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DENTAL IMPLANT CLINICAL INNOVATIONS

J Oral Maxillofac Surg


62:2-16, 2004, Suppl 2
Fixed Partial Denture or Single-Tooth
Implant Restoration? Statistical
Considerations for Sequencing
and Treatment
Thomas J. Salinas, DDS,* Michael S. Block, DMD, and Avishai Sadan, DMD
The choice to replace a single missing tooth can be based on the primary decision that the restorability
of the tooth is in doubt. Many teeth are decimated by incipient or recurrent caries, trauma, endodontic
complications, or periodontal disease which requires extraction. It is our objective to familiarize the
participant with literature comparing success rates of xed partial dentures and single-tooth implant
restorations and a repertoire of prosthodontic techniques used in replacement of single missing teeth
with osseointegrated dental implants. The xed partial denture (FPD) has been regarded as the standard
of care for some time in replacement of single and multiple missing teeth. Many studies surveying long
term survival have been compiled and analyzed to arrive at a generalized outcome. Most of these studies
arrive at common conclusions. Studies surveying success of single-tooth implant-supported restorations
are not comparably abundant nor survey for comparable time as those for FPDs. Although, many of the
outcomes are statistical survival estimates such as Kaplan-Meier survival tables, implant restorations in
partially dentate patients are a predictable means of tooth replacement. There are certain factors which
make FPD more appropriate and conversely factors which make an implant restoration more appropri-
ate. Indications and contraindications for each treatment scenario will also be reviewed based on the
literature and clinical experience. It is hoped that the practitioner will be able to appropriately identify
those cases in which either an FPD or an implant restoration is the appropriate treatment option.
2004 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 62:2-16, 2004, Suppl 2
The choice to replace a single missing tooth can be
based on the primary decision that the restorability of
the tooth is in doubt. Many teeth are decimated by
incipient or recurrent caries (Fig 1), trauma (Fig 2),
endodontic complications (Fig 3), or periodontal dis-
ease that requires extraction. It is not the scope of this
article to aid in this decision, rather to familiarize the
reader with literature reviewing success rates of xed
partial dentures (FPDs) and single-tooth implant res-
torations and a repertoire of prosthodontic tech-
niques used in the replacement of single missing teeth
with osseointegrated dental implants.
Fixed Partial Denture Success
The FPD has been regarded as the standard of care
for some time in the replacement of single and mul-
tiple missing teeth. However, to obtain optimal func-
tional and aesthetic results for full-veneer FPDs, a
signicant reduction in the amount of tooth structure
is necessary occasionally predisposing to endodontic,
periodontal, and structural complications (Fig 4).
Many studies surveying long-term survival have been
compiled and analyzed to arrive at a generalized out-
come. Creugers et als
1
study was inclusive of 26
studies that followed multi-unit xed replacements
for 15 years. A literature search was performed on
the dental literature from 1970 to 1994, presenting
clinical data of conventional bridges. Forty-two pub-
*Assistant Professor, Department of Otolaryngology, The Univer-
sity of Nebraska Medical Center, Omaha, NE.
Professor, Department of Oral and Maxillofacial Surgery, Loui-
siana State University Health Science Center, School of Dentistry,
New Orleans, LA.
Associate Professor and Chairman, Department for the Practice
of General Dentistry, School of Dental Medicine, Case University,
Cleveland, OH.
Address correspondence and reprint requests to Dr Salinas:
Department of Otolaryngology, The University of Nebraska Medical
Center, 981225 Nebraska Medical Center, Omaha, NE 68198-1225;
e-mail: tsalinas@unmc.edu
2004 American Association of Oral and Maxillofacial Surgeons
0278-2391/04/6209-0205$30.00/0
doi:10.1016/j.joms.2004.06.001
2
lications were found that contained durability data of
conventional xed bridges. These publications dealt
with 33 different samples. According to the exclusion
criteria, 26 studies were excluded for the meta-analy-
sis and the remaining data of 4,118 conventional
bridges were analyzed. The denition of failure in this
compilation meant that the bridge was not present or
for any reason a remake was required. Meta-analysis is
a statistical method that identies trends in multiple
studies arriving at a common conclusion. This can be
especially useful when predicting outcomes of proce-
dures that have only been performed for a short
period of time. With studies that are few and follow
up-periods limited, performing a statistical analysis
and arriving at clinically relevant conclusions may be
better achieved by combining them for meta-analysis.
The calculated overall survival rate in this study was
90% after 10 years and 74.0 2.1% after 15 years.
Criticism of this study would indicate the lack of
dening what survival meant. Any misclassication of
failure could lead to an overestimate or underestimate
of FPD survival.
Scurrias Medline search
2
incorporated all studies
published in English from 1966 to 1996 and evaluated
8 studies by Kaplan-Meier modeling to calculate sur-
vival probability and combined the proportions
through meta-analysis. Less than 15% of FPDs were
removed or in need of replacement at 10 years. At 15
years, the statistics changed dramatically in that
nearly one third were removed or in need of replace-
ment. This equates to FPD removal as failure, 92%
success at 10 years and 75% success at 15 years. This
study almost duplicates the Creugers et al study
1
4
FIGURE 1. Caries extending subgingivally below the level of alveolar
bone may frequently necessitate removal based on lack of adequate
tooth structure for creation of ferrule effect.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant
Restoration. J Oral Maxillofac Surg 2004.
FIGURE 2. Traumatic fracture of both central incisors may necessitate
removal of teeth in instances where root length is insufcient for
orthodontic extrusion.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant
Restoration. J Oral Maxillofac Surg 2004.
FIGURE 3. Residual periapical pathology that is unresolved despite
efforts at nonsurgical and surgical endodontics.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant
Restoration. J Oral Maxillofac Surg 2004.
FIGURE 4. Full veneer preparation for FPD. Required reduction may
predispose abutment teeth to endodontic complications and subse-
quent failure by recurrent caries.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant
Restoration. J Oral Maxillofac Surg 2004.
SALINAS, BLOCK, AND SADAN 3
years previous, although different exclusion criteria
resulted in different studies surveyed. When failure
was dened as FPD removal, 92% and 75% of the FPDs
were estimated to survive at 10 and 15 years, respec-
tively.
When a broader denition of failure was used,
namely, combining FPDs removed with those that tech-
nically failed and needed replacement, 87% and 69%
were estimated to survive at 10 and 15 years, respec-
tively. Walton
3
looked at 515 metal ceramic FPDs longi-
tudinally for 15 years and reported similar survival rates.
Factors that predisposed complications included nonvi-
tal anterior abutments and pier abutments.
It is generally accepted that FPD survival is approx-
imately 87% at 10 years, dropping to 69% at 15 years.
General indications for an FPD would be consider-
ations for replacement of a single or 2 missing teeth
by support of abutment teeth with equal or greater
root surface area (Antes law
4
). Fixed partial dentures
are applicable to most situations where abutment
crown-to-root ratio is less than 1:1.
5
General contraindications to the use of FPD would
be where more than 1:1 crown-to-root ratio of abut-
ment exists, excessive mobility of the abutment(s),
and cantilevered designs on incisor teeth. Based on
the literature review, it is noted that endodontically
treated anterior teeth are predisposed to long-term
failure as FPD abutments, as are pier abutments. Ad-
ditionally, prospective abutment teeth that were sub-
ject to luxation or avulsion injuries are at signicant
risk for resorption.
6-8
Likewise, teeth that are pulp
capped are at high risk for requiring endodontic treat-
ment and make poor choices for abutment teeth be-
cause endodontic treatment would remove the tooth
structure necessary for long-term stability of an FPD.
Single-Tooth Implant Success
Studies surveying success of single-tooth implant-
supported restorations are not comparably abundant
nor survey for comparable time as those for FPDs.
Although, many of the outcomes are statistical sur-
vival estimates, such as Kaplan-Meier survival tables,
implant restorations in partially dentate patients are a
predictable means of tooth replacement. Lindh et al
9
searched the English literature between 1986 and
1996 and retrieved 66 studies of single and multiple
tooth implant-supported restorations. Inclusion crite-
ria applied were threaded cylindrical metallic in-
traosseous implants and minimum follow-up period
for 1 year of loading. Implant failure was dened and
cumulative survival rate calculated. Nine studies con-
taining 570 implant-supported single teeth t the cri-
teria for meta-analysis. The survival rate for single
crowns was in the high ninetieth percentile, with the
exception of 1 study by Jemt et al,
10
where the sur-
vival rate was 91.3% after 3 years. It could be argued
that the failure rate in this study can be correlated to
undeveloped prosthetic components for single-tooth
replacement. Another study, by Buser et al,
11
re-
viewed a mix of single-tooth and free-standing FPD
prostheses supported by ITI implants (Straumann
USA, Waltham, MA) installed as a 1-stage protocol.
This showed similar results in all of the other Brne-
mark studies. Of the 9 studies, 5 were prospective and
4 were retrospective. There was no signicant differ-
ence in cumulative survival between the groups (98.0
vs 97.0). These studies reect most failures occurring
during the rst year of service.
Eckert and Wollan
12
reviewed 1,170 implants in the
partially dentate arch for which the cumulative sur-
vival rates were based on 4 divisions of the oral cavity
into the anterior/posterior mandible and maxilla. The
cumulative 10-year survival in all but posterior man-
dible was in the mid to high 90s percent. Cement-
retained restorations were included in the study and
had cement failures at 5 years of 22.5%. What is noted
to be of signicance with this report is identifying a
reference date of June 1, 1991. Prosthetic compo-
nents were improved after this time, and this study
reects a statistically signicant improvement of im-
plant survival for combined maxillary and mandibular
posterior implants. The relative risk for implants
placed and restored before June 1991 indicates that
major complications occur 2.096 times as frequently
with older prosthetic components than with the
newer components (P .0110). Reduction in screw
loosening decreased from more than 46% to 3.2%
after abutment screw redesign.
Another comprehensive literature review by Good-
acre et al
13
and colleagues compiled all available stud-
ies from 1981 to 1997 published in English. It re-
ported types of complications related to types of
prosthesis, arch, time, implant length, and bone qual-
ity. In comparison to other prosthetic designs, im-
plant single crowns had the lowest failure rate at
2.7%. The types of studies related to follow-up of
implants supporting crowns that were placed and
lost, and time of loss were limited to 4 combined
studies; 3.6% were lost postprosthetically. (Implant
loss in the second year was signicantly lower than
the rst year, as was the third year.) Although the
article cited single-tooth restorations as having com-
plications of prosthetic/abutment screw loosening
prevalent in the premolar and molar area, many of the
early studies used abutment screws made of titanium;
the change to gold alloy screws and the use of
counter torque devices made the incidence of this
problem much less.
Naert et als study
14
was aimed at surveying the
success of the implant, prosthesis, and biologic out-
come (bone levels). The study was 12 years long and
4 FPD VERSUS SINGLE TOOTH IMPLANT RESTORATION
varied in its length of time of assessment. The major-
ity of failures occurred at stage II or within 6 months.
The cumulative success for the implants was 93%.
The prostheses survival was 96.5% over the 11-year
period. The rst 6 months after abutment connection
resulted in a 0.71 mm bone loss to an annual of
0.036 mm over the remaining 10-year period.
Treatment of partially dentate patients with osseointe-
grated implants has comparably limited data, but these
preliminary estimates show that success rates for single-
tooth implant-supported restorations approach the high
90th percent at 8 to 10 years. This assumes the implant
integrates and what is quoted is inclusive of prosthetic
complications of abutment/coping screw loosening and
porcelain fracture.
15
In the case of osseointegration fail-
ure, limited to no detrimental effect would be encoun-
tered with abutment teeth as opposed to failure of a
FPD. Comparing these scenarios may encompass either
retreatment with an implant restoration or with a FPD.
Implant restorations, therefore, offer a distinct predict-
able advantage over FPDs for replacement of single
missing teeth.
General indications for the use of an implant-sup-
ported restoration would predicate rst on the con-
dition of the abutment teeth. Abutment teeth without
restoration or the need for restoration, abutment
teeth with large pulp chambers, are better left free of
coverage because long-term success is at risk as cited
previously. Nonvital abutment teeth, abutment teeth
with a history of avulsion or luxation, and abutment
teeth that are prospective pier abutments for either
xed or removable partial dentures are all high risk
for FPD failure long-term and point to the alternative
of implant restorations for better outcome. The con-
dition of the implant site may also give indication
whether an implant restoration is the correct choice.
The prospective implant site should possess a full
complement of bone and soft tissue in the implant
site or the potential to create it, minimum restorative
and surgical mesiodistal dimension of 6 mm, mini-
mum vertical surgical dimension of 10 to 12 mm of
bone, and available restorative dimension to provide
prosthetic material for aesthetics and occlusal func-
tion. Secondary indications for implant restorations
are patients who desire a restoration similar to natural
tooth aesthetics that facilitate regular hygiene proce-
dures.
Contraindications for the use of an implant restora-
tion are in developing patients (particularly in the max-
illa, where vertical growth continues after permanent
teeth are fully erupted), uncontrolled periodontal dis-
ease, aesthetic areas with thin, highly scalloped gingiva,
adjacent periapical pathology, and nonmotivated pa-
tients. Relative contraindications where adjacent root
aring precludes placement (correction needed with
orthodontics), smokers (increased failure rate especially
in type IV bone),
16,17
connective tissue diseases,
18
and
diabetes and autoimmune diseases.
19,20
Treatment Planning
Primary selection of appropriate single missing
tooth cases begins with a thorough clinical examina-
tion to include adequate quantity and quality of hard
and soft tissue. This requires an adequate band of
keratinized tissue where peri-implant tissues are to be
located. Specically, 3 to 5 mm of keratinized tissue
to the facial and lingual aids in hygiene procedures
and is easily maintained (Fig 5). Also, mesiodistal
prosthetic (proximal contacts) spacing of at least 6
mm for most missing teeth is appropriate for installa-
tion of standard implant diameter unless mandibular
incisors or maxillary lateral incisors are being re-
placed. The surgical distance can be calculated from
periapical radiographs and may be tailored more ap-
propriately to modern tapered implant designs (Fig
6). Vertical restorative space should also be assessed
for proper restorative height. This is best completed
with a diagnostic wax-up, which will help aid in the
design of the nal prosthesis. In general, screw-re-
tained restorations will be of aid in those spaces that
are constricted in vertical height (less than 6 mm).
When these dimensions are not available, it occasion-
ally becomes necessary to treat the adjacent or oppos-
ing dentition with orthodontics or restorative den-
tistry to optimize the treatment outcome. Periodontal
biotyping is also of prime importance because many
of those cases with missing teeth in the aesthetic zone
become challenging when the teeth take on a tapered
form and the corresponding gingiva is highly scal-
loped (Fig 7). In these cases, there is a signicant
difference in the attachment height between the in-
FIGURE 5. Presurgical assessment begins with the inspection of soft
tissues. Adequate band of keratinized mucosa is essential.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant
Restoration. J Oral Maxillofac Surg 2004.
SALINAS, BLOCK, AND SADAN 5
terproximal and facial areas. Therefore, minimal insult
to the adjacent periodontium becomes critical when
selecting the vertical placement of the implant plat-
form.
RADIOGRAPHS
A standard radiographic survey starts with periapi-
cal radiographs to appreciate the periodontal health
of the adjacent dentition. The periodontal biology of
surrounding teeth is a critical factor of success be-
cause the interproximal bone is largely maintained by
the neighboring teeth. Root inclination is better ap-
preciated from a periapical lm to ascertain if the site
can accommodate installation of an implant. Pan-
oramic radiographs are also helpful to determine
placement height over a mandibular canal, nasal oor,
or sinus oor (Fig 8). Magnication on or about 25% is
typical to interpolate these measurements to actual
magnitude. More specic methods of calculating this
magnication mandates the use of radio-opaque ob-
jects known to size incorporated into the lm (Fig 9).
IMPLANT SELECTION
Philosophies of treating partially dentate patients
have changed signicantly over the last several years.
Tapered implants afford greater stability in relatively
porous bone allowing more 1-stage or immediate-
loading treatment options. These contemporary de-
signs also incorporate restorative hardware conducive
to treating these cases aesthetically with immediate
restoration or 1-staged procedures. Internal connec-
tion type implants also offer an advantage of less
FIGURE 6. Presurgical planning of extraction of tooth #7 (nonrestor-
able) and immediate replacement with tapered implant.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant
Restoration. J Oral Maxillofac Surg 2004.
FIGURE 7. Thin scalloped gingiva that may create difculties related
to tissue migration. Note the signicant differences in height between
papilla and facial gingiva.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant
Restoration. J Oral Maxillofac Surg 2004.
FIGURE 8. Panorex indicating positions of inferior alveolar canals.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant
Restoration. J Oral Maxillofac Surg 2004.
6 FPD VERSUS SINGLE TOOTH IMPLANT RESTORATION
stress to the abutment screw and reduced vertical
space requirement for restorative hardware. Two-
staged procedures have excellent data, and although
they are more difcult to re-establish soft tissue, are
better suited in cases with difcult-to-control occlu-
sion. Therefore, the choice of using a 1- or 2-staged
approach with a standard external hexed implant
versus tapered-screw design with internal connection
rests with the preference of the treating team.
Surgical Considerations
Optimal spatial location for an osseointegrated im-
plant is based on several biologic principles. First,
peri-implant biology is similar to natural teeth
21
in
that standard biologic height is commonly found.
22
In
general, vertical placement of the implant platform
should not exceed 3.5 to 4 mm apical to the adjacent
gingival margins. The horizontal distance that an im-
plant assumes from the adjacent tooth should approx-
imate 2 mm to preserve the viability of bone.
23
These
guidelines serve as general suggestions; in some cases
where a thin scalloped periodontal biotype is present,
recession of soft tissues and resorption of bone be-
comes an even greater concern. In these cases, inter-
disciplinary consulting with orthodontics and peri-
odontal grafting may be deemed appropriate. Surgical
stents made of thermoplastic vacuform material
(.04-inch thickness) are especially useful for aiding
placement of the implant (Fig 10). These stents are
cost-effective, easily made, and require minimal to no
adjustment for proper tting. They should convey 2
main pieces of information: the occlusal/incisal plane
and cervical margin. When bone grafting is concom-
itantly performed with implant placement, these
stents also serve well to provide a tooth-supported
tooth replacement without mobilizing bone graft ma-
terials. Soft tissue grafts may be used in the interim
phase between placement and uncovering. These can
be taken from the posterior hard palate from subcu-
taneous tissue.
Prosthetic Considerations
Implant restorations for single teeth in the aes-
thetic zone can be a challenge to maintain soft-
tissue position and contour. It is generally accepted
that bone loss occurs around implants in the rst 18
months under Albreksstons criteria of success.
24
As a result of this bone loss, soft tissues follow the
change in topography and may expose either the
restorative components and/or the implant body.
Anticipating this loss in the aesthetic zone may
dictate specically locating the implant strategically
in the connes of peri-implant biology as well as
camouaging restorative components by using ce-
ramic materials.
The 2 major designs of single-tooth implant resto-
rations are cemented or screw-retained. A combina-
tion of both designs, screwmented, may be used in
cases where angle correction is needed and specic
retention to the abutment is achieved by custom
screw retention in an orientation different than the
implant long axis (Fig 11).
25
This alternative design is
used in gold or porcelain fused to metal restorations
only. Cemented-designed restorations are often indi-
cated where angle correction is needed from the
implant axis relative to the tooth long axis. This is
frequently seen in the maxillary anterior area, where
orientation of greatest bone is disparate from the long
axis of the teeth. Cemented-designed prostheses for
anterior teeth mandate placement of the long axis
through the palatal aspect of the incisal edge. For
posterior restorations, the long axis should be aimed
through the center of the occlusal table. A cemented
design incorporates the use of an abutment with a
FIGURE 9. Panorex with stainless steel shots indicating that the
magnication factor is present.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant
Restoration. J Oral Maxillofac Surg 2004.
FIGURE 10. Surgical stent made from a .04 inch vacuform material
is self-retained during the surgical procedure.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant
Restoration. J Oral Maxillofac Surg 2004.
SALINAS, BLOCK, AND SADAN 7
total occlusal convergence of 6, similar to standard
tooth preparation. This abutment may be made of 3
main materials: titanium, cast gold alloy, or high-
strength ceramics (alumina, zirconium) (Fig 12). Al-
though titanium has a predictable biologic attach-
ment,
26
its use in the aesthetic zone may be
problematic as a grey sheen can be appreciated
through thin gingiva. In these cases, the use of high-
strength ceramics affords better opportunity for ac-
ceptable aesthetic outcomes and location of the re-
storative interface.
Screw-retained designs start with meticulous place-
ment of the implant axis through a specied area of
the restoration. In anterior teeth, this mandates place-
FIGURE 11. A, Cast gold abutments with tube and screw attachment for the screwmented design. B, Porcelain fused to metal crowns to be
cemented and screwed in place for retention.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant Restoration. J Oral Maxillofac Surg 2004.
FIGURE 12. A,Titanium abutment of the standard stock design. B,
Porcelain-fused metal abutment camouaged with gingival porcelain.
C, Zirconium abutment used for cemented restoration.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant
Restoration. J Oral Maxillofac Surg 2004.
8 FPD VERSUS SINGLE TOOTH IMPLANT RESTORATION
ment through the cingulum area for concealment of
the access channel. Secondly, the use of a prema-
chined abutment may be preferable in cases where
the biologic height exceeds 3 mm. It is the preference
of the author to make screw-retained restorations
single piece, which allows simplicity of placement
and retrieval, if necessary. Screw-retained restoration
offers distinct advantages over cemented restorations
in that cement retrieval is avoided, subgingival emer-
gence with porcelain is predictable, and retrieving
the restoration is also very predictable. Posterior res-
torations, if planned well, can be exclusively screw-
retained, allowing more versatility and retreivability.
ONE STAGE
One-stage placement of the implant may be prefer-
able either some time after tooth extraction or the
same day of tooth extraction. With the 1-stage ap-
proach, the decision to place a provisional restoration
may be based on primary stability of the implant and
the ability to properly control occlusion. Usually, the
decision of placing a restoration on a 1-stage implant
is associated with single missing teeth in the aesthetic
zone (Fig 13). Otherwise there is limited reasoning for
providing a provisional restoration unless the opera-
tor wishes to transitionally load the implant or form
soft tissues from the time of implant placement, sim-
plifying impression procedures for the denitive res-
toration at a later time. If the implant is placed in a
nonaesthetically critical area, it is merely a matter of
placing a gingival healing abutment and closing tissue
around it.
Suggested protocol for making a provisional resto-
ration with 1-stage implant placement may be accom-
plished in 1 of 3 routes:
1. Fabrication of the provisional by mock place-
ment of an implant in a diagnostic cast.
2. Fabrication of the provisional/abutment chair-
side after implant placement (Fig 14).
3. Impression of the implant after placement and
fabrication in the laboratory with delivery the
same day or a short time thereafter.
TWO STAGE
Usually, 2-stage surgical protocol of implant resto-
ration may allow either the use or not of a provisional
restoration. Provisional restorations are indicated in
several clinical circumstances:
1. Where a cemented restoration will be used in
the aesthetic zone.
2. Where screw-retained restorations will be used
in the aesthetic zone.
3. Where soft-tissue proles are in need of re-
establishment.
4. Where orthodontic anchorage is needed for re-
establishment of space.
Suggested protocol for making a provisional resto-
ration with 2-stage implant placement may be accom-
plished in 1 of 3 routes:
1. Fabrication of the provisional on a modied
diagnostic cast created from a surgical index of
the implant at stage I (Fig 15).
2. Fabrication of the provisional from a xture-
level impression of the implant.
3. Fabrication of the provisional chair-side with
restorative components (Fig 16).
FIGURE 13. A, Implant placed in the patient shown in Figure 6 with abutment attached the same day of extraction. B, Immediate provisional
restoration inserted on provisional abutment.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant Restoration. J Oral Maxillofac Surg 2004.
SALINAS, BLOCK, AND SADAN 9
Impression Procedures
After soft tissues have been formed, adequate time
should transpire before impression procedures are
begun. If a cemented restoration will be made, it is
very important to know the exact soft tissue margin
so that the proper level of prosthesis/abutment con-
nection is created at the appropriate level. The prac-
titioner has the choice at this point to decide if a
FIGURE 14. A, Insertion of a screw-type implant into site 8. B, Preparation of the abutment under copious irrigation. C, Insertion of the prepared
ceramic abutment on the implant platform. D, Suturing of peri-implant tissues around the cemented provisional created chair-side.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant Restoration. J Oral Maxillofac Surg 2004.
FIGURE 15. A, Surgical index of the implant platform created by impression coping. Note that care is taken to avoid extending the acrylic under
height of contour. B, Modication of the diagnostic cast to receive the implant analog. The void will be lled in with stone and creation of the
abutment/provisional can be completed in the laboratory.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant Restoration. J Oral Maxillofac Surg 2004.
10 FPD VERSUS SINGLE TOOTH IMPLANT RESTORATION
direct or indirect approach is preferable for fabrica-
tion.
The direct impression uses conventional crown
and bridge procedures with gentle cord packing and
elastomeric impression material (Fig 17). This tech-
nique is preferable with white or high-strength ce-
ramic abutments because the nish line for these
abutments is similar to that of porcelain veneers and
FIGURE 16. A, Punch uncovering of a previously placed implant. B, Modication to the titanium abutment. C, Centric stop and denture tooth facing
created from auto-polymerizing acrylic resin. D, Placement of temporary to start formation of soft tissues to the ideal contour.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant Restoration. J Oral Maxillofac Surg 2004.
FIGURE 17. A, Patient depicted in Figure 14 where soft tissues have healed to allow direct impression of the abutment with retraction cord and
regular crown and bridge technique. B, Final result of the alumina core restoration cemented onto the alumina abutment.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant Restoration. J Oral Maxillofac Surg 2004.
SALINAS, BLOCK, AND SADAN 11
may be placed at or slightly below the free gingival
margin. There are distinct advantages to the use of
this technique because no additional components
other than the abutment itself are needed to complete
the restoration. Therefore, only 1 abutment is needed,
unlike the indirect procedure, which uses both pro-
visional and denitive abutments. A disadvantage to
the technique may be leaving impression material
around the abutment without directly visualizing it.
Meticulous inspection after the impression is sug-
gested to minimize soft tissue reaction.
The indirect impression procedure (also known as
a xture level transfer) incorporates the use of com-
ponents to transfer the position of the implant plat-
form (Fig 18). This may use the provisional restora-
tion/abutment or a customized impression post.
27
A
way of customizing the impression post is to use a
owable composite resin into the sulcus shortly after
removal of the provisional restoration and abutment.
If the restoration is screw-retained, an extended-
length screw from the impression post can be used
and a pick-up impression made to transfer both im-
plant position and soft tissue prole (Fig 19). The goal
is to make a soft tissue master cast that duplicates the
soft tissue proles and implant position in the mouth.
The advantage to this technique is to clearly visualize
the implant platform and soft tissue architecture, al-
lowing planning of where to establish the prosthesis/
abutment margin. Also, the prosthesis can be fabri-
cated directly on the abutment ensuring an intimate
t between the abutment and prosthesis. If a screw-
retained restoration will be fabricated, subtle contour
changes can be incorporated to reshape the surround-
ing gingiva.
Delivery Procedures
The rst procedures to take place at the delivery
appointment involve removal of the provisional
and/or abutment with careful inspection to eradicate
any residual debris from the gingival area. Second, if a
cemented design is used, a placement jig can be
benecial to facilitate placement of the abutment in
the correct position (Fig 20). After the abutment has
been placed, it should be secured with an abutment
screw by hand-tightening only at this point. A radio-
FIGURE 18. A, Soft tissues formed by the provisional to ideal contour. B, Provisional and abutment are removed and impression post inserted for
modication by owable composite. C, Soft tissue cast created from xture level impression. Components are selected in the laboratory and
restoration made on the abutment. D, The nal all-ceramic restoration is cemented to the alumina abutment.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant Restoration. J Oral Maxillofac Surg 2004.
12 FPD VERSUS SINGLE TOOTH IMPLANT RESTORATION
graph should be made with the incident beam per-
pendicular to the long axis of the implant. After com-
plete seating is afrmed, trial insertion of the crown
should be accomplished in the usual fashion by prox-
imal contact adjustment with subsequent occlusal
correction (Fig 21). An additional radiograph can be
made to determine complete seating on the abut-
ment. After it is determined that the restoration ts
correctly and occlusion is functional and aesthetically
pleasing, the abutment screw is then tightened to the
recommended torque value. This should be per-
formed with a recommended torque wrench cor-
rectly calibrated, with a repeat torque 5 minutes after
the rst torque application.
28
A screw-retained resto-
FIGURE 19. A, An extended-length impression pin is placed through
the access channel of the screw-retained restoration. B, An open tray
pick-up impression of the provisional restoration used to create the soft
tissue master cast preserving the soft tissue prole. C, Attachment of the
implant replica and addition of the soft tissue simulation before pouring
the master cast.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant
Restoration. J Oral Maxillofac Surg 2004.
FIGURE 20. A, Insertion of 3 abutments using a positioning jig from adjacent teeth. B, Placement of 1 alumina and 2 titanium abutments into
position after securing the abutment screws.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant Restoration. J Oral Maxillofac Surg 2004.
SALINAS, BLOCK, AND SADAN 13
ration is inserted in the same fashion, with attention
paid to proximal contacts rst and complete seating
before adjustment of occlusal contacts. This is espe-
cially true if a signicant change will be made to the
soft tissue topography and no provisional restoration
was used before the nal impression. In extreme
cases, it may be necessary to create a releasing inci-
sion in the col or lingual gingiva area to allow com-
plete seating. After complete seating of the restora-
tion has been conrmed, the access channels of either
the abutment or restoration should be closed with
some material to protect the screw head from subse-
quent defacement by rotary instrumentation. The use
of compacted cotton, vinyl polysiloxane putty, or
gutta percha are reasonable choices. The addition of a
restorative material (amalgam or composite resin)
should be considered as well if the restoration is
single-piece screw-retained. Therefore, the depth of
the access channel after placement of protectant ma-
terial over the screw should be enough to retain the
restoration (2 to 3 mm). Cementation of the prosthe-
sis can be performed with a myriad of materials tar-
geted at either retrieval or retention. Temporary lut-
ing cements can be used in cases where it is desirable
to remove the restoration periodically. Lubrication of
the internal portion of the crown can be accom-
plished with petrolatum and the use of either a den-
itive cement or provisional luting agent. This type of
cementation is also indicated for restorations that are
of sufcient strength to withstand occlusal forces
without being bonded (gold, porcelain fused to
metal, high-strength bilaminar ceramics). An alter-
FIGURE 21. A, Insertion of the titanium abutment with hand tightening of the abutment screw. B, Conrmation of the seating of the abutment and
adjustment of the proximal contacts and occlusal adjustments. Torquing of the abutment using calibrated torque wrench. C, Packing of the retraction
cord for retrieval of cement. D, Postcementation follow-up.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant Restoration. J Oral Maxillofac Surg 2004.
14 FPD VERSUS SINGLE TOOTH IMPLANT RESTORATION
native to traditional luting cements may allow the
use of silicone materials that seal the internal areas
of the abutment restoration interface as well. Rela-
tively denitive luting or bonding agents can also
be used where a more stringent retentive capacity
is needed. This is indicated for restorations that are
not of sufcient strength to withstand occlusal load-
ing on their own (such as leucite reinforced all-
ceramic restorations). Meticulous attention to en-
sure no residual cement is left behind can be
addressed by careful use of retraction cords, scal-
ing, and post-cementation radiographs.
If an auxiliary screw is used for the screwmented
design, it should be inserted before set of the luting
cement. In these cases, temporary luting cements are
more appropriate to allow some element of retriev-
ability should the need arise (Fig 22).
Troubleshooting
Many complications associated with implant-sup-
ported single-tooth restorations are related to abut-
ment screw loosening and porcelain fracture. Because
proprioception is largely absent with dental implants,
occlusal contacts should be meticulously adjusted by
afrming a slightly heavier contact on the adjacent
dentition with (0.001 inch) stainless steel shimstock.
Lateral excursion and anterior guidance should be
shared with adjacent anterior teeth to minimize the
potential for screw loosening. These are relatively
common complications related to insufcient torque
application, excessive lateral loads, and occlusal pre-
maturities. This may be especially problematic with
cemented restorations, whereby the abutment screw
becomes loose but the restoration maintains its ce-
mented and intimate relation to the abutment. In
these cases, it may be prudent to remove the restora-
tion from the abutment if cementation was performed
on a provisional basis. If not, it may be wise to at-
tempt at removing the abutment screw by creating an
access channel through the restoration. This may be
aided by consulting the master cast for orientation of
the implant long axis. In anterior restorations, the
FIGURE 23. A, Postcementation of # 9. Note the position of gingiva and papilla. B, Three-year follow-up of a case with migration of soft
tissues.
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant Restoration. J Oral Maxillofac Surg 2004.
FIGURE 22. A, Combination cemented crown and set screw for auxiliary retention #6. B, The nal aesthetic result of osseointegrated implant #6
with veneers. (Courtesy of Dr Sean McCarthy.)
Salinas, Block, and Sadan. FPD Versus Single Tooth Implant Restoration. J Oral Maxillofac Surg 2004.
SALINAS, BLOCK, AND SADAN 15
implant long axis may traverse through the incisal
edge and sacrice of the restoration is occasionally
necessary.
Other complications are related to soft tissue/aes-
thetic complications that, in the aesthetic zone, can
be problematic to maintain the integrity of papilla and
facial gingival margin (Fig 23). Apparently, the pre-
dictability of losing soft tissue coverage appears to be
signicant even at 1 to 2 years.
29
Therefore, the use of
single-tooth implants in the aesthetic zone where the
periodontal biotype is thin scalloped gingiva should
be cautiously approached due to the long-term soft
tissue loss typically observed in these areas.
Since the introduction of osseointegration, the level
of predictability was extended to incorporate treating
partially dentate patients. The replacement of single
missing teeth by this method becomes a standard of
care based on this high treatment outcome. High-
strength ceramics, contemporary dental materials,
and newer implant designs allow a unique approach
to these challenging cases in the aesthetic zone.
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16 FPD VERSUS SINGLE TOOTH IMPLANT RESTORATION