clinical occlusal view displays the bilat-

eral edentulous spaces in the premolar area. Despite a

previously performed orthodontic therapy, aiming at

reducing the edentulous spaces to the size of one pre-

molar, the mesio-distal gap width on the right side is in-

sufficient for the insertion of an implant.

Fig. 41-111. After six months of additional orthodontic

treatment using an upper fixed full-arch appliance, the

dimensions of the two prospective implant sites appear

compatible with this kind of therapy.

974 • CHAPTER 41

Fig. 41-112. The respective radiograph confirms ade-

Fig. 41-113. A similar presurgical situation is radiog-

quate space in the upper right premolar region for the

raphically confirmed for the upper left premolar site.

placement of a standard single-tooth implant.

Fig. 41-114. The right oblique occlusal view of the im-

plant restoration clearly demonstrates the advantage of

the transverse screw-retention design: no occlusal

screw

access channel interfering with the functional

occclusal

morphology and esthetics or with structural

requirements inherent to the metal-ceramic technology.

Fig. 41-115. As described for the patient's right side, the

left maxillary fixed single-tooth implant restoration in-

tegrates appropriately the existing natural dentition.

Fig. 41-116. The follow-up radiograph taken one year

after the insertion of the 12 mm solid screw implant,

shows adequate marginal fidelity and stable conditions

the bone-to-implant interface.

Fig. 41-117. Similar findings are present in the corre-

sponding left-sided follow-up radiograph.

plant connections, as well as general guidelines for in general and occurrence of peri-implant crestal bone

optimal

suprastructure design.

resorption in particular, little information is presently

Regarding an eventual direct relationship between available (Wiskott & Belser 1999, Duyck et al. 2001,

occlusal

loading and maintenance of osseointegration Engel et al. 2001, Gotfredsen et al. 2001a-c, O'Mahony

IMPLANTS IN THE LOAD CARRYING PART OF THE DENTITION • 975

Fig. 41-118. The final right lateral view in centric occlu

sion features acceptable general interarch conditions

and related intercuspation.

et al. 2001, Engquist et al. 2002, Wright et al. 2002).

Attempts have been made to take into account the

fundamental differences between a tooth surrounded

by a periodontal ligament and an "ankylosed"

osseointegrated implant, the latter disposing neither

of local mechanoreceptors nor of a so-called "damp-

ing" capacity. This led to a hypothetical implant-spe-

cific occlusal concept (Table 41-7), featuring parame-

ters such as lighter contacts in centric occlusion when

compared with the surrounding natural dentition,

and no or only minimal contacts on implant restora-

tions during mandibular excursions. One should

clearly note, however, that these guidelines are pri-

marily derived from clinical experience, subjective

opinions and eventually common sense, and that

there is little or no solid scientific evidence available

date which would support such a concept (Taylor et

al. 2000).

CONCLUDING REMARKS AND

PERSPECTIVES

Early and immediate fixed implant

restorations

Currently, one can observe a strong tendency towards

shortened healing delays and ultimately towards im-

mediate loading or at least "immediate restoration"

protocols in association with dental implants (Tarnow

et al. 1997, Ericsson et al. 2000, Gatti et al. 2000, Szmuk

ler-Moncler et al. 2000, Bernard et al. 2001,

Chiapasco

et al. 2001b, Ganeles et al. 2001, Gomez-

Roman et al.

2001, Roccuzzo et al. 2001, Romanos et

al. 2002). Im

proved implant surface characteristics

have contrib

uted to this evolution (Buser et al. 1998a,

Deporter et

al. 2001, Gotfredsen et al. 2001b, Roccuzzo

et al. 2001,

Cochran et al. 2002). Numerous studies

have reported

that such an approach can be

considered predictable

under certain well-defined

conditions. Under these

Fig. 41-119. During the right lateral excursion of the

mandible (working-side movement), a canine guidance

could be established.

Table 41.7. Hypothetical implant-specific occlusal

concept

•

"Light infraocclusion" in centric occlusion position (CO) on

posterior implant restorations

"Narrow" occlusal table

•

Only "axial" loading on implant restorations

•

No or only "minimal contacts" on implant restorations during

mandibular excursions"

•

no canine guidance on implants

•

eventually "minimal" group function on the working side

conditions fall four to six implants inserted in the

interforaminal part of the edentulous mandible and

which are subsequently splinted with a bar device

(

Gatti et al. 2000), as well as multiple implants evenly

distributed around an edentulous arch and then im-

mediately restored - according to the principle of

cross-arch stabilization" - with a splinted full-arch

FPD (Tarnow et al. 1997). Achieving adequate primary

stability at the moment of implant installation, and

confining, during the crucial first healing period, an

eventual mobility below the threshold of approxi-

mately 50 microns, appear to be among the decisive

parameters for predictably achieving osseointegra

tion

(Szmukler et al. 2000). With regard to the routine

application of immediate loading protocols for poste-

rior single-tooth restorations, it appears advisable to

wait for scientific confirmation of its respective poten-

tial in the form of randomized controlled clinical trials.

In conclusion, the possibility of performing highly

predictable treatments which are more simple, require

less time and which can be conducted in a standard

dental practice set-up, as well as the associated quality

of treatment outcomes, have nowadays made implant

therapy in the load carrying part of the dentition an

integral part of the restorative spectrum for any kind

of edentulism. This evolution is most dynamic and

holds promise for further significant developments.

976 • CHAPTER 41

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