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Single-Tooth Implant Restoration

The use of dental implants has become a popular way to replace missing dentition. This is
especially true when the teeth adjacent to the edentulous space are unrestored or unsuitable as fixed
prosthodontic abutments. The replacement of a maxillary anterior tooth seems simple because of
accessibility, but it can be one of the most challenging applications for the use of a single dental
implant because of the esthetic demands.1–5 There are numerous dental implant systems currently
available in the marketplace, and each system has its own specific components and instruments.
While these parts and instruments may be interchangeable between systems, it is best to use the
restorative components of the manufacturer of the dental implant to be restored. The primary reason
for this is compatibility (fit) of the various restorative components. Although different dental implant
manufacturers may use different names, often trademarked, for similar components, a common
terminology has evolved for dental implant components and instruments, and this terminology is used
throughout this chapter.6

Implant Placement and Healing


A patient presenting with a missing central incisor is not an uncommon occurrence. After a dental
implant has been placed, it is allowed to heal for the prescribed time,7 which is usually 3 months in
the mandible and 4 to 6 months in the maxilla, before the dental implant is uncovered and a healing
abutment is placed (Figs 28-1a and 28-1b). The dental implant is then ready for restoration.
The desired emergence of the dental implant is shown by the position of the healing abutment (Fig
28-1c). The anteroposterior position of the dental implant is important for a suitable esthetic result in
the definitive restoration. A dental implant that is placed too far to the facial will create an unnatural
soft tissue emergence profile,3,4 and a dental implant placed too far to the lingual will create an
unnatural lingual contour of the definitive restoration.
The process of fabricating a dental implant–supported restoration requires a series of individual
steps, beginning with the removal of the healing abutment with a hex driver (Fig 28-2), which exposes
the top of the dental implant (Fig 28-3).
Fig 28-1 (a) Facial view of single-tooth dental implant with healing abutment in place. (b) Same
view as (a) with internal hex dental implant superimposed to show its position in the bone. (c)
Incisal view of single-tooth dental implant with healing abutment in place.

Fig 28-2 (a) Hex driver removing healing abutment from patient. (b) Hex driver for insertion and
removal of healing abutment.

Fig 28-3 Incisal view of top of implant with healing abutment removed.

Evaluation of Gingival Tissue


The gingival tissue surrounding the dental implant should be evaluated for health and thickness.
The gingival tissue should be the same color as the healthy tissue surrounding the natural dentition.
The depth of the gingival cuff (thickness) surrounding the dental implant is important; this depth
preferably should be 2 to 3 mm. A gingival cuff deeper than 3 mm is prone to suffer from chronic
irritation due to difficulty with hygiene procedures.3,8 A depth less than 1 mm may present an esthetic
problem by displaying metal at the gingival margin of the restoration. A gingival cuff that is too deep
or too shallow may require periodontal therapy to provide the optimum environment for restoration
fabrication.

Impression Taking and Cast Fabrication


The general process of fabricating a dental cast upon which a dental restoration can be fabricated
begins with taking an impression. Dental implant impressions are taken after removing the healing
abutment and attaching an impression coping to the dental implant. The shape of the impression
coping is captured in the impression.

Closed and open tray impression techniques


Impression copings are fabricated for both a closed tray and an open tray impression technique. In
the closed tray impression technique, the impression coping remains attached to the dental implant
when the impression is removed from the mouth. In an open tray impression technique, the impression
coping remains in the impression when the impression is removed from the mouth.9
To accomplish the removal of the implant impression coping with the impression, the impression
coping is attached to the dental implant with a separate long attachment screw. This attachment screw
must be removed prior to the impression tray removal from the mouth. This requires an opening in the
impression tray that allows access to the attachment screw. This opening is the reason it is referred to
as an open tray impression technique.
Upon removal of the closed tray impression from the patient’s mouth, the impression coping is
removed from the dental implant, attached to a laboratory implant analog, and reinserted into the
impression. The open tray impression technique only requires the attachment of the laboratory implant
analog to the impression coping, which remains within the impression. The impression can then be
poured in dental stone, recording the location of the dental implant in the dental arch.
Fig 28-4 (a) Closed tray impression coping with attachment screw. (b) Intraoral facial view of
closed tray impression coping connected to the implant with an attachment screw. (c) Palatal
view.

Fig 28-5 Taking the preliminary closed tray alginate impression.

P reliminary alginate impression and study cast


fabrication
A closed tray impression technique is routinely used for a preliminary alginate impression. The
open tray impression technique, which will produce a more accurate cast10 because the impression
coping remains undisturbed in the impression material, is employed for the final impression.
An internal hex dental implant is generally used with an impression coping that is retained with an
attachment screw for both the closed tray and the open tray impression techniques. The primary
difference between the two impression copings is that the open tray impression coping is more
irregular in shape and has a longer attachment screw to protrude through the impression tray than the
closed tray impression coping (Fig 28-4a). Intraoral facial (Fig 28-4b) and palatal (Fig 28-4c) views
show a closed tray impression coping attached to a dental implant, so the preliminary alginate
impression can be taken (Fig 28-5).

Fig 28-6 (a) Intaglio view of preliminary closed tray alginate impression. Note the detail of the
impression coping in the impression material. (b) Closed tray impression coping with attachment
screw and laboratory implant analog. (c) Closed tray impression coping with attached laboratory
implant analog inserted into the preliminary alginate impression.

Fig 28-7 Dental stone is poured around the laboratory implant analog.

The preliminary alginate impression (Fig 28-6a) is removed from the patient’s mouth, revealing the
negative of the closed tray impression coping and the natural dentition. The closed tray impression
coping of each manufacturer has a unique shape that allows it to be accurately reinserted into the
preliminary alginate impression. A laboratory implant analog is a replica of the top of the dental
implant.
After the preliminary alginate impression is made, the closed tray impression coping is removed
from the dental implant, and the healing abutment is replaced. The closed tray impression coping is
then secured to the laboratory implant analog with the attachment screw (Fig 28-6b). The combined
impression coping, attachment screw, and laboratory implant analog are reinserted into the
preliminary alginate impression in preparation for diagnostic cast fabrication (Fig 28-6c). The cast is
poured by initially placing dental stone around the exposed laboratory implant analog (Fig 28-7) and
then filling the remaining impression with dental stone.
The closed tray impression coping will remain attached to the laboratory implant analog when the
preliminary alginate impression tray is separated from the cast (Fig 28-8a). The closed tray
impression coping is removed from the cast by unscrewing the attachment screw. This will reveal the
top of the laboratory implant analog, which is a replica of the patient’s dental implant with the
internal hex (Fig 28-8b). The detailed shape of a closed tray impression coping, while well recorded
within impression material, can present a challenge when reseating the impression coping in the
impression for cast fabrication.

Fig 28-8 (a) Diagnostic cast following impression separation with closed tray impression coping
in place. (b) Diagnostic cast with preliminary impression coping removed, showing the top of the
implant analog.

Fig 28-9 (a) Open tray impression coping with attachment screw and laboratory implant analog.
(b) Facial view of open tray impression coping seated on diagnostic cast with attachment screw.
(c) Palatal view.

F inal impression and master cast fabrication


The open tray impression coping (Fig 28-9a) has an even more detailed shape and a longer
attachment screw than the closed tray impression coping. As stated earlier, an open tray impression
technique will produce a more accurate cast than a closed tray impression technique because the
impression coping remains within the impression material when the impression tray is removed from
the mouth. Therefore, the open tray impression technique is recommended for taking a final
impression and fabricating a master cast.
The open tray is fabricated on the diagnostic cast with the open tray impression coping attached to
the laboratory implant analog with the attachment screw (Figs 28-9b and 28-9c). The diagnostic cast
is blocked out around the dentition with two sheets of pink baseplate wax (approximately 2 mm
thick), leaving the top two-thirds of the attachment screw exposed. Four vertical stops are cut through
the occlusal surface of the block-out wax. The stops should be well spaced to provide impression
tray stability during the impression-taking process. They should not be placed immediately adjacent
to the implant site because the impression tray may need adjustment in this area, and the vertical stops
could be destroyed if they are too close. The custom impression tray may be fabricated from the tray
material of choice. The tray material should be pressed firmly to record the vertical wax cutouts and
the location of the impression coping attachment screw.

Fig 28-10 Custom open tray impression. Note opening in impression tray for access to attachment
screw. (inset) Close-up of opening to gain access to the impression coping attachment screw when
the impression is made.

Fig 28-11 (a) Open tray impression coping with attachment screw. (b) Palatal view of open tray
impression coping seated with attachment screw. (c) Facial view of open tray impression coping
seated in the patient’s mouth with attachment screw.

After the impression tray material has polymerized, the impression tray is removed from the
diagnostic cast. Any block-out wax remaining in the custom impression tray is removed. A hole is
created in the custom impression tray to provide access to the impression coping attachment screw
(Fig 28-10). The access hole in the top of the open tray should provide at least 2 mm of space around
the impression coping attachment screw. A piece of boxing wax is placed over the access hole to
contain the impression material within the impression tray while it is being carried and seated in the
patient’s mouth.
To begin the final impression process, the implant healing abutment is removed, and the open tray
impression coping with the attachment screw (Fig 28-11a) is transferred from the diagnostic cast to
the patient (Figs 28-11b and 28-11c). A radiograph should be taken at this time to ensure that the
impression coping is fully seated onto the dental implant.11 This radiograph will also provide
information regarding the amount and quality of the bone surrounding the dental implant at the time of
implant restoration. This is the first time during patient restorative treatment that a radiograph needs
to be taken. This radiograph will serve as a baseline radiograph to monitor long-term implant health.

Fig 28-12 Taking the final impression with a custom open tray impression. (inset) Custom open
tray impression with attachment screw protruding through boxing wax to contain impression
material while seating the tray.

A piece of boxing wax is placed over the opening for the abutment screw on the open impression
tray to contain the impression material in the custom impression tray. The use of the final impression
material is opposite that of the standard impression technique in that the heavy-body impression
material is injected around the open tray impression coping and the impression tray is filled with
medium-body impression material. The heavy-body impression material is placed around the open
tray impression coping to minimize any movement that may occur during the removal of the
impression tray and pouring of the master dental cast.
During the impression-taking process, the custom impression tray must be oriented to allow the
impression coping abutment screw to penetrate the boxing wax placed over the abutment screw hole
(Fig 28-12) before the impression material sets. Upon polymerization of the impression material, any
wax around the implant abutment screw is removed to provide access to the implant abutment screw.
The implant abutment screw is unscrewed and removed from the top of the open impression tray. The
final impression is removed from the patient’s mouth, and the healing abutment is replaced on the
dental implant. The heavy-body impression material stabilizes the open tray impression coping,
which remains undisturbed within the impression material until the master cast is poured in dental
stone.
The final impression is inspected for completeness. The surface of the open tray impression coping
that was in contact with the dental implant should be free of impression material11 (Fig 28-13a). The
open tray impression coping attachment screw that had been removed from the impression tray in
order to remove the impression tray from the patient’s mouth is reinserted into the open tray
impression coping (Fig 28-13b).
The laboratory implant analog is secured to the open tray impression coping with the attachment
screw9,11 (Fig 28-13c). The laboratory implant analog hex must be correctly aligned with the open
tray impression coping hex to be seated fully (Fig 28-13d). When the attachment screw is secured
with the hex driver, care must be taken to not overtighten the attachment screw because there is a risk
of the open tray impression coping moving, which will render the master cast inaccurate.
Improved restorative esthetics can be achieved when the top of the dental implant is approximately
2 to 3 mm below the surrounding gingival tissue. An impression of a dental implant that is lower than
the surrounding gingival tissue will yield a stone cast with a dental implant analog that is below the
level of the surrounding dental stone. This dental stone will restrict access to the top of the laboratory
implant analog during restoration fabrication. To facilitate restoration fabrication, a soft tissue
replica material (Gingitech, Ivoclar Vivadent) is placed around the portion of the open tray
impression coping that was below the level of the gingival tissue intraorally but is now exposed
because the impression is a negative representation of the patient’s intraoral situation. The presence
of the soft tissue replica material on the master cast is helpful because it is removable, allowing
access to the top of the laboratory implant analog during restoration fabrication.9
Soft tissue replica material will adhere to many impression materials. Therefore, the separating
medium provided by the manufacturer of the soft tissue replica material should be applied to the
intaglio surface of the final impression surrounding the exposed portion of the open tray impression
coping and approximately 1 mm onto the laboratory implant analog. The soft tissue replica material is
applied around the exposed open tray impression coping and approximately 1 mm onto the laboratory
implant analog (Fig 28-14a). The soft tissue replica material should not extend into the impression of
the teeth proximal to the dental implant (Fig 28-14b). Pouring of the final impression is begun by
placing dental stone around the laboratory implant analog (Fig 28-15a). The remainder of the
impression is then poured in dental stone to fabricate the master cast. Separation of the master cast
from the final impression requires removal of the attachment screw. The master cast will have the soft
tissue replica material surrounding the top of the laboratory implant analog (Fig 28-15b).
Fig 28-13 (a) Intaglio surface of final impression. Note the impression coping surface that was in
contact with the dental implant. (b) Intaglio surface of final impression with the attachment screw
ready for the laboratory implant analog. (c) Hex driver is stabilizing the attachment screw during
connection of the laboratory implant analog to the impression coping. (d) Final impression with
laboratory implant analog secured to the impression coping with an attachment screw.

Fig 28-14 (a) Placing gingival tissue material in the final impression to simulate patient soft
tissue. (b) Gingival tissue material is only placed around the portion of the impression coping that
was subgingival in the patient’s mouth.
Fig 28-15 (a) Pouring dental stone around the laboratory implant analog. (b) Master cast with
laboratory implant analog surrounded by gingival soft tissue replica material.

Fig 28-16 (a) Internal hex machined metal cylinder with waxing sleeve and abutment screw. (b)
Palatal view of internal hex machined metal cylinder with waxing sleeve and abutment screw on
master cast.

Definitive Implant Restoration

Articulation of the master cast


The maxillary master cast and opposing mandibular cast are articulated. A prefabricated, machined
hex metal cylinder with attached plastic waxing sleeve (waxing abutment) (Fig 28-16a) is secured to
the laboratory implant analog on the master cast with an abutment screw (Fig 28-16b). When the
waxing abutment is in place on the articulated master cast, it will create a premature incisal contact
(Fig 28-17a) requiring equilibration12 (Fig 28-17b). Completion of the waxing abutment equilibration
will reestablish normal occlusion (Figs 28-17c and 28-17d). The plastic sleeve of the waxing
abutment has horizontal ridges placed by the manufacturer to aid in wax retention. However, it is
often necessary to place additional retention to prevent wax rotation around the waxing abutment.
Roughening and/or placing vertical grooves on the plastic sleeve of the waxing abutment for
additional wax retention is strongly recommended. The abutment screw access hole in the plastic
sleeve of the waxing abutment should be obturated with a cotton pellet prior to initiating restoration
waxing to prevent wax from obstructing the hex of the abutment screw.
Fig 28-17 (a) Premature incisal contact of waxing cylinder on articulated casts. (b) Equilibration
of waxing cylinder to eliminate premature incisal contact. (c) Waxing cylinder equilibrated into
occlusion. (d) Note the amount of equilibration of waxing cylinder required to achieve centric
occlusion.

Restoration wax-up
Waxing of the restoration begins with the addition of wax to the waxing abutment with a no. 7 wax
spatula (Fig 28-18a). Additional wax may be added with the aid of a beavertail burnisher (Fig 28-
18b). The restoration is waxed to full contour (Fig 28-18c). The palatal view of the contour wax-up
reveals the access hole for the abutment screw (Fig 28-18d). The full-contour wax-up is then cut back
to allow room for the addition of porcelain. The palatal (or lingual) cutback should allow for the
abutment screw access hole to be surrounded by metal (Fig 28-19). The incisal cutback should be
marked at 3 mm to allow for translucency of the incisal porcelain (Fig 28-20). A facial groove depth
of 1 mm will assist in achieving adequate, uniform facial reduction (Fig 28-21). The incisal aspect
may now be reduced to the desired level (Fig 28-22). The next step is proximal reduction (Fig 28-
23). The completed wax pattern reduction is shown in Figs 28-24 and 28-25.

Restoration placement
The completed dental implant restoration can provide a natural appearance (Fig 28-26a). The
abutment screw access hole is encircled with metal to prevent the fracture of unsupported porcelain
(Fig 28-26b). The abutment screw access hole is closed by first placing cotton pellets over the top of
the abutment screw to within 2 mm of the access hole opening to protect the hex of the abutment
screw. The cotton pellets are then covered with a 2-mm layer of light-polymerizing resin.12 The use
of a wet cotton-tipped applicator to smooth and remove excess light-polymerizing resin prior to
polymerization will produce a surface that will require no further finishing.

Fig 28-18 (a) Adding wax to implant waxing cylinder with a no. 7 wax spatula. (b) Adding more
wax to implant waxing cylinder with a beavertail burnisher. (c) Labial view of full-contour wax-up
of the implant-retained restoration. (d) Palatal view of full-contour wax-up showing screw access
hole.

Fig 28-19 Outline of the palatal wax pattern cutback around the waxing cylinder.

Fig 28-20 Facial view of wax pattern incisal reduction.


Fig 28-21 Facial reduction groove on wax pattern.

Fig 28-22 Incisal reduction of wax pattern.

Fig 28-23 Proximal reduction of wax pattern.

Fig 28-24 Palatal view of completed wax pattern cutback.


Fig 28-25 Facial view of completed wax pattern cutback.

Fig 28-26 (a) Facial view of definitive restoration. (b) Palatal view of definitive restoration. Note
that the palatal screw access hole is surrounded by metal.

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