ImplantDentistry Enhanced CPD DO C

Despoina Chatzistavrianou

Paul HR Wilson and Philip Taylor

A Guide to Implant Dentistry Part

2: Surgical and Prosthodontic
Considerations
Abstract: Implant rehabilitation is a successful treatment modality for the replacement of missing teeth, but careful treatment planning,
restoratively-driven implant placement and individualized maintenance are prerequisites for success in order to control and minimize
technical and biologic complications. The first part of the series focused on new patient assessment and pre-operative planning. The
second part of the series will discuss the surgical and prosthodontic considerations and maintenance of implant-supported restorations.
CPD/Clinical Relevance: To provide the dental practitioner with an evidence-based overview regarding treatment planning, surgical and
prosthodontic considerations and maintenance of implant-supported restorations.
Dent Update 2019; 46: 514–523

Replacement of missing teeth with implant-
supported prostheses is a challenging
process and each case presents different
Despoina Chatzistavrianou, DDS,
MClinDent(Pros), MPros RCS(Ed), MFDS
RCS(Ed), Specialty Registrar in Restorative
Dentistry, Specialist in Prosthodontics,
Birmingham Community Healthcare NHS
Trust, Birmingham, Birmingham Dental
Hospital and University of Birmingham
School of Dentistry, 5 Mill Pool Way
(email: despoinachatzis06@gmail.com),
Paul HR Wilson, BSc(Hons), BDS(Glasg),
MSc(Lond), FDS RCPS FDS(RestDent),
DipDSed(Lond), Consultant and Specialist
in Restorative Dentistry, Oxford University
Hospitals NHS Foundation Trust, Oxford
and Bath Dental Clinic, Bath and Philip
Taylor, BDS(Ncle), MGDS(RCS Eng),
MSc(Lond), MRD RCS(RCS Eng), FDS(RCS
Edin), Professor in Prosthodontics and
Consultant in Restorative Dentistry,
The Royal London Dental Hospital and
Queen Mary University of London, Barts
and the London School of Medicine and
Dentistry, London, UK.
514 DentalUpdate June 2019
degrees of complexity and surgical,
restorative and aesthetic risk factors.1,2
Although implant reconstructions offer
high survival rates, their complication
rate and level of maintenance are high as
well.3 The first part of the series focused
on new patient assessment regarding
general and local factors that affect the case
complexity and pre-operative planning. The
second part of the series will discuss the
surgical and prosthodontic considerations
and maintenance of implant-supported
restorations, equally important factors to
their long-term success.
Surgical considerations
Successful implant rehabilitation
requires careful surgical manipulation
which will take into consideration anatomic
structures and will follow a strict surgical
protocol regarding drill sequence and an
aseptic technique.4 Each case will have a
different degree of surgical complexity
depending on the site (aesthetic versus
non-aesthetic), the number of missing teeth
and the soft and hard tissue deficiencies
(Table 1).2
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A surgical guide is advisable
to facilitate a restoratively-driven implant
placement; fixtures should be positioned
in the correct three-dimensional position
to achieve an optimum emergence profile
(Figure 1).4 The correct type of implant
should also be selected for a favourable
emergence profile; narrow neck implants
are used for maxillary lateral incisors and
mandibular incisors, standard-neck implants
are used for maxillary central incisors,
canines and premolar teeth and wide-neck
configuration for replacement of molar
teeth.1,5
The timing of implant
placement following tooth extraction has
been investigated in various studies in
the literature (Table 2).6-8 Similar survival
rates have been reported for all types of
implant placement but outcomes might
be adversely affected by timing of implant
placement.6-8
Type 1 implant placement
This allows the extraction and
implant placement to take place in the
same surgical procedure, thereby reducing
 ImplantDentistry

Simple Advanced Complex

Sites without bone defects
Sites with bone defects
Table 1. Surgical SAC Classification of implant sites with and without bone deficiencies (Classification of the Swiss Society of Oral Implantology, 1999).2
• Edentulous mandible with
2 implants for a removable
denture (ball attachment or
bar)
• Distal-extension situation
maxilla/mandible
• Extended edentulous gap in
posterior maxilla/mandible
• Extended edentulous gap in
anterior mandible
• Single-tooth gap in posterior
area
• Single-tooth gap in anterior
mandible
• None
• Edentulous mandible with 4 to • Edentulous maxilla for a fixed
6 implants for a bar-supported full-arch prosthesis
prothesis or full-arch prosthesis
• Edentulous maxilla for
removable denture
• Single-tooth gap in anterior
maxilla
• Extended edentulous gap in
anterior maxilla
• Implants with simultaneous • All 2-stage bone augmentation
membrane application procedures
• Implants placed with • Sinus floor elevation with the
osteotome technique window technique
• Implants combined with 'bone • Combined bone and soft tissue
splitting' of the alveolar crest augmentation procedures

Figure 1. The correct three-dimensional implant position (a) mesio-distal, (b) oro-facial, (c) apico-coronal.4

the treatment time. Immediate implant
placement shows similar survival rates as
delayed implant placement, but cannot
prevent bone remodelling after tooth loss.9,10
An immediate implant placement requires
primary implant stability and a restoratively-
driven implant placement. It can be related
to increased risk of gingival recession. For this
June 2019 DentalUpdate 515
latter reason, immediate placement can be It offers additional soft tissue volume,
considered in cases of minimal aesthetic which facilitates the surgical manipulation
risk, such as replacement of mandibular and enhances soft tissue aesthetics. This
incisors or premolar teeth.11,12 approach also allows resolution of local
pathology through bone remodelling.12,13
Type 2 implant placement
This is the most commonly Type 3 implant placement
employed technique in the aesthetic zone. This facilitates additional soft
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 ImplantDentistry
Classification Descriptive terminology Desired clinical outcome
Type 1 Immediate placement An extraction socket with no
healing of bone or soft tissues
Type 2 Early placement with soft tissue A postextraction site with
healing (typically 4 to 8 weeks healed soft tissues but without
of healing) significant bone healing
Type 3 Early placement with partial A postextraction site with
bone healing (typically 12 to 16 healed soft tissues and with
weeks of healing) significant bone healing
Type 4 Late placement (more than 6 A fully healed socket
months of healing)
Table 2. Classification and descriptive terms for timing of implant placement after tooth extraction.6-8
a a
b for spontaneous bone regeneration.11
b localized alveolar ridge defects using
c Bone augmentation procedures
c in peri-implant defects, improved soft
Figure 3. (a–c) Improved soft tissue contour and
aesthetics with type 2 implant placement of UR3
with the use of simultaneous GBR technique.
d tissue volume for flap closure and partial
bone healing for primary stability but
varying amounts of resorption might
compromise bone availability.11,13 Type
3 implant placement is indicated for the
replacement of multi-rooted teeth.
Type 4 implant placement
This shows additional soft tissue
Figure 2. (a–d) Type 2 implant placement with
volume and bone healing but greatest
GBR technique (double layer technique).
chance of increased bone resorption,
516 DentalUpdate June 2019
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Figure 4. All-ceramic crown supported by
zirconium abutment at UL3 site.
thereby limiting the volume of bone for
implant placement.11,13 Type 4 implant
placement should be considered in cases of
excessive local pathology.11,13
Peri-implant defects with
gaps of less than 2 mm following type 1
and type 2 implant placement may heal
spontaneously.11 However, peri-implant
defects of 2 mm or more in the oro-facial
dimension show reduced predictability
Guided Bone Regeneration (GBR) is
a bone augmentation technique in
semi-permeable membranes with different
particulate bone filler materials.14
show high survival rates of 95.7%, and
dehiscence and fenestration resolution
of 54% and 97%, respectively. GBR is
more effective with type 1 and 2 implant
placement (Figure 2).12 The technique
offers bone fill and defect resolution
tissue contour and hence aesthetics, and
minimizes the risk of gingival recession
(Figure 3).15,16
Survival rates of implants
placed in guided tissue regenerated bone
after treatment of localized defects in an
alveolar ridge are comparable to survival
rates of implants placed in native bone.17
Furthermore, the superiority of one
augmentation technique over another,
based on implant survival rates, was not
demonstrated.17
Prosthodontic considerations
Fixed or removable implant-
supported prostheses can be used to
replace missing teeth as part of implant
rehabilitation. Fixed implant-supported
prostheses can be classified based on the
number of teeth they are replacing: single
 ImplantDentistry

a a desirable since they offer restoration

retrievability, which facilitates long-term
maintenance provision.24 The provision of a
screw-retained prosthesis requires accurate
restoratively-driven implant placement,
so that the implants are parallel and the
screw emergence is not visible. It can be
technique-sensitive, as optimal implant
position and passive fit of the prosthesis are
a pre-requisite to avoid problems.1
b The choice of material for
the abutment of the definitive implant-
b supported reconstruction is generally
between zirconium and titanium. Which
material is more appropriate remains highly
debatable in the available literature.24-26 The
5-year survival rate, technical and biological
complications are similar for zirconium
and titanium abutments supporting
c implant restorations.25,26 Moreover, no
differences have been found in soft tissue
response in the peri-implant area between
zirconium and titanium surfaces.27 For
c prostheses in the aesthetic zone, zirconia
abutments may be indicated to enhance
the aesthetic outcome, but the clinical use
of ceramic abutments in posterior sites
d or bridges should be used with caution
(Figures 4−6).25,28 Although zirconium
and titanium abutments show similar
survival rates, zirconium abutments require
careful manipulation since adjustment
of zirconium can adversely affect its
mechanical properties.29 Careful polishing
is recommended after adjusting the
abutments to keep surface roughness and
d
phase transformation (commonly referred
e to as ‘ageing’) low.29
Apart from the abutment
material, the design of the prosthetic
superstructure is of paramount importance.
Designs should be smooth and convex
to allow oral hygiene access and hence
minimize biological complications.19,28
Figure 6. (a−e) Full arch, metal-ceramic bridge Although CAD/CAM fabricated prostheses
Figure 5. (a−d) Metal-ceramic bridges supported supported by milled framework with individual demonstrate similar survival rates to
by milled titanium framework. crowns at the maxillary anterior teeth to correct conventionally fabricated prostheses,
angulation discrepancies. reproducibility, passive fit and reduced
stress at the implant-fixture interface
crowns, short span, long span or full arch can be more easily achieved with digital
bridges, or classified based on the type of as screw loosening or ceramic fracture technology.19
retention: screw- or cement-retained. compared to cemented-retained Removable implant-supported
The choice between screw- restorations that can present with prostheses can be classified as bar-retained
and cement-retained, implant-supported greater biological complications, such as or retained on individual attachments
prostheses remains controversial in the peri-implant bone loss associated with (balls, studs or magnets) (Figures 7, 8). For
literature.18,19 Screw-retained prostheses marginal cement extrusion.20-23 Ideally, mandibular overdentures, two individual
show more technical problems, such screw-retained prostheses may be more attachments are preferable to bars
June 2019 DentalUpdate 517
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 ImplantDentistry

since they offer adequate retention and a a

stability, similar patient satisfaction, easier
fabrication, maintenance and are cost-
effective.30 For maxillary overdentures, bars
supported by four or more implants show
better outcomes regarding survival of both
the implants and the prosthesis compared b
to four or less implants and individual b
attachments. 31,32
Implant-supported
prostheses offer improved outcomes
compared to conventional dentures and
some clinicians suggest that two-implant
supported mandibular overdentures should
be the minimum offered to edentulous c
patients as a first choice of treatment.33,34 Figure 7. Implant reconstruction for
overdentures: (a) individual attachments; (b) cast
bar.
Maintenance
Although clinical and
technological advances have led to an
(1.2% complications per year) compared to
evolution in implant therapy, technical and
milled bars (0.3% complications per year)
biological complications are commonly
due to reduced movement and rotation
encountered both in fixed and removable d
of the prosthesis.40 Also, the presence of
prostheses.3,35,36 Systemic conditions and
cantilever extension(s) over 15 mm are
treatments that might affect healing or
related to increased incidence of technical
susceptibility to disease, history of treated
complications.38,39
periodontitis and smoking are related
Implant rehabilitation with fixed
to increased incidences of biological
implant-supported prostheses demonstrate
complications. Mechanical factors such as
high survival rates; the 10-year survival
excessive cantilever extension, the vertical
rate of implant-supported crowns and
height of the superstructure, parafunctional
implant-supported bridges are 89.4% and
activity or a patient with a history of
86.7%, respectively.3,41 Although survival e
previous complications, may increase the
rates are high, the complication rate is
incidence of technical complications.37−39
also high; 38.7% over a 5-year period, with
Implant-supported overdentures
implant-supported bridges showing higher
are a favourable solution for edentulous
incidences of technical complications
patients with 80% survival rate over 10
compared to implant-supported crowns
years.35 Overdentures require regular
(Table 3).3,42 The most frequent technical
maintenance, such as replacement of
complications were fractures of the veneer
worn or deformed female retainers, repair
material (ceramic fractures or chipping),
of fractured bars, fractured acrylic or
abutment or screw loosening and loss
replacement of worn abutments. These
of retention.3 Biological complications f
maintenance episodes are reported to be
were encountered with similar incidences
approximately 85% for such prostheses.35
between the two treatment modalities.3,42
Other common complications are
repeated adjustment, loose abutments
or attachments, denture fracture, denture Summary
reline, soft tissue hypertrophy around bars, Implant rehabilitation is
peri-implant bone loss and implant failure.36 considered a predictable treatment
Bar-retained overdentures require less modality to replace single and multiple
maintenance compared to those dentures missing units with high survival rates.
retained on individual attachments, but Technical and biological complications
the former complications are usually more are commonly encountered and careful Figure 8. (a−f) Oral rehabilitation of a case with
complex and financially costly.37 Bar design treatment planning, restorative-driven an edentulous maxilla and partially dentate
and configuration may influence prosthetic implant placement and long-term mandible with an implant-supported overdenture
on individual attachments and a conventional
maintenance. For example, round cross- maintenance are prerequisites of a
removable prosthesis.
sectional bars require more maintenance successful implant rehabilitation minimizing
520 DentalUpdate June 2019
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 ImplantDentistry
SC
Implant fracture 0.14%
Screw abutment loosening 5.6%
Screw abutment fracture 0.35%
Ceramic/veneer fracture 3.5%
Loss of retention 5.5%
Soft tissue complication 7.1%
Table 3. The 5-year complication rate of single crowns (SCs) and fixed implant-supported prostheses
(FDPs).
these complications. The buccal bone
thickness and interproximal bone levels
for soft tissue stability, the correct implant
dimensions for a favourable emergence
profile, careful surgical technique, pink
and white aesthetic harmony, design of
the prosthesis to permit adequate oral
hygiene, and planning for long-term
maintenance care are the most important
elements of treatment planning for implant-
supported reconstructions. Attention paid
to these factors will result in successful
reconstructions with high patient satisfaction
levels.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
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June 2019 DentalUpdate 523
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37. Martin W, Lewis E, Nicol A. Local risk factors for
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