BY
Implant supported prosthesis design Shimaa Mohamed Eltantawy
Implant supported prosthesis design
• Prosthodontic procedures on dental implant are much simpler
than those for conventional crown and bridge work.
• The ease of prosthodontic procedures depend primarily on
implant position.
The first rule
• Plane your prosthesis before
surgery.
• Therefore, prosthetically driven
implant placement is mandatory
The second rule
• Emergence profile:
• The profile of the tooth while emerging
from the gingiva.
• Is defined as the transmucosal area between
the implant shoulder and the mucosal margin.
• This transition zone is vital as it provides the
support and stability of the peri-implant soft
tissues allowing to fabricate natural-looking
implant-supported restorations.
Emergence profile:
• The BC ( biological zone) refers to the
typical concave shape near the
abutment connection,
• While the EC (esthetic zone) represents
the convexity extending up to the neck
of the implant-supported restoration.
• Significance:
• Esthetic
• hygiene
Emergence profile affected
by:
❑Gingival phenotype:
•Thick phenotype: More resistant to recession, can better
tolerate minor positional errors.
•Thin phenotype: Highly sensitive to implant malposition;
small errors can lead to visible esthetic problems and soft
tissue breakdown.
Emergence profile:
❑Implant selection:
• Wide diameter for narrow teeth
gives bad profile.
Emergence profile:
❑Implant position:
• Mesiodistally
• Apicoincisally
• Buccolingually
Emergence profile:
❑Healing abutment : 2-3
week.
❑Customized healing
abutment
❑ Temporary crown.
Emergence profile:
❑Impression coping:
customized to get perfect contour of the
gingiva in the impression.
The third rule
❑Abutment selection
▪ Single or multiple units
▪ Cement or screw retained
Implant supported prosthetic design
Fixed Removable
Implant Cement Splinted
supported retained prosthesis Implant
• Non supported
Screw
retained splinted cantilever
Tooth
implant
supported
Hybrid
prosthesis
Fixed implant supported
prosthesis
• 1- Cement retained
prosthesis.
• The cement-retained restoration is a two-
piece prosthesis, an abutment and a crown.
Fixed implant supported
prosthesis
• 1- Cement retained prosthesis.
• Advantages:
• 1- Retrevability
• Cementation can be achieved with provisional or
definitive cement. Provisional cementation allows
retrievability to a certain extent, while the risk for
leakage and loss of retention may be higher compared
with definitive cementation.
Fixed implant supported
prosthesis
• 1- cement retained prosthesis.
• Advantages:
• 2- low screw lossening problems.
• It is easy to splint cemented crown than screw
retained.
• 3- reduced un retained restoration.
• Less than 5% of cases show de-cemented
crown
Fixed implant supported
prosthesis
• 1- Cement retained prosthesis.
• Advantages:
• 4- passive fit.
• Due to stone die expansion
• Cement space
• 5- Correction of non passive
prosthesis.
• Adjusting the abutment or internal surface of
crown.
Fixed implant supported
prosthesis
• 1- Cement retained prosthesis.
• Advantages:
• 5- axial load:
• Cement retained prosthesis is loaded axially thus
decreasing crestal bone strain and bone loss.
• also due to absence of screw hole, it can be
designed with narrow occlusal table.
• 6- More esthetic :
• No occlusal composite restoration
Fixed implant supported
prosthesis
• 1- Cement retained prosthesis.
• Advantages:
• 7- less incidence of occlusal material fracture.
• Due to absence of screw hole that lead to
stress concentration.
• 8- Access in limited mouth opening.
• Screw driver is 15mm
• May use small screw driver but increase the chance of swallowing it.
• 9- No component fracture:
• No prosthetic screw which is small
• No metal to metal contact so no wear.
• 10- Cost and time : cost is 1.5 :2 times less
Cement retained prosthesis complications
• 1- Residual cement.
• Source for prei-implantitis
• Residual cement has more complication in
implant than natural teeth due to:
❖Adherence to rough implant surface.
❖the position of prosthesis margin in relation to
free gingival margin.
❖Laboratory consider the flare as the crown margin.
❖Cement extruded to the area of undercut below the flare.
Conditions where the flare lies deep subgingivally
• The abutment is too short relative to the soft tissue height.
• The implant is placed deep (too apical), which increases the
vertical distance between implant platform and soft tissue
margin.
• The soft tissue is very thick or the gingival margin is high
coronally.
❖difference in sulcular attachment than
natural teeth
How to reduce the residual cement
• Brush tech.
but take long time in splinted prosthesis so thicker cement.
• Modification in abutment.
• Margin application tech.
• Cementation jig.
Cement retained prosthesis complications
2- Un retained restoration:
The implant abutment is of great risk of de-cementation
than natural teeth.
How to remove cemented crown to retighten the abutment
screw.
• Difficult to applicate the crown remover especially if
it is subgingivally.
• Removing cemented crown from mobile abutment is
difficult. The impact force applied to the crown is
dissipated because of mobile abutment.
Cement retained prosthesis.
Abutments
One piece abutment:
❖does not engage the hexagon of the implant body,
eliminating the risk of incomplete seating. The abutment
is less expensive.
❖the post may loosen and rotate, contraindicated in
single crown.
❖Indicated for splinted prosthesis.
❖ the rotational force applied to the abutment is
transferred to the implant–bone interface.
Two-Piece Abutment
Screw retained prosthesis
• Advantages:
• 1- Easy retrevability
• 2- low profile retention:
• Short abutment can be used in screw
retained with proper retention but in
cemented, 5mm is needed for retention
and resistance form.
• Small interocclusal space.
• In lingually positioned implant in
anterior mandible.
Screw retained prosthesis
• Advantages:
• 3- No risk of residual cement.
• No inflammation and irritation
Screw retained prosthesis
• Complications.
• 1- screw lossening.
• When external force is greater than
clamping force ( force holding the
screw), the screw will become loose.
• More in single crown than splinted
prosthesis
Screw retained prosthesis
• Complications.
• 1- difficult to fabricate
passive restoration.
• If the forces are beyond the
physiologic limits, bone resorption
at implant bone interface will
occur.
Abutments for screw retained prosthesis
Splinted versus un splinted prosthesis
• Splintd implants increase the functional surface area.
Splinted versus un splinted prosthesis
• Splintd implants increase
anteroposterior surface area.
• Rotational force, cantilever force and
angled forces on facial and lingual are all
reduced when splinted implant aren`t in
the same plane.
Splinted versus un splinted prosthesis
• Splintd implants increase abutment
surface area and resistance form.
• There is less force transferred to the
cement interface.
• Less likely to be uncemented.
Splinted versus un splinted prosthesis
• Easy prosthesis removal.
• Engaging the gingival margin for single crown
is more difficult especially if it is subgingival.
Splinted versus un splinted prosthesis
• Less marginal bone loss.
• Less risk of porcelain fracture
• Less risk of implant fracture.
Splinted versus un splinted prosthesis
• Complications are easy to treat.
• In un splinted, if implant failed:
• It may be removed, the site of bone grafted and the
reimplanted
Splinted versus un splinted prosthesis
• The exception of splinted prosthesis is full arch
mandibular implant prosthesis.
• Full arch mandibular prosthesis should have cantilever or made in
two or three sections.
Engaging and non engaging abutment
Implant supported cantilever
• Cantilever act as a force magnifier
• The presence of a cantilever had no effect on implant survival rate
or marginal bone loss, although cantilevers increased the
incidence of mechanical complications.
Implant supported cantilever
• Indication:
• Cantilever length not more than 8mm.
• Avoid narrow diameter or short implant
• Minimal biting force on the prosthetic tooth
• A missing front tooth
• Small mesiodistal dimensions to put two implants
• Mesial cantilever is more favorable.
• A good bite
Implant supported cantilever
Implant supported cantilever
• Contraindication:
• Limited applicability — Cantilever bridges aren’t strong
enough to replace molars..
• Potential for damage or failure — Cantilever bridges
may eventually crack, come apart, or fail mechanically.
Tooth implant supported prosthesis
Difference between implant and tooth
biomechanics
• Natural tooth act as a viscoelastic shock absorber
which lessen the stresses inbound to the bone.
• Implant isn`t flexible so overloading is fatal.
• Mobility of a natural tooth may increase with the
occlusal trauma. Tooth may become its original
occasion, after eliminating occlusal trauma.
• Mobility of an implant may be formed in same way
under occlusal trauma.
• mobility of implant may continue, health of
surrounding tissues become worse, and commonly
implant is lost in a short time period
Implant connected to teeth.
• Conventional FPD design
• FPD with non rigid connector
Biomechanics of implant
connection to teeth
• According to Carl Mish.2nd edition
1. Vertical movement.
A- implant and tooth.
Implant movement is not rapid as tooth because it occur
due to viscoelasticity of bone. But in tooth , it occur due to PDL
Initially then bone viscoelasticity.
Biomechanics of implant
connection to teeth
• According to Carl Mish.
1. Vertical movement.
B- prosthesis movement
C- Prosthetic components
The abutment and gold cylinder screw joint act as
a flexible element.
Biomechanics of implant connection to teeth
• 2- Horizontal movement
Biomechanics of implant connection to teeth
• 2- Horizontal movement
Biomechanics of implant
connection to teeth
Guidelines for tooth implant connection.
• 1. non mobile tooth.
• Mobile tooth will act as a cantilever.
• Increase lateral stresses on implant and bone loss.
• 2. Connecting to posterior tooth not anterior
tooth.
• Anterior teeth have more lateral force than posterior.
• 3. No mobile attachment between the tooth and the
implant.
• The attachment move more than tooth and implant
• Act as the pontic is cantilevered on the implant
Guidelines for tooth implant connection.
• 4. if there is tooth mobility:
• Extract it and put implant.
• Splinting with another tooth until no mobility is observed.
• 5. Proper retention and resistance form of the tooth
supported crown
• For splinting teeth together:
• 1. the last tooth connected in the splint should not be mobile.
• 2. Should be parallel to each other and to implant for proper path of
insertion.
• 3. the terminal abutment shouldn`t has poor retention form.
• 4. adjacent teeth shouldn`t be crowded to allow proper interproximal
hygiene.
Tooth implant connection
• Cantilever design.
• Disadvantages:
• No proper stress distribution.
• Move more than tooth and implant so the implant supported part is cantilevered.
• More cost
• Over contoured abutment.
• Impair the daily hygiene.
• Intrusion of the natural tooth.
Complications of tooth implant connection
• Mechanical complications • Biological complications
• Tooth intrusion • caries
• Cement breakdown
• Endodontic treatment
• Abutment tooth fracture
• Tooth loss
• Screw lossening
• Prosthesis fracture
• periimplantitis
Fixed implant supported hybrid prosthesis
FP hybrid prosthesis
FP bridge
Fixed implant supported hybrid prosthesis
• A hybrid denture is one that is fabricated over a metal framework
and retained by screws threaded into the implant abutments.
Fixed implant supported hybrid prosthesis
• Advantages
• It is considered an alternative method to treat a case with severe maxillary
atrophy.
• The proper choice in cases of increased inter arch space.
• With more than 15 CHS the size of the metal casting is a problem; too much metal is fabricated to support 2mm of porcelain, it acts
as heat sink, resulting in porosities as well as risk of fracture of porcelain. The weight is also quite considerable, so screw retained
hybrid prosthesis is the treatment of choice for these cases
• The comfort that the patient presents, the prosthesis is fixed and is screwed
to the implants so that the patient feels with their own teeth.
• good aesthetic result.
• A good proprioception, because the impact of occlusal forces during the
exercise of chewing is reduced.
• The acrylic resin part of the prosthesis acts as an intermediary between
the teeth and the metal structure.
• Ease of maintenance by the specialist dentist.
• are much cheaper and any modification made is a much simpler, cheaper
and faster process.
References
• Carl E. Misch dental implant prosthetics. 2nd edition.
• Connecting teeth to implants: a critical review of the literature and
presentation of practical guidelines. Gary GreensteinGary GreensteinJohn
CavallaroJohn CavallaroRichard B SmithRichard B SmithDennis P TarnowDennis P Tarnow
• Tooth-Implant Connection: A ReviewSerhat Ramoglu, Simge Tasar,
Selim Gunsoy, Oguz Ozan, and Gokce Meric.
• Connecting implants to teeth.Saj JivrajSaj Jivraj. 2006, British
Dental Journal
