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Introducing
Dental Implants
Commissioning Editor: Michael Parkinson
Project Development Manager: Janice Urquhart
Project Manager. Frances Affleck
Designer: Judith Wright
Illustrator: Robert Britton
Introducing
Dental Implants

J ohn A. Hobkirk PhD, BDS, FDSRCSEd, FDSRCSEng, DrMedHC

Professor of Prosthetic Dentistry, Eastman Dental Institute for Oral Health Care Sciences,
University College London, University of London, UK

Roger M. Watson MDS, BDS, FDSRCSEng

Emeritus Professor of Prosthetic Dentistry, Guy's King's and St Thomas's Dental Institute,
King's College London, University of London, UK

Lloyd J. J. Searson BDS, MSc Michigan, FDSRCSEng

Consultant in Restorative Dentistry, Eastman Dental Hospital, London, UK

Foreword by

George A. Zarb BChD (Malta) DDS MS (Michigan) MS (Ohio) FRCD(C) DrOdont LLD MD
Professor and Head of Prosthodontics, Faculty of Dentistry, University of Toronto, Canada

CHURCHILL
LIVINGSTONE

EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2003
CHURCHILL LIVINGSTONE
An imprint of Elsevier Science Limited

© 2003, Elsevier Science Limited. All rights reserved.

The right of John A. Hobkirk, Roger M. Watson and Lloyd J. J. Searson to be

identified as authors of this work has been asserted by them in accordance with
the Copyright, Designs and Patents Act 1988.

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by selecting 'Customer Support' and then 'Obtaining Permissions'.

First published 2003

ISBN 0 443 07185 3

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of Congress

Notice
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 Foreword

Today's miracle medicine scenario of genetic and research. As a result, the prescription of dental
engineering and regenerative medicine is a timely implants has gradually eclipsed traditional techniques
reminder of dentistry's relatively small yet indis- of pre-prosthetic surgery and offered predictable
pensable, role in advancing health care. The dental and even optimal treatment outcome alternatives to
profession has been in the body 'spare parts' business routine fixed and removable prostheses. In the past
for a very long time, but without the anguish inherent 20 years numerous fine publications have sought to
in the tricky ethical questions associated with organ articulate a strong case for inclusion of dental implant
transplantation. Dentistry's term for hard and soft techniques in the dentist's routine clinical repertoire.
tissue analog replacement - prosthodontics - remains However, this is the first text which I have been privi-
a tongue twister. It also conjures up memories of leged to read which addresses the topic in a manner so
frustrating dental school pre-clinical experiences. Yet comprehensive, and yet so superbly organized, that it
our profession's long-standing tradition of readily may very well qualify not only as the finest book for
endorsing evidence-based, applied replacement the novice in the field, but also as a landmark publica-
bio-technology has served us well, as we sought to tion. The authors have distilled their own considerable
replicate artificially what has been lost in the oral and internationally recognized scholarship into 10
cavity. Hence the commitment of leading clinical very well balanced and rationally argued chapters.
educators, particularly the authors of this very lucid They are to be congratulated for raising the standard
and intelligent text, to use applied dental implant of communication in the fascinating field of dental
research to enhance the life quality of prosthodontic implants. As a result, all of us in the profession -
patients. dentists, dental specialists and above all prosthodontic
Branemark's seminal research in osseointegration patients - will be the beneficiaries of the authors'
enabled the surgically related and prosthodontic outstanding contribution.
disciplines exciting scope to enlarge and fulfil all three
remits of dental scholarship - education, service Professor George A. Zarb Toronto, Canada
This page intentionally left blank
 Preface

It is now seven years since our Color Atlas and Text of reflected in the illustrations. Geoffrey Forman, Hardev
Dental and Maxillo-Facial Implantology was published, a Coonar, Hind Abdel-Latif, Margaret Whateley,
period during which osseointegration has remained Vladimir Nikitin, Trevor Coward, Cameron Malton,
the basis of this form of treatment. While the funda- David Davis, and Nadin Kurban have all helped the
mental principles may have remained largely project in various ways, for which we are most
unchanged the range and volume of research, clinical grateful. Our biggest thanks are however due to our
applications and manufacturers' products have all wives and families, who have cheerfully supported us
continued to expand. This has been reflected in the during many evenings and weekends of very personal
range of textbooks on the subject, although the novice computing.
to the field has been less well catered for. We hope that
this book will be helpful to this group of colleagues. John A. Hobkirk London 2003
We should like to thank the many who have helped Roger M. Watson
with this project, including those whose skills are Lloyd J. J. Searson
This page intentionally left blank
 Contents

1. Using this book 1

2. Implants: an introduction 3

3. General treatment decisions 19

4. Gathering information and treatment planning 29

5. Basic implant surgery 43

6. The edentulous patient 63

7. The partially dentate patient 81

8. Single-tooth implants 101

9. Other applications 117

10. Problems 131

Self-assessment questions 153

Index 161

IX
This page intentionally left blank
 Using this book

INTRODUCTION intended to explain the essential aspects of the subject

and introduce the terminology that is in current use.
This book is intended principally for undergraduate
dental students in their final year and dentists taking
postgraduate courses. It should also be of interest to GENERAL TREATMENT DECISIONS
professionals complementary to dentistry, seeking an Treatment with dental implants has considerably
introduction to the subject. The text is not intended to extended the range of care that we can offer our
develop skills to the specialist level, but rather to help patients; however, despite its applications in new
in preparing for examinations or clinical situations in areas such as maxillofacial prosthodontics, the anchor-
which basic knowledge of the topic is required. ing of hearing aids and in orthodontic therapy, it is
The text has been arranged in an ordered sequence principally used for prosthodontic rehabilitation. If the
from an introduction to the subject, through to potential benefits of such uses are to be maximized,
completion of treatment using implant-stabilized then it is essential that implant treatment be selected
prostheses and the all-important management of on a logical basis, and placed within the context of the
problems. Since there are a number of clinical full range of treatment modalities available in
situations where it may be advantageous to use dental restorative dentistry.
implants, several of the chapters describe procedures
that could be used in different circumstances.
The text is not primarily intended to be read from GATHERING INFORMATION AND
cover to cover, but rather as a series of discrete TREATMENT PLANNING
chapters, although many build on knowledge Treatment should not be based on hope, be it in
acquired in earlier sections. Readers may therefore the mind of the dentist or the patient, but rather on
find it helpful to select particular chapters when accurate information, an understanding of the
seeking information on one aspect of implant therapy. patient's problems, recognition of suitable treatment
Consequently, many chapters contain brief resumes of alternatives and the agreed selection of the one most
information covered earlier in the book to avoid appropriate to their needs. This may not necessarily be
needless cross-referencing. the most complex procedure or involve the use of
The information has been arranged in three ways. dental implants. Their use is most likely to succeed
Firstly, there is the body text, which covers each topic where it has been selected on a sound basis.
in the intended detail; secondly there are supplemen-
tary photographs and diagrams; and finally there are
a number of summary lists which are intended to be IMPLANT SURGERY
used by the reader as an aid when preparing for an The correct insertion of dental implants is essential for
examination or wishing to use the material in a clinical their optimal utilization and involves far more than
setting. merely the surgical creation of an intra-bony defect
and insertion of the implant body. The technique must
IMPLANT TREATMENT involve appropriate planning and consultation by the
dental team, even where the surgeon and prostho-
Treatment with dental implants has evolved from dontist are the same individual. While an integrated
earlier much-derided procedures to a mainstream dental implant is essential for success, it is of little use
clinical activity. However, its potential benefits and high if it is inappropriately located.
success rates have led to the procedure sometimes
being incorrectly used, with unfortunate outcomes. THE EDENTULOUS CASE
A wide range of components is now available from
many different manufacturers, and the technique is While the number of edentulous individuals is falling
developing its own jargon, which is a mixture of in many countries, those that remain are often oral
traditional dental terminology, new terms and cripples. It was for this reason that treatment of such
manufacturers' catalogue descriptions. This can be patients was one of the priorities for the early pioneers
confusing for the novice. The introductory chapter is of dental implantology. The procedure can bring
 INTRODUCING DENTAL IMPLANTS

enormous benefits to such patients but must be set easily solved using traditional restorative techniques.
against a background of prosthodontic knowledge; an However, there are some situations where this is not
inadequate prosthesis does not become ideal merely technically feasible or produces an inferior result.
because it is implant stabilized. The nature of these Recognizing these cases, planning and carrying out
issues and the associated treatment procedures are appropriate implant-based treatment are discussed in
considered in this chapter. this chapter.

THE PARTIALLY DENTATE CASE OTHER APPLICATIONS

The great benefits achievable with implant treatment The ability of osseointegrated interfaces to develop in
in the edentulous patient were soon translated into the many locations has led to a wide range of potential
resolution of specific problems in the partially dentate applications for dental and skull implants, which are
patient, where they have been shown to be highly briefly considered in this chapter.
effective in appropriate cases. The situation is,
however, more complex than in the edentulous case,
since there are often several treatment modalities that
PROBLEMS
could be used, while the status of the existing teeth Treatment with dental implants can be a very complex
and their supporting structures are additional procedure in terms of planning, execution and
complications. Dental implants are not an alternative management of the subsequent problems. Despite the
to inadequate oral hygiene or poor treatment high success rate of the technique, these are not
planning, and if inserted inappropriately in the unknown and are best managed by avoidance rather
partially dentate patient can present a major problem than correction after the event. This chapter places
when further teeth are lost. This chapter is concerned great emphasis on this approach from the initial
with the selection of appropriate patients and the consultation onwards, while covering the various
treatment procedures that may be employed. techniques that may need to be employed when
difficulties arise.
THE SINGLE-TOOTH SCENARIO
Missing single teeth, especially due to trauma, are a
not uncommon problem, which in many cases can be
 Implants:
ts: an introduction

MANAGEMENT OF MISSING TEETH surrounding bone, which is capable of load trans-

mission, associated with healthy adjacent tissues,
Teeth are commonly absent from the dental arch either predictable in outcome and with a high success rate.
congenitally or as a result of disease, of which caries This outcome proved elusive until the discovery of the
and periodontal breakdown are the most common. phenomenon of osseointegration.
While it is not axiomatic that a missing tooth should
always be replaced, there are many occasions where
this is desirable to improve appearance, masticatory OSSEOINTEGRATION
function or speech, or sometimes to prevent harmful Extensive work by the Swedish orthopaedic surgeon
changes in the dental arches, such as the overeruption P.-I. Brånemark led to the discovery that commercially
or tilting/drifting of teeth. Tooth loss is also followed pure titanium (CPTi), when placed in a suitably
by resorption of the alveolar bone, which exacerbates prepared site in the bone, could become fixed in place
the resultant tissue deficit. due to a close bond that developed between the two
In most countries with an oral care service a consid- (Fig. 2.1), a phenomenon that he later described as
erable component of the work of the dental team is osseointegration (OI). This state has anatomical and
directed towards prevention of tooth loss, repair of functional dimensions, as it requires both a close
damaged teeth, and the replacement of those which contact between the implant and surrounding healthy
are missing together with their supporting tissues. bone and the ability to transmit functional loads
Where patients are edentulous, treatment for tooth over an extended period without deleterious effects
loss has largely been restricted to the use of complete either systemically or in the adjacent tissues. OI is not
dentures; however, in the partially dentate, the poten- defined in terms of the extent of the bone-implant
tial treatments are more numerous, since a variety of contact, provided that functional requirements are
techniques may be used to stabilize prostheses by met and the tissues are healthy. Many of the factors
linking them to the natural teeth. Removable partial that predispose to the development of OI are now
dentures (RPDs) are widely employed because of their known, and where these exist a successful outcome
versatility and can give effective long-term results in will probably follow the placing of a suitable implant.
suitable circumstances. They do, however, suffer from Similarly, failure is more likely where factors known
being relatively bulky, frequently need metal to predispose to an unsuccessful outcome exist. Occa-
components, which may be difficult to disguise, are sionally, implants fail for no apparent reason, some-
patient removable, and are inherently less stable than times in groups in one patient - the so-called 'cluster
a fixed bridge that is secured permanently to one or
more teeth. These may be based either on traditional
designs involving extensive preparation of the
abutment teeth, or more modern and less destructive
adhesive techniques. In general, RPDs are used to
manage extensive tooth loss or significant alveolar
resorption and where there are advantages in their
relative simplicity of fabrication and replacement.
Fixed restorations are typically less versatile and more
expensive to provide, but have advantages related to
their stability and reduced bulk.
Clinicians have long sought to provide their patients
with an artificial analogue of the natural teeth and a
wide variety of materials and techniques have been
used for this. However, it has not been possible to
replicate the periodontal tissues and alternative
strategies have therefore been adopted. These have Fig. 2.1 Close physical approximation between the surface of a
been based on the principles of creating and maintain- dental implant and vital bone is a key structural characteristic of
ing an interface between the implant and the osseointegration, which also has important functional parameters.
 INTRODUCING DENTAL IMPLANTS

phenomenon'. It is therefore important to advise Surface composition and structure

patients that a satisfactory outcome cannot be
guaranteed. It is thought that CPTi owes its ability to form an
OI is currently viewed as the optimum implant- osseointegrated interface to the tough and relatively
inert oxide layer, which forms very rapidly on its
bone interface, without which success cannot be
surface. This surface has been described as osseo-
obtained, and great emphasis has been placed on its
production and maintenance. Nevertheless, it is only conductive, that is, conducive to bone formation.
Other substrates also have this property and may also
one component of successful dental implant treatment
stimulate bone formation, a property known as
and does not in itself prevent that treatment from
osseoinduction. While the initial bone-implant contact
failing. While the absence of OI is equated with treat-
with such a material can be more extensive and occur
ment failure, its achievement does not guarantee
success, which is dependent on the design and sooner than around CPTi, the long-term benefits
are less evident. Nevertheless, there is considerable
performance of the final prosthesis. This may be
clinical and research interest in modifying the compo-
precluded by an inappropriately placed implant, even
sition of implant surfaces for the purpose of obtaining
if it is integrated.
more rapid OI and/or a mechanically and clinically
While the osseointegrated interface and associated
superior host/implant interface (Fig. 2.2). This can
soft-tissue cuff where the implant penetrates the oral
take the form of surface coatings (such as hydroxy-
mucosa are often thought of as dental analogues, they
apatite), changes in the composition of the implant
have a number of important differences. In particular,
material by selective surface coping with small quan-
the interface is more rigid and less displaceable than
tities of other elements, or the local use of biochemical
the periodontal ligament, and behaves essentially
molecules involved naturally in mediating bone
elastically as opposed to the viscoelasticity of the
periodontal ligament. The stability of the interface formation, such as bone morphogenic protein (BMP).
Implant surface structure is also known to influence
also precludes implant repositioning by orthodontic
cellular behaviour, and a range of microstructured
manoeuvres, but may permit dental implants to be
surfaces has been shown to modify cell spreading and
used as anchorage for fixed orthodontic appliances.
orientation on the implant, benefiting initial anchorage
The osseointegrated interface is also associated with a
in bone. The influence of these factors on OI in the long
slow rate of loss of crestal alveolar bone, typically less
term, however, is not known.
than 0.1 mm per annum after the first year of implan-
tation. As a result, most implants can be expected to be
Heat
functional throughout adult life.
Inflammation of the tissues around an endosseous Heating of bone to a temperature in excess of 47°C
implant is sometimes observed; it is described as during implant surgery can result in cell death and de-
peri-implant mucositis when it involves only the soft naturation of collagen. As a result, OI may not occur;
tissues and peri-implantitis where loss of the bone instead the implant becomes surrounded by a fibrous
interface occurs. While the microorganisms associated capsule and the shear strength of the implant-host
with these lesions are similar to those seen in perio- interface is significantly reduced. For these reasons
dontal disease, it is currently unclear whether they great care has to be taken when preparing implant
cause the lesion or colonize the region subsequently. sites to control thermal trauma. This is related to drill
speed, drill design, amount of bone being removed at

Factors influencing OI
A number of systemic and local factors have been
identified as being associated with the production of
an osseointegrated interface. Fewer systemic factors
are now thought to be of significance than was once
believed, and are considered below. Local factors are
as follows.

Material
Osseointegration was originally believed to be unique
to high-purity titanium (commercially pure or CPTi,
99.75%) and this material still forms the basis of the
technique; however, it is known that a range of other
materials can also form intimate bonds with bone.
These include zirconium and some ceramics, particu-
Fig. 2.2 Manufacturers have modified the surfaces of their dental
larly hydroxyapatite; however, they have not been as implants with the intention of improving tissue responses so as to
extensively researched as CPTi for dental implant enhance osseointegration. This picture shows the TiUnite™ surface
applications. utilized by Nobel Biocare. (Courtesy Prof. N. Meredith)
 IMPLANTS: AN INTRODUCTION

one pass, bone density and use of coolants. In general,

slow drill speeds and the use of copious amounts of
coolant are recommended.

Contamination
Contamination of the implant site by organic and
inorganic debris can prejudice the achievement of OI.
Material such as necrotic tissue, bacteria, chemical
reagents and debris from drills can all be harmful in
this respect.

Initial stability
It is known that where an implant fits tightly into its
osteotomy site then OI is more likely to occur. This is
often referred to as primary stability, and where an
implant body has this attribute when first placed Fig. 2.3 A scheme for classifying patterns of bone in the edentulous
jaw: (1) thick cortex and plentiful cancellous bone; (2) thin cortex and
failure is less probable. This property is related to the plentiful cancellous bone; (3) dense cortex with minimal cancellous
quality of fit of the implant, its shape, and bone bone; and (4) sparse cancellous bone and a thin cortex. All can
morphology and density. Thus screw-shaped implants provide effective support for a dental implant; however, there is an
will be more readily stable than those with little increased risk of thermal trauma in types 1 and 3, and problems are
often encountered obtaining good primary fixation in types 2 and 4.
variation in their surface contour. Soft bone with large
marrow spaces and sparse cortices provides a less
favourable site for primary stability to be achieved. Some
manufacturers produce 'oversized' and self-tapping bone bulk is lacking, then small implants may need
screw designs to help overcome these problems. to be used, with the consequent risk of mechanical
overload and implant failure.
Bone quality
This bone property is well recognized by clinicians Epithelial downgrowth
but is more difficult to measure scientifically. It is a Early implant designs were often associated with
function of bone density, anatomy and volume, and downgrowth of oral epithelium, which eventually
has been described using a number of indices. The exteriorized the device. When the newer generation of
classifications of Lekholm and Zarb and of Cawood CPTi devices was introduced great care was taken to
and Howell are widely used to describe bone quality prevent this by initially covering the implant body
and quantity (Figs 2.3, 2.4). The former relates to the with oral mucosa while OI occurred. The implant
thickness and density of cortical and cancellous bone, body was then exposed and a superstructure added,
and the latter to the amount of bone resorption. Bone since it was known that the osseointegrated interface
volume does not by itself influence OI, but is an was resistant to epithelial downgrowth. More recently,
important determinant of implant placement. Where there has been a growing interest in using an implant

Fig. 2.4 A scheme for classifying the extent of bone resorption in the edentulous maxilla and mandible based on that proposed by Cawood and
Howell in 1988.
 INTRODUCING DENTAL IMPLANTS

design, which penetrates the mucosa from the time of Dental implant body
placement. While this technique has no long-term data
to rival that of the earlier methods, it does appear on This term describes the component placed in the bone,
the basis of preliminary findings to be effective and which is sometimes also referred to as an implant,
successful in suitable patients and locations. A recent fixture or implant fixture. Occasionally the term is
development of this has been the introduction of a used colloquially to describe both the endosseous
technique for placing a prefabricated superstructure component and those parts placed immediately on
on dental implants, which permits their use within top. The preferred term for the endosseous component
hours of placement. is 'dental implant body', or 'implant body' where its
application is clear from the context (Fig. 2.5).
Early loading The majority of dental implants are designed to
be placed into holes drilled in the bone and are thus
There is good research evidence that high initial loads
axisymmetric. Many are screw shaped, since this aids
on an implant immediately following placement result
in primary stability, and are inserted into tapped holes.
in the formation of a fibrous capsule rather than OI.
Where bone has a low density this may result in
Nevertheless there is evidence from clinical studies
poor stability and thus some designs incorporate self-
that where the implant has good primary stability,
tapping features to overcome this problem. Others are
early loading does not apparently preclude OI, below made with a tapering design, which creates a wedging
an ill-defined threshold.
effect as the implant body is seated.
In addition to screw threads, other surface features
Late loading
may be included with the intention of enhancing OI.
It has been shown that excessive mechanical loads on Typical of these are macro surface irregularities, and
an osseointegrated implant can result in breakdown of porous metallic and ceramic coatings, typically of
the interface with resultant implant failure, and it is hydroxyapatite. These features usually also enhance
generally considered that overload is therefore to be retention, which is important since an osseointegrated
avoided. This could arise as a result of bruxism, in smooth titanium surface has a low shear strength.
patients who habitually use high occlusal forces, and The implant may either be of a multi-part design,
as a result of superstructure designs in which the which is intended to be buried while OI occurs, or a
use of excessive cantilevering causes high forces on single-part design, which will penetrate the mucosa
the implants. The research evidence for a link from the time of placement. Multi-part designs incor-
between occlusal loads and loss of OI is, however, porate various mechanical linkages to facilitate the
not extensive, and there are currently no clinical joining of the different components and the mechan-
guidelines as to its determination in a particular ical integrity of the joint (Fig. 2.6). These usually
patient other than by general principles. Since bone is include a hexagonal socket on one component to pro-
a strain-sensitive material, the modelling and vide resistance to rotation, or a tapered joint to provide
remodelling of which is influenced by deformation, it both this and a seal. The joint is commonly held closed
is thought that there is probably a range of strains that by a screw, although some manufacturers employ
are associated with bone formation and could thus be cement fixation. Following placement of a buried
of therapeutic value. implant it is usual to insert a cover screw in its central

IMPLANT COMPONENTS
There is a wide range of terms used to describe the
various components employed in implant treatment,
and attempts to standardize terminology have proved
unhelpful. Some common descriptions are included
here, under the heading of the term used in this book.

Box 2.1
2*1 Local factors that may influence
osseointegration

Material
Surface composition and structure
Heat
Contamination
Initial stability Fig. 2.5 Components used in dental implantology: (a) a threaded
Bone quality tapered implant body; (b) cover screw, used to cover the top of the
Epithelial downgrowth implant; (c) parallel-sided transmucosal abutment; and (d) an
Loading abutment screw; this is used to secure the abutment to the implant
body.
 IMPLANTS: AN INTRODUCTION

Fig. 2.6 Examples of the principles of some of the methods used by

manufacturers to link implant abutments to the implant itself. The top of Fig. 2.7 Implant components. A standard abutment complete with
the implant body (a) may incorporate a threaded hole in combination screw (a), and the associated healing cap (b) and gold cylinder (c).
with a butt joint, which will provide limited resistance to rotation (b), When using tapered abutments (d) a special tapered healing cap (e)
an external hexagonal feature that will provide resistance to rotation should be employed, while a pre-manufactured gold cylinder (f) is
(c), an internal tapered recess that can provide a strong linkage with incorporated into the prosthesis to provide a precise and secure
an enhanced sealing effect (d) and an internal hexagonal recess linkage with the underlying implant.
which provides good resistance to rotation (e).

hole to prevent tissue ingress and bone growth over

the top of the implant body.

Cover screw
This is placed at the time of first-stage surgery, and
removed when locating the abutments. Where the
implant body is not internally threaded the descrip-
tion 'screw' is inappropriate. Although the term
'dental implant obturator' has been proposed the
name 'cover screw' is in wide use (Fig. 2.5).

Transmucosal abutment (TMA)

This is used to link the implant body to the prosthesis,
and may also be referred to as an implant abutment.
The proposed standard term is 'dental implant Fig. 2.8 An angled abutment with gold cylinder. This device enables
the implant body and crown to have divergent long axes. Note that
connecting component'. These parts have evolved
the shoulder of the abutment is higher on one side than the other as a
from a simple cylindrical device into a family of result of its angulation. This can create problems when designing a
components basically of four types: cylindrical, restoration.
shouldered, angled and customizable. They are
usually, but not exclusively, made of CPTi, and are
provided in a range of lengths and, in the case of the
shouldered design, shoulder heights (Figs 2.7, 2.8). similar configuration to a crown preparation on a
The cylindrical designs are employed where the natural tooth, with a narrow shoulder surmounted by
mucosal aspect of the prosthesis is to be placed some a largely tapered profile. As the components are pre-
distance above the oral mucosa to aid cleaning, the manufactured, some constraints are placed on their
so-called 'oil rig' design. While this gap can prove applications; in particular, the shoulder is often the
troublesome to some patients, it is not normally same height around the abutment. Most manufac-
evident where the adjacent lip is long, and can turers provide a range of lengths and shoulder heights
undoubtedly aid cleaning. to cater for different clinical situations.
Shouldered designs permit the prosthesis to finish Since the bony anatomy places constraints on the
at or below the 'gingival margins', providing a more location and orientation of a dental implant, there are
natural-appearing emergence profile for the super- situations where the crown on the superstructure is
structure. They are shaped so as to have a stylistically required to have a long axis markedly divergent from
 INTRODUCING DENTAL IMPLANTS

that of the implant. This can be managed with an Healing caps

angulated abutment in which the long axes of the two
linking surfaces, to the implant and the crown, are Most manufacturers provide temporary polymeric
divergent. Some designs appear less suited to use with covers for their abutments to prevent damage and
single teeth, as they are vulnerable to rotation under fouling of the screw retainer when the patient has to be
occlusal loads. In addition, the divergence imposes without the superstructure during its fabrication or
a minimum shoulder height on the external aspect repair. Some of these are of a larger diameter than the
(Fig. 2.8). abutment and are intended to retain a surgical pack
The customized abutment is pre-manufactured to immediately after its placement, typically at second-
fit the implant but has excess bulk, permitting its stage surgery.
modification to a particular situation after the fashion
of preparing a conventional crown. These abutments Joints
may be made in a dense ceramic, CPTi or gold alloy,
and may be supplied as a gold core onto which a There are two methods of joining implant superstruc-
crown may be bonded using traditional techniques. tures to the abutments: screwed and cemented joints.
While they allow considerable flexibility in crown The latter use standard dental cements, sometimes
design and placement, their ability to correct for reformulated by the manufacturer for this application.
incorrect implant location and angulation is limited.
All are difficult to trim and this is best accomplished in Screwed joints
the laboratory. A screwed joint functions by virtue of its components
being held tightly together by the tension in the screw,
acting after the fashion of a spring. Provided that
Healing abutment
This is a temporary implant-connecting part placed on
the implant body to create a channel through the Dental implant components
mucosa while the adjacent soft tissues heal.
They are normally wider than the corresponding IMPLANT BODY
regular abutment to compensate for some tissue
Often referred to as an implant
collapse into the space when placing the regular
abutment. They also allow for a period of resolution of COVER SCREW
tissue swelling before selecting the final abutment so
Prevents bone ingress in the implant head
as to ensure its optimum height. This is particularly
important since soft-tissue contours can often change TRANSMUCOSAL ABUTMENT (TMA)
significantly in the period following placement of the
Links the implant body to the mouth. May be
abutments. This therefore greatly aids abutment
pre-manufactured or custom formed
selection, which is particularly important when using
abutments that are intended to replicate a natural HEALING ABUTMENT
emergence profile, requiring the metal shoulder to be
Placed temporarily on the implant body to maintain
submucosal.
patency of the mucosal penetration

TEMPORARY COMPONENTS
Impression coping
Pre-manufactured components used to make temporary
This is also described as a dental implant impression crowns and bridges for fitting on dental implants and
cap, and is used to transfer the position of the implant abutments
body or the abutment to the working cast.
IMPRESSION COPING
Used to transfer the location of the implant body or
Gold cylinder abutment to a dental cast

This pre-manufactured component is used to link LABORATORY ANALOGUE

the superstructure to the abutment, and is usually A base metal replica of the implant body, or a
screw retained. It can be provided in a range of shapes pre-manufactured abutment
depending on the abutment design and may be
intended for soldering to a gold bar for use with an GOLD CYLINDER
overdenture, incorporation in a cast superstructure as Pre-manufactured to fit an abutment and form part of a
the basis of a fixed bridge or as part of a single crown. prosthesis
Where it forms the basis of a single crown it is normal
for it to incorporate an anti-rotation feature, such as an HEALING CAPS
internal hexagon, a feature that may be present for Temporary covers for abutments
other applications.
 IMPLANTS: AN INTRODUCTION

the loads on the joint do not exceed the tension in the Access holes
screwed joint (pre-tension) then it will remain closed; A screw joint requires access, which can sometimes be
however, once the pre-tension force is exceeded the difficult if the gape is restricted, or if the implant is
joint will open and the screw will be subject to unfavourably angled or positioned in the posterior
unfavourable bending moments. When securing the molar region. In addition, the hole must be concentric
joint it is important to produce the maximum with the long axis of the implant body or angled abut-
pre-tension without causing permanent distortion of ment, if used. The access hole may therefore penetrate
the screw. There will nevertheless subsequently the prosthesis at an aesthetically unfavourable site
be some loss of pre-tension. This can occur due to or compromise the occlusion.
deformation of the screw and joined components,
counter-rotation of the screw or plastic deformation of Contamination
the surfaces of the screwed joint in a process known as
embedment relaxation. Many manufacturers therefore Screwed joints can provide a pathway for bacteria to
recommend routine checking of screw tightness after a colonize the interfaces between the components, and
short period of service. act as a potential source of infection or track into the
deeper tissues. Some screwed joints incorporate a
Advantages tapered design, which provides a seal between the
components, while others may include a synthetic
Retrievability rubber O-ring to reduce the risk of oral bacteria
A major advantage of the screwed joint is its retriev- infecting deeper tissues.
ability, which greatly aids the checking of the various
connecting components and abutments and the Angulation problems
surrounding soft tissues, the replacement of failed Due to the axisymmetric design of most dental
components such as abutments and abutment screws, implants the orientation of the long axis of the fixture
and the superstructure itself. This may also be con- determines the angulation of the superstructure,
veniently remounted on a dental cast for analysis and
modification in the laboratory, including replacement
of any plastic components.
Box 2.3
2.3 What local factors should be
Control of gap when contemplating possible
If constructed correctly a screw-retained implant treatment?
superstructure can fit the implants closely and con-
sistently around the dental arch. There is considerable ACCESS
evidence of the difficulty of achieving this, and it is Room to insert the implants?
generally accepted that a truly passive fit of the super-
structure is rarely achieved in clinical practice. Never- PROSTHETIC SPACE
theless, the repeatability of location has advantages Room to place a restoration?
in terms of the ability to remove and replace the pros-
thesis for servicing. In addition occlusal adjustments DYNAMIC SPACE TO RESTORE THE IMPLANT
made in the laboratory are less likely to be rendered Do occlusal interferences preclude superstructure
inaccurate as can occur with a cementation process. placement?
There are also advantages in the minimization of soft-
tissue irritation due to gaps adjacent to the gingival SIZE OF SPACES
cuff, or as a result of cement accretions. How many implants?

Predictable failure BONE VOLUME

Screwed joints can be designed to be the weakest part Will it house a suitable implant?
of a linkage and thus fail preferentially. This can pro-
tect other components from mechanical overload, such BONE CONTOUR
as screws, which are difficult to retrieve if fractured, Will the implant penetrate a concavity?
the bone-implant interface and the superstructure.
BONE ORIENTATION
Disadvantages Can the implant be oriented correctly?
Mechanical failure PROGNOSIS OF REMAINING TEETH?
Where mechanical failure of a screw occurs it can be Restore the mouth in its entirety
difficult, and sometimes impossible, to retrieve the
broken component, for example where it is within an STATUS OF EXISTING PROSTHESES
implant body. A cementation procedure, in contrast, Could they be improved upon? With implants?
can usually be repeated.
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