Tooth-implant Connection: A Literature Review.

World Journal of Dentistry 2012;3(2):213-219.

 INTRODUCTION
 Every historical truth should be evaluated precisely with
development in information and technology. This statement also
applies to tooth-implant connection. It appears that connecting
tooth to implant despite this historical truth that ‘they cannot be
directly connected’ is a useful option in appropriate cases.
 Based on declaration by ‘Academy of osseointegration’ in 2001,
one of the most argued issues in the field of fixed partial dentures
(FPDs) support is probably the combination of teeth and implants.
 The history of connecting implant to the tooth dates back to early
1980s, when there was no implant with antirotational feature, and
connecting the implant to the natural tooth or another implant
was an obligation to prevent rotation of the restoration and its
related complications, such as screw loosening or fracture.
 In 1988, Dr John Beumer of the UCLA
university introduced the first screw- retained
abutment with anti-rotational feature:‘The
UCLA abutment’.
 With this invention, creation of freestanding

implant restoration without the obligation of

connecting it to other implants and teeth
became feasible for the first time.
 Today connecting the implant to the tooth is

not always a necessity but there are

conditions where such a connection is our
first choice .
 However, because of inherent differences
between these two components (tooth and
implant) particularly in their supporting
mechanisms and survival rate, as well as a
higher risk of technical complications in tooth-
implant supported fixed prosthesis, this
procedure has been a topic of argumentation
and controversies in last decades.
 Differences between dental implants and teeth

Natural teeth Implant

Osseointegration and
Junction Periodontal ligament.
functional ankylosis.
Hemidesmosomes & Hemidesmosomes and
basal lamina(lamina basal lamina(lamina
Junctional epithelium (JE)
lucida & lamina densa lucida, lamina densa &
zones) sublamina lucida)
2 group: parallel &
circular fibers.
13 groups: perpendicular
Connective tissue (CT) No attachment on
to tooth surfaces.
implant surface and
bone.

Biological width (BW) BW: 2.04–2.91 mm BW: 3.08 mm

Blood supply High Low

 Natural tooth Implant

Pressure sensivity High Low

Axial movability 25-100µm 3–5 µm

Two phased.
Primary: complex and Linear and elastic
Movement type nonlinear movement. movement.
Secondary: linear and
elastic movement.

Hinge point in lateral 1/3 apex region of the

Crestal Bone
movements root.

Widening in periodontal Loss of screw or fracture,

ligament, movement, fracture in abutment or
Overload findings
abrasion surface, prosthesis, bone loss,
fremitus, and pain. and implant fracture.
 Rationale of using tooth-implant connection

 The reasons of connecting the tooth to the implant are

summarized in five categories:
1) To gain support from the tooth or implant:
As an example in the patients with bruxism, properioception of
the tooth may help to reduce applied stresses to the implants.
2) The absence of other options:
Because of systemic, local or financial limitations, bone
augmentation and insertion of additional implants are not always
possible.
 3)To preserve a key tooth or teeth with good
prognosis.

 4) To provide stability against rotational forces.

 5) For esthetic reasons:

Implants unlike natural teeth always present
challenges with regard to esthetic.
Furthermore, retaining the tooth preserves the
adjacent papillae
 Methods of tooth-implant connection

 Celso Hita-Carrillo has classified the methods of

connection into two main groups:

Rigid Connection Non-rigid connection

 Rigid connections could be screw retained abutments,

coping with permanent cement and soldered connectors
 Nonrigid connections could be in the form of
attachment or intermobile element (IME).
 Several different solutions have been proposed to
compensate for different resiliencies of the tooth
and implant: Internal flexion elements in the
implant- abutment connection, telescopic coping
that are cemented or freefloating and internal
nonrigid keyway attachments (stressbreakers)
Rigid connection
 Authors have different opinions about rigid
connection.
 Some authors believe that rigid connection of the
teeth to the implants is not rational due to the
adverse effects on the implant in long-term.
 It will produce greater marginal bone loss, with a
corresponding increase in probing depth around
the supporting abutment (tooth or implant).
 Clinicians, who advocate connecting the tooth to
the implant rigidly, accept the differential mobility
of the implant and natural teeth, but they seem
there is sufficient flexibility in the implant complex
to compensate this and allow sharing of the load.
 Rigid connection achieves better outcomes with
regard to avoiding dental intrusion.
 Finite element analysis showed greater stress
concentrated on the neck of the implant and the
connector near the tooth.
 Lin CL in 2006 reported microgap formation
between the implant abutment and the fixture
under the lateral occlusal forces
Non-rigid connection
 A. Intermobile elements (IME)
 There are few studies about these elements. It
has been said that these elements provide
flexibility to compensate for the mobility of the
tooth.
 Uysal in 1996 reported that these elements
reduced the strain up to 60% compared to the
rigid internal elements.
 In an in vitro study, it was demonstrated that
IME did not contribute to the flexibility of the
system and the bending force was transmitted
to the retaining screw of the implant abutment.
B. Attachments
 It has been mentioned that the attachments

reduced the level of stresses in the bone, coz it

breaks the stress transfer process and more
efficiently compensates for dissimilar mobility of
the tooth and implant but intrusion in 3 to 4% of
the cases has been reported to cause cantilever
formation on the implant and increase the
unfavorable stress values in the implant and
prosthesis.
 Hoffmann reported that nonrigid connections
drastically reduce the stress on the superstructure
while increasing the forces on the supporting teeth
and implants
 Fig 1: Diagram of tooth to
implant connection with
attachment placed between the
pontic and the tooth.

 Fig 1 illustrates how most clinicians connect implants to

teeth. In this system if we assume that the implant
restoration and pontic segment are rigid, then no load
sharing is possible with the tooth, since the tooth has
much more mobility than the implant. In addition the
tooth can intrude. So with this system there is a cantilever
to the implant support placing stress on the screw joint
and to the implant itself.
 Fig 2: Diagram of tooth to implant
connection with attachment placed
between the implant supported
restoration and pontic.

 Figure 2 illustrates a more rational connection of

implants and teeth; in this system the tooth-pontic
segment can move independently of the rigid
implant and occlusal loads on the pontic area can
be shared between tooth and implant abutments.
 Fig 3:Diagram of the suggested
method of connecting implants
to teeth with connection using
a deep removable partial
denture-type rest with the rest
seat on the implant supported
restoration.

 Fig 3: is a modification of the idea presented

in Fig 2; the attachment is substituted with a
deep removable partial denture-like rest
which allows more freedom of movement.
This is the method used when no choice
remains but to connect teeth to implants.
 Lang et al determined in their meta analysis
that most of the technical complications
associated with TISPs occurred when there
was a nonrigid connection between abutment
teeth. They also concluded screw-retained
restorations needed more maintenance than
cemented crowns.
 In summary, the literature indicates use of

rigid connections between teeth and implants

in a TISP usually reduces mechanical
complications to a level that appears to be
comparable with problems associated with an
ISP.
Advantages of connecting teeth to
implants
 Cavicchia reported that problems such as
loosening and fracture of fixation screws and
abutments, ceramic fracture and tooth
migration seem to occur more frequently in
free standing implants compared to the tooth
connected restorations. This result can be
related to the decrease bite force in tooth-
implant supported prosthesis because of
tooth related proprioception.
 Causes of potential problems
 The virtual problems refer mainly to
the difference in the tooth and
implant supporting mechanisms. PDL
causes greater movement in the
tooth.
 Lateral movement of the teeth is
about 56 to 108 µm in comparison
to 10 to 50µm in the implant
 Apical movement of the tooth is 25
to 100µm and that of the implant is
3 to 5µm. When force is applied to
the pontic connecting the tooth to
the implant, this difference can cause
greater stress on the implant.
 This movement is primarily due to bone flexure.
Therefore, if a three-unit TISP is functioning,
differences in mobility patterns between a tooth
and an implant could result in the tooth being
depressed into the socket, which might cause
the prosthesis to be cantilevered off the implant
causing ↑ed stress on crestal bone around implant .

 Theoretically, this could increase stress on the

implant and lead to both technical and biologic
complications
Technical complications Biological complications
 The other cause of potential problems is
difference in survival rates of the tooth and
implant. The tooth, as opposed to the implant,
might decay or need endodontic therapy. These
problems may cause the whole system failure.
 In the studies on survival rate of the tooth
supported FPDs vs the implant (ITI system), the
difference was noticeable whereas tooth-implant
supported FPDs (TISP) in comparison to the
implant supported FPDs (ISP) do not significantly
show more failure rate.
 In other studies, implant survival and prosthesis
success rate in TISP have been evaluated, the
values being between 80 and 100%.
 Intrusion of Tooth

 When implants were connected to natural

teeth to support a fixed partial denture, the
incidence of tooth intrusion varied
(movement of a tooth out of its crown in an
apical direction)

A TISP with an implant at site

that is connected via a
nonrigid connector to a natural
tooth showing intrusion of the
tooth and female portion of
the interlock on tooth.
 An assessment by Reider and Parel found 50% of
intrusions happened in individuals with parafunctional
habits, specifically bruxism & also noted it usually
occurred in patients with nonrigid attachments.
 Intrusion of teeth associated with nonrigid attachments
usually contained the female portion of the keyway in
the natural tooth.
 Some authors reported no intrusion of teeth associated
with rigid connectors
 In recent studies with long term follow ups, intrusion
has been reported even in cases with rigid attachments
and the rate of bone loss was reported lesser in implants
with nonrigid attachments than rigid attachments
Pesun IJ. Intrusion of teeth in the
combination implant-to-natural
tooth fixed partial denture: A
Review of the Theories. J Prosthod
1997;6:268-277
 Reasons for tooth intrusion
Several theories have been presented to explain
the intrusion of natural teeth in combination
implant to-natural-tooth fixed partial dentures,
including
 1) DISUSE ATROPHY:
 Rieder and Parel stated that, fibers of the PDL,

when not in use may atrophy when a tooth is

splinted to a dental implant.
 2) DIFFERENTIAL ENERGY DISSIPATION:
 This theory suggests that stress waves are

induced by loading the fixed partial denture

suprastructure. In turn, these stress waves
are transmitted to the abutments.
 The natural tooth receives an abnormally high
level of the mechanical stress because
implants are quite rigid & so are the energy
conservative structures. The absorbed energy
results in the stimulation of osteoclastic
activity in the PDL which produces apical
migration of the abutment tooth.
 3) MANDIBULAR FLEXURE AND TORSION

 The mandible flexes and

torques with every
opening and closing of
the mandible.
 With the opening of the
mandible, there is a
narrowing of the
intermolar width.
 This narrowing occurs
due to the forces
produced by the muscles
of mastication & muscles
of facial expression,
pulling the angles of the
 While PDLs can absorb small changes in tooth
position, larger discrepancies may produce difficulties.
 For a patient in whom implants and natural teeth are
splinted together, an inclined plane effect may be
established coz of the flexure of mandible & the
rigidity of the framework pushing the tooth laterally &
intrudes it out of the framework
 4) FLEXURE OF FIXED PARTIAL DENTURE
FRAMEWORKS
 As a fixed partial denture is placed
in function, the framework can flex.
As one of the functions of the PDL
is to act as a shock absorber for the
teeth.
 When natural teeth are used as
abutments on both ends of a FPD,
mandibular flexure and flexure of
fixed partial denture frameworks do
not result in intrusion of teeth as
teeth have PDLs to absorb forces.
 Whereas in TOOTH –IMPLANT FPDs
there is tooth on side acting as
shock absorber & implants on other
side which get osseointegrated in
the bone.
 5) IMPAIRED REBOUND MEMORY
 According to the impaired rebound memory theory, the
constant pressure on the PDL of the tooth compresses
PDL & causes to lose its elastic memory and allows to
remodel at the new, less-traumatic position.
 The new position that the tooth takes up is apical to
the tooth's original position.
 The tooth will continue to move farther apically (ie,
intrude), until no compressive forces are placed on the
PDL.
 6) DEBRIS IMPACTION OR MICROJAMMING

 Debris impaction occurs

when food and oral debris
get under components of
casting .
 Micro-jamming of food
particles under an attachment
is said to cause a similar
intrusion as impaction of
particles will prevent the
tooth from returning to its
original position.
 Compression of the PDL is
observed. Remodeling of the
bone at the tooth's new
position occurs as long as
force is placed on the teeth.
 7) RATCHET EFFECT
 The ratchet effect and impaired
rebound effects are similar.
 Vertical forces on a tooth result in
apical movement of the tooth. Once
the tooth is pushed down under the
forces of occlusion, the tooth is
prevented from returning to its
original position .
 It is unclear whether the etiology of
the binding occurs with the tooth in
the socket or within the attachment
apparatus. The orthodontic result is
the same, with the tooth being
unable to return to its normal
orientation in the socket and the PDL
remodeling to a new configuration.
To avoid this dilemma, Clarke et al. has advised;

 (i) Selection of the appropriate patient (avoidance of those with

bruxism),

 (ii) The use of rigid connectors.

 (iii) Avoid making coping on teeth which will be used as an

abutment.

 (iv) Proper preparation of the abutment (parallel walls) to ensure

maximum retention and resistance.

 (v) Permanent cementation of prostheses

 In dental literature reported that intrusion can be prevented with

using rigid connectors, bone resorption can be reduced with
using nonrigid connectors.
 Potential risks of connecting the
tooth to the implant

A. Overloading:
 Connecting an implant to the tooth depends on

occlusal force factors, tooth mobility and the number

of other implants already in the mouth can overload
the implant and its peripheral bone.
 The stress of transitional loads, coz of viscoelastic

properties of the PDL, is better distributed whereas

static load causes progressive deformation of the PDL
and so, the tooth would sink into the alveolus & then
the bridge would act as a cantilever on the implant
and overstress it.
B. Loss of irretrievability (when the screw is loosened or
broken).
C. Progressive bone loss :
 In a study with the follow-up ranging from 1.5 to 15

years, the authors found a statistically significant

difference in marginal bone loss between ISP and TISP,
yet there are controversies about this result.
 In one study, slight apposition of the marginal bone

was noted around the implant in TISP. The stability of

the marginal bone over time in this study was in
accordance with similar findings in other studies.
 Guidelines for TISP
The literature supports the idea that a rigid connection between a
tooth and an implant usually precludes intrusion of teeth. The
following guidelines can help prevent intrusion of teeth and enhance
patient care when contemplating fabricating a TISP.

 1. Select healthy teeth—

periodontally stable and
in dense bone.
 2. Rigidly connect the

tooth and implant (no

stress breakers),employ
large solder joints (4mm)
to enhance rigidity, or
use one-piece castings.
 3. Avoid telescopic crowns (no copings).

4. Provide retention form

with minimal taper of axial
walls on abutment teeth.
Enhance resistance form
with boxes and retention
grooves if the clinical crown
is not long.
 When implant act as a pier
abutment b/w the 2 natural teeth
the difference in movement
between implant and tooth may
increase the complication rate
compared, with one tooth joined
to two implants.

A better option is to graft the sites and place

implants in terminal abutment locations and to
fabricate an independent prosthesis.
When grafting and additional implants are not an
option, a nonmobile attachment may be used to
prevent the pier implant from acting as a fulcrum.
 When a natural tooth serves as
a pier abutment between two
or more implants, the tooth
may act as a living pontic. No
stress breaker is needed in this
situation.

 5. Parallel the implant abutment to the preparation of

the tooth and use a rigid connection.
 6. Use permanent cementation (no screw retention or
temporary cementation).
 7. The bridge span should be short.
 Preferably, place one pontic between two abutments.
However, with additional tooth or implant support or
cross-arch stabilization, additional pontics can be
used.
 8. Occlusal forces should be meticulously
directed to the opposing arch.

Lingualized occlusal scheme

with palatal cusps of max
restorations contacting
occluding areas of mand.
teeth. Lateral excursions are
free of eccentric contacts.

 9. In general, do not use TISPs in patients with

parafunctional habits. If they are treated with
TISPs, treat the case by maximizing the
number of implants and splinting.
 10. Cantilever extensions should be used
cautiously; however, they may be employed when
tooth or implant support is adequate, eg,
cantilever-implant-implantpontic-tooth-tooth.

 11. TISPs in patients with uncontrolled caries

should be avoided; ISPs are preferred.
 12. Pulpless teeth with extensive missing
coronal tooth structure or root canal anatomy
that is inadequate to predictably retain a core
or post and core should not be used in a TISP.
 13. High-risk TISPs (eg, multiple adjacent

pontics, double cantilevered pontics) or

prostheses with minimal abutment support
should be expected to have a higher failure
rate even though these treatment plans may
benefit certain patients.
 14. In the esthetic zone, if a papilla or
papillae is crucial for esthetics or function
(eg, phonetics), consider using natural teeth
(TISPs) because the supracrestal gingival
fibers associated with healthy teeth will
provide interproximal soft-tissue support.
 15. If appropriate case selection principles
are applied (eg, minimal caries rate, good
root anatomy, minimal tooth mobility,
adequate retention and resistance form, rigid
prosthesis design, adequate overall abutment
support for the prosthesis), then combining
implants and natural teeth may permit
segmentation of a prosthesis into smaller
sections, which may provide an alternate
treatment plan to a large one-piece bridge.
REVIEW OF LITERATURE
Mamalis A, Markopoulou K, Kaloumenos K, Analitis A.
Splinting Osseointegrated Implants and Natural Teeth in
Partially Edentulous Patients: A Systematic Review of the
Literature. J Oral Impl 2012;38(4):424-34

In this study, a MEDLINE (PubMed) search was

conducted to retrieve relevant articles published
between January 1980 and May 2010.
Furthermore, a manual search of all full text
articles and related reviews was applied.
 From a total yield of 3290 titles and abstracts,

only 16 studies concerning combined tooth-

implant supported FPDs met the inclusion
criteria. Five were retrospective cohort studies
and 11 were prospective studies.
 For the 5-year follow-up - survival rate was 94.73% &
failure was 1.08%
 For the 10-year follow-up , survival rate was 77.71%
and failure rate was 2.51%.

 Implant failure and survival rates were estimated for

all 16 studies. Of the original 1740 implants that were
placed, 117 were lost; 25 were lost before functional
loading(1.6%) and 68 were lost during function(7.4%).

 Loss of abutment teeth was primarily due to caries,

fractures, endodontic complication, and periodontitis.
 Tooth-to-implant supported FPD survival rates -
After an observation period of 5 years, 2.76% of the
abutment teeth and for 10 yrs – 5.64%.
Lindh T, Dahlgren S, Gunnarsson K, Josefsson T, Nilson H,
Wilhelmsson P, Gunne J. Tooth-implant Supported Fixed
Prostheses: A Retrospective Multicenter Study. Int J
Prosthodont 2001;14:321–328

 AIM: to investigate the implant survival rate and

loss of marginal bone, as well as indications and
complications pertinent to this form of implant
therapy.
 Materials and Methods: The study comprised 185

implants in 111 patients from six different clinics

in Sweden. The registrations included indications
for treatment, failure of implants, radiographs
from baseline and follow-up, and information on
complications.
 Results: The cumulative implant survival was
found to be 95.4% up to 3 years of follow-up.
The marginal bone level at baseline was lower
in the maxilla compared with the mandible, but
any further loss did not differ between the jaws.
 The most severe complication other than loss of
osseointegration (6/185) or periimplant
infections (4/183) was intrusion of the abutment
teeth, which occurred in 5% of the cases. In all
instances, the intrusion was seen in constructions
with non-rigid connection between the implants
and teeth.
T.M. Mostafa et al. Clinical and radiographical comparative
evaluation of implant connected versus tooth-connected
implant supported partial dentures. Tanta Dental Journal
2013;10:145-152.
 AIM- the purpose of this study was to test the null
hypothesis that there is no difference in connecting
implants to natural teeth and connecting implant to implant
to support fixed detachable mandibular partial dentures.
 Materials & methods - 20 partially edentulous patients with
age range (25-50) years old of mandibular class II Kennedy
with missing all mandibular molars were equally divided into
two groups receiving a three unit fixed detachable screw
retained partial denture,
 Group (I):Patients with unilateral missing mandibular molars
and premolars. Two implants were placed at the mandibular
first premolar and first molar areas.
 A three unit fixed
detachable screw
retained partial
dentures were
fabricated to be
screwed to the
implants after twelve
weeks
 Group (II): Patients were selected with missing
mandibular molars and second premolar,
having the mandibular first premolar in a good
periodontal health and good bone support.
 An implant was placed at the mandibular first
molar area and preparation of the first premolar
was done and a coping was cemented to the
tooth with permanent cement.
 A three unit fixed
detachable partial
denture was
fabricated with a
telescopic crown
cemented to the
natural tooth with a
provisional cement
(TempBond) and
screw retained to the
implant after twelve
weeks
 Each case was evaluated clinically and radiographically
at base line (partial denture insertion) and after 3, 6
and 12 months. Data were collected and statistically
analyzed using repeated measures way ANOVA test.
 Results: There was no statistical significance
difference between the two groups (P > 0.05).
 Conclusions: The tooth-implant supported prosthesis,
is an equal predictable treatment as the implant
supported prosthesis concerning implant survival and
loss of marginal bone in the short term evaluation.
 Gunne J, Astrand P et al.Tooth-Implant and
Implant Supported Fixed Partial Dentures: A
10-Year Report. Int J Prosthodont
1999;12:216-221.
 Purpose: The purpose of this longitudinal study with 10
years of follow-up was to evaluate the use of short
implants supporting fixed partial dentures (FPD) in the
posterior part of the mandible, and to compare implant
supported FPDs to tooth-implant supported FPDs,
 Materials and Methods: 23 patients with residual
mandibular anterior teeth were selected and each patient
received FPDs unilaterally.
 On one side the FPD was supported by two implants, and
on the other side by one implant and one tooth, thus
permitting intraindividual comparison.
 The distribution of the two types of FPDs in each jaw was
randomized. Implant success rates, marginal bone
changes, and mechanical complications were studied.
 Results: The tooth implant connection did not
demonstrate any negative influences on the
overall success rates for the 10-year period,
nor were the shorter implants found to be
less favorable.
 Conclusion: It is suggested that a prosthetic

construction supported by both a tooth and

an implant may be recommended as a
predictable and reliable treatment alternative
in the posterior mandible.
 Conclusion
 Although the best option in partially edentulous
patients appears to be complete implant-supported
prosthesis, there are specific conditions in which
the dentist should select between connecting the
implant to the tooth in a fixed partial denture or
using a removable denture.
 Based on literature reviewed, using implant-tooth
splinting can be reliable treatment option in
properly selected patients.
 This method has its own advantages,
disadvantages, risks and complications, but what
justifies its application is risks- benefit evaluation
with attention to patient requirements.
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