I M

I M P L A N TO L O G Y P L A N T O L O G Y

Single-tooth Implant-supported
Restorations. Planning for an
Aesthetic and Functional Solution
MICHAEL R. NORTON
favoured cement retention.11,13 This
Abstract: The single-tooth implant has found widespread support within the field of helped to reduce bulk, eradicate the
implant dentistry, with numerous studies reporting high success rates that surpass unsightly screw access holes and
those recorded for splinted implant bridgework. Improvements in implant design, range
improve the inclination of the implant
of prosthetic components and restorative materials have made it possible to achieve
optimal functional and cosmetic results. Coupled with an appropriate approach to to avoid unhealthy labial cantilevers
treatment planning and patient assessment, use of the single-tooth implant may be and aid papilla reformation.
considered a highly predictable treatment solution. One of the unforeseen complications
of these new abutment designs was not
Dent Update 2001; 28: 170-175 implant failure but mechanical failure,
with abutment screw loosening and
Clinical Relevance: The general dental practitioner needs to understand the
essential diagnostic and clinical requirements for producing aesthetic and functional
fracture.14 However, the introduction of
single-tooth implant restorations. the torque driver and a re-think of joint
design has helped to overcome this
problem.15 Nevertheless, an optimal
outcome requires more than
development of product design: it
requires a thorough understanding of
ver the past two decades many these implants seemed to perform even the rules that govern implant
O articles have evaluated the
success rates of bridgework supported
better than could have been
anticipated. Clinical studies soon
placement, with a need to prepare the
case thoroughly by appropriate
by osseointegrated implants, with the offered confirmation that this modality planning and assessment. It also
work of Adell et al.1, Arvidson et al.2 of tooth replacement was sound.8–11 requires close co-operation with the
and Makkonen et al.3 indicating high Where juxtaposing teeth are healthy laboratory to ensure an appropriate
rates of success for prostheses 5–15 and unrestored, the provision of single crown form, based on an appreciation
years in function. These, and other implant-supported crowns provides of emergence profile, the soft-tissue
studies4–7 reporting on a variety of better long-term guarantee against the envelope, and the need to maintain or
implant systems used to restore fixed need for additional dentistry to the re-create the interdental soft tissues.
full-arch or partial prostheses, have healthy teeth than more conventional This article will review the factors
tended to link the supporting implants restorative treatments.12 that help to ensure that a functional
together to improve functional load As demand to use implants to replace and aesthetic restoration can be
distribution. the single missing tooth increased, so achieved and maintained over the long
However, the belief that implants too did the demand for a superior term.
require splinting if they are not to fail aesthetic outcome, which had been
was challenged by clinicians who, limited by the widely accepted protocol
through anecdote, trial and error, began that implant restorations should be ASSESSMENT AND
to determine that single unsplinted screw-retained for retrievability. PLANNING
implants did not fail. On the contrary, Considerable effort was therefore
placed into product development,
which resulted in a range of Clinical Examination
Michael R. Norton, BDS, Specialist in Surgical components that would allow the Without offering an exhaustive guide to
Dentistry, Honorary Associate Specialist, restorative dentist to achieve an treatment planning, which can be
Department of Oral & Maxillofacial Surgery, optimal aesthetic outcome, in particular sourced from other texts,16 it is
Charing Cross Hospital, London.
through new abutment designs that pertinent to point out the need to

170 Dental Update – May 2001

 I M P L A N TO L O G Y

Alveolar form Presence or absence of bony defects

hole that can be filled with gutta-
percha for radiographic examination is
Alveolar volume Available bone height and width drilled through the long axis of the
Vital structures Location of neurovascular structures, sinuses, nasal cavity
template (Figure 4). When worn during
the radiographic examination this will
Soft tissues Presence or absence of keratinized tissues and interdental papillae not only demonstrate the relative
Surgical access Optimal implant orientation
position of the tooth on the
radiograph but also provide
Table 1. Surgical considerations. information on radiographic distortion
(if the length of the marker is known).
Adjacent teeth Healthy or compromised Any distortion can be calculated by
measuring the length of the marker on
Restorative space Minimum 5 mm for component height (will vary)
the radiograph and dividing it by the
Occlusal relationship Class I > Class II division 1 > Class III > Class II division 2 true diameter. Only in this way can an
accurate measure of bone height be
Occlusal scheme Anterior guidance, canine guidance, group function
determined from a conventional
Tissue defects Labial concavities, vertical tissue defects radiograph.
Occasionally, when there is an
Smile line Cosmetic envelope
apparent bone defect or when implants
Table 2. Prosthetic considerations. are to be placed close to vital
structures, computed tomography
scanning can be employed. When
assess certain factors that directly examination may provide information combined with the diagnostic
impinge upon the suitability of a on many or all of the factors listed in template, the CT scan can provide
candidate for placement of a single the tables, it is desirable that there is unparalleled diagnostic information in
implant. These can be split into surgical continuity of diagnostic information,
and restorative categories (Tables 1 which helps to link the surgical and
and 2). prosthetic assessments. It is well
Although a clinical and radiographic understood that implant treatment
should be ‘restoratively led’ – in other
words, one should determine the
optimal restorative solution and apply
this information to decide on the
surgical requirements to deliver the
desired result.

Diagnostic Evaluation Figure 3. The diagnostic wax-up is converted

Figure 1. Mounted diagnostic study models on
the Denar semi-adjustable articulator ensures
the proposed tooth fits into the appropriate
occlusal scheme.
Figure 2. The wax-up further confirms the
desired form, orientation and inclination of the
proposed restoration, which will affect the
implant position.
into an acrylic template, which derives support
In order to achieve this continuity of from the adjacent teeth. This provides an
information it is imperative that indication of the intended restorative outcome
impressions are taken, along with an during surgery.
earbow and bite registration for the
mounting of articulated study models
(Figure 1). The dental technician can
then determine the optimal tooth form,
orientation and inclination, which can
be indicated on the model via a
diagnostic wax-up (Figure 2). This
helps the clinician to indicate to the
patient the aims and aspirations of the
treatment, without committing to the
sort of visual result that can be Figure 4. A central hole drilled through the long
created on computer and which may axis of the tooth allows the initial osteotomy drills
to pass through, thus relating position and
prove difficult to re-create in practice.
inclination to the underlying osteotomy. This hole
The wax-up is easily converted to an can be filled with gutta-percha for use during the
acrylic template (Figure 3). A central radiographic evaluation.

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 I M P L A N TO L O G Y
Figure 5. This CT scan has been evaluated using the Simplant software and shows the position of the
gutta-percha marker in the mid-axial slice 53. The proposed implant is a 15 x 4.5 Astra ST.
three dimensions. In addition, the
application of new software programs
such as Simplant (Columbia Scientific
Inc., Columbia, Maryland, USA) allows
the clinician to effectively carry out the
placement of an implant interactively,
as the program provides information on
optimal implant dimension, orientation,
inclination, and surrounding bone
density (Figure 5). Should there be a
need for grafting, such as in a sinus lift,
the scan can be further used to
Figure 6. The CT scan has identified limited
bone height above the radiographic marker and
the computer has calculated the need for 0.46
ml of graft material to provide an adequate sinus
lift around the apex of the implant.
172
determine the volume of graft required –
as in the case shown in Figure 6.
CLINICAL MANAGEMENT
Surgical Technique
There have been a number of techniques
recommended for flap design, all aimed
at preserving the interdental papilla.
When wider access is required for
grafting, the need for vertical relieving
incisions dictates that the interdental
tissues should be left attached to the
adjacent teeth. However, when no
grafting is anticipated and limited flap
elevation is appropriate, it is preferable
to opt for sulcular relief around the
adjacent teeth, maintaining the papillae
intact with the flap – as shown in Figure
7. In both cases the horizontal cut is
made to the palatal aspect.
The surgical template is now used to
ensure accurate positioning of the
osteotomy. The use of the template acts
as the cornerstone that links the implant
placement (Figure 8) to the diagnostic
and radiographic evaluation, and hence
the anticipated outcome.
Preparation will vary according to
manufacturer’s protocol, but the implant
dimension should be carefully chosen to
conform as closely as possible to the
desired emergence profile, without
compromising the ‘interdental’ bone
which is essential to support the
interdental soft tissues.
In some circumstances manufacturers
provide implants designed specifically
for single-tooth replacement, in
particular the Astra Tech ST (Astra
Tech, Mölndal, Sweden; see Figure 8)
and the Frialit II (Friadent AG,
Mannheim, Germany) implants. In any
event it is usual to place the head of the
implant approximately 2 mm below the
cemento-enamel junction of the adjacent
teeth, within the cortical bone. In this
way it is possible to ensure a more
aesthetic emergence of the crown
through the soft tissues.
Prosthetic Techniques
Exposure of the implant has historically
been a surgical part of the treatment,
because it clearly involves anaesthesia
and a second incision, with the location
of a temporary healing abutment.
Figure 7. When minimal flap elevation is
indicated, sulcular relief around the adjacent
teeth helps to preserve the papillae and ensures
minimal postoperative morbidity.
Figure 8. Location of the implant should take
account of the diagnostic information, ensuring
the correct buccopalatal, mesiodistal and
coronoapical position.
Dental Update – May 2001
 I M P L A N TO L O G Y
Figure 9. A friction-fit temporary acrylic crown is
fabricated around an Astra ST plastic coping.
The lack of need for cement helps to promote
rapid, unimpaired healing. The crown can also
be easily removed for submucosal irrigation with
topical chlorhexidine.
Figure 10. Prosthetically guided soft-tissue
healing provides optimal interdental tissues and
an appropriate scalloped architecture.
However, advances in our understanding
of how this small surgical procedure
impacts upon the soft tissue result has
led to an increase in the use of one-stage
or transmucosal techniques when
appropriate.
Alternatively, it may be preferable to
maintain a two-stage technique but avoid
the use of healing abutments, which do
not generally conform to the specific
anatomy of the teeth or the individual
circumstances. In this case, most
clinicians will opt for the fabrication and
placement of a temporary crown on the
day of exposure because this allows for
what has been termed ‘prosthetically
guided’ healing of the soft tissues
(Figure 9). In this way it is possible to
obtain a soft-tissue drape, which both re-
creates the scalloped architecture and
maintains the interdental tissue (Figure
10).
The use of friction-fit plastic copings
that bond to cold-cure acrylic, such as
the Astra ST temporary coping or the
CeraOne impression coping, will also
negate the need for temporary cement,
which can impair healing of the soft
174
tissues. This also allows easy removal of crown form and shade conform to the
the temporary crown for weekly cleaning surrounding hard and soft tissue anatomy.
and irrigation, ensuring a healthy In this way even a high smile line need not
outcome (Figure 10). pose a threat to the result (Figure 13).
The final piece of this jigsaw is, of
course, the fabrication of the crown. In
the first instance it is desirable that the
master model be poured up to incorporate REFERENCES
1. Adell R, Lekhom U, Rockler B, Brånemark P-I. A
a soft silicone ‘gingival mask’. This 15-year study of osseointegrated implants in the
provides the technician with additional treatment of the edentulous jaw. Int J Oral Surg
visual information to aid in the 1981; 10: 387–416.
2. Arvidson K, Bystedt H, Frykholm A, von Konow L,
sculpturing of the cervical tooth form. Lothigius E. Five-year prospective follow-up report
In an effort to enhance the life-like of the Astra Tech Dental Implant System in the
nature of the result, a number of treatment of edentulous mandibles. Clin Oral
manufacturers produce ceramic Implant Res 1998; 9: 225-234.
3. Makkonen TA, Holmberg S, Niemi L, Olsson C,
abutments, which helps to avoid the risk
of altering the soft-tissue colour due to
the presence of subgingival metal. More
recently, the application of the Procera
technique (Nobel Biocare, Gothenburg,
Sweden) has provided the implant
prosthodontist with the same potential to
enhance aesthetics as is provided by the
increasing variety of ceramic and
composite materials used in conventional
dentistry. The Procera technique can be
used on most of the implant abutment
designs from the various manufacturers. Figure 11. A Procera core is milled to replicate
the desired form. In this photograph it is possible
It is based on a CAD/CAM milling to appreciate the internal octagonal design of the
concept, whereby a wax-up of the core definitive abutment.
and die (or in the case of an implant, the
abutment analogue) is scanned and
replicated by milling a solid block of
ceramic (Figure 11). The crown is then
built up using All-Ceram porcelains
(Nobel Biocare, Gothenburg, Sweden) to
achieve the final result (Figure 12).
CONCLUSIONS
Although the placement of a single Figure 12. All-Ceram porcelains are then used
to produce an all-ceramic crown of high
implant into a single unit space might at aesthetic quality and strength. The crown
first appear a relatively simple task, it is appears to emerge from the gingival drape in a
one that is rated as the most challenging natural manner.
by experienced implantologists.
In the first instance, the juxtaposition
of two normally healthy natural teeth
means that there is little room for error in
the aesthetic outcome. This is made all
the more crucial given that most single-
tooth implants are placed in the anterior
maxillary segment, and thus fall well
within the cosmetic envelope.
Only the most fastidious treatment Figure 13. The high lip line does not threaten
planning and diagnostic assessment will the aesthetic outcome, and allows the patient to
ensure that implant placement as well as smile broadly, for all to see.
Dental Update – May 2001

Tammisalo T, Peltola J. A 5-year prospective clinical
study of Astra Tech dental implants suppor ting
fixed bridges or overdentures in the edentulous
mandible. Clin Oral Implant Res 1997; 8: 469–475.
4. Buser D, Weber HP, Brägger U, Balsiger C. Tissue
integration of one-stage ITI implants: 3-year
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Implant 1991; 6: 405–412.
5. Cox JF, Zarb GA. The longitudinal clinical efficacy
of osseointegrated dental implants: A 3-year
report. Int J Oral Maxillofac Implant 1987; 2: 91–
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6. Babbush CA, Shimura M. Five-year statistical and
clinical observations with the IMZ two-stage
osteointegrated implant system. Int J Oral
Maxillofac Implant 1993; 8: 245–253.
7. Stultz ER, Lofland R, Sendax VI, Hornbuckle C. A
multicentre 5-year retrospective survival analysis of
BOOK REVIEW
Orthodontic Materials. Scientific and
Clinical Aspects. William A. Brantley and
Theodore Eliades (editors). Thieme,
Stuttgart, New York, 2001 (310 pp., £58.75).
ISBN 3 13 125281 2 655.
This hard-backed textbook, edited by
William Brantley and Theodore Eliades,
brings together a wealth of information
related to scientific and clinical aspects of
orthodontic materials through its
impressive mix of European and American
contributors. There are 15 chapters, each
supplemented with a useful reference list.
Each chapter is well illustrated with high
quality line diagrams and photographs.
The book also includes an appendix listing
the contact details of major orthodontic
materials companies which will be very
helpful to all readers.
The structure and properties of
orthodontic metallic, ceramic and
polymeric materials are covered in Chapter
1, followed by mechanics and mechanical
testing of orthodontic materials in Chapter
2. The latter includes sections on bending
tests, as well as measurement of bond
strength, fracture toughness and fatigue
behaviour. Both of these chapters are easy
to follow and understand. Chapter 3
presents a most comprehensive array of
instrumental techniques for the study of
orthodontic materials, ranging from X-ray
fluorescence spectrometry and electron
probe microanalysis through to differential
scanning calorimetry. Chapter 4 is devoted
to orthodontic wires and the specifics
related to gold alloy, stainless steel,
Dental Update – May 2001
I M P L A N TO L O G Y
6200 Integral® implants. Compend Contin Educ 1993;
14: 478–486.
8. Laney WR, Jemt T, Harris D et al. Osseointegrated
implants for single-tooth replacement: Progress
report from a multicenter prospective study after
3 years. Int J Oral Maxillofac Implant 1994; 9: 49–54.
9. Jemt T, Lekholm U, Gröndahl K. Single implant
restorations ad modum Brånemark. A three year
follow-up study of the development group. Int J
Periodont Restor Dent 1990; 5: 341–349.
10. Schmitt A, Zarb GA. The longitudinal clinical
effectiveness of osseointegrated dental implants
for single-tooth replacement. Int J Prosthodont
1993; 6: 197–202.
11. Norton MR. The Astra Tech single tooth implant
system: A report on 27 consecutively placed and
restored implants. Int J Periodont Restor Dent 1997;
17: 575–583.
12. Priest G. Single-tooth implants and their role in
cobalt-chromium-nickel, beta-titanium and
nickel-titanium wires are described. There
are also sections on clinical selection and
the future of orthodontic wires.
Enamel etching and bond strength are
covered in Chapter 5. The effects of
important variables on bond strength,
together with the results of related
laboratory and clinical trials, are
summarized. Chapter 6 gives a very
thorough overview of oral microbiological
changes with fixed appliance therapy,
long-term enamel alterations due to
decalcification and caries prophylactic
aspects. Bracket types and bracket slot-
archwire friction are dealt with in Chapter
7, which then leads the reader into Chapter
8 on elastomeric ligatures and chains.
Chapters 9 and 10 deal with orthodontic
adhesive resins and composites and give
a clear account of all available bonding
agents. Cements and impression materials
are presented in Chapters 11 and 12,
respectively, while bonding to non-
conventional surfaces (ceramics, casting
alloys, dental amalgam, acrylic resins and
implant attachments) is discussed in
Chapter 13. The final two chapters are
timely and highlight the principles of
biocompatibility, as well as the important
areas of allergic reactions and safety
concerns related to orthodontic materials.
Overall this is a very readable and well
crafted textbook. It fills a gap in the
orthodontic literature and will be of great
value to all practising orthodontists, as
well as those involved in laboratory-based
research related to orthodontic materials.
D.T. Millett
University of Glasgow Dental School
preserving remaining teeth – A 10-year survival
study. Int J Oral Maxillofac Implant 1999; 14: 181–
188.
13. Jaggers A, Simons AM, Badr SE. Abutment selection
for anterior single tooth replacement. A clinical
report. J Prosthet Dent 1993; 69: 133–135.
14. Wannfors K, Smedberg. A prospective clinical
evaluation of different single tooth restoration
designs on osseointegrated implants. A 3-year
follow-up of Brånemark implants. Clin Oral Implant
Res 1999; 10: 453–458.
15. Norton MR. An in vitro evaluation of the strength
of an internal conical interface compared to a butt
joint interface in implant design. Clin Oral Implant
Res 1997; 8: 290–298.
16. Norton MR (ed.). Patient assessment and
radiographic evaluation. In: Dental Implants. A Guide
for the General Practitioner. London: Quintessence,
1995; pp.15–31.
ABSTRACT
CAN YOU ETCH PULPS – THE
DEBATE CONTINUES!
Human Pulpal Response to Direct Pulp
Capping with an Adhesive System. J.C.
Pereira, A.D. Segala and C.A.S. Costa
American Journal of Dentistry 2000; 13:
139–147.
Fifty-one sound human premolars
scheduled for orthodontic extraction
had their pulp horns exposed with a
diamond bur. Following careful sterile
cleaning, the pulps were capped with
either an adhesive system or calcium
hydroxide, followed by a composite
restoration.
There were very few complaints of
pulpal symptoms from the patients
during the investigation. However, the
clinical findings did not correlate with
the histological findings. The teeth were
extracted after standard short- or long-
term time intervals, and were processed
for light microscope examination. The
teeth restored with calcium hydroxide
showed no inflammation, and evidence
of repair and dentine bridge formation in
long-term cases. The cases treated by
an acid-etched adhesive system showed
a persistent mild inflammatory pulp
response, with no evidence of healing or
bridge repair.
It is concluded that further
experiments and investigations must be
carried out before this technique can be
recommended.
Peter Carrotte
Glasgow Dental School
175