implant restorationshe has had a practice limited to ﬁxed, removable, and implant prosthodontics...

CARL DRAGO

A Step-by-Step Guide

Implant Restorations

2nd Edition

Implant Restorations: A Step-by-Step Guide offers clinicians a practical, step-by-step approach to treatment planning and restoring dental implants. This highly illustrated, case-based book demonstrates how to treat the most commonly encountered treatment scenarios, describing the procedures, techniques, and sequences required in clear, concise language and in an easy-to-use format. The book takes the theory of implant restoration, using as its basis 3i’s implant systems, and places it directly in the operatory, concentrating in detail on each stage of the actual clinical procedures involved in treating different patients. It integrates implant treatment with the realities of running a successful restorative practice. Building on the work of the 1st edition, the 2nd edition of this successful text reflects the advances of implant prosthetics over the intervening years, providing all new cases, exploring new techniques and technology, and demonstrating updated system components and armamentarium.

Implant Restorations: A Step-by-Step Guide follows a logical structure of three sections. The first section introduces implant restorative dentistry, how to develop an implant restorative practice, the issues involved, the technical components of the 3i systems, diagnosis, and treatment planning. The central section of the book devotes separate chapters to in-depth descriptions of each of several types of patients that the restorative dentist may encounter, ranging from basic to more challenging cases. Every step of each procedure is described and illustrated with clinical photographs. Laboratory work orders are presented for use with commercial dental laboratories. The final section discusses record-keeping, patient compliance, hygiene regimes and follow-up, and provides the reader with an outline of best-practice procedural protocols.

An excellent and accessible guide on the most burgeoning subject in modern dental practice by one of its most experienced clinicians, Implant Restorations: A Step-by-Step Guide will appeal to prosthodontists, general dentists, implant surgeons, dental students, dental laboratory technicians, and dental assistants.

• Step-by-step format for quick and clear reference

• Highly illustrated with full color throughout

• Focuses on the practical aspects of actual clinical procedures

• Profiles several common basic and more advanced cases in a simple, concise, and straightforward manner

• Advises on procedural protocols, treatment planning, and sequencing

• Includes single-unit and implant-supported denture prostheses

Implant Restorations A Step-by-Step G

uide Carl Drago

2nd Edition

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Implant Restorations:A Step-by-Step Guide

2nd Edition

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Implant Restorations:


2nd Edition

Carl Drago, DDS, MS

Gundersen Lutheran Medical Center

LaCrosse, Wisconsin

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Carl Drago is Clinical Science Editor of the Journal of Prostho-dontics, the journal of the American College of Prosthodontists.He has had a practice limited to fixed, removable, and implantprosthodontics since 1981, and practices as a prosthodontist atthe Gundersen Lutheran Medical Center in LaCrosse, Wisconsin.He has also held positions as Assistant Clinical Professor at theUniversity of Texas Dental School at San Antonio. He is a Diplomate of the American Board of Prosthodontics (ABP).

©2007 Carl Drago

Editorial Offices:Blackwell Publishing Professional,2121 State Avenue, Ames, Iowa 50014-8300, USA

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All rights reserved. No part of this publication may be repro-duced, stored in a retrieval system, or transmitted, in any form orby any means, electronic, mechanical, photocopying, recordingor otherwise, except as permitted by the UK Copyright, Designsand Patents Act 1988, without the prior permission of the pub-lisher.

First published 2007 by Blackwell Munksgaard, a Blackwell Publishing Company

Library of CongressCataloging-in-Publication DataDrago, Carl J.

Implant restorations : a step by step guide / Carl J. Drago. —2nd ed.

p. ; cm.Includes bibliographical references and index.ISBN-13: 978-0-8138-2883-1 (alk. paper)1. Dental implants. I. Title.[DNLM: 1. Dental Implantation, Endosseous—methods.

2. DentalAbutments. 3. Jaw, Edentulous—surgery. WU 640 D759i 2006]RK667.I45D73 2006617.6�92—dc22

2006009527

ISBN-13: 978-0-8138-2883-1

Printed and bound by Replika Press

For further information onBlackwell Publishing, visit our website:www.blackwellpublishing.com

The last digit is the print number: 9 8 7 6 5 4 3 2 1

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vi Table of Contents

Table of Contents

Contributors xivForeword xvAcknowledgments xvi

Chapter 1. Introduction to Implant Dentistry 3

Introduction 3Purpose of Textbook 3Economics of Implant Dentistry 3

Predictability of Fixed Prosthodontics 4Development of Prognosis for Teeth: Extract or Maintain 6

The Heavily Restored Tooth 6The Furcation Involved Tooth 7The Periodontal Prosthesis Patient 8Difficult Aesthetic Cases 10

Development of Prognosis for the Dentition 13Summary 15Bibliography 15

Chapter 2. Implants and Implant Restorative Components 17

Introduction 17Implants 17Implant/Abutment Connections 18External Implant/Abutment Connections 19Internal Implant/Abutment Connections 20Healing Abutments 22

EP® Healing Abutments 22Encode� Healing Abutments 26

Impression Copings 28Implant Impression Copings 28Abutment Impression Copings 31Abutments 31Standard Abutments 31LOCATOR® Overdenture Abutments 31Immediate Occlusal Loading (IOL®) Abutments 32GingiHue® Posts 33ZiReal� Posts 34Provide� Abutments 36UCLA Abutments 38CAD/CAM Abutments (Encode� Abutments) 41

Screws (Clinical) 44Cylinders 46

Standard Gold Cylinders 46IOL® Abutment Gold Cylinders 47

Drivers and Placement Instruments 48Large Hex Drivers 48Large Hex Driver Tips 48Square Drivers 48Square Driver Tips 48

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User

Abutment Drivers 49Abutment Driver Tips 49

Laboratory Components 49Implant Analogs 50Abutment Analogs 51Try-In Screws 51Abutment Holders 52

Bibliography 53

Chapter 3. Diagnosis and Treatment Planning in Implant Restorative Dentistry 55

Patient Selection 55Medical History 56

Outcome Assessment Indices 56Diagnostic Procedures 56Radiographs 57CT Scans 58Diagnostic Casts 60

Physical Examination 60Extra-Oral Examination 61Intra-Oral Examination 62Diagnostic Articulator Mounting 62Diagnostic Wax Patterns 62Surgical Guides 63Implant Bone Volume 64Implant Restorative Volume 67Treatment Planning 70Edentulous Patients 70Overdentures 71Fixed Hybrid Implant-Retained Prostheses-Edentulous Mandible 72Fixed Hybrid Implant-Retained Prostheses-Edentulous Maxillae 73Partially Edentulous Patients 75Treatment Goals 76Screw-Retained Restorations 76Cement-Retained Restorations 77Implant Loading Protocols 79

Two-Stage Surgical Protocol 79Single-Stage Surgical Protocol 80Early Loading Protocol 80Immediate Occlusal Loading Protocol 81Immediate Non-Occlusal Loading Protocol 81

Patient Consultation 81Principles 81Informed Consent 82Implant Coordinators 82

Summary 83Bibliography 83

Chapter 4.Treatment of an Edentulous Mandible with an Implant-Retained Overdenture and Resilient Attachments 87

Literature Review 87Clinical Case Presentation 91

Appointment 1. Initial Examination (3⁄4 Hour) 91Radiographs 92

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Physical Examination 92Diagnostic Casts 93Diagnoses 93

Appointment 2. Consultation Restorative Dentist/Patient (1⁄2 Hour) 93Treatment Options 93

Appointment 3. Consultation Restorative Dentist/Surgeon (1⁄2 Hour) 93Type/Number/Size of Implants 93Abutment Prosthesis Design 93Implant/Abutment Connection 93Surgical Guide 95Surgical Protocol 95Healing Abutment Selection 96Implant Restorative Wish List 96

Appointment 4. Implant Placement 96Two-Stage Surgical Protocol 96Postoperative Instructions 96

Appointment 5. Follow-Up Appointments (1⁄2 Hour) 97Suture Removal 97Tissue Conditioning 97

Appointment 6. Stage II Surgery 98Healing Abutments (1⁄2 Hour) 98Tissue Conditioning 98

Appointment 7. Abutment Connection and Reline Impression (3⁄4 Hour) 99LOCATOR® Abutment Connection 100Torque 100Impression Copings 100Reline Impression 101Laboratory Work Order/Procedures 101

Appointment 8. Insertion Relined Denture (1⁄2 Hour) 104Appointment 9. Follow-Up Appointments (1⁄2 Hour) 104

Two Weeks 104One-Year Recall Clinical and Radiographic Evaluations 104

Costs/Fees/Profitability 105Bibliography 105

Chapter 5.Treatment of a Partially Edentulous Mandible with a Pre-Machined Titanium Abutment and Single-Unit Porcelain Fused to Metal Crown 107


Appointment 1. Initial Examination (3⁄4 Hour) 108Diagnostic Casts 109Diagnoses 109


Appointment 3. Consultation Restorative Dentist/Surgeon (1⁄2 Hour) 112Type/Number/Size of Implants 112Abutment/Prosthesis Design 113Implant/Abutment Connection 113Surgical Protocol 114Healing Abutment Selection 114Implant Restorative Wish List 114

Appointment 4. Implant Placement (1 Hour) 114Appointment 5. Restorative Follow-Up Appointments (1⁄4 to 1⁄2 Hour) 114Appointment 6. Reevaluation and Determination of Implant Impression Date (1⁄2 Hour) 115

Laboratory Procedures 116

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Custom Open Face Impression Tray 116Tentative Abutment Selection 116

Appointment 7. Implant Level Impression (1⁄2 Hour) 116Clinical Procedures 116Laboratory Procedures 118

Master Cast 118Laboratory Work Order for Abutment Preparation and Crown Fabrication 118

Appointment 8. Abutment and Crown Insertion Appointment (3⁄4 Hour) 120Abutment Placement 120Radiographic Verification and Crown Try-In 120Torque 121Cementation 123

Appointment 9. Follow-Up Appointments 123Two Weeks/Six Months 123One-Year Recall Clinical and Radiographic Evaluation 123


Chapter 6. Re-Treatment of a Fractured Implant Fixed Partial Denture in the Posterior Maxilla with CAD/CAM Abutments and a New Fixed Partial Denture 125


Appointment 1. Initial Examination (3⁄4 Hour) 128Diagnostic Casts 128Diagnosis 128

Appointment 2. Consultation Restorative Dentist/Patient (1⁄2 Hour) 130Treatment Options 130Laboratory Procedures 130Custom Impression Tray 130

Appointment 3. Removal of Existing Prosthesis/Abutments; Implant Impression (1 Hour) 131Implant Level Impression 131Laboratory Procedures/Work Orders 132

Fabrication of Master Cast (Implant Analogs) 132CAD/CAM Protocol 134Articulator Mounting 135CAD Design of Abutments 135CAM Milling of Abutments 137Fabrication of 3-Unit Fixed Partial Denture 137

Appointment 4. Bisque Bake Try-In (3⁄4 Hour) 139Removal of Preexisting Prosthesis and Abutments 139Try-In CAD/CAM Abutments 139Verification Radiograph (Abutments) 140Try-In Bisque Bake FPD 140Verification Radiograph (FPD) 140

Appointment 5. Insertion Appointment (3⁄4 Hour) 140Removal of Preexisting Abutments and Fixed Partial Denture 140CAD/CAM Abutment Placement 141Torque 141Fixed Partial Denture Cementation 141

Appointment 6. Follow-Up Appointments (1⁄2 Hour) 142Two Weeks/Six Months 142One-Year Recall Clinical and Radiographic Evaluations 142


Table of Contents ix

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Chapter 7.Treatment of an Edentulous Mandible with a CAD/CAM TitaniumFramework/Fixed Hybrid Prosthesis 145

Clinical Case Presentation 146Appointment 1. Initial examination (3⁄4 Hour) 146

History of the Present Illness 146Radiographic Examination 147Physical Examination 147Diagnosis 147


Appointment 3. Consultation Restorative Dentist/Surgeon (1 Hour) 149Prosthesis Design 149Type/Number/Size of Implants 149Abutment/Prosthesis Design 149Implant/Abutment Connection 152Surgical Protocol 152Surgical Guides 152Anticipated Healing Time 152

Appointment 4. Implant Placement (21⁄2 Hours) 153Appointments 5–7. Prosthetic Follow-Up Appointments ( 3⁄4 Hour) 153

Ten Days 153Tissue Conditioning 153Four Weeks (1⁄2 Hour) 154Eight Weeks—Tissue Conditioning ( 3⁄4 Hour) 155

Appointment 8. Reevaluation ( 1⁄2 Hour) 155Diagnostic Impressions and Diagnostic Casts 155Tentative Abutment Selection 155Custom Impression Tray 155

Appointment 9. Implant Level Impression (One Hour) 156Clinical Procedures 156Laboratory Procedures/Laboratory Work Orders 157

Implant Analogs 157Master Cast Work Order 158

Verification Index 158Work Order 159

Appointment 10. Verification Index/Definitive Impression (3⁄4 Hour) 159Clinical Procedures 159Laboratory Procedures/Laboratory Work Orders 159

Master Cast (Definitive) 159Maxillary Occlusion Rim/Mandibular Record Base 160

Appointment 11. Jaw Relation Records, Tooth Selection (1⁄2 Hour) 160Clinical Procedures 160Laboratory Procedures 160

Articulator Mounting 160Initial Denture Set-Up 161

Appointment 12. Wax Try-In (1⁄2 Hour) 161Verification of Jaw Relation Records 161CAD/CAM Protocol 161CAM StructSURE� Precision Milled Bar 161Virtual Design of Framework 163Mill Framework 163Laboratory Evaluation of Framework/Master Cast Fit (Square Try-In Screws) 163

Appointment 13. Clinical Framework Try-In ( 3⁄4 Hour) 164Clinical One-Screw Test 164Radiographic One-Screw Test 164

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Laboratory Procedures 164Silicoat Framework 164Denture Set-Up 164

Appointment 14. Wax Try-In with Framework (3⁄4 Hour) 164Verification of Jaw Relation Records, Approval of Aesthetics, Vertical Dimension, Centric Relation,

Lip Support, Incisal Display, and Tooth Arrangement 164Laboratory Procedures and Laboratory Work Orders 166

Appointment 15. Prosthesis Insertion (3⁄4 Hour) 166Removal of Healing Abutments 166Insertion of Mandibular Prosthesis 167

Abutment Screws 167Torque 167Final Prostheses 168Oral Hygiene Instructions 168

Appointments 16 and 17. Prosthetic Follow-up Appointments: Two Weeks, Six Months (1⁄2 Hour) 168Appointment 18. One-Year Recall 169

Radiographs 169Clinical Examination 170

Future Recall Appointments 170Costs/Fees/Profitability 170

Bibliography 171

Chapter 8.Treatment of the Edentulous Mandible with an Immediate Occlusal Loading® Protocol 173

Literature Review 173The Pre-Osseointegration Era 173The Osseointegration Era 173Immediate Occlusal Loading® in the Edentulous Mandible 174DIEM � Protocol 175

Clinical Case Presentation 175Appointment 1. Initial Examination (Surgical Office; One Hour) 175

Radiographs 175Chief Complaint 176Physical Examination 176Diagnosis 176Prognosis 176

Appointment 2. Examination/Consultation Restorative Dentist/Patient (One Hour) 177Examination 177Diagnosis 177Treatment Options 177

Appointment 3. Consultation Restorative Dentist/Surgeon (1⁄2 Hour) 180Number/Size of Implants 180Prosthesis Design 183Implant/Abutment Connection 183Surgical Work-Up and Protocol 183

Appointment 4. Surgical Reevaluation (1⁄2 Hour) 184Appointment 5. Definitive Impressions and Jaw Relation Record (1⁄2 Hour) 184

Diagnostic Casts 184Articulator Mounting 184

Appointment 6. Wax Try-In (1⁄2 Hour) 185Laboratory Procedures/Work Orders for Processing Dentures 186

Appointment 7. Implant/Prosthesis Placement 186Surgical Protocol (21⁄2 Hours) 186Prosthetic Protocol (21⁄2 Hours) 190Postoperative Instructions 192

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Appointment 8. Prosthetic Follow-Up Appointments (1⁄2 Hour) 19224-Hour Follow-Up Appointment (1⁄2 Hour) 192One-Week Follow-Up Appointment (1⁄2 Hour) 194Four-Week Follow-Up Appointment (1⁄2 Hour) 194Eight-Week Follow-Up Appointment (1⁄2 Hour) 195

Appointment 9. One-Year Recall (3⁄4 Hour) 195Radiographs 195Clinical 195Definitive Prosthesis (CAD/CAM Framework) 196


Chapter 9. Immediate Non-Occlusal Loading Provisional Restoration; Definitive Restoration Maxillary Central Incisor 199


Appointment 1. Initial Clinical Visit (3⁄4 Hour) 201History of the Present Illness 201Radiographs 202Physical Examination 202Diagnostic Casts 202Surgical Guide 202Diagnoses 203Prognosis 203


Appointment 3. Consultation Restorative Dentist/Surgeon (1⁄2 Hour) 203Number/Size of Implant 203Implant/Abutment Connection 205Surgical Protocol 205Interim Abutment 205Implant Restorative Wish List 205

Appointment 4. Implant and Interim Abutment Placement (Surgical Office—One Hour) 207Implant Placement and Insertional Torque 207Interim Abutment Placement 208

Appointment 5. Restorative Appointment INOL Provisional Restoration—Same Day (3⁄4 Hour) 208

Abutment Preparation 208Immediate Non-Occlusal Loading Provisional Crown (INOL-No Centric/Eccentric Contacts) 209Dietary and Oral Hygiene Instructions 209

Appointment 6. Reevaluation Appointment—24 hours (1⁄2 Hour) 209History 209Clinical Examination 210

Appointment 7. Reevaluation Appointment—10 Days (1⁄2 Hour) 210History 210Clinical Examination 210

Appointment 8. Reevaluation Appointment—10 Weeks (1⁄2 Hour) 210History 210Clinical Examination 210

Appointment 9. Reevaluation—12 weeks (1⁄2 Hour) 210History 210Clinical Examination 210Diagnostic Impressions/Casts (Optional) 211Custom Impression Tray (Pick-Up Technique) 211

Appointment 10. Implant Impression (3⁄4 Hour) 211

xii Table of Contents

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INOL Provisional Restoration and Interim Abutment 211Implant Level Impression 212Interim Abutment Re-Preparation 213Provisional Crown with Occlusal Contacts 213Laboratory Procedures for the Master Cast 214Implant Analogs 214Master Cast 214Abutment Selection 215Protocol for Fabrication of Final Encode� Abutment 216Laboratory Fabrication of Encode Master Cast 216Laboratory Work Orders 220

Appointment 11. Abutment and Crown Insertion (3⁄4 Hour) 220Interim Abutment and Provisional Crown Removal 220Definitive Abutment Placement 221Radiographic Verification 222Torque 222Crown Try-In 222Cementation 223Postoperative Instructions 223

Appointment 12. Two-Week Follow-Up Appointment (1⁄4 Hour) 223Appointment 13. Six-Month Follow-Up Appointment (1⁄4 Hour) 223

History 223Clinical Examination 224

Appointment 14. One-Year Recall (1⁄2 Hour) 224History 224Radiograph 224Clinical Examination 224


Chapter 10. Surgical Considerations in Implant Dentistry: Integration of Hard and Soft Tissues 227

Introduction 227Implant Design 227Hard Tissue Integration 227Soft Tissue Integration 229Traditional/Early Loading Protocols for Dental Implants 230Quantitative Measurements of Implant Success 230Implant Failure 231Maintenance 231Conclusions 232Bibliography 232

Index 235

Table of Contents xiii

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C. Garry O’Connor, DDS, MSGundersen Lutheran Medical Center1900 South AvenueLaCrosse, WI 54601

Phone: 608 775 2696Fax: 608 775 [email protected]

Paul J. Kelly, DMD, MSArizona Maxillofacial Surgeons PC6755 East Superstition Springs BlvdSuite 103Mesa, AZ 85206

Phone: 480-830-5866Fax: 480-807-0606Email: [email protected]

Formerly, Chief Resident, Oral and Maxillofacial SurgeryGundersen Lutheran Medical Foundation

xiv Contributors

Contributors

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Dr. Carl Drago is an educator and practitioner with a visionto share his experiences with dental colleagues. His firstbook, Implant Restorations: A Step-by-Step Guide for Den-tists, illustrated his approach for multiple, basic implantcase reconstructions. Carl now supports your move to thenext level with this book. Each clearly written chapter con-tinues your growth in implant placement and reconstruc-tion with insightful treatment plans, explanations, and solu-tions for patients requesting implant restorations. Dr. Dragodescribes our multidisciplinary team approach for the totalcare of implant patients.

Carl explains the communication between cliniciansand laboratory technicians on an appointment-by-appoint-

ment basis. He discusses the restorative options, his billingprogram, loading protocols, implant component selection,work orders, and clinical procedures for each case type.The patient’s aesthetics and functional goals are identifiedand their accomplishments in each case are his measureof success. This book will expand your practice and enjoy-ment of implant dentistry. Include it with your favorite textsthat define the way you practice.

C. Garry O’Connor, D.D.S., M.S.Chairman, Department of Dental SpecialistsGundersen Lutheran Medical Center2006

Foreword xv

Foreword

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The author would like to acknowledge the assistance of thefollowing people in development of this textbook:

Gundersen Lutheran Department of ProsthodonticsLaCrosse, Wisconsin

Nan Dreves, RDH, BSStephanie GerlachAndrew GingrassoCarole JoseNicole StakstonJamie TranbergMary Rumble, RDH

Gundersen Lutheran Department of PeriodonticsLaCrosse, Wisconsin

Linda Sing Claudia Devens, RDHMichelle Wruck Amy Moriarty, RDHMary Johnson BenchinaAmy BergeyMary Ellen FreisingerCheryl OlsonLinda Pampuch

Gundersen Lutheran Department of Oral SurgeryLaCrosse, Wisconsin

P. Michael Banasik, DDSAjit Pillai, DMDPaul J. Kelly, DMD, MS

Implant Innovations, Inc. (All “product shot” photo-graphs courtesy of Implant Innovations, Inc.)Palm Beach Gardens, Florida

Lisa Adams, Associate Manager of Marketing Commu-nications

Hannah Johnson, Director of Corporate Communica-tions

Stephanie Schoenrock, Territory Manager, WisconsinRuss Bonafede, Vice President of Global MarketingSteve Schiess, President

Family and FriendsMatthew Brisgal Drago Kara KellyBetty Drago Candace O’Connor, DDSStephanie Drago Bottner Connie O’ConnorEleanor Drago SeversonJill Jensen

xvi Acknowledgments

Acknowledgments

The preceding registered trademarks and trademarks are registered to Implant Innovations, Inc.®, Palm Beach Gardens,Florida. For clarity, the author did not identify each specific product with its specific trademark symbol each time the prod-uct was mentioned. This list serves notice that the above are registered to Implant Innovations, Inc.®.LOCATOR® is a reg-istered trademark of Zest Anchors, Inc.

3i ® Trademarks� (5/10/05)ARCHITECH PSR�

CAM StructSURE� Precision Milled BarsDIEM�

Encode�

Gold Standard ZR�

Gold-Tite�

Patient Specific Restorations�

Prep-Tite�

Prevail�Provide�

QuickSeat� ConnectionTwist Lock�

ZiReal� Post

3i ® Registered Trademarks (5/10/05)ASYST®

Certain®

EP®

GingiHue® PostImplant Innovations, Inc.®

Immediate Occlusal Loading®

IOL®

OSSEOTITE®

OSSEOTITE® Certain®

OSSEOTITE NT®

OSSEOTITE XP®

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Implant Restorations:


2nd Edition

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INTRODUCTION

The successful, long-term clinical use of dental endos-seous implants requires some type of biologic attachmentof implants to bone. In 1969 Brånemark and others definedthis process as osseointegration (Brånemark and others1977). This process has been subsequently studied bynumerous authors and has come to identify the functionalstability of the endosseous implant/bone connection(Davies 1998). The histology and biomechanics of osseo-integration is beyond the scope of this text; the reader isreferred to other sources for further information andincreased understanding relative to osseointegration.

Treatment of edentulous or partially edentulous patientswith endosseous implants requires a multidisciplinary teamapproach. This team generally consists of an implant sur-geon, restorative dentist and dental laboratory technician.Each team member needs to be aware that implant den-tistry is a restorative-driven service and the ultimate suc-cess of implant treatment will be measured, at least in part,by the aesthetic and functional results as perceived bypatients. The design of the prosthesis, whether it be a sin-gle implant retained crown or a full-arch prosthesis, willhave a major impact on the number, size, and position ofthe implant(s) that will be used in a particular treatmentplan. Treatment planning for implant dentistry must there-fore begin with the restorative phase prior to consideringthe surgical phases of treatment.

Brånemark and co-workers introduced a two-stage surgi-cal protocol into North America in 1982 (Zarb 1993). Numer-ous, long-term clinical studies have proven the efficacy oftitanium, endosseous implants (Adell 1981; Sullivan andSherwood 2002; Friberg and Jemt 1991; Testori and DelFabbro 2002). Many clinicians now consider osseointegra-tion of dental implants to be predictable and highly effec-tive in solving clinical problems associated with missingteeth (Davarpanah and Martinez 2002).

PURPOSE OF TEXTBOOK

The purpose of this textbook is to provide cliniciansand dental laboratory technicians with a step-by-stepapproach to the treatment of certain types of edentulousand partially edentulous patients with dental implants. Sixtypes of patient treatments are featured. The treatmentsare illustrated with emphasis on diagnosis and treatmentplanning, restorative dentist/implant surgeon communica-tion and restorative treatments, on an appointment-by-appointment basis. Implant components are identified foreach specific appointment. Laboratory procedures and

work orders are also included. Implant loading protocolsare discussed for each particular case presentation.

The biologic and theoretical aspects of osseointegrationare not reviewed. Osseointegration is defined as clinicallyimmobile implants; absence of peri-implant radiolucenciesas assessed by an undistorted radiograph; mean verticalbone loss less than 0.2 mm annually after the first year ofocclusal function; absence of pain, discomfort and infection(Smith and Zarb 1989). Clinical verification of osseointegra-tion can be difficult at best. Some implants that have beenconsidered successful at the second surgical or impressionappointments have subsequently failed prior to or aftercompletion of the prosthetic portion of treatment. Zarb andSchmitt (1990) have found that “late failures” occurred 3.3%of the time in patients with mostly edentulous mandibles.Naert and Quirynen (1992) published a report that con-tained data from partially edentulous patients, maxillae andmandibles. They reported late failures of 2.5%. Late failuresare important to clinicians and patients because of theadditional expense and treatment that patients may elect toundergo in replacing prostheses on failed implants.

This text concentrates on how clinicians may successfullyincorporate implant restorative dentistry into their prac-tices. A team approach is emphasized among members ofthe implant team: restorative dentists, implant surgeons,dental laboratory technicians, dental assistants and officestaff. Appointment sequencing, laboratory work orders andfee determination for restorative dentists are also dis-cussed, including identification of fixed overhead, implantcomponents, laboratory costs and profit margins.

Clinicians have multiple implant systems to choose from.There are similarities and differences among systems,including but not limited to macroscopic surface morphol-ogy, implant/abutment connections, diameters, threadpitch, and screw hex/morphology. This textbook illustratesthe surgical and restorative components manufactured by3i ®, Implant Innovations, Inc., Palm Beach Gardens, FL.The author is not a representative of Implant Innovations,Inc., and purchased all the components that were used.The principles described in this textbook should be appli-cable to other implant manufacturers.

ECONOMICS OF IMPLANT DENTISTRY

One of the major reasons cited by general dentists relativeto including or excluding implant dentistry in their prac-tices is the cost involved in dental implant treatment.Levin has reported that more than 35% of patients referred

3

Chapter 1: Introduction to Implant Dentistry

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from general dentists to oral surgeons or periodontists forimplant dentistry never actually make the appointment(Levin 2004). He has recommended that financing beoffered to every implant patient because it is not knownwhich patients will require financing for treatment andwhich ones will not. Levin considered that financing was nolonger an option; it should be considered a necessity. Hereported that clients of The Levin Group significantlyincreased their levels of case acceptance by makingfinancing options available to patients.

Levin (2005) described a comprehensive approach todentistry that included four significant parts:

1. The comprehensive exam

2. Tooth-by-tooth exam

3. Cosmetic exam

4. Implant exam

Levin identified implant dentistry for his general practi-tioner clients as an enormous growth opportunity and alsostated that more than half of general dentists do not restorea single implant in any given year. Implant dentistry notonly improves the lives of patients but also can be a signif-icant profit center for dental practices. Because implantdentistry generally is not covered by dental insurance,Levin stated that implants should be viewed as an oppor-tunity to increase the elective portions of dental practices.

Implant treatment may be divided into treatment of partiallyedentulous and edentulous patients. Partially edentulouspatients may warrant treatment involving the replacementof one tooth or they may require replacement of multipleteeth (Table 1.1). Patients will frequently call for “compari-son shopping.” A common question is, “How much will animplant cost?” Patients may also request the costs of a sin-gle crown for comparison purposes. It is the responsibility

of the dental staff to make sure patients know that in orderto make fair comparisons, patients must compare the costsassociated with a 3-unit fixed partial denture (FPD) or simi-lar prosthesis to the costs of an implant retained restorationreplacing one tooth (Tables 1.2 and 1.3).

Implant dentistry should also be profitable for restorativedentists. Initially, as with other new technologies thatrequire the acquisition of learned, skilled behaviors,implant restorative dentistry may not be as profitable asother aspects of restorative dentistry. Restorative dentistsshould expect a learning curve relative to diagnosing;treatment planning and treatment in implant restorativedentistry. With practice and reasonable efforts on behalf ofthe dentist and staff, implant dentistry may become one ofthe most profitable aspects of general practice.

Predictability of Fixed Prosthodontics

The goal of prosthodontic treatment is to provide aestheticand functional replacements for missing teeth on a long-term basis. Clinicians would like to attain these goals withrestorations that have a predictable prognosis, minimalbiologic trauma and at reasonable cost. For the majority ofrestorative dentists, there are multiple advantages to con-ventional fixed prosthodontic therapy: familiarity with proto-cols, techniques, and materials. There are also multiplelimitations associated with conventional fixed prosthodon-tics: tooth preparation and soft tissue retraction, potentialpulpal involvement, recurrent caries, and periodontal dis-ease. Missing teeth may be predictably replaced with fixedpartial dentures, but there are increased stresses anddemands placed on the abutment teeth.

In 1990, more than four million fixed partial dentures wereplaced in the United States (ADA Survey, 1994). It may besurprising to note that there is little long-term research onthe longevity of these restorations, and comparisons

4 Implant Restorations

TABLE 1.1. Costs/Fees/Profits Associated with a 3-Unit Porcelain Fused-to-Metal Fixed Partial Denture (FPD)

Fixed LaboratoryChair Time Overhead Expenses Fees

Preparations Casts $ 50Impression Dies $ 25Provisional Restoration Articulation $ 251.75 hours $350/hr � $613 FPD $775

$875FPD Insertion.75 hours $350/hr � $263TOTALS $876 $ 875Professional Fee $2700Costs (fixed overhead and laboratory expenses) $1751Profit (fees less costs) $ 949Profit per hour ($949/2.5 hrs) $ 380

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TABLE 1.2. Costs/Fees/Profits Associated with an Implant-Retained Crown (Premachined Abutment/PFM Crown)

Fixed Laboratory FeesChair Time Overhead Expenses

Casts $ 45Impression Articulation $ 15

PFM crown $275Mill abutment $ 75

.5 hours $350/hr � $175 Sub Total $410

Implant ComponentsHealing abutment $ 36Impression Coping $ 45Analog $ 21Pre-machined abutment $ 90Lab screw $ 14Abutment Screw $ 54Sub Total $260

Crown Insertion.5 hours $350/hr � $175TOTALS $350 $ 670Professional Fee $1400Costs (fixed overhead and laboratory expenses) $1020Profit (fees less costs) $ 380Profit per hour ($380/1 hr) $ 380

Note: Because the profit per hour is equivalent to the 3-unit FPD but the clinical time required is significantly less,restorative dentists can be more profitable with implant dentistry by seeing more patients.

Healing abutments, impression copings, and lab screws may be used multiple times; therefore, costs will bedecreased for each succeeding case and profits will be increased. Analogs should not be re-used.

between studies cannot be easily accomplished due to thelack of established parameters (Mazurat 1992). Authorshave reported on the failure rates of FPDs over time, butthe definitions of failures are inconsistent: recurrent caries,fractured porcelain, broken rigid connectors, loss of peri-odontal attachment (Schwartz and Whitsett 1970; Reuterand Brose 1984; Walton, Gardner, and Agar 1986; Foster1990; Randow and Glantz 1993).

Fixed partial dentures have documented long-term suc-cess. Scurria (1998) performed a meta-analysis of multiplepublished studies and documented success rates as highas 92% at 10 years and 75% at 15 years. Other authorshave recorded failure rates of 30% or more for FPDs at 15–20 years (Lindquist and Karlsson 1998). A key point thatshould be recognized from these reports is that it is impor-tant for clinicians to realize that for younger patients, fixed

Chapter 1: Introduction to Implant Dentistry 5

TABLE 1.3. Comparison of Costs, Fees, and Profits Per Hour for 3-Unit FPD versus Single-Unit Implant-Retained Crown

LaboratoryAnd Implant

Fixed ComponentsOverhead Costs Fees Profit/HR

3-Unit FPD $876 $875 $2700 $380ImplantRestoration $350 $275 $1400 $380

Note: Implant-retained crown needs to be compared to the costs for a 3-unit FPD in order to accurately comparethe costs associated with replacing a single missing tooth.

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partial dentures may need to be replaced 2–3 times duringtheir lifetimes.

In a concise literature review, Priest (1996) reviewed multi-ple papers to compare the efficacy of implant-retainedcrowns and conventional fixed partial dentures over time.He found that although FPDs were assumed to demon-strate predictable longevity, failure rates have beenreported from 20% over a three-year time, to 3% failuresover 23 years. Implant longevity, on the other hand,appears to be more promising and generally displaysmore narrow ranges of failures: 9% over three years to 0%over 6.6 years. Priest cautioned that failure rates for FPDsand implant-retained crowns cannot be easily comparedamong studies because parameters had not been estab-lished and that replacing missing teeth is a complex issue.There is sufficient data for single-tooth implant retainedrestorations to be used as a functional and biologicmethod for satisfactory tooth replacement.

DEVELOPMENT OF PROGNOSIS FOR TEETH:EXTRACT OR MAINTAIN

A question often asked by clinicians and patients relates tothe viability and prognosis of maintaining compromisedteeth. Even with the advances in implant dentistry since the1970s, the predictability of implants is still not 100%.Therefore, it may still be difficult to recommend the extrac-tion of a tooth with a compromised prognosis and replace itwith a dental implant. The American Academy of Periodon-tology’s position paper on dental implants stated that allpatients should be informed as to the risks and benefits ofimplant and alternative treatment prior to implant place-ment and restoration (AAP Position Paper 2000).

O’Neal and Butler discussed the clinical and economicfactors that clinicians should consider in making decisionsrelative to extraction and implant placement versus reten-tion of compromised teeth (O’Neal and Buler 2002). Theydivided the clinical issues into four basic categories:

1. The heavily restored tooth

2. The furcation-involved tooth

3. The periodontal-prosthesis patient

4. Difficult aesthetic cases

The Heavily Restored Tooth

This type of tooth may have been damaged as a result ofblunt trauma, dental caries, or multiple dental restorations(Figure 1.1). In Figure 1.1, this mandibular molar has beentreated endodontically and had moderate bone loss anddental caries. The long-term prognosis for this tooth wouldbe poor if used as the distal abutment for a 3-unit fixed par-tial denture. The treatment choices for this patient couldinclude a mesial root amputation, osseous surgery and a


Figure 1.1. Radiograph of mandibular molar that may be considered foruse as the distal abutment for a 3-unit FPD. It has been treatedendodontically and restored with a crown. There are recurrent cariesbeneath the mesial margin.

Figure 1.2. Clinical view of implant-retained crowns replacing themandibular right second premolar and first molar.

Figure 1.3. Radiograph of a maxillary lateral incisor with previousendodontic therapy. The post retained the crown.

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new 3-unit FPD. Or, the tooth could be extracted, thesocket grafted with bone or a bone substitute, and theextraction site allowed to heal prior to placing an implantand implant restoration (Figure 1.2). The prognosis for thelatter choice is much better and may be more conservativethan the first treatment option.

The clinical condition exemplified by Figure 1.3 is also fre-quently encountered in clinical practice: an incompletelyfractured tooth with previous endodontic therapy where thecrown was held in place by a post. Numerous authors havesuggested that the axial walls of tooth preparations forendodontically treated teeth should include at least 1 mmof dentin in order to provide the requisite ferrule effectneeded for predictable retention for the crown, even in thepresence of a post (Fan, Nicholls and Kois 1995; Libmanand Nicholls 1995; Sorenson and Engelman 1990). Crownlengthening procedures can be accomplished in order toobtain greater access to dentin for increased retention ofthe crown, but the surgery is associated with moderate tosignificant surgical morbidity and is accomplished at theexpense of the supporting bone.

The Furcation Involved Tooth

Posterior teeth with advanced bone loss are the most com-monly lost teeth. Hirschfeld studied natural teeth over a 22-year period and found that 31.4% of molars and 4.9% ofsingle rooted teeth were lost (Hirschfeld and Wasserman1978). Therefore, decisions to retain or extract posteriorteeth generally involve molars. Both maxillary andmandibular molar teeth exhibit concavities associated withmultiple roots. The anatomy may also be compromisedwith recurrent caries and lateral canals. In Figure 1.4, themandibular right first molar has had previous endodontictherapy, advanced bone loss around both roots and in thefurcation, mobility, and was uncomfortable for the patient.The patient’s chief complaint was related to the discomfortthat she was feeling anytime she attempted to chew on theright side. Yet she did not feel that she wanted to have this


Figure 1.4. Radiograph of mandibular right posterior segment thatdemonstrates advanced bone loss around the first molar. This tooth wasa poor candidate for root resection and an abutment for a 3-unit FPD.

tooth extracted. Even with a root resection, this tooth had apoor prognosis as an abutment for an FPD. A more appro-priate choice would be extraction, grafting, and placementof one implant to replace the missing molar.

The most common causes of failure in posterior, furcation-involved teeth have been reported to be recurrent cariesand endodontic failure (Buhler 1994). When clinical suc-cess is likely, root resection procedures can be clinicallyand financially sound. In Figures 1.5–1.7, compromised

Figure 1.5. Radiograph after endodontic therapy for the mandibularright first and second molars prior to resection of the second molar’smesial root.

Figure 1.6. Mandibular FPD cemented in place.

Figure 1.7. Radiograph at FPD try-in appointment, post extraction ofthe mesial root of the mandibular second molar.

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mandibular molars were treated with endodontic therapy,posts, root resections and a fixed periodontal splint. Thepostoperative radiograph was taken 15 years after theprosthesis was inserted. This treatment can be consideredan unqualified success.

The Periodontal Prosthesis Patient

Dentistry has witnessed tremendous advances in treat-ment alternatives for the severely compromised dentition.In the 1960s and 1970s these advances resulted in the sal-vaging of many teeth that were formerly extracted (Yalisoveand Dietz 1977). Conventional fixed and removableprosthodontic treatments were not applicable to treatseverely compromised dentitions, especially in cases in


Figure 1.8. Pre-operative anterior view of centric occlusion.

Figure 1.9. Pre-operative panoramic radiograph.

Figure 1.10. Pre-operative diagnostic articulator mounting. Verticaldimension of occlusion has not been changed.

Figure 1.11. Diagnostic wax patterns; incisal plane of mandibular teethhas been modified.

which there were multiple missing teeth and moderate toadvanced bone loss. Amsterdam defined the sophisti-cated dental therapy to treat such patients as periodontalprosthesis (Amsterdam 1974). Periodontal prosthesis isthe treatment required to stabilize and retain dentitions thathave been weakened by the loss of alveolar bone and mul-tiple teeth. In the past, periodontal prostheses were the pri-mary means to treat these debilitated dentitions. Today theuse of dental implants has decreased the frequency forthese complex patients to be treated with periodontal pros-thesis (Nevins 1993).

This patient presented to the author in 1988 with multiplemissing teeth, an end-to-end dental occlusion, moderateto advanced bone loss, and a severe gag reflex (Figure

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in conjunction with the maxillary reconstruction and themandibular teeth were restored with individual crownrestorations.

The patient functioned comfortably for several years andthen presented with a problem with the maxillary rightcanine eight years post insertion. (Figure 1.15) This toothwas diagnosed as having a combined periodontal/endodontic lesion. The periodontal prosthesis was tappedoff and the cuspid was extracted. The periodontal prosthe-sis was re-cemented and remained in place for an addi-tional eight years (the last recall appointment). Note theamount of residual ridge resorption gingival to the cuspidpontic (Figure 1.16).


Figure 1.12. Clinical anterior view with maxillary copings in place.

Figure 1.13. Periodontal prosthesis in place at insertion.

Figure 1.14. Post-operative panoramic radiograph.

1.8). Treatment consisted of thorough radiographic andphysical examinations (Figure 1.9). The treatment plancalled for diagnostic articulator mountings (Figure 1.10),diagnostic wax patterns (Figure 1.11), extraction of severalhopeless teeth, periodontal osseous and soft tissue sur-gery, and a maxillary periodontal prosthesis (Figures 1.12,1.13, 1.14). The mandibular incisal plane was recontoured

Figure 1.15. Clinical anterior view eight years post insertion. Maxillaryright cuspid needed to be extracted secondary to a combined periodontal/endodontic lesion.

Figure 1.16. Clinical left lateral view two years post extraction of maxil-lary right cuspid (10 years post insertion of original prosthesis). Note theamount of alveolar ridge resorption gingival to the cuspid pontic.

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implant restorationshe has had a practice limited to ﬁxed, removable, and implant prosthodontics...

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