A Review of Implant Abutments - Abutment Classification
T
to Aid Prosthetic Selection
Sanjay Karunagaran, B.D.S., D.D.S., M.S.D., Gregory J. Paprocki, D.D.S.,
Russell Wicks, D.D.S., M.S., Sony Markose, B.D.S., D.D.S., M.S.D.
Introduction
The dental implant is rapidly
becoming a cornerstone in the
current practice of dentistry. The
predictability of dental implants as a
treatment modality has sustained a
considerable amount of research and
investment in producing more durable
restorations. The development of
implant surfaces, surgical protocols
and prosthetic components have
helped to provide the dentist with
the required armamentarium to aid in
planning, placing and restoring missing
dentition.1
An abutment is a component that is
intermediate between the implant and the
restoration and is retained to the implant
by a screw or locking taper. Abutments
can usually be separated from the implant,
but in some cases they may form part of
the implant itself. Additionally, not all
implant restorations require abutments. In
these cases, the crown is fabricated to be
attached directly to the implant platform.
Abutments effectively help form the
restorative part of the implant prosthesis.
The abutment provides the retention,
support, stability and optimal position for
the final restoration.
The integration of the final restoration
to the implant platform can either be
planned as a three-tier or two-tier system,
| Continuing Education Exam #50
as outlined in Figure 1. A three-tier
system incorporates three separate
component, the implant, the abutment
and the crown. A two-tier system
incorporates two separate components,
the abutment and the crown form a
single unit and the implant is a separate
component or conversely, the implant
and the abutment form a single unit and
the crown is separate.
Implant Tier System
Most abutments are retained
into the implant platform by a screw
(Screw-retained) and the final crown
can be screw-retained directly onto the
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D
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EXAM #50
ABSTRACT
With an increase in the availability of implant restorative components, the
selection of an appropriate implant abutment for a given clinical situation has
become more challenging. This article describes a classification system that will
help the practitioner understand the different implant abutments available and
therefore be able to understand the selection of abutments for single and multiple
unit fixed implant prosthesis.
abutment (Three-Tier system) or directly protocol to help with the process of
onto the implant platform (Two-Tier implant crown fabrication.
system). Alternatively, the crown can be 1. Diagnostic wax up or Trial tooth set
cemented as in a conventional crown and up
bridge protocol (Cement-retained) onto 2. Fabrication of Radiographic and
the abutment which is retained to the Surgical template
implant by a screw (Three-Tier system). 3. Surgical Phase and placement
There are also current implant systems 4. Provisional Phase and soft tissue
that enable the abutment to be locked contouring
or friction fit into the implant, without a 5. Impression making
screw or cement method of retention. 6. Jaw Relation record
The availability of a vast number of 7. Prosthetic Abutment selection and
prosthetic components has left many Crown Design
dentists confused at the selection process 8. Prosthesis delivery
of these components and in particular
the indications for the use of such Types of Abutment
components. This article will outline a Implant abutments are generally
method to classify appropriate abutments either custom made in a dental
for implant restorations. This will laboratory or prefabricated from implant
hopefully serve to enhance understanding manufacturers.2 Custom abutments
of the best available options for the require the dentist to make an implant or
treatment of our patients. fixture level impression of the implant
When considering restorative options, platform with the aid of an impression
the clinician should consider the following coping. A prefabricated abutment is
Figure 1 - Implant Tier System
Three-Tier System Two-Tier System
Journal of the Tennessee Dental Association ­• 93-2
machine made by the manufacturer, and connect to the implants with an implant to establish tooth and gingival contours.
it may be selected directly by an implant platform that is either internally or Many of these abutments are modified
or fixture level impression or it may be externally connected. The type of to establish tissue contours especially in
directly adapted to an existing platform connection seems to have an influence the esthetic region. These abutments help
and impressed as a conventional crown. on the incidence of prosthetic failures, create the emergence profile, esthetic,
Custom abutments can be costly as and internal connections are used more phonetic boundaries, the position and
they are commonly used in situations commonly.4 the shade of the desired final restoration.
when prosthetic It can be used
corrections with to help establish
the standard Figure 2 - Customized Lingual Set Screw Abutment the final form
prefabricated of the definitive
implant parts are not restoration.
possible. Insufficient time
Prefabricated spent on this stage
abutments are less can often lead
expensive and to an inadequate
easy to use, but restoration and
they do have some unsatisfied patients.
limitations and there Impression
are instances where Abutments
such abutments are
contraindicated.3 Open tray
Situations that may impression
require custom abutments are
abutments may often called
include: (1) if there pick-up or direct
is insufficient copings. Closed
interocclusal tray impression
restorative space, (2) abutments are often
if there is an angle called Transfer or
correction problem indirect copings.
greater than 15°, (3) Figure 3 - Temporary Abutment Classification Table 1 illustrates
if the collar height the differences
needed is more between the two
than 1 mm greater as well as the
than the largest indications for their
collar height offered uses. Figure 4
by the implant shows an open tray
manufacturer, (4) pick-up coping.
if there is a need to Healing Abutments
replicate the original
The abutments
cross-sectional
illustrated in Figure
profile of the tooth
5 are used to cover
in order to obtain

Continuing Education Exam #50 |

the implant platform
an ideal emergence
following surgical
profile, and finally
placement of the
(5) if there is a need
implant and to
to splint three or
prevent tissue and
more implants. In
bone growth into
these situations customizing the implant Temporary Abutments the implant body. It also helps establish
abutment may be more beneficial as
Temporary abutments are usually epithelization of the tissue and prevents
the standard stock abutments might not
produced in a stock prefabricated fashion, influx of fluids from the oral cavity into
be able to accommodate the corrected
in that they are machine premade. They the implant body. They can be used as a
changes needed. Figure 2 illustrates
include impression abutments, healing one-stage or two-stage protocol. A one-
a customized abutment to help correct
abutments and metal or plastic provisional stage surgical protocol allows the healing
incorrect implant angulations.
abutments, as illustrated in Figure 3. The abutment to traverse the soft tissue in
Abutments can be divided into
clinician has the option to use them as a transmucosal fashion and is exposed
two forms: temporary abutments and
during the healing phase. This allows
definitive abutments. These abutments is or to try to customize them as needed
the dentist access directly to the implant

93-2 • A Review of Implant Abutments-Abutment Classification to Aid Prosthetic Selection 19

 platform without involving a second stage either a standard prefabricated, custom
manufactured stock abutments to try
of surgery. A two-stage protocol involves castable or computer generated abutment,
to cut down the preparation time by the
covering the entire implant platform, as illustrated in Figure 6. The choice
dentist. This has included abutments
sealed with a cover screw, under the soft is dictated by the individual clinical
which are shaped more to the natural
tissue and requires a second surgery to situation, clinical experience level and
contours of the crown and are termed
expose the implant. patient preference. esthetic abutments. In addition these
Metal or Plastic abutments also come in a variety of
Abutments angulations to
deal with implant
These abutments Figure 4 - Impression Abutments Nobel Biocare™ positional problems.
are used following Standard stock
exposure of the abutments vary
implant platform according to the
and prior to the manufacturer
final restoration. and they come
They are used in as fixed and
the provisional removable abutment
phase and help restorations each
to customize the having their own
form, shade, soft indications. Fixed
tissue profile and abutments include
the occlusion prior Snappy abutments,
to the definitive Multi-unit
restoration. abutments, Esthetic
They can be abutments, Procera
metal titanium, abutments, Gold
ceramic zirconia adapt abutments
or acrylic PEEK and single tooth
(polyetheretherketone). abutments.
The abutments can Removable
also be engaging abutments are
or non-engaging at Table 1 - Differences between Closed Tray and Open Tray Locator, GPS
their interfaces to Impression Copings abutments, ERA,
the implant surface, Mini ERA, Ball
which can provide Factors Transfer Coping Pick up coping attachments, ZAG
the dentist with etc.
the option of using Less space needed for More space required to
them in single or Interarch Space impression, Suitable for accommodate the larger Custom Castable
Abutments
multi-unit situations. posterior areas copings
Abutments are Customized
also fabricated in a Must be perforated to abutments,
Tray Preparation No preparation necessary
standard stock round, accommodate the coping illustrated in
stock anatomical Figure 7, are
profile which follows Splinting more commonly
Multiple Not possible Possible
| Continuing Education Exam #50

the patient’s natural used in situations

gingival profile. Copings where stock
These abutments can Less distortion because abutments cannot
Possible distortion because
also be customized the coping remains in the be used to correct
by the technician Precision of the copings have to extreme angulation
impression. Splinting the
(indirect lab Impression be reinserted into the problems or to deal
copings have no value on
fabrication) or by impression with corrective
accuracy
the dentist (direct abutment designs to
intraoral fabrication). accommodate proper
Definitive Abutments coping and crown
Standard Stock Abutments designs. In addition to the previously
Permanent abutments are used for Stock abutments are pre-machined mentioned criteria, Table 2 also illustrates
the final restoration and will remain abutments that can be modified by the some of the situations that may require the
in place definitively. The dentist has a dentist or the laboratory technologist. selection of custom castable abutments.
choice during the final fabrication to use Implant companies have recently These abutments are waxed by the

20 Journal of the Tennessee Dental Association ­• 93-2

technician to the required contours and 1) NobelProcera® (Nobel Biocare 2) Bella Tek® Endocde® (BIOMED
custom fit into the restorative space. They USA, LLC, Yorba Linda, CA) 3i, Palm Beach Gardens, FL)
tend to be quite labor intensive and costly. provides abutments in titanium, is a robotic analog design. This
They utilize UCLA, gold adapt, or cast to zirconia or alumina. Fixture system uses an impression of
abutments for the casting process. level impressions are made and a the healing abutment to design
Computer Generated Abutments master cast is produced. This cast and fabricate the final abutment.
can then produce the abutment These healing abutments come in
CAD/CAM a two-piece system
technology was which has notches
incorporated into Figure 5 - Healing Abutments on its occlusal
the production of surface which act
implant abutments as codes that the
and frameworks in computer can scan
the 1980s.5 These and translate into
abutments are implant abutment
fundamentally designs.7 The
changing present scanner can extract
restorative protocols. information about
Traditional the position of the
techniques relied hex, the diameter
on the accuracy of the implant
of the processes platform, the collar
of impression height and then
materials, gypsum exact 3D placement
products, waxing of the implant.
crowns, investing This then allows
and casting with CAD and CAM
alloys at high fabrication.
temperatures. These 3) Straumann®
produce avenues
Figure 6 - Definitive Abutment Classification CARES®
for inaccuracies (Straumann, USA,
to develop. CAD/ Andover, MA)
CAM has introduced makes two-types
methods of of abutments:
fabricating the final zirconium dioxide
impression with and titanium. In this
digital methods of system an implant
impression making level impression
and scanning and is made and then
then milling out duplicate model
prefabricated metal of the master cast
alloys to produce is fabricated. This
a restoration that is called the scan
is more precise model and is made

Continuing Education Exam #50 |

than the traditional
casting methods.
When considering
CAD/CAM implant
abutments there are several systems
available on the market currently, but
they all seem to stem from the following
protocol:6
a. Scannable Abutments (Scan bodies)
b. Prepable Scanned Abutments
c. Virtual Assisted Design
d. Robotic Analog Design
Implant manufacturers have developed
unique proprietary systems. Some of the
common systems are outlined below:
in two modes.6 The cast can be
scanned and the abutment can be
designed in an entirely 3D fashion
by computer software. Another
method would allow a preprepared
base cylinder to be placed on the
cast and then waxed. This wax-up
is then transferred to the scanner.
This information for both systems
is then sent to the Nobel Biocare
facility for CAM and sent back as
either a metal or ceramic coping.
of a type of plaster
that is scanable.6 A
scan body is also
attached to the implant analog
prior to the scan to delineate
implant position. The custom
abutment is then designed CAD
on screen to the contours needed
and transmitted to the Straumann
center. Etkon is another system that
uses the same principles of waxing
up onto a plastic cylinder which is
then removed and scanned.
4) Atlantis™, (DENTPSLY,
International, York, PA) abutments

93-2 • A Review of Implant Abutments-Abutment Classification to Aid Prosthetic Selection 21

 can be fabricated
in titanium or gold Figure 7 - Customized Abutments
shaded titanium
or zirconium.
The gold-shaded
abutments aid in
covering up the
silver color of the
titanium and provide
a more esthetic
value to the patient.
Thissystem can be
used with any of the
available implant
systems and begins
with a fixture level
impression and
then the diagnostic
cast and the master
cast are scanned.
The abutment is
then designed on
software termed
virtual assisted
design (VAD) and
milled. Guidelines
for the design are
incorporated into
the prescription,
Table 2 - Factors Requiring Customized Abutments
including:
a. Implant
information:
Tooth number,
implant brand
and platform
diameter
b. Abutment
material:
Titanium,
gold shaded
titanium,
zirconia and
Gemini
c. Margin design: Interproximal Distance
| Continuing Education Exam #50
Conclusion
Understanding
abutment
classification is
just one step in the
process of creating
the ideal restorative
prosthesis. This
article presents
a classification
system to outline a
method for abutment
selection. The
treatment, however
remains the same
and will invariably
involve correct
treatment planning,
decision making
and sequencing of
treatment that will
ensure a successful
end result.
Disclosure:
The authors did
not report any
disclosures.
References:
1. Giglio, G.D., Abutment
selection in implant-
Criteria for supported fixed
Implication for abutment selection prosthodontics. Int J
Customization Periodontics Restorative
Dent, 1999. 19(3): p. 233-41.
Abutment margins should be supragingival in 2. Misch, C.E., Screw-retained
versus cement-retained
Tissue Collar Height nonesthetic zones and slightly subgingival in the implant-supported
prostheses. Pract
esthetic zone Periodontics Aesthet Dent,
1995. 7(9): p. 15-8.
Abutment height must not exceed the space 3. Philip G Kotick, B.B.,
Crown Height Abutment selection for
available for the crown materials Implant Restorations. Inside
Dentistry, July 2011. 7(7).
Abutment width must be sufficient to support
4. Gracis, S., et al., Internal
vs. external connections for
the crown but interproximal access to hygiene abutments/reconstructions: a

systematic review. Clin Oral

Chamfer, instruments must be sufficient Implants Res, 2012. 23 Suppl
6: p. 202-16.
Shoulder 5. Priest, G., Virtual-designed
d. Retentive
Implant Angulation Abutment must counter an implant angulation
and computer-milled implant
abutments. J Oral Maxillofac
Surface: Yes Surg, 2005. 63(9 Suppl 2):
or no p. 22-32.

e. Healing Margin should be subgingival in the esthetic 6. Kapos, T., et al., Computer-
aided design and computer-
Abutment zone, and the emergence profile must support assisted manufacturing in
Esthetics
the gingival tissues. A porcelain abutment may
prosthetic implant dentistry.
diameter Int J Oral Maxillofac
f. Margin improve the esthetics Implants, 2009. 24 Suppl:
p. 110-7.
Position: 7. Drago, C.J., Two new
Free gingival clinical/laboratory protocols

margin (FGM) g. Emergence profile options: Full for CAD/CAM implant

restorations. J Am Dent
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abutment Support tissue or no tissue
displacement

22 Journal of the Tennessee Dental Association ­• 93-2

 Sanjay Karunagaran, B.D.S., D.D.S.,
M.S.D., Assistant Professor, Department
of Prosthodontics, University of Tennessee
Health Science Center College of Dentistry,
Memphis, Tennessee. Contact Dr.
Karunagaran at skaruaga@uthsc.edu or 901-
448-6380.
93-2 • A Review of Implant Abutments-Abutment Classification to Aid Prosthetic Selection - Exam
Questions
Gregory J. Paprocki, D.D.S., Assistant
Professor and Director, Maxillofacial
Prosthodontics, Assistant Director, Advanced
Prosthodontic Program Co-Director, Head
and Neck Cancer Clinic University of
Tennessee Health Science Center College of
Dentistry, Memphis, Tennessee.
Russell Wicks, D.D.S., M.S., Chairman
and Professor, Department of Prosthodontics,
University of Tennessee Health Science Center
College of Dentistry, Memphis, Tennessee.
Sony Markose, B.D.S., D.D.S., M.S.D.,
Private Practice, Carrolton, TX
Continuing Education Exam #50 |
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