PART 4:  ORAL IMPLANTOLOGY
SECTION I:  BIOLOGY, DIAGNOSIS, BIOMECHANICS, AND TREATMENT PLAN
CHAPTER 74 
Peri-implant Anatomy, Biology, and Function
Joseph Fiorellini | Keisuke Wada | Hector Leonardo Sarmiento | Perry R. Klokkevold
CHAPTER OUTLINE
Implant Geometry (Macrodesign) Hard Tissue Interface
Implant Surface Characteristics Soft Tissue Interface
(Microdesign) (e-only)
For online-only content on endosseous implants, root form (cylindrical) implants, transmandibular implants, subperiosteal
implants, and implant surface characteristics (microdesign), go to the companion website at www.expertconsult.com. Some
figures may be out of numeric order in this printed chapter.
The history of modern implant dentistry began with the introduction
of titanium implants.41 In the 1950s, Per-Ingvar Brånemark, a Swedish
professor of anatomy, had a serendipitous finding while studying
blood circulation in bone that became a historical breakthrough in
medicine. He discovered an intimate bone-to-implant apposition with
titanium that offered sufficient strength to cope with load transfer.
He called the phenomenon osseointegration and developed an implant
system with a specific protocol to predictably achieve it. The implants
were used to anchor prosthetic replacement teeth in the edentulous
jaw,27 and the first patient was successfully treated in 1965.30,72
Subsequent clinical studies proved that commercially pure (CP)
titanium implants, placed with a strict protocol, including an unloaded
healing period, could predictably achieve osseointegration and retain
a full-arch prosthesis in function with long-term success (15 years).8
FLASH BACK
The history of modern implant dentistry began with the introduction of
titanium implants. In the 1950s, Per-Ingvar Brånemark, a Swedish professor
of anatomy, had a serendipitous finding while studying blood circulation
in bone that became a historical breakthrough in medicine. He coined the
phenomenon osseointegration and developed an implant system with a
specific protocol to achieve it predictably.
Today, implant designs, surgical placement techniques, healing
times, and restorative protocols continue to evolve with the goal of
improving outcomes. It is important for clinicians to know peri-implant
anatomy, to understand the biology, and to appreciate the functional
capacity of osseointegrated implants. This chapter reviews implant
geometry and surface characteristics, as well as the anatomic and
biologic relationships of peri-implant tissues.
732
Clinical Comparison of Teeth and
Implants
Conclusion
Implant Geometry (Macrodesign)
Numerous implant systems with various geometric (macrodesign)
designs have been developed and used before the current implant
systems in use today. Previous implant designs included blade vents
(narrow, flat shape; tapped into bony trough prepared with rotary
burs),69 press-fit cylindrical (bullet shape; pressed or tapped into
prepared hole),102 subperiosteal (custom-made framework; adapted
to the surface of jawbone),37 and transmandibular (long rods or posts;
placed through the anterior mandible).107 Some of these implant
systems were initially stable and appeared to be successful over
short-term periods (e.g., 5 years) but failed to remain stable, became
symptomatic or loose, and failed over longer periods.100,124 Lacking
predictability, these implant systems are no longer used.
Since the time of the Brånemark studies, millions of patients
have been treated worldwide using variations of these techniques
with implants of different geometries and surface characteristics.
Similar research including that of André Schroeder in Switzerland
in the mid-1970s contributed to the success of endosseous dental
implants. The serendipitous finding of Brånemark was that when a
hole is prepared into bone without overheating or otherwise traumatiz-
ing the tissues, an inserted biocompatible implantable device would
predictably achieve an intimate bone apposition, as long as micromove-
ments at the interface were prevented during the early healing period.
The history of the research endeavors in Sweden provides a better
understanding of the relevant biologic parameters involved.72
The macroscopic configuration of implants has varied widely;
the most common types are listed in Box 74.1. Currently, most
endosseous implants have a cylindrical or tapered, screw-shaped/
threaded design. The disastrous results with other implant configura-
tions were largely responsible for the evolution toward the current
popular designs.13 See online for a detailed description of the various
 CHAPTER 74  Peri-implant Anatomy, Biology, and Function 732.e1

Abstract
Osseointegrated dental implants can provide patients with predictable
tooth replacement options, including but not limited to an implant-
retained removable prosthesis and an implant-supported fixed
prosthesis. Although implants are predictable and long lasting, there
are biologic and functional problems. It is essential for clinicians to
understand and appreciate the biologic aspects of dental implant
therapy, including bone biology, the phenomenon of osseointegration,
and the relationship of peri-implant soft tissues with dental implants.
This chapter reviews implant design, implants surface characteristics,
the biology of osseointegration, and the interface between implants
and soft tissues. The functional aspects of osseointegrated dental
implants is also considered.
Key Words
implant geometry
macrodesign
implant surface characteristics
microdesign
hard tissue interface
soft tissue interface
implants
 CHAPTER 74  Peri-implant Anatomy, Biology, and Function
implant designs including blades, pins, disks, root form, transman-
dibular, and subperiosteal implants.
Hard Tissue Interface
The primary goal of implant installation is to achieve and maintain
a stable bone-to-implant connection (i.e., osseointegration).29,30
Histologically, osseointegration is defined as the direct structural and
functional connection between ordered, living bone and the surface of
a load-bearing implant without intervening soft tissues (Fig. 74.1).27,28
Clinically, osseointegration is the asymptomatic rigid fixation of an
alloplastic material (implant) in bone with the ability to withstand
occlusal forces.12,126 The hard tissue interface is a fundamental require-
ment for and an essential component of implant success.
BOX 74.1  Implant Geometry (Macrodesign)
1. Endosseous implants
• Blade like
• Pins
• Root form, cylindrical (hollow and full)
• Disk like
• Screw shaped
• Tapered and screw shaped
2. Subperiosteal (custom frame) implants
3. Transmandibular implants
A B
Fig. 74.1  (A) Three-dimensional diagram of the tissue and titanium interrelationship showing an overall view
of the intact interfacial zone around the osseointegrated implant. (B) Physiologic evolution of the biology of the
interface over time.
733
KEY FACT
Histologically, osseointegration is defined as the direct structural and
functional connection between ordered, living bone and the surface of a
load-bearing implant without intervening soft tissues. Clinically, osseo-
integration is the rigid fixation of an alloplastic material (implant) in bone
with the ability to withstand occlusal forces.
Initial Bone Healing
The osseointegration process observed after implant insertion can
be compared with bone fracture healing. Implant site osteotomy
preparation (bone wounding) initiates a sequence of events, including
an inflammatory reaction, bone resorption, release of growth factors,
and attraction by chemotaxis of osteoprogenitor cells to the site.
Differentiation of osteoprogenitor cells into osteoblasts leads to bone
formation at the implant surface. Extracellular matrix proteins, such
as osteocalcin, modulate apatite crystal growth.123 Specific conditions,
optimal for bone formation, must be maintained at the healing site
to achieve osseointegration.
Immobility of the implant relative to the bone must be maintained
for bone formation at the surface. A mild inflammatory response
enhances the bone healing, but moderate inflammation or movement
above a certain threshold is detrimental.6 When micromovements at
the interface exceed 150 µm, the movement will impair differentiation
of osteoblasts and fibrous scar tissue will form between the bone
and implant surface.91 Therefore it is important to avoid excessive
forces, such as occlusal loading, during the early healing period.
 CHAPTER 74  Peri-implant Anatomy, Biology, and Function
eFig. 74.1  Blade implant shows a large radiolucency, indicating that the
fibrous encapsulation has led to deep pocketing and subsequent bone loss.
Neighboring teeth bear the load of the implant restoration.
Blade Implants
Blade implants were designed and developed by Linkow69 and used
clinically in the 1960s and 1970s. Blade implants were inserted into
the jawbone after mucoperiosteal flap elevation and preparation of
a channel with a high-speed rotary bur. They were tapped into the
narrow trench. One or several posts pierced through the mucoperi-
osteum after suturing of the flaps. After a few weeks of healing, a
fixed prosthesis was fabricated by a classic method and cemented
on top of it.
Because the high-speed drilling leads to extensive bone necrosis
at the histologic level, fibrous scar tissue forms. This allows down-
growth of the epithelium, which leads to marsupialization of the
blade implants (eFig. 74.1).59 If a bacterial infection occurs, it can
lead to an intractable peri-implantitis with ample bone loss. More
important, removal of such implants after complications implies
sacrificing surrounding jawbone. Because of its retentive geometry,
the blade implant cannot simply be extracted or removed by a trephine,
as with a cylindrical or screw-shaped implant.
The interface between blade vent implant and bone was called
fibroosseous integration, which was defined as tissue-to-implant
contact: interposition of healthy dense collagen fibers at the interface
between the implant and bone.14 At that time, the fibrous tissue was
thought to be the replacement of the periodontal ligament119; however,
it was fibrous scar tissue following the bone necrosis initiated by
high-speed drilling. This allows epithelial downgrowth around the
post caused by the bacterial infection, which leads to encapsulation
of blade implant with the fibrous scar tissue.
Most of the studies reported less than 50% success rate for 5-year
duration with the complication of pocket formation exceeding 6 mm,
followed by the significant alveolar bone loss around the implant.36,110
It was also more complicated and invasive surgery to remove the
failed implant, which was sacrificing significant surrounding jawbone.
As a result of the poor long-term success, as well as the high complica-
tion rate, the use of blade vent implants has been significantly reduced.
Removal of failed blade implants often requires significant cutting
and bone removal despite being mobile.
Pins
Although seldom used at present, in the classic technique, three
diverging pins were inserted either transgingivally or after reflection
of mucoperiosteal flaps in holes drilled by spiral drills. At the point
of convergence, the pins were interconnected with cement to ensure
the proper stability because of their divergence. On top of this
arrangement, a single tooth could be installed. In edentulous jaws,
733.e1
eFig. 74.2  International Team for Implantology (ITI) hollow cylinder implant.
Note the hollow geometry, which should provide large bone-to-implant
contact, and holes that theoretically should be favorable for the additional
fixation of the implant.
several of these pin triads could be used to interconnect with a fixed
prosthesis.
As with blade implants, the bone necrosis during drilling leads
to fibrous encapsulation, marsupialization, and loss of the implants
because of infections. A positive aspect, however, is that when such
implants must be removed, removing the connection at the place of
convergence is sufficient to allow easy extraction of each individual
pin. Thus bone loss from removal is minimal.
Disk Implants
Disk implants are rarely used at present. The concept developed
by Scortecci is based on the lateral introduction into the jawbone
of a pin with a disk on top.104 Once introduced into the bone, the
implant has strong retention against vertical extraction forces. Implants
have been used with one, two, and even three disks. Unfortunately,
as mentioned previously for blade implants, the cutting of the
bone by means of high-speed drills leads to a fibrous scar tissue
surrounding the implant, as revealed frequently by peri-implant
radiolucencies. Data on the clinical success of disk implants are mostly
anecdotal.
Root Form (Cylindrical) Implants
The first implant in this category, designed and developed by Schroeder
and colleagues between 1974 and 1985, was called an ITI (International
Team for Implantology) hollow-cylinder, plasma-sprayed, one-stage
implant102 (eFig. 74.2). It was thought that the hollow geometry
should provide large bone-to-implant contact and holes would be
favorable for the additional fixation of the implant. However, the
survival rates were less favorable compared with the other system.7
Thus this system was withdrawn from clinical use.
When discussing cylindrical implants, it is important to distinguish
between hollow and full cylindrical implants. Straumann and cowork-
ers introduced hollow cylinders in the mid-1970s with the ITI
system.111 The idea was that implant stability would benefit from
the large bone-to-implant surface provided by means of the hollow
geometry. It was also thought that the holes (vents) would favor the
ingrowth of bone to offer additional fixation. The same concept was
used in the Core-Vent system developed by Niznick.81 Although it
was not clarified whether the cause was geometry or the associated
surface characteristics (titanium plasma–sprayed surface, titanium
733.e2 Part 4  Oral Implantology
eFig. 74.3  The IMZ implants. The roughened surface of the fixture had
an advantage of higher integration of bone. Conversely, the surface char-
acteristic added to the high frequency of peri-implantitis in long-term use.
alloy), survival statistics were disappointing for hollow cylinder
implants.115
Solid cylindrical implants were used by Kirsch and became
available under the name IMZ, referring to the internal mobile shock
absorber.65 The IMZ system, developed by Kirsch, prevailed in the
market (eFig. 74.3). The characteristic function of this system was
the internal mobile element (IME) shock absorber, which was able
to connect with the adjacent natural tooth. The system presented
successful results in the short term, but long-term success rates were
unacceptable (38% in 10 years), leading to the limited use of this
implant design.50 For this reason, this implant is rarely seen in the
market.
Even when an intimate bone apposition is achieved, extraction
forces on such cylindrical implants lead to strong shear forces at the
bone-to-implant interface. Only the microscopic surface irregularities
offer some mechanical retention by interdigitation of bone growing
onto the implant surface. With a screw-based geometry, forces acting
parallel to the long axis of the implants are dispersed in many
directions.106
Transmandibular Implants
Transmandibular implants were developed to retain dentures in the
edentulous lower jaw. They were indicated for use in the extremely
resorbed edentulous mandible with a minimal alveolar ridge height
less than 10 mm. The implant was inserted through a submandibular
skin incision and required general anesthesia. Two models were
available in the 1960s. The first, called the staple-bone implant, was
developed by Small. It consisted of a splint adapted to the lower
border of the mandible, to which it is fixed by stabilizing pins.108
Two transmandibular screws were driven transgingivally into the
mouth. The reported implant survival rate was 93% after 5 years
and continued to exceed 90% after 15 years.107,109 The other model,
introduced by Bosker, has two metal splints, one below the lower
border of the mandible and one positioned intraorally to connect the
four posts piercing through the soft tissues.24 The Bosker implant
seemed less reliable than the staple-bone implant, achieving only
70% survival after 5 years in the mandibular symphyseal area.115
Both transmandibular implants presented with the gingival hyperplasia
or infection, with the incidence of 10% to 15% of all cases.107 Despite
the good long-term survival data reported (especially for the staple
implant), because of the high incidence of complications and the
necessity of using general anesthesia for implant placement, the
transmandibular implant design is rarely used today.
Subperiosteal Implants
Subperiosteal implants are customized according to a plaster model
derived from an impression of the exposed jawbone, before the
surgery planned for implant insertion. The implant was designed
with several posts, typically four or more for an edentulous jaw,
which passed through the gingival tissues.11
Subperiosteal implants are designed to retain an overdenture,
although fixed prostheses have also been cemented onto the posts.
As a result of epithelial migration, the framework of subperiosteal
implants usually becomes surrounded by fibrous connective tissue
(scar), including the space between the implant and the bone surface.
The marsupialization, as described earlier, often leads to infectious
complications, which frequently necessitates removal of the implant.
Furthermore, while being loaded by jaw function, jawbone resorption
occurs rapidly, resulting in a lack of adaptation of the frame to the
bone surface. As a result of this type of outcome, subperiosteal
implants are now rarely used.
The subperiosteal implant was used in the treatment of atrophic
mandibles. The implant is custom designed to fit the mandibular
jawbone using a plaster model obtained from an impression of the
exposed mandible. It consisted of a cast metal framework with a
subperiosteal component in contact with the bone and a transgingival
component (posts), which were used to retain the dental prosthesis.
The number of transgingival posts on the implants depends on the
number of missing teeth, averaging four to six for the totally eden-
tulous jaw. Several clinical studies reported poor survival rates of
less than 50% for 5 to 10 years, with the frequent complication of
gingival inflammation, involving tissue reaction around the post
caused by the lack of soft tissue attachment to the metal post. These
complications led to the development of sinus tract resorption of
the cortical bone and exposure of framework.82,125 As a result of this
higher rate of failure, as well as the significant complications and
surgical invasion, subperiosteal implants are rarely used.
The most common implant design being used today is the screw-
shaped or threaded cylindrical implant (eFig. 74.4A). A threaded
implant design is preferred because it engages bone well and is able
to achieve good primary stabilization. Even systems that started with
cylindrical press-fit (nonthreaded) designs progressively evolved to
a threaded geometry. The (longitudinal) shape of implants may be
parallel or tapered (eFig. 74.4B). Although a majority of all implants
have been parallel walled, the use of a tapered implant design has
been advocated because it requires less space in the apical region
(i.e., better for placement between roots or in narrow anatomic areas
with labial concavities). Tapered implants have also been advocated
for use in extraction sockets (eFig. 74.5).
Implant Surface Characteristics
(Microdesign)
Implant surface characteristics (microtopography) have been shown
to positively influence the healing process.31,63,77,88 Accordingly,
modification of implant surface characteristics has been a major area
of research interest and development. Modifications in surface energy,
chemical composition, and surface topography are known to influence
cellular activity and tissue responses, leading to enhanced osteogen-
esis.26,32,75,118 At the molecular level, modified implant surfaces increase
adsorption of serum proteins, mineral ions, and cytokines, which
subsequently promote cellular migration and attachment.64,88,104 Implant
surface characteristics can also aid in the retention of a fibrin clot,
thus providing a migratory pathway for the differentiating osteogenic
 CHAPTER 74  Peri-implant Anatomy, Biology, and Function 733.e3

B
eFig. 74.4  (A) Illustration of a parallel, threaded implant. (B) Illustration of a tapered, threaded implant.
(Copyright 2012 BIOMET 3i, LLC. Used by permission, all rights reserved.)

eFig. 74.5  A tapered, threaded implant design is helpful to minimize

apical bone fenestration in areas such as the anterior maxilla, as the result
of the presence of labial concavities. Tapered implant designs are also
advantageous for immediate implant placement into extraction sockets.

cells to reach the implant surface.38,39,90 Today, implants are treated

with a variety of technologies to modify surface characteristics
(microscale or nanoscale) to enhance bone formation.
Additive Processes
The additive process modifies the microstructure/macrostructure and
chemical nature of the implant surface by adding materials or
chemicals to the existing surface. Several methods are used to add
materials or chemicals to the implant surface, such as inorganic
mineral coatings, plasma spraying, biocoating with growth factors,
fluoride, and particulates or cements containing calcium phosphates,
sulfates, or carbonates. The addition of materials, such as hydroxy-
apatite (eFig. 74.6), to the implant surface has been shown to enhance
eFig. 74.6  High magnification (acid fuchsin–toluidine blue; original
magnification, ×100) of a hydroxyapatite-coated implant with intimate bone
approximation. Parts of the hydroxyapatite coating are observed on the
surface.
or accelerate the initial bone cells, adaptation or proliferation.42,43,54,122
In general, additive surface modifications tend to increase the surface
texture greater than subtractive surface modifications, resulting in
topographically “rougher” implant surfaces (eFig. 74.7). Surface
roughness can also be increased by oxidizing or adding an oxide
layer (eFig. 74.8).
733.e4 Part 4  Oral Implantology

A B

C D
eFig. 74.7  Scanning electron microscope (SEM) image of titanium plasma–sprayed surface implant with
rough surface characteristics. (A) Implant with titanium plasma–sprayed surface (original magnification, ×40).
(B) Notably complex macrotopography on titanium plasma–sprayed surface (original magnification, ×100). (C)
Titanium plasma–sprayed surface with 1- to 25-µm particles (original magnification, ×500). (D) Titanium
plasma–sprayed surface with 1- to 25-µm particles (original magnification, ×1000).

Subtractive Processes
The subtractive process modifies the microstructure and chemical
nature of the implant surface by removing or altering the existing
surface. The roughness of implant surface can be modified by
machining, acid etching, blasting, or a combination of these processes
to enhance the amount or speed of osseointegration.36,43,94 The changes
are most notable at the microscopic level (eFigs. 74.9 and 74.10).
Implant surfaces that are modified at the microscopic level with
techniques such as acid etching are thought to promote favorable
cellular responses and increased bone formation in close proximity
to the surface16,57 (eFig. 74.11).

Implant Surface Chemical Composition

eFig. 74.8  Roughened surfaces are achieved by plasma spraying, by acid
etching, or as shown here by oxidizing (TiUnite surface). (Courtesy Nobel
Biocare Services AG, Zurich, Switzerland.)
There have been unsuccessful trials with oral implants made of
carbon or hydroxyapatite. The lack of resistance, because of material
properties, to occlusal forces led to frequent fractures. The so-called
noble metals or alloys, however, do not resist corrosion and have
thus been abandoned. Today, the majority of oral implants are made
 CHAPTER 74  Peri-implant Anatomy, Biology, and Function 733.e5

A B

C D
eFig. 74.9  Scanning electron microscope (SEM) image of machined surface implant with characteristic
grooved pattern. (A) Implant with machined surface (original magnification, ×40). (B) Grooved pattern apparent
on machined surface (original magnification, ×100). (C) Machined surface with distinct ridges and grooves
(original magnification, ×500). (D) Machined surface with distinct ridges and grooves (original magnification,
×1000). (Courtesy Nobel Biocare Services AG, Zurich, Switzerland.)

of CP titanium or titanium alloys. The following discussion relates
to titanium implants.
Titanium is a reactive metal that oxidizes within nanoseconds
when exposed to air. Because of this passive oxide layer, the titanium
then becomes resistant to corrosion in its CP form. Some alloys,
such as titanium-aluminum 6%, vanadium 4% (Ti6Al4V), are known
to provoke bone resorption as the result of leakage of some toxic
components. The oxide layer of CP titanium reaches 10 nm of
thickness. It grows over the years when facing a bioliquid. It consists
mainly of titanium dioxide (TiO2).
All titanium oxides have dielectric constants, which are higher
than most other metal oxides. This factor may explain titanium’s
tendency to adsorb biomolecules, as seen during surgery when the
blood creeps up the surface during implant insertion. The biomolecules
normally appear as folded-up structures to hide their insoluble parts,
while putting water-soluble radicals on their surface. Thus they will
adhere to the TiO2 surface after displacing the original water molecules
sitting on its surface. Although initially attracted by weak van der
Waals forces, the high dielectric constant of titanium oxides and the
polarizability of the molecules after adsorption will lead to high
bond strengths, which are considered irreversible when they surpass
30 kcal/mol.61 In fact, because of its propensity for being covered
by an uninterrupted oxide layer, which has ceramic-like properties
similar to other metal oxides (e.g., aluminum oxides), titanium makes
the coating of implants superfluous. This should be stressed because
many authors hope for even better osseointegration potential with
calcium phosphate (CaP)–coated surfaces and strongly advocate their
use. To date, clinical results with CaP-coated implants have not been
encouraging from a long-term perspective.22
Thus the overall view of potential advantages for different implant
surface characteristics is complex, and only clinical observations
can determine their validity. For good-quality bone, after 15 years
of follow-up, clinical success rates of 99% have been reported for
implants with a turned surface.67 Enhanced implant surface charac-
teristics are likely to be most beneficial for the more challenging
situations, such as poor quality bone and early and immediate loading.
733.e6 Part 4  Oral Implantology

A B

C D
eFig. 74.10  Scanning electron microscope (SEM) image of acid-etched surface implant with typical microscopic
peak-valley appearance. (A) Implant with acid etched surface (original magnification, ×40). (B) Microtextured
surface alteration on acid-etched surface (original magnification, ×100). (C) Acid-etched surface with micropits
of 1 to 3 µm (original magnification, ×500). (D) Acid-etched surface with micropits of 1 to 3 µm surrounded by
larger areas with 6 to 10 µm peak–valley pits (original magnification, ×1000).

Implant Surface Free Energy and Microscopic
Roughness
When an implant is brought into contact with bodily tissues and
fluids, in this case mostly bone, it faces a “bioliquid,” an aqueous
environment. Within milliseconds, water, ions, and small biomolecules
are absorbed. One could imagine that this absorbed layer renders
all surfaces equal. However, the large molecules and the cells that
will subsequently adhere to this surface are influenced by the surface
characteristics of this pellicle layer. The composition and structure
of the initial layer are largely determined by the underlying surface.97
Thus the three-dimensional shape of the molecules will be modified
during their adherence to this pellicle layer and will unveil different
radicals, depending on this metamorphosis.
The surface free energy, often called wettability, is an important
parameter for these interactions. It can be assessed through the shape
of a standardized drop of liquid put on the clean implant surface.
The angle of this drop toward the underlying surface reveals that
the cohesive forces between liquid molecules are stronger than the
adhesive forces between the liquid and the surface. Thus a ball-shaped
drop would reveal a low surface free energy.
Surface topography at the cellular and molecular level means
microscopic roughness. A surface roughness can be measured with
a profilometer, a stylus that follows the surface and measures the
peak-to-valley dimensions (expressed as Ra values) or the spacing
between irregularities (expressed as Scx values). Wennerberg and
Albrektsson120 provide guidelines for topographic evaluation of implant
surfaces.120 No implant surface is smooth, although several reports
have incorrectly referred to the “turned” (machined) implant surface
as “smooth” (see eFig. 74.9). Roughened implant surfaces speed up
the bone apposition; as demonstrated in vitro, more prostaglandin
E2 (PGE2) and transforming growth factor beta 1 (TGF-β1) are
produced on rough than on smooth surfaces.64 Rough surfaces may
show some disadvantages, such as increased ion leakage and increased
adherence of macrophages and subsequent bone resorption.76
It was also reported that in vitro adsorption of fibronectin was
higher on smooth than on rough CP titanium surfaces.45 Fibronectin
is a glycoprotein quickly adhering on hard surfaces and known to
determine subsequent cell adhesion.84 Microtopography also influences
the number and morphology of cell adhesion pseudopods and cell
orientation.53 Grooves in an implant surface will guide the cell
 CHAPTER 74  Peri-implant Anatomy, Biology, and Function 733.e7

A B

C
eFig. 74.11  Histologic appearance of bone apposition. (A) At 2 weeks, bone is deposited on the bony wall
of the tissue chamber and on the implant surface. Both layers are connected by a scaffold of tiny trabeculae.
Woven bone is characterized by the intense staining of the mineralized matrix and the numerous osteocytes
located in large lacunae (undecalcified ground section, surface-stained with toluidine blue and basic fuchsin).
(B) At 4 weeks, the volume density of this scaffold has increased both by the formation of new trabeculae and
by deposition of more mature, parallel-fibered bone onto the primary scaffold. Woven bone is mainly recognized
by the numerous large osteocytic lacunae (bright). The gap between bone and implant surface is an artifact.
(C) At 8 weeks, growth and reinforcement result in a further increase in bone density and an almost perfect
coating of the implant surface with bone. Remodeling has started, replacing the primary bone by secondary
osteons (arrows).

migration along their direction. Bone growth can enter altered
microtopographic features such as pits and porosities with internal
dimensions that are only a few microns.
Lack of load can also be detrimental and can lead to cortical
bone resorption. This is well documented in orthopedics and is termed
stress shielding.55 This phenomenon has not been properly evaluated
for oral implants in which marginal bone resorption is thought to
be associated with chronic inflammation of the overlying soft tissues.
The use of finite element analysis (FEA) has become popular
but lacks value by itself; invalid assumptions, such as the isotropic
nature of the bone, must be used in the modeling. The deviation of
FEA data from in vivo data has been well documented.74 FEA data
should be considered “descriptive” models that require confirmation
by biologic data. However, as with photoelastic studies, FEA analyses
do provide some insight on stress concentrations and their relation
to implant geometry and the prosthetic superstructures.
734 Part 4  Oral Implantology

B B

I I

Osteoblasts
Blood supply
Osteoclasts
Fig. 74.2  The basic multicellular unit is the basic remodeling process for
bone renewal. Osteoclasts are imported by the vascular supply, and the
resorption lacunae are soon filled by the lining osteoblasts.

Bone tissue damage and debris created by the osteotomy site

A B
preparation must be cleared up by osteoclasts for normal bone
healing. These multinuclear cells, originating from the blood, Fig. 74.3  (A) After initial healing, woven bone, as characterized by its
can resorb bone at a pace of 50 to 100 µm per day. There is a irregular pattern, is laid down. (B) After weeks or months, progressively a
coupling between bone apposition and bone resorption (Fig. 74.2). lamellar bone is laid down, with regular concentric lamellae. B, Bone; I,
Preosteoblasts, derived from primary mesenchymal cells, depend on implant. (Courtesy Professor T. Albrektsson, Gothenburg, Sweden.)
a favorable oxidation-reduction (redox) potential of the environment.
Thus a proper vascular supply and oxygen tension are needed. If
oxygen tension is poor, the primary stem cells may differenti-
ate into fibroblasts, form scar tissue, and lead to implant failure
(nonintegration).
If bone is overheated or crushed during preparation, it will become
necrotic and may lead to nonmineralized (soft tissue) scar formation
or be sequestered. The critical temperature for bone cells that should
not be exceeded is 47°C (116.6°F) at an exposure time of 1 minute.6
Thus preparation of implant osteotomy sites requires profuse irrigation
(cooling) along with gentle, intermittent, moderate-speed drilling
using sharp drills. Another complicating factor, well recognized from
open wound fractures, is that microbial contamination jeopardizes the
normal bone healing. Accordingly, strict aseptic techniques should
be maintained.

KEY FACT
Immobility of the implant must be maintained during the early postinsertion
healing for bone formation at the surface. Moderate inflammation or
movement above a certain threshold is detrimental and may lead to implant
failure. If micromovements exceed 150 µm, the movement will impair the
differentiation of osteoblasts, and fibrous scar tissue will form between
the bone and implant surface.
Fig. 74.4  Once a steady state has been achieved at the bone-to-implant
interface, an intimate contact can be observed, with some marrow spaces
seen in between at the light microscopic level.
ascertained by human histology from implants retrieved because of
hardware fractures.10

New bone formation follows a specific sequence of events. Woven

bone is quickly formed in the gap between the implant and the bone;
it grows fast, up to 100 µm per day, and in all directions. Characterized
by a random orientation of its collagen fibrils, high cellularity, and
limited degree of mineralization, the biomechanical capacity of woven
bone is poor (Fig. 74.3A). Thus any occlusal load should be well
controlled or avoided in the early phase of healing. After several
months, woven bone is progressively replaced by lamellar bone with
organized, parallel layers of collagen fibrils and dense mineralization.
Contrary to the fast-growing woven bone, lamellar bone formation
occurs at a slow pace (only a few microns per day). Ultimately, after
18 months of healing, a steady state is reached where lamellar bone
is continuously resorbed and replaced (Fig. 74.3B).27 At the light
microscopic level, an intimate bone-to-implant contact has been
extensively reported (Fig. 74.4).98 Once the bone-to-implant interface
has reached a steady state, it can maintain itself over decades, as
FLASH BACK
The biomechanical capacity of woven bone is poor. New bone formation
adjacent to an implant follows a specific sequence of events with woven
bone forming quickly in the gap; it grows fast (100 µm per day) and in all
directions. It is characterized by a random orientation of its collagen fibrils,
high cellularity, and a limited degree of mineralization.
Bone Remodeling and Function
Clinically, both primary stability and secondary stability of an implant
are critical to success. Primary stability, achieved at the time of
surgical placement, depends on the implant geometry (macrodesign),
as well as the quality and quantity of bone available for implant
anchorage at a specific site. Studies using resonance frequency analysis
(RFA) have reported decreased implant stability in the early weeks
 CHAPTER 74  Peri-implant Anatomy, Biology, and Function
of postinsertion healing.18,44,56,93 Secondary stability, achieved over
time with healing, depends on the implant surface (microdesign),
as well as the quality and quantity of adjacent bone, which will
determine the percentage of contacts between the implant and
bone.18,48,96,113 For example, areas such as the anterior mandible have
dense cortical bone and provide rigid primary stabilization and good
support throughout the healing process. Conversely, areas such as
the posterior maxilla have thin cortical bone, and large marrow spaces
provide less primary stability. For this reason, the posterior maxilla
has been associated with lower success rates compared with other
sites with greater bone density and support.17,60 Interestingly, a new
implant with unique knife-edge wide threads (macrodesign) has been
shown, in completely healed sites, to maintain stability without the
typical drop in the implant stability quotient (ISQ) through the early
bone remodeling phase.73
Once osseointegration is achieved, implants can resist and function
under the forces of occlusion for many years. Longitudinal biome-
chanical assessments seem to indicate that during the first weeks
after placement of one-stage implants, decreased rigidity is observed.46
This may be indicative of bone resorption during the initial phase
of healing. Subsequently, rigidity increases and continues to increase
for years.112 Thus when a prosthesis is installed immediately (in 1
day) or early (in 1 to 2 weeks), care must be taken to control against
overload. It is important to recognize that sites with limited primary
stability or less bone-to-implant contact (e.g., posterior maxilla) will
likely go through a period of even less bone support in the early
stages of bone healing due to the initial phase of bone resorption.
Soft Tissue Interface
Not surprisingly, for two decades, research and clinical interest focused
on the bone-to-implant interface of osseointegrated implants, and
the overlying soft tissues were largely ignored. Except for a few
descriptive sentences, the classic handbook by Brånemark and col-
leagues27 presented no data or information about the soft tissue
interface. This may be due in part to the fact that most patients were
fully edentulous and the Brånemark system implants had turned
(machined) surfaces, which are less likely to be associated with soft
tissue inflammatory problems.5 Today, there is greater interest in
and appreciation for peri-implant soft tissues and the soft tissue-to-
implant interface as a function of aesthetics and maintenance of a
seal or barrier against microbial invasion.
Peri-implant soft tissues are similar in appearance and structure
to periodontal soft tissues (see Chapter 3).5 Clearly, both implants
and teeth emerge through the soft tissues on the alveolar ridge. The
soft tissues consist of connective tissue covered by epithelium. There
is a gingival/mucosal sulcus, a long junctional epithelial attachment,
and a zone of connective tissue above the supporting bone (Fig.
74.5). Despite the apparent similarities in soft tissues around teeth
and implants, the presence of a periodontal ligament around teeth
and not around implants is an important, distinct difference. Whereas
natural teeth have a periodontal ligament with connective tissue
fibers inserting into the cementum and suspending them in the alveolar
bone, osseointegrated implants do not. There are no inserting collagen
fibers anywhere along the interface of osseointegrated implants. Bone
is in direct contact with the implant surface without intervening soft
tissues.
FLASH BACK
Sharpey’s fibers are bundles of collagenous fibers that pass into the outer
circumferential lamellae of alveolar bone and the cementum of teeth.
735
Clinically, the thickness of the peri-implant soft tissues varies
from 2 to several millimeters (Fig. 74.6). An animal study determined
the total height of the peri-implant “biologic width” to be approxi-
mately 3 to 4 mm, where about 2 mm is the epithelial attachment
and about 1 to 2 mm is the supracrestal connective tissue zone.19
Consistent with this finding, a human histologic study determined
the height of the peri-implant “biologic width,” consisting of an
epithelial attachment and supracrestal connective tissue, to be about
4 to 4.5 mm47 (Fig. 74.7).
Epithelium
As in the natural dentition, the oral epithelium around implants is
continuous with a sulcular epithelium that lines the inner surface of
the gingival sulcus; the apical part of the gingival sulcus is lined
with long junctional epithelium.71 Ultrastructural examination of the
long junctional epithelial attachment adjacent to dental implants has
demonstrated that epithelial cells attach with a basal lamina and
hemidesmosomes2,4,49,62,115 (Fig. 74.8). Histologic studies indicate that
these epithelial structures and the surrounding lamina propria cannot
be distinguished from those structures around teeth.33 In health, the
dimension of the sulcular epithelium is about 0.5 mm,95 and the
dimension of the epithelial attachment is about 2 mm,19 which is
higher than that of the periodontal epithelial attachment.
The apical edge of the epithelial attachment is about 1.5 to 2 mm
above the bone margin.89 In healthy peri-implant tissues, progressive
epithelial downgrowth does not occur, indicating that factors other
than inserted collagen fiber bundles (i.e., Sharpey’s fibers in natural
dentition) prevent it.
Connective Tissue
Peri-implant connective tissue morphology closely resembles that
of the natural dentition except that it lacks a periodontal ligament,
cementum, and inserting fibers (Fig. 74.9). No significant differences
were found at the biochemical level between the peri-implant and
the periodontal soft tissues,34 whereas the dimension of the peri-implant
connective tissue is 1 to 2 mm, which is higher than that of the
average periodontal connective tissue.19,89
The zone of supracrestal connective tissue has an important
function in the maintenance of a stable soft tissue–implant interface
and as a seal or barrier to the “outside” oral environment. The orienta-
tion of connective tissue fibers adjacent to an implant differs from
that of periodontal connective tissue fibers. In the absence of cementum
and inserting connective tissue fibers (i.e., as in a natural tooth),
most peri-implant connective tissue fibers run in a direction more
or less parallel to the implant surface. Even when the fiber bundles
are oriented perpendicularly, which occurs more often in the gingiva
than in the mucosa surrounding implants, the bundles are never
embedded in the implant surface.
The fiber bundles can also have a cufflike circular orientation.20,93
The role of these fibers remains unknown, but it appears that their
presence helps to create a soft tissue “seal” around the implant. The
adaptation of the connective tissue to an implant surface may also
be affected by the mobility of the soft tissue around the implant.
The connective tissue in direct contact with the implant surface is
characterized by an absence of blood vessels and an abundance
of fibroblasts interposed between collagen fibers.68 Several animal
and human studies have shown that the alignments of connective
fibers were circular and horizontal around the implants1,15,35,48,51,52,99
(Fig. 74.10).
More recent studies have shown histologic evidence of connective
tissue attachment perpendicular to the microgrooved implant surface
on both animal and human studies.78-80 These laser-microtextured
grooves (Fig. 74.11) have been shown to be able to stop the epithelial
736 Part 4  Oral Implantology

Enamel
Titanium implant
Sulcus

Sulcular
(crevicular) Sulcular
epithelium epithelium

Junctional
epithelium Junctional
epithelium

Connective
tissue Connective
tissue

Cementum

Bone
Bone

A B
Fig. 74.5  Schematic illustration of hard and soft tissue around a tooth and an implant. (A) Hard and soft
tissue anatomy around a natural tooth demonstrates bone support with a periodontal ligament, a connective
tissue zone above the crest of bone with connective tissue fibers (Sharpey’s) inserting into dentin, a long
junctional epithelial attachment, a gingival sulcus lined with sulcular epithelium, and oral gingival epithelium
(outer surface of gingiva). (B) Hard and soft tissue anatomy around an implant demonstrates some similarities
and some distinct differences. There is supporting bone in direct approximation to the implant surface without
any intervening soft tissues (i.e., no periodontal ligament). A connective tissue zone is present above the level
of bone with fibers running parallel to the implant surface and no inserting fibers. There is a long junctional
epithelial attachment, a gingival/mucosal sulcus lined with sulcular epithelium, and oral gingival/mucosal
epithelium (outer surface of soft tissue). (From Rose LF, Mealey BL: Periodontics: medicine, surgery, and implants,
St. Louis, 2004, Mosby.)

downgrowth and establish connective tissue insertion right at the

Fig. 74.6  Clinical appearance of normal, healthy peri-implant tissue with
implant restoration removed. Soft tissue thickness varies from site to site,
depending on quantity and quality of tissue, as well as the anatomy of the
surrounding area (e.g., adjacent to natural teeth with healthy periodontal
attachment versus adjacent to a space). Note that the intrasulcular tissue
appears more erythematous as the result of the thin, nonkeratinized layer
of epithelium overlying the connective tissue.
most coronal part of the laser microgrooved area. (Fig. 74.12). A
prospective controlled clinical study showed that laser-grooved surface
resulted in shallower probing depth and less peri-implant crestal
bone loss than that seen around implants with machined collars.25,85
This connective tissue interface has been examined by probing
attachment level measurements in patients. Probing attachment levels
were consistently found coronal to the alveolar crest in patients with
peri-implant tissue health, indicating the presence of a zone of direct
connective tissue contact to the implant surface. This means that the
probing depth measurement performed with a periodontal probe may
be about 1.5 mm higher above the bone level in healthy tissues. At
inflamed sites, the probe may penetrate to the bone, with the probing
depth measurement reflecting the total soft tissue thickness above bone.
In cases with inflammatory peri-implant tissue disease, increasing
probing depth and reduced attachment levels have been reported.3,40,86,117
Keratinized Tissue
Questions emerged decades ago, as it did for the natural dentition,
about the need for keratinized tissue to surround implants. Prospective
and cross-sectional studies, evaluating screw-shaped implants with
a machined surface, suggest that the presence or absence of keratinized
gingiva is not a prerequisite for long-term stability.101 However, it
has been suggested that implants surrounded by mucosa only (i.e.,
 CHAPTER 74  Peri-implant Anatomy, Biology, and Function 737

* JE
OE

aJE

CTC

A BC
B

Fig. 74.8  (A) Overview of ground section showing peri-implant tissues

covered with keratinizing oral epithelium (OE). Junctional epithelium (JE) is
interposed between connective tissue and alveolar bone crest (BC). Apical
Fig. 74.7  Buccolingual section (basic fuchsin stain; original magnification, end of junctional epithelium (arrow). Toluidine blue stain. (Bar = 200 µm.)
×12.5; one-part SLA implant, 3 months unloaded) showing the gingiva and (B) Transmission electron microscopic view of sulcular epithelium showing
the most coronal part of alveolar bone. Rete peg formation is only apparent tightly sealed intercellular spaces by numerous spot desmosomes (arrows),
in the area of the keratinized oral gingival epithelium. The oral sulcular contributing to low permeability of this portion of peri-implant mucosa. Bar
epithelium exhibits no keratinization. In the area of the most coronal point = 3 µm.14
of the junctional epithelium (cJE), the soft tissues are slightly torn away
(artifact) because of nondecalcified histologic processing. The most apical
point of the junctional epithelium is indicated (aJE). No rete peg formation
is evident adjacent to the basal cell layer of the junctional epithelium (JE),
all showing healthy and physiologic soft tissue structures. In addition, the
area of connective tissue contact (CTC) adjacent to the machined titanium
surface is marked. A slight round cell infiltrate in the connective tissue
indicates a mild inflammation. Note bone remodeling/new bone formation
in the crestal bone region indicated by saturated, dark red stained areas.

Sulcular epithelium

JE

Junctional epithelium

A B
Fig. 74.9  (A) Scanning electron microscope (SEM) image of the junctional epithelium. Note the neutrophils
located between the cells (red arrows). Bar = 40 µm. (B) Higher magnification of Fig. 74.8 with polarized light
showing the apical extent (red arrow) of the junctional epithelium (JE). Note the dense collagen fibers running
apicocoronal (i.e., parallel to the implant surface).
738 Part 4  Oral Implantology

T/I I
c a b
b
T/I 3 MR
D c
Ab
HD 2 aAE
HD A/I
4
a LD
5 Im
EA
BC LL Bo

LBI
LBE
A B C

Fig. 74.10  (A) Histologic scheme of epithelial attachment (EA) (identical for tooth and implant). T/I, Titanium
implant; BC, basal complex; LBI, lamina basalis interna; LBE, lamina basalis externa (only location where cell
divisions occur); a, long junctional epithelial attachment zone; b, sulcular epithelial zone; c, oral epithelial zone.
(B) At the electron microscopic level, basal complex at the epithelial attachment (three most apical cells) and
connection with stroma. HD, Hemidesmosomes; D, desmosome; LL, lamina lucida; LD, lamina densa; C, cuticle.
(C) Implant, abutment (Ab), and crown within alveolar bone and soft tissues. Im, Endosseous part of implant;
MR, margin of gingiva/alveolar mucosa; Bo, marginal bone level; 1, implant crown; 2, vertical alveolar-gingival
connective tissue fibers; 3, circular gingival connective tissue fibers; 4, circular gingival connective tissue fibers;
5, periosteal-gingival connective tissue fibers; a, junctional epithelium; b, sulcular epithelium; c, oral epithelium;
A/I, abutment/implant junction; aAE, apical (point) of attached epithelium.

A B
Fig. 74.11  (A) Laser-microtextured surface. (B) Machined collar, original
magnification, ×500. (Botos S, Yousef H, Zweig B, et al: The effects of laser
microtexturing of the dental implant collar on crestal bone levels and
peri-implant health. Int J Oral Maxillofac Implants 26:492–498, 2011. With
the permission of Dr. Spyros Botos.)

nonkeratinized) are more susceptible to peri-implant problems. An
animal study observed that ligature-induced peri-implantitis occurs
more frequently when alveolar mucosa surrounds the implant as
compared with when keratinized mucosa surrounds the implant.116
Keratinized mucosa tends to be more firmly anchored by collagen
fibers to the underlying periosteum than nonkeratinized mucosa,
which has more elastic fibers and tends to be movable relative to
the underlying bone. In clinical studies evaluating intraoral implants,
with or without peri-implant keratinized mucosa, no clinically sig-
nificant difference in implant success was reported.66,121 However,
when there is a lack of keratinized tissue, patients tend to complain
about pain and discomfort while performing oral hygiene procedures
or other functions in the area. The symptoms are alleviated by
increasing the amount of keratinized (firmly bound) tissue around
Fig. 74.12  Laser-ablated surface: epithelial downgrowth was stopped
right at the coronal-most microgrooved area (arrow). Apical to the junctional
epithelium, healthy connective tissue fibers attached perpendicularly to the
laser-ablated channels. (Courtesy Dr. Myron Nevins.)
the implant(s) via soft tissue grafting (see online Fig. 65.5, A–L).9,66,121
Finally, although it may not be comparable to intraoral implants,
mobility of soft tissues surrounding extraoral implants is associated
with a higher incidence of implant failure.9
Vascular Supply and Inflammation
The vascular supply of the peri-implant gingival or alveolar mucosa
may be limited, as compared with periodontal gingiva, due to the
 CHAPTER 74  Peri-implant Anatomy, Biology, and Function 739

lack of a periodontal ligament (Fig. 74.13).21 This is especially true presence of a premature occlusal contact (as teeth can). Implants
in the tissue immediately adjacent to the implant surface. However, and the rigidly attached implant restorations do not move. Thus any
capillary loops in the connective tissue under the junctional and occlusal disharmony will have repercussions at either the restoration-
sulcular epithelium around implants appear to be anatomically similar to-implant connection, the bone-to-implant interface, or both.
to those found in the normal periodontium (Fig. 74.14).114 Proprioception in the natural dentition comes from the periodontal
Emerging knowledge indicates that the peri-implant gingival or ligament. The absence of a periodontal ligament around implants
alveolar mucosa has the same morphology as the corresponding reduces tactile sensitivity58 and reflex function.23 This can become
tissues around teeth. These soft tissues also react the same way to even more challenging when osseointegrated, implant-supported,
plaque accumulation. Studies investigating the histology (light fixed prostheses are present in both jaws.
microscopic and ultrastructural) of healthy and inflamed tissues
surrounding implants in humans have indicated that the inflammatory
response to plaque is similar to that observed in periodontal tissues.95
Polymorphonuclear cells and mononuclear cells transmigrate normally Epithelial attachment
through the peri-implant sulcular epithelium (Fig. 74.15).95
Abutment
Connective tissue cuff
Implant
shoulder Gingival
Clinical Comparison of Teeth and Implants epithelium
Although the soft tissue-to-implant (abutment) interface offers striking Cortex
similarities with tissue surrounding the natural dentition, some
differences should be considered. At the bone level, the lack of a Cancellous
bone
periodontal ligament is the most striking difference. The following
discussion elaborates on the clinical perspectives of these similarities
Mucogingival
and differences. junction
At the bone level, the absence of the periodontal ligament sur- Fig. 74.13  Schematic illustration of the blood supply in the connective
rounding an implant has important clinical consequences. This means tissue cuff surrounding the implant/abutment, which is scarcer than in the
that no resilient connection exists between implants and supporting gingival complex around teeth because none originates from a periodontal
bone. Implants cannot intrude or migrate to compensate for the ligament.

A B
Fig. 74.14  (A) Microvascular topography surrounding a tooth. (B) Microvascular topography surrounding an
implant. Bar = 5 µm.105 (Courtesy Drs. N. Selliseth and K. Selvig, Bergen, Norway.)

A B
Fig. 74.15  (A) Histologic slide from healthy gingiva surrounding a well-functioning implant in a human patient.
No morphologic characteristics differentiate tissue around implant from that around teeth. (B) When gingivitis
occurs, a profuse migration of inflammatory cells through the pocket epithelium can be observed. (Courtesy
Professor Mariano Sanz, Madrid, Spain.)
740 Part 4  Oral Implantology
The lack of a periodontal ligament and the inability of implants
to move contraindicates their use in growing individuals. Natural
teeth continue to erupt and migrate during growth, whereas implants
do not. Implants placed in individuals prior to the completion of
growth can lead to occlusal disharmonies with implants.83 Likewise,
it may be problematic to place one or more implants in a location
adjacent to teeth that are very mobile from the loss of periodontal
support because, as the teeth move in response to or away from the
occlusal forces, the implant(s) will bear the entire load.
Overload, because of improper superstructure design, parafunc-
tional habits, or excessive occlusal load, may cause microstrains and
microfractures in the bone, which will lead to bone loss and a fibrous
inflammatory tissue at the implant interface.114
Conclusion
A thorough understanding of bone biology is essential for clinicians
to fully appreciate the phenomenon and limitations of osseointegration.
Many factors can interfere with the predictable establishment and
maintenance of a long-term rigid connection between the implant
surface and the surrounding bone that is able to sustain occlusal
loads. The bone-to-implant interface and its rigidity are a predominant
biomechanical aspect of coping with the time and intensity of loading.
The quality of the soft tissue-to-implant interface also plays an
important role in the long-term maintenance of stable marginal bone
levels around implants. Clinicians must familiarize themselves with
the underlying molecular and cellular events to evaluate the future
evolution of implant design and implant protocols, including surgical
placement, restoration, and maintenance.
A Case Scenario is found on the companion website
www.expertconsult.com.
References
References for this chapter are found on the companion
website www.expertconsult.com.
 CHAPTER 74  Peri-implant Anatomy, Biology, and Function 740.e1

CASE SCENARIO 74.1 

Patient:  47-year-old male
Chief Complaint:  “I’m here for a routine check of my teeth and
implants.”
Background Information
The patient reports that he recently moved to the area (job transfer) from
another state. He has no complaints but wants to establish a new dentist
for follow-up care. He denies any health conditions, does not take any
medications except vitamins, and does not use tobacco. He does not have
allergies to any medications. He reports that he has implants that replace
his maxillary central incisors. The implant crowns have been in place for
about 6 to 7 years.
Current Findings:  Exam reveals good periodontal and peri-implant
health. Hygiene (biofilm control) is good. Tissues are pink without signs
of swelling or erythema. Dentition is intact and appears to be stable.
There is no obvious pathology and no need to repair/replace restorations.
Routine periodontal/peri-implant maintenance is recommended.
Radiographic evaluation of implants #8 and #9 show good bone support
with crestal levels maintained just slightly below the implant-abutment
junction.

CASE-BASED QUESTIONS SOLUTION AND EXPLANATION

1. What mediates the attachment of cells to the implant surface? Answer: B
A. Lamina lucida Explanation: There is not a true connective tissue attachment on dental
B. Lamina densa implant. The lamina densa form scar-like tissue around the dental
C. Hemi-desmosomes implant surface.
D. Desmosomes
2. The peri-implant sulcular complex includes all of the following Answer: A
EXCEPT: Explanation: Sulcular complex around the dental implant is considered
A. Bone a soft tissue complex, which does not include hard tissue.
B. Junctional epithelium
C. Connective tissue attachment
D. Sulcular epithelium
3. How can the connective tissue fibers around a dental implant be Answer: D
described? Explanation: Several animal and human studies have shown that the
A. Circular alignments of connective fibers around implants are circular and
B. Vertical alveolar-gingival horizontal.
C. Periosteal-gingival
D. All of the above
4. The apical extent of the junctional epithelium is __________ the Answer: A
implant/abutment interface. Explanation: The peri-implant soft tissues consist of connective tissue
A. above covered by epithelium. Apical to the long junctional epithelial
B. equal to attachment is a zone of connective tissue above the supporting bone.
C. below
5. What typically surrounds the top of the dental implant? Answer: C
A. Bone and epithelium Explanation: In healthy patients, the most coronal aspect of the implant
B. Connective tissue alone is surrounded by bone and connective tissue.
C. Bone and connective tissue
D. Epithelium alone
740.e2 Part 4  Oral Implantology
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Clinical Evaluation of the Implant Patient
Perry R. Klokkevold | David L. Cochran
CHAPTER OUTLINE
Case Types and Indications
Risk Factors and Contraindications
Posttreatment Evaluation
Conclusion
Over the past several decades, following the landmark research and
development of osseointegrated dental implants by Brånemark and
colleagues,15-17 treatment options and treatment planning in dentistry
have evolved tremendously. Initially, prosthetic reconstructions with
osseointegrated implants were limited to use in the edentulous patient,
with many reports documenting excellent long-term success.1,2,25
Shortly thereafter, the original implant treatment protocols were
adapted for use in partially edentulous patients. There were some
transitional challenges associated with the early use of dental implants
being adapted to the partially edentulous patient, but ultimately
successes were achieved for this population as well. Modifications
in implant design, procedural techniques, and treatment planning
greatly improved implant therapy for the partially edentulous
patient. Currently, the long-term success of dental implants used to
replace single and multiple missing teeth in the partially edentulous
patient is very good29,40,42,48,52 (see Chapter 87). The implementation
of bone augmentation procedures further increased the option for
patients with inadequate bone volume to be successfully restored
with implant-retained prostheses.27,34,53 Virtually any patient with
an edentulous space could be a candidate for endosseous implants,
and studies suggest that success rates of 90% to 95% can be
expected in healthy patients with good bone and normal healing
capacity.24
The ultimate goal of dental implant therapy is to satisfy the patient’s
desire to replace one or more missing teeth in an aesthetic, secure,
functional, and long-lasting manner. To achieve this goal, clinicians
must accurately diagnose the dentoalveolar condition, as well as the
overall mental and physical well-being of the patient. It is necessary
to determine whether implant therapy is possible, practical, and,
perhaps most important, whether it is indicated for the particular
patient who is seeking implants. Local evaluation of potential jaw
sites for implant placement (e.g., measuring available alveolar bone
height, width, and spatial relationship) and prosthetic restorability
are essential considerations in determining whether an implant(s) is
possible. However, making as assessment of the patient and determin-
ing whether that patient is a good candidate for implants is an equally
important part of the evaluation process. The patient evaluation
includes identifying factors that might increase the risk of failure or
the possibility of complications, as well as determining whether the
patient’s expectations are reasonable.
CHAPTER 75 
This chapter presents an overview of the clinical aspects of dental
implant therapy, including an assessment of possible risk factors
and contraindications. It also provides guidelines for the pretreatment
evaluation of potential implant patients and the posttreatment evalu-
ation of patients with implants.
Case Types and Indications
Edentulous Patients
The patients who seem to benefit most from dental implants are
those with fully edentulous arches. These patients can be effectively
restored, both aesthetically and functionally, with an implant-assisted
removable prosthesis, an implant-supported removable prosthesis,
or an implant-supported fixed prosthesis.
The original design for the edentulous arch was a fixed-bone–
anchored bridge that used five to six implants in the anterior area
of the mandible or the maxilla to support a fixed, hybrid prosthesis.
The design is a denture-like complete arch of teeth attached to a
substructure (metal framework), which in turn is attached to the
implants with cylindrical titanium abutments (Fig. 75.1). The
prosthesis is fabricated without flange extensions and does not rely
on any soft tissue support. It is entirely implant supported. Usually,
the prosthesis includes bilateral distal cantilevers, which extend to
replace posterior teeth (back to premolars or first molars).
Another implant-supported design used to restore an edentulous
arch is the ceramic-metal fixed bridge (Fig. 75.2). Some patients
prefer this design because the ceramic restoration emerges directly
from the gingival tissues in a manner that makes its appearance
similar to that of natural teeth.
One limitation of both hybrid and ceramometal implant-supported
fixed prostheses is that they provide very little lip support and thus
may not be indicated for patients who have lost significant alveolar
dimension. This is often more problematic for maxillary reconstruc-
tions because lip support is more critical in the upper arch. Further-
more, for some patients, the lack of a complete seal (i.e., spaces
under the framework) allows air to escape during speech, thus creating
phonetic problems.
Depending on the volume of existing bone, the jaw relationship,
the amount of lip support, and phonetics, some patients may not be
able to be rehabilitated with an implant-supported fixed prosthesis.
741
 CHAPTER 75  Clinical Evaluation of the Implant Patient 741.e1

Abstract
Dental implants have become a very popular treatment for the replace-
ment of missing teeth in the partially and fully edentulous patient.
The demand for tooth replacement with dental implants has increased
with more and more patients seeking care. As with any treatment,
it is important to conduct a thorough history and comprehensive
clinical examination. Potential implant sites need to be assessed for
adequate bone height, width, and volume in the location compatible
with the proposed restoration. Because the clinical exam may or
may not detect alveolar ridge deficiencies, radiographs—especially
three-dimensional imaging (e.g., CBCT scan)—are essential for
an accurate diagnosis and planning of implant cases. This chapter
reviews important aspects of the clinical evaluation that are critical
to consider. Dimensional requirements for implant size and spacing
are presented. Risk factors and contraindications are also considered.
Keywords
edentulous
partially edentulous
missing single tooth
clinical examination
radiographic evaluation
implant selection
implant size
implant spacing
risk factors
contraindications
742 Part 4  Oral Implantology

Fig. 75.1  Clinical photograph of patient with a complete maxillary denture

opposing a full-arch implant-supported fixed prosthesis in the mandibular
arch.

For these patients, a removable, complete-denture type of prosthesis

is a better choice because it provides a flange extension that can be
adjusted and contoured to support the lip, and there are no spaces
for unwanted air escape during speech. This type of prosthesis can B
be retained and stabilized by two or more implants placed in the
anterior region of the maxilla or mandible. Methods used to secure
the denture to the implants vary from separate attachments on each
individual implant to clips or other attachments that connect to a
bar, which splints the implants together (Fig. 75.3). It is also possible
to design a removable prosthesis to intimately and securely attach
to a precision-fit substructure (e.g., milled bar), making it an implant-
supported removable prosthesis.
Although the stability of the implant-retained overdenture does
not compare with the rigidly attached, implant-supported fixed
prosthesis, the increased retention and stability over conventional C
complete dentures is an important advantage for denture wearers.55
Fig. 75.2  (A) Clinical photograph of acrylic provisional fixed full-arch
Additionally, implant-assisted and implant-supported prostheses are
prosthesis in the maxilla. (B) Clinical photograph of the final ceramometal
thought to lessen the amount of alveolar bone loss associated with restoration, anterior view. (C) Occlusal view of final restoration on master
long-term use of removable prostheses that bear directly on the cast. (Courtesy Dr. Russell Nishimura, Westlake Village, California.)
alveolar ridges.

Partially Edentulous Patients
Multiple Teeth
Partially edentulous patients with multiple missing teeth represent
another viable treatment population for osseointegrated implants,
but the remaining natural dentition (occlusal schemes, periodontal
health status, spatial relationships, and aesthetics) introduces additional
challenges for successful rehabilitation.41 The juxtaposition of implants
with natural teeth in the partially edentulous patient presents the
clinician with challenges not encountered with implants in the
edentulous patient. As a result of distinct differences in the biology
and function of implants compared with natural teeth, clinicians
must educate themselves and use a prescribed approach to the
evaluation and treatment planning of implants for partially edentulous
patients (see Chapter 77). In general, endosseous dental implants
can support a freestanding fixed partial denture. Adjacent natural
teeth are not necessary for support, but their close proximity requires
special attention and planning.11 The major advantage of an implant-
supported restoration in the partially edentulous patient is that it
replaces missing teeth without invasion or alteration of adjacent
teeth. Preparation of natural teeth becomes unnecessary, and larger
edentulous spans can be restored with implant-supported fixed
bridges.49 Moreover, patients who previously did not have a fixed
option, such as those with Kennedy class I and II partially edentulous
situations, can be restored with an implant-supported fixed restoration
(Fig. 75.4).
Early attempts to use endosseous implants to replace missing
teeth in the partially edentulous patient were a challenge partly because
the implants and armamentarium were designed for the edentulous
patient and did not have much flexibility for adaptation and use in
the partially edentulous patient. Today, clinicians have many choices
in terms of implant length, diameter, and abutment connection to
choose for the optimal replacement of any missing tooth, large or
small (Fig. 75.5).
The primary challenge with partially edentulous cases is an
underestimation of the importance of treatment planning for implant-
retained restorations with an adequate number of implants to withstand
occlusal loads. For example, one problem that required correction
was the misconception that two implants could be used to support
 A B

C D
Fig. 75.3  (A) Maxillary overdenture bar attached to four implants with anterior clips and posterior extracoronal
resilient attachments (ERAs). (B) Clinical view of maxillary overdenture bar. (C) Palateless maxillary complete
overdenture. (D) Tissue surface of the same maxillary implant-assisted overdenture showing clips and ERAs.
(Courtesy Dr. John Beumer, University of California, Los Angeles, Maxillofacial Prosthodontics.)

A B

Fig. 75.4  (A) Clinical view of a partially edentulous

posterior mandible (Kennedy class II distal extension).
(B) Occlusal view of the same patient as in part A
restored with an implant-supported fixed restoration
replacing teeth #18 and #19. Note that the dimensions
of the crowns are smaller than typical mandibular molars
C (i.e., closer to bicuspid size). (C) Buccal view of the
same restorations.

3.5 4 5.5 5 5 9 8

8 8 5 5 5.5 5 7.5

A B
Fig. 75.5  Diagram representing the use of wide-, narrow-, and standard-diameter implants for molars,
mandibular incisors, and other teeth (different-sized implants superimposed over various teeth). (A) Maxillary
teeth. (B) Mandibular teeth.
744 Part 4  Oral Implantology

a long-span, multiunit fixed bridge in the posterior area. Multiunit

fixed restorations in the posterior jaw are more likely to experience
complications or failures (mechanical or biologic) when they are
inadequately supported in terms of the number of implants, quality
of bone, or strength of the implant material (see Chapter 77). Better
treatment planning with the use of an adequate number and size of
implants, particularly in areas of poor-quality bone, has solved many
of these problems.

FLASH BACK
The Kennedy Classification refers to a system developed by Dr. Edward
Kennedy for the classification of an edentulous jaw and partial dentures.
It is based on the distribution of edentulous spaces. Kennedy class I is a
bilateral free-end posterior edentulous area. Kennedy class II is a unilateral A
free-end posterior edentulous area. Kennedy class III is a single bounded
edentulous area that does not cross the midline (unilateral). Kennedy class
IV is a single anterior bounded edentulous area that crosses the midline
(bilateral).

Single Tooth
Patients with a missing single tooth (anterior or posterior) represent
another type of patient who benefits greatly from the success and
predictability of endosseous dental implants (Video 75.1). Replacement
of a single missing tooth with an implant-supported crown is a much
more conservative approach than preparing two adjacent teeth for
the fabrication of a tooth-supported fixed partial denture. It is no
longer necessary to “cut” healthy or minimally restored adjacent
teeth to replace a missing tooth with a nonremovable prosthetic
replacement (Fig. 75.6). Reported success rates for single-tooth
implants are excellent.23
Replacement of an individual missing posterior tooth with an
implant-supported restoration has been successful as well. The greatest
challenges to overcome with the single-tooth implant restorations
were screw loosening and implant or component fracture. Because
of the increased potential to generate forces in the posterior area,
the implants, components, and screws often failed. Both of these
problems have been addressed with the use of wider-diameter implants
and internal fixation of components (Fig. 75.7). Wide-diameter
implants often have a wider platform (restorative interface) that
resists tipping forces and thus reduces screw loosening. The wide-
diameter implant also provides greater strength and resistance to
fracture as a result of increased wall thickness (i.e., the thickness of
the implant between the inner screw thread and the outer screw
thread). Implants with an internal connection are inherently more
resistant to screw loosening and thus have an added advantage for
single-tooth applications.
Aesthetic Considerations
Anterior single-tooth implants present some of the same challenges
as the single posterior tooth supported by an implant, but they also
are an aesthetic concern for patients. Some cases are more aesthetically
challenging than others because of the nature of each individual’s
smile and display of teeth. The prominence and occlusal relationship
of existing teeth, the thickness and health of periodontal tissues, and
the patient’s own psychological perception of aesthetics all play a
role in the aesthetic challenge of the case. Cases with good bone
volume, bone height, and tissue thickness can be predictable in terms
of achieving satisfactory aesthetic results (see Fig. 75.6). However,
achieving aesthetic results for patients with less-than-ideal tissue
qualities poses difficult challenges for the restorative and surgical
team.12 Replacing a single tooth with an implant-supported crown
B
Fig. 75.6  Single-tooth replacement. (A) Implant in place. (B) Metalloceramic
crown.
in a patient with a high smile line, compromised or thin periodontium,
inadequate hard or soft tissues, and high expectations is probably
one of the most difficult challenges in implant dentistry and should
not be attempted by novice clinicians.
Pretreatment Evaluation
A comprehensive evaluation is indicated for any patient who is being
considered for dental implant therapy. The evaluation should assess
all aspects of the patient’s current health status, including a review
the patient’s past medical history, medications, and medical treatments.
Patients should be questioned about parafunctional habits, such as
clenching or grinding teeth, as well as any substance use or abuse,
including tobacco, alcohol, and drugs. The assessment should also
include an evaluation of the patient’s motivations, level of understand-
ing, compliance, and overall behavior. For most patients, this involves
simply observing their demeanor and listening to their comments
for an impression of their overall sensibility and coherence with
other patient norms.
An intraoral and radiographic examination must be done to
determine whether it is possible to place implant(s) in the desired
location(s). Properly mounted diagnostic study models and intraoral
clinical photographs are useful parts of the clinical examination and
treatment-planning process to aid in the assessment of spatial and
occlusal relationships. Once the data collection is completed, the

A B
Fig. 75.7  (A) Occlusal view of healing abutment, which is attached to a wide-diameter implant used to
replace a single missing molar. (B) Radiograph of the same patient depicted in part A, showing the wide-diameter
implant supporting the final restoration (molar replaced with a single-tooth implant-supported crown).
clinician will be able to determine whether implant therapy is possible,
practical, and indicated for the patient.
Conducting an organized, systematic history and examination is
essential to obtaining an accurate diagnosis and creating a treatment
plan that is appropriate for the patient. Each treatment plan should
be comprehensive and provide several treatment options for the
patient, including periodontal and restorative therapies. Then, in
consultation, the clinician can agree on the final treatment plan with
the patient. Information gathered throughout the process will help
the clinician’s decision making and determination of whether a patient
is a good candidate for dental implants. A thoughtful and well-executed
evaluation can also reveal deficiencies and indicate what additional
surgical procedures may be necessary to accomplish the desired
goals of therapy (e.g., localized ridge augmentation, sinus bone
augmentation). Each part of the pretreatment evaluation is briefly
discussed here.
KEY FACT
Every treatment plan should be comprehensive. It should provide multiple
treatment options, including periodontal and restorative therapies. Then,
once presented with good information, the patient can ask questions and
make an informed decision about the final treatment plan. Information
gathered throughout the process will help the clinician’s decision making
and determination of whether a patient is a good candidate for dental
implants.
Chief Complaint
What is the problem or concern in the patient’s own words? What
is the patient’s goal of treatment? How realistic are the patient’s
expectations? The patient’s chief concern, desires for treatment, and
vision of the successful outcome must be taken into consideration.
The patient will measure implant success according to his or her
personal criteria. The overall comfort and function of the implant
restoration are often the most important factors, but satisfaction with
the appearance of the final restoration will also influence the patient’s
perception of success. Furthermore, patient satisfaction may be
influenced simply by the impact that the treatment has on the patient’s
perceived quality of life. Patients will evaluate for themselves whether
the treatment helped them to eat better, look better, or feel better
about themselves.
The clinician could consider an implant and the retained prosthesis
a success using standard criteria of symptom-free implant function,
CHAPTER 75  Clinical Evaluation of the Implant Patient 745
implant stability, and lack of peri-implant infection or bone loss. At
the same time, however, the patient who does not like the aesthetic
result or does not think the condition has improved could consider
the treatment a failure. Therefore it is critical to inquire, as specifically
as possible, about the patient’s expectations before initiating implant
therapy and to appreciate the patient’s desires and values. With this
goal in mind, it is often helpful and advisable to invite patients to
bring their spouses or family members to the consultation and
treatment-planning visits to add an independent “trusted” observer
to the discussion of treatment options. Ultimately, it is the clinician’s
responsibility to determine if the patient has realistic expectations
for the outcome of therapy and to educate the patient about realistic
outcomes for each treatment option.
! CLINICAL CORRELATION
It is essential to listen to a patient’s chief concerns. The patient will
ultimately decide whether the implant is successful based on his or her
personal criteria. The overall comfort and function of the implant restoration
are often the most important factors, but satisfaction with the appearance
will also influence the patient’s perception of success. Patient satisfaction
will be influenced by the impact of treatment on their perceived quality
of life. Patients will evaluate for themselves whether the implant treatment
helped them to eat better, look better, or feel better.
Medical History
A thorough medical history is required for any patient in need of
dental treatment, regardless of whether implants are part of the plan.
This history should be documented in writing by the patient’s
completion of a standard health history form and verbally through
an interview with the treating clinician. The patient’s health history
should be reviewed for any condition that might put the patient at
risk for adverse reactions or complications.
Patients must be in reasonably good health to undergo surgical
therapy for the placement of dental implants. Any disorder that
may impair the normal wound-healing process, especially as it
relates to bone metabolism, should be carefully considered as a
possible risk factor or contraindication to implant therapy (discussed
later).
A thorough physical examination is warranted if any questions
arise about the patient’s health status.15 Appropriate laboratory tests
(e.g., coagulation tests for a patient receiving anticoagulant therapy)
should be requested to evaluate further any conditions that may
746 Part 4  Oral Implantology
affect the patient’s ability to undergo the planned surgical and
restorative procedures safely and effectively. If any questions remain
about the patient’s health status, a medical clearance for surgery
should be obtained from the patient’s treating physician.
Dental History
A review of a patient’s past dental experiences can be a valuable
part of the overall evaluation. Does the patient report a history of
recurrent or frequent abscesses, which may indicate a susceptibility
to infections or diabetes? Does the patient have many restorations?
How compliant has the patient been with previous dental recom-
mendations? What are the patient’s current oral hygiene practices?
The individual’s previous experiences with surgery and prosthetics
should be discussed. If a patient reports numerous problems and
difficulties with past dental care, including a history of dissatisfaction
with past treatment, the patient may have similar difficulties with
implant therapy. It is essential to identify past problems and to
elucidate any contributing factors. The clinician must also assess
the patient’s dental knowledge and understanding of the proposed
treatment, as well as the patient’s attitude and motivation toward
implants.
Intraoral Examination
The oral examination is performed to assess the current health and
condition of existing teeth, as well as to evaluate the condition of
the oral hard and soft tissues. It is imperative that no pathologic
conditions are present in any of the hard or soft tissues in the
maxillofacial region. All oral lesions, especially infections, should
be diagnosed and appropriately treated before implant therapy.
Additional criteria to consider include the patient’s habits, level of
oral hygiene, overall dental and periodontal health, occlusion, jaw
relationship, temporomandibular joint condition, and ability to open
wide.
After a thorough intraoral examination, the clinician can evaluate
potential implant sites. All sites should be clinically evaluated to
measure the available space in the bone for the placement of implants
and in the dental space for prosthetic tooth replacement (Box 75.1).
The mesial-distal and buccal-lingual dimensions of edentulous spaces
can be approximated with a periodontal probe or other measuring
instrument. The orientation or tilt of adjacent teeth and their roots
should be noted as well. There may be enough space in the coronal
area for the restoration but not enough space in the apical region
for the implant if roots are directed into the area of interest (Fig.
75.8). Conversely, there may be adequate space between roots, but
the coronal aspects of the teeth may be too close for emergence and
restoration of the implant. If either of these conditions is discovered,
orthodontic tooth movement may be indicated. Ultimately, edentulous
areas need to be precisely measured using diagnostic study models
and imaging techniques to determine whether space is available and
whether adequate bone volume exists to replace missing teeth with
implants and implant restorations. Fig. 75.9 diagrams the minimal
space requirements for standard-, wide-, and narrow-diameter implants
placed between natural teeth, and the minimal interocclusal space
needed to restore implants.
Diagnostic Study Models
Mounted study models are an excellent means of assessing potential
sites for dental implants. Properly articulated models with diagnostic
wax-up of the proposed restorations allow the clinician to evaluate
the available space and to determine potential limitations of the
planned treatment (eFig. 75.1). This is particularly useful when
multiple teeth are to be replaced with implants or when a malocclusion
is present.
BOX 75.1  How Much Space Is Required for Placement of One
or More Implants?a
Alveolar Bone
Assuming an implant is 4 mm in diameter and 10 mm long, the
minimal width of the jawbone needs to be 6 to 7 mm, and the
minimal height should be 10 mm (minimum of 12 mm in the posterior
mandible, where an additional margin of safety is required over the
mandibular nerve). This dimension is desired to maintain at least 1 to
1.5 mm of bone around all surfaces of the implant after preparation
and placement.
Interdental Space
Edentulous spaces need to be measured to determine whether
enough space exists for the placement and restoration with one or
more implant crowns. The minimal space requirements for the
placement of one, two, or more implants are illustrated
diagrammatically in Fig. 75.9. The minimal mesial-distal space for an
implant placed between two teeth is 7 mm. The minimal mesial-
distal space required for the placement of two standard-diameter
implants (4-mm diameter) between teeth is 14 mm. The required
minimal dimensions for wide-diameter or narrow-diameter implants
will increase or decrease incrementally according to the size of the
implant. For example, the minimal space needed for the placement of
an implant 6 mm in diameter is 9 mm (7 mm + 2 mm). Whenever the
available space between teeth is greater than 7 mm and less than
14 mm, only one implant, such as placement of a wide-diameter
implant, should be considered. Two narrow-diameter implants could
be positioned in a space that is 12 mm. However, the smaller implant
may be more vulnerable to implant fracture.
Interocclusal Space
The restoration consists of the abutment, the abutment screw, and
the crown (it may also include a screw to secure the crown to the
abutment if it is not cemented). This restorative “stack” is the total
of all the components used to attach the crown to the implant. The
dimensions of the restorative stack vary slightly depending on the
type of abutment and the implant-restorative interface (i.e., internal
or external connection). The minimum amount of interocclusal space
required for the restorative “stack” on an external hex-type implant is
7 mm.
a
All of the minimal space requirements discussed here are generic averages. The
actual space limitations for any particular implant system must be determined according
to the manufacturer’s specifications.
Hard Tissue Evaluation
The amount of available bone is the next criterion to evaluate. Wide
variations in jaw anatomy are encountered, and it is therefore important
to analyze the anatomy of the dentoalveolar region of interest both
clinically and radiographically.
A visual examination can immediately identify deficient areas
(Fig. 75.10), whereas other areas that appear to have good ridge
width will require further evaluation (Fig. 75.11). Clinical examination
of the jawbone consists of palpation to feel for anatomic defects and
variations in the jaw anatomy, such as concavities and undercuts. If
desired, it is possible with local anesthesia to probe through the soft
tissue (intraoral bone mapping) to assess the thickness of the
soft tissues and measure the bone dimensions at the proposed
surgical site.
The spatial relationship of the bone must be evaluated in a three-
dimensional view because the implant must be placed in the appropri-
ate position relative to the prosthesis. It is possible that an adequate
 CHAPTER 75  Clinical Evaluation of the Implant Patient 746.e1

A B

C D

E
eFig. 75.1  Photographs of a diagnostic model with proposed lateral incisor and first molar tooth replacement
waxed up to evaluate the amount of space and contours. (A) Diagnostic cast of maxillary arch with missing
left lateral incisor and left first molar. (B) Diagnostic wax-up of lateral incisor and first molar in the maxillary
arch. (C) Diagnostic cast of mandibular arch with missing left first molar. (D) Diagnostic wax-up of first molar.
(E) Articulated maxillary and mandibular diagnostic models with wax-up of lateral incisor and first molars to
evaluate dimensions and contours. (Courtesy Dr. Stacy Yu, University of California, Los Angeles.)
Fig. 75.8  (A) Clinical photograph of maxillary premolar space with apparently
adequate space between the remaining teeth for an implant-supported crown.
(B) Radiograph clearly shows a lack of space between the roots of the adjacent
teeth as a result of convergence into the space (same patient as in part A).

A B

A B

A B CD

d d

The minimum mesial-distal space (d ) required for a: The minimum mesial-distal space (d ) required for two
A. Narrow diameter implant (e.g., 3.25 mm) is 6 mm. standard diameter implants is 14 mm wide.
B. Standard diameter implant (e.g., 4.1 mm) is 7 mm.
C. Wide diameter implant (e.g., 5.0 mm) is 8 mm.
D. Wide diameter implant (e.g., 6.0 mm) is 9 mm.
Fig. 75.9  (A) Minimum amount of mesial-distal space (d) required for placement of single-tooth implant
between natural teeth: A, 6 mm for narrow-diameter implant (3.25 mm); B, 7 mm for standard-diameter implant
(4.1 mm); C and D, 8 mm and 9 mm, respectively, for wide-diameter implants (5 mm and 6 mm). (B) Minimum
amount of mesial-distal space (d) required for placement of two standard-diameter implants (4.1 mm) between
natural teeth is 14 mm. This allows approximately 2 mm between teeth/implants and between implant/implant.
Minimum amount of space required between implant/restoration interface and opposing occlusal surfaces for
restoration of an implant. This dimension will vary depending on implant design and manufacturer component
dimensions. The minimal dimension of 7 mm is based on an externally hexed implant and UCLA abutment.
748 Part 4  Oral Implantology

A B

C D
Fig. 75.10  Clinical photographs of edentulous areas with obvious deficient areas of alveolar dimension noted
on visual examination: (A) anterior maxilla, (B) posterior maxilla, (C) anterior mandible, and (D) posterior mandible.
These clinical images all represent buccal-lingual deficiencies in the alveolar dimensions.

A B

C D
Fig. 75.11  Clinical photographs of edentulous areas with apparent good alveolar dimension noted on visual
examination: (A) anterior maxilla, (B) posterior maxilla, (C) anterior mandible, and (D) posterior mandible. It is
likely that these sites have adequate bone volume for implant placement. However, it is also possible to find
alveolar deficiencies despite the appearance of wide ridges.

dimension of bone is available in the anticipated implant site (see
Box 75.1), but that the bone and thus the implant placement might
be located too lingual or too buccal for the desired prosthetic tooth
replacement.30 Bone augmentation procedures may be necessary to
facilitate the placement of an implant in an acceptable prosthetic
position despite the availability of an adequate quantity of bone (i.e.,
the bone is in the wrong location). Bone augmentation procedures
are discussed in Chapters 79 and 80.
Radiographic Examination
Radiographic assessment of the quantity, quality, and location of
available alveolar bone in potential implant sites ultimately determines
whether a patient is a candidate for implants and if a particular
implant site needs bone augmentation. Appropriate radiographic
procedures, including periapical radiographs, panoramic projections,
and cross-sectional imaging, can help identify vital structures such
as the floor of the nasal cavity, maxillary sinus, mandibular canal,
and mental foramen (see Chapter 76). In addition to the absolute
dimensional measurement of the alveolar bone, it is important to
determine whether the volume of bone radiographically (as well as
clinically) is located in a position to allow for the proper position
of the implant to facilitate restoration of the tooth/teeth in proper
aesthetic and functional relationship with the adjacent and opposing
dentition. The best way to evaluate the relationship of available bone
to the dentition is to image the patient with a diagnostically accurate
guide using radiopaque markers that are positioned at the proposed
prosthetic locations, ideally with appropriate restorative contours
(see Fig. 76.5).
KEY FACT
Implant planning should be “prosthetically driven.” This can be achieved
with a diagnostic wax-up of the proposed prosthesis and radiographic
imaging with radiopaque markers, ideally tooth-shaped, that show the
desired tooth position(s) relative to the available bone.
Soft Tissue Evaluation
Evaluation of the quality, quantity, and location of soft tissue present
in the anticipated implant site helps to anticipate the type of tissue
that will surround the implant(s) after treatment is completed (keratin-
ized vs. nonkeratinized mucosa). For some cases, clinical evaluation
may reveal a need for soft tissue augmentation (Box 75.2). Areas
with minimal or no keratinized mucosa may be augmented with
gingival or connective tissue grafts. Other soft tissue concerns, such
as frenum attachments that pull on the gingival margin, should be
thoroughly evaluated as well.
Risk Factors and Contraindications
Clearly, there are numerous indications for the use of endosseous
dental implants to replace missing teeth. Most patients who are
missing one or more teeth can benefit from the application of an
implant-retained prosthesis provided they meet the requirements for
surgical and prosthetic rehabilitation. Edentulous patients who are
unable to function with complete dentures and who have adequate
bone for the placement of dental implants can be especially good
dental implant candidates. More and more partially edentulous
patients are also being treated with dental implant restorations.
Many patients, whether they are missing one, several, or all of
their teeth, can be predictably restored with implant-retained
prostheses.
CHAPTER 75  Clinical Evaluation of the Implant Patient 749
BOX 75.2  How Much Keratinized Tissue Is Required for the
Health and Maintenance of Implants?
Debate continues about whether it is necessary to have a zone of
keratinized tissue surrounding implants. Despite strong opinions and
beliefs about the need for keratinized mucosa around implants versus
this mucosa being unnecessary, neither argument has been proved.
Some studies have concluded that, in the presence of good oral
hygiene, a lack of keratinized tissue does not impair the health or
function of implants.54 Others strongly believe that keratinized
mucosa has better functional and aesthetic results for implant
restorations. Keratinized mucosa is typically thicker and denser than
alveolar mucosa (nonkeratinized). It forms a strong seal around the
implant with a cuff of circular (parallel) fibers around the implant,
abutment, or restoration that is resistant to retracting with
mastication forces and oral hygiene procedures. Implants with coated
surfaces (i.e., hydroxyapatite [H] or titanium plasma spray [TPS]
coating) demonstrate greater peri-implant bone loss and failures in
the absence of keratinized mucosa.13,38
In this era of high implant success and predictability and thus
possible complacency, it is imperative for clinicians to recognize
risk factors and contraindications to implant therapy so that problems
can be minimized and patients can be accurately informed about
risks. As such, the clinician must be knowledgeable in this area and
inform patients about risk factors and contraindications before initiat-
ing treatment. Contraindications for the use of dental implants,
although relatively few and often not well defined, do exist. Some
conditions are probably best described as “risk factors” rather than
“contraindications” to treatment because implants can be successful
in almost all patients; implants may be less predictable in some
situations, and this distinction should be recognized. Ultimately, it
is the clinician’s responsibility with the patient to make decisions
as to when implant therapy is not indicated.
Table 75.1 lists some conditions and factors that are thought to
increase the risk for implant failure or otherwise deem the patient
a poor candidate for implant therapy. Some of these conditions are
briefly discussed here.
Medical and Systemic Health–Related Issues
Although few absolute medical contraindications to implant therapy
exist, some relative contraindications are important to consider. The
clinician must consider medical and health-related conditions that
affect bone metabolism or any aspect of the patient’s capacity to
heal normally.10 This category includes conditions such as diabetes,
osteoporosis, and immune compromise; medications; and medical
treatments such as chemotherapy and irradiation.
Diabetes Mellitus
Diabetes is a metabolic disease that can have significant effects on
the patient’s ability to heal normally and resist infections. This is
particularly true for patients whose diabetes is not well controlled.
Patients with poorly controlled diabetes often have impaired wound
healing and a predisposition to infections, whereas patients with
well-controlled diabetes experience few, if any, problems (see
Chapter 14).
There is concern about the success and predictability of implants
in patients with diabetes. Several studies have reported moderate
failure rates in patients with diabetes, with implant success ranging
from 85.6% to 94.3%.8,26,36,39 A prospective study demonstrated 2.2%
early failures and 7.3% late failures in patients with diabetes.51 After
5 years, the overall success rate for this group of diabetic patients
750 Part 4  Oral Implantology

(type II), or idiopathic causes (type III). Secondary osteoporosis has

TABLE 75.1  Risk Factors and Contraindications for Implant
been attributed to many different diseases and conditions, including
Therapy
diabetes, alcoholism, malnutrition, and smoking.31
Risk Factor Contraindication All the various types of osteoporosis share the same fundamental
Medical and Systemic Health–Related Issues problem of decreased bone mineral density and the concern that this
Diabetes (poorly controlled) ??—Possibly Relative condition may impair the patient’s ability to achieve and maintain
implant osseointegration. The premise that implants will not perform
Bone metabolic disease ??—Probably Relative as well in a patient with osteoporosis is reasonable given that
(e.g., osteoporosis) osseointegration depends on bone formation adjacent to the implant
Radiation therapy (head Yes Relative/absolute surface and that success rates are highest in dense bone and lowest
and neck) in poor-quality, loose trabecular bone. However, to date, there is no
clear evidence to suggest that implants will not be successful in
Bisphosphonate therapy ??—Probably Relative/absolute
patients with osteoporosis, so the issue continues to be debated.9,19
(intravenous)
On the positive side, although the evidence is weak, case reports
Bisphosphonate therapy ??—Possibly Relative have demonstrated successful implant treatment in patients with
(oral) osteoporosis.30 Some investigators advocate the use of longer healing
Immunosuppressive ??—Probably Relative times for osseointegration to occur before loading the implants in
medication patients with osteoporosis.28 Conversely, in a retrospective analysis
of 49 patients who received sinus bone augmentation, individuals
Immunocompromising ??—Possibly Relative
(11 patients) with lower bone mass density had significantly lower
disease (e.g., HIV, AIDS)
implant success rates as compared with age- and sex-matched
Psychological and Mental Conditions controls.14 Other parameters evaluated in this study did not demonstrate
Psychiatric syndromes (e.g., No Absolute any significant differences.
schizophrenia, paranoia) Interestingly, there is a trend in aging adults (men older than 50
Mental instability (e.g., No Absolute years and postmenopausal women) for bone mass to decrease progres-
neurotic, hysteric) sively through bone demineralization at a rate of 1% to 2% per year
and in some individuals as much as 5% to 8% per year throughout
Mentally impaired; No Absolute their later life.21,35 If one considers this decline in bone mass with
uncooperative aging along with a continually increasing life expectancy in the
Irrational fears; phobias No Absolute population, the number of individuals with osteopenia or osteoporosis
will continue to increase, and the concern about this condition’s
Unrealistic expectations No Absolute
influence on implant success will become increasingly more important
Habits and Behavioral Considerations for clinicians.
Smoking; tobacco use Yes Relative
Bisphosphonate Therapy
Parafunctional habits Yes Relative
Some prescribed medications, including steroids and bisphosphonates,
Substance abuse (e.g., ??—Possibly Absolute may be cause for concern relative to the potential implant patient.
alcohol, drugs) A brief statement regarding the risk of bisphosphonate therapy is
Intraoral Examination Findings offered here. Readers are encouraged to review more detailed
Atrophic maxilla Yes Relative explanations in Chapters 14 and 39 and to consult online information
as well as other resources to get updated information about this
Current infection (e.g., Yes Relative
important subject as more is learned and recommendations are
endodontic)
developed.
Periodontal disease ??—Possibly Relative Although there is heightened awareness and great concern about
risk of bisphosphonate-related osteonecrosis of the jaw (BRONJ),
AIDS, Acquired immunodeficiency syndrome; HIV, human immunodeficiency virus.
the causal relationship and pathogenesis of the problem has not been
defined. A review of available literature offers information that will
was 90%.47 None of these studies was able to correlate gender, age, guide clinicians in their decision making, but it is far from definitive.
smoking, diabetes type, or level of diabetic control with implant The prevalence and incidence remains uncertain. In general, the risk
failure. In a meta-analytical review of implant failures in patients of BRONJ is between 1 in 10,000 and 1 in 100,000 but may increase
who were not diabetics, the early implant failure rate was 3.2% and to 1 in 300 after an oral surgical procedure. The great majority of
the late implant failure rate 5.2%.22 The finding that patients with BRONJ cases will likely remain in the population of patients who
diabetes experience slightly more late failures may be related to less receive intravenous administration of bisphosphonates. Cofactors,
tissue integrity caused by reduced tissue turnover and impaired tissue such as smoking, steroid use, anemia, hypoxemia, diabetes, infection,
perfusion. These results suggest that diabetes may be a risk factor and immune deficiency, have not been firmly established but may
for implants, particularly for late failures. However, the risk does be important.45 Rarely does BRONJ in the oral bisphosphonate patient
not appear to be particularly high. appear to progress beyond stage 2, and many cases reverse with
discontinuation of oral medication. Procedures reported to have
Bone Metabolic Disease contributed to the development of BRONJ include extractions,
Osteoporosis is a skeletal condition characterized by decreased mineral periodontal surgery, root canal treatment, and dental implant surgery.46
density. The two main classifications are primary (three types) and Dental implant therapy, as well as other surgical procedures, should
secondary (multiple types) osteoporosis. Primary osteoporosis has be avoided in individuals who have been treated with intravenous
been attributed to menopausal changes (type I), age-related changes (IV) bisphosphonate therapy and carefully considered with caution

in patients treated with oral bisphosphonate therapy, particularly
those with a history of more than 3 years of use.3
Immune Compromise and Immune Suppression
Corticosteroid therapy, whether used for hormone replacement, cancer
treatment, immune suppression, or another chronic condition, may
suppress the immune response, impair wound healing, or compromise
the normal adrenal response to stress. See Chapters 14 and 39 for
more information on the treatment of patients taking corticosteroids.
Individuals undergoing chemotherapy or taking medications that
impair healing potential (e.g., steroids) are probably not good can-
didates for implant therapy because of the effects these agents have
on normal healing. This is especially true for cancer chemotherapy.
A lowered resistance to infection may also be problematic for these
patients. Past history of chemotherapy or immunosuppressive therapy
may not be problematic if the patient has recovered from the side
effects of treatment.
Patients with an immunocompromising disease, such as human
immunodeficiency virus (HIV) infection or acquired immunodeficiency
syndrome (AIDS), are not good candidates for implants when their
immune system is seriously impaired. Patients with very low or
undetectable viral loads and normal (T cell counts) immune function
may be candidates for implant therapy (see Chapter 30).
Radiation Therapy
Patients with a history of radiation treatment to the head and neck
region may not heal well after surgery. Soft tissue dehiscence may
follow surgical manipulation, which may lead to osteoradionecrosis
(ORN), a serious condition of nonhealing exposure and infection of
bone. This is especially problematic for patients who have received
radiation dosages greater than 60 Gy. Surgical procedures, or any
procedure that may initiate a wound, are generally avoided in patients
with a history of radiation therapy. If deemed necessary, surgical
procedures can be done in conjunction with hyperbaric oxygen (HBO)
therapy to reduce the risk of ORN.
Several studies have documented poor success rates for implants
in patients with a history of radiation therapy.32,33,44 In a literature
review, Sennerby and Roos50 found irradiation to be associated with
high failure rates, as did Esposito and colleagues24 in their review.
Beumer and colleagues12 reported success rates as low as 60.4% in
the irradiated maxilla. Granstrom and colleagues32 reported a sig-
nificant improvement in survival rates for implants in patients treated
with HBO. However, in a systematic review, Coulthard and col-
leagues18 concluded that the evidence is lacking to support the clinical
effectiveness of HBO in irradiated patients receiving implants. The
application of implants in patients with a history of irradiation, with
or without the use of HBO, is not resolved and continues to be
debated. Clearly, irradiation is a risk factor for implant success and
may be a contraindication.
Psychological and Mental Conditions
In general, any type of psychological abnormality can be considered
a contraindication to dental implant treatment because of the patient’s
uncooperativeness, lack of understanding, or behavioral problems.
Physiologically, there is no reason to suspect that implants could
not become osseointegrated in these patients. However, the patient’s
ability to tolerate the number and type of treatment appointments
required for implant placement, restoration, and maintenance could
be problematic. All psychological conditions have the potential to
be absolute contraindications to implant treatment depending on the
severity of the condition. The exception might be individuals who
demonstrate good cooperative behavior with only mild psychological
or mental impairment. The clinician should take great care before
CHAPTER 75  Clinical Evaluation of the Implant Patient 751
accepting a mentally or psychologically impaired individual for
treatment with implants.
Habits and Behavioral Considerations
Patients have a variety of habits and behaviors that may increase
the risk of failure for dental implants. Smoking, clenching or grinding
of teeth, and drug or alcohol abuse are among the most well-known
habits that should be identified because of the increased risk for
implant failure or complications.
Smoking and Tobacco Use
Moderate to heavy smoking has been documented to result in higher
rates of early implant failure and adversely affect the long-term
prognosis of dental implant restorations.6,20,43 This is particularly true
for implants placed in poor-quality bone such as the posterior maxilla.39
The mechanisms of action responsible for higher implant failures
associated with smoking are not understood. Plausible explanations
include the effect of smoking on white blood cells, vasoconstriction,
wound healing, and osteoporosis.4,37 Smoking is a known risk factor
for osteoporosis and thus may adversely affect implant success through
its effect on bone metabolism. Smoking cessation may improve the
success rate of implants.5 In a meta-analytical review, Bain and
coworkers7 found that implants with an altered surface microto-
pography (Biomet 3i, Osseotite; dual acid-etched surface) seemed
to significantly lessen the adverse effects of smoking on implant
success.
Parafunctional Habits
Parafunctional habits, such as clenching or grinding of teeth (con-
sciously or unconsciously), have been associated with an increased
rate of implant failure (e.g., failure to integrate, loss of integration,
implant fracture). Repeated lateral forces (i.e., parafunctional habits)
applied to implants can be detrimental to the osseointegration process,
especially during the early healing period. Patients with known
parafunctional habits should be advised of an increased risk of
complications or failures as a result of their clenching or grinding.
Many consider bruxism to be a contraindication to implant treatment,
especially in the case of a short-span, fixed partial denture or a
single-tooth implant. If implants are planned for a patient with
parafunctional habits, protective measures should be employed, such
as creating a narrow occlusal table with flat cusp angles, protected
occlusion, and the regular use of occlusal guards.
Substance Abuse
Drug and alcohol abuse should be considered a contraindication for
implant therapy for reasons similar to the psychological problems
discussed earlier. Patients with drug or alcohol addictions can be
irresponsible and noncompliant with treatment recommendations.
Depending on the severity and duration of an individual’s addiction,
some patients may be malnourished or may even have impaired
organ function and therefore may not be good surgical candidates
because of poor healing capacity. All elective treatments, including
implant therapy, should be refused until addictions are treated and
controlled.
Posttreatment Evaluation
Periodic posttreatment examination of implants, the retained prosthesis,
and the condition of the surrounding peri-implant tissue are important
components of successful treatment. Aberrations and complications
can often be treated if discovered early, but many problems will go
unnoticed by the patient. Thus periodic examination is essential to
discovering problems early and to intervening and preventing problems
752 Part 4  Oral Implantology
from getting worse. Several parameters are available to evaluate the
condition of the prosthesis, the stability of the implants, and the
health of surrounding peri-implant tissues after implant integration
and prosthetic restoration. Intraoral radiographs should be taken at
the time of placement (baseline), at the time of abutment connection
(to confirm seating and serve as another baseline), at the time of
final restoration delivery (loading), and subsequently to monitor
marginal or peri-implant bone changes. Periapical radiographs have
excellent resolution and provide adequate details for evaluating bone
support around implants if taken at a perpendicular direction.
The long-term success of dental implants is dependent on the
health and stability of supporting peri-implant tissues. Good oral
hygiene and regular professional care are essential to maintaining
peri-implant health, and the importance of good oral hygiene should
be stressed as early as possible. Patients should be taught to maintain
good oral hygiene. Their performance should be monitored and
reinforced at each visit.
See Chapter 86 for a detailed description of important clinical
and radiographic monitoring methods as well as oral hygiene and
implant maintenance protocols.
Conclusion
Today, clinicians are able to predictably replace missing teeth with
endosseous dental implants. Whether missing a single tooth, several
teeth, or all teeth, many patients can be candidates for dental implant
therapy. It is important for clinicians to recognize factors that influence
implant success. In addition to the quantity, quality, and location of
available bone, the patient’s health, risk factors, and contraindications
must be assessed. Patients should be informed about risk factors and
provided with treatment options both with and without dental implants.
Periodic evaluation, good oral hygiene, and regular maintenance are
important aspects of care for the long-term success and the prevention
of complications with dental implants.
A Case Scenario is found on the companion website
www.expertconsult.com.
References
References for this chapter are found on the companion
website www.expertconsult.com.
 CHAPTER 75  Clinical Evaluation of the Implant Patient 752.e1

CASE SCENARIO 75.1 

Patient:  27-year-old female Current Findings:  The mandibular right cuspid has drifted mesial to close
the space for the missing lateral incisor. The open space is distal to the
Chief Complaint:  “I want to replace my missing tooth with an implant.”
cuspid. The mesial-distal dimension of the edentulous space is 4.5 mm.
Background Information A scan of the area reveals that the mesial-distal space between the roots
The patient was congenitally missing the mandibular right lateral incisor. of the cuspid and the premolar is about 4 to 4.5 mm.
She has worn a removable partial denture for as long as she can
remember but now wants to replace the tooth in a more permanent
fashion.

A B

Case-Based Questions Solution and Explanation

1. What are the options for replacing this missing tooth? Answer: D
A. Single tooth implant Explanation: Some options are better than others, but all of these are
B. Fixed partial denture #27 and #28 possible. The implant option is challenging due to limited space.
C. Removable partial denture
D. All of the above
2. How much space is needed to replace a tooth in this position? Answer: C
A. 4  mm Explanation: The minimum required mesial-distal space for a narrow
B. 5  mm (3.2–3.5 mm) diameter implant is 6 mm. It is desirable to maintain a
C. 6  mm minimum of 1 to 1.5 mm of bone around all surfaces, especially
D. 7  mm between the implant and the adjacent tooth.
3. What is the ideal amount of interocclusal space required for the Answer: D
implant crown, abutment, and screw? Explanation: The minimum amount of interocclusal space is probably
A. 4  mm about 4 to 5 mm, but the restorative unit would be very short. The ideal
B. 5  mm amount of interocclusal space required for an implant crown is 7 mm.
C. 6  mm
D. 7  mm
752.e2 Part 4  Oral Implantology
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assessments in a type 2 diabetic population: a prospective study, Int J
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integrated oral implants: a review of the literature, Int J Prosthodont
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Osseotite implants: a 6-year clinical follow-up, Compend Contin Educ
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CHAPTER 75  Clinical Evaluation of the Implant Patient 752.e3
53. Wallace SS, Froum SJ: Effect of maxillary sinus augmentation on
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Diagnostic Imaging for the Implant Patient
Sotirios Tetradis | Sanjay M. Mallya | Perry R. Klokkevold
CHAPTER OUTLINE
Standard Projections Patient Evaluation
Cross-Sectional Imaging Clinical Selection of Diagnostic
Interactive “Simulation” Software Imaging
Programs
Several radiographic imaging options are available for the diagnosis
and treatment planning of patients receiving dental implants.2,17,18
Options range from standard projections routinely available in the
dental office to more complex radiographic techniques typically
available only in radiology centers. Standard projections include
intraoral (periapical, occlusal) and extraoral (panoramic, lateral
cephalometric) radiographs. More complex imaging techniques include
cone-beam computed tomography (CBCT) and multislice computed
tomography (MSCT). The CBCT and MSCT image data files can
be reformatted and viewed on a personal computer using simulation
software, making the diagnosis and treatment-planning process
interactive and visually more meaningful. Often, combinations of
various modalities are used because no single modality can provide
all information pertinent to the radiographic evaluation of the implant
patient. Familiarity with the benefits and limitations of various
techniques and awareness of the specific clinical questions that need
to be answered should guide the decision-making process and selection
of radiographic examinations for individual patients.
Multiple factors influence the selection of radiographic technique(s)
for a particular case, including cost, availability, radiation exposure,
and case type. The decision is a balance between these factors and
the desire to minimize risk of complications to the patient. Accurately
identifying vital anatomic structures and being able to perform implant
placement surgery without injury to these structures are critical to
treatment success. Diagnostic imaging must always be interpreted
in conjunction with a good clinical examination.
This chapter discusses common imaging techniques used for
evaluation of the implant patient. Indications for each technique are
outlined, along with the advantages and limitations of each technique.
KEY FACT
Accurate identification of vital anatomic structures is critical to treatment
success when performing dental implant surgery. Diagnostic imaging must
always be interpreted along with a clinical examination.
Standard Projections
Standard diagnostic imaging modalities include periapical, panoramic,
lateral cephalometric, and occlusal radiographs. Table 76.1 summarizes
the advantages and disadvantages of each modality.
CHAPTER 76 
Conclusion
Periapical Radiographs
Periapical radiographs are often the first imaging modality used to
evaluate the implant patient.19,20 These radiographs provide an overall
assessment of the quantity and quality of the edentulous alveolar
ridge and the adjacent teeth. They are easy to obtain in the dental
office, are relatively inexpensive, and deliver low radiation dose to
the patient8 (Table 76.2). Dentists are familiar with the depicted
anatomy and possible pathology. Because these direct-exposure
projections do not use intensifying screens, intraoral radiographs
offer the highest detail and spatial resolution of all radiographic
modalities (Fig. 76.1). Thus intraoral radiographs are the projection
of choice when subtle, localized pathology, such as a retained root
tip, needs to be detected and evaluated.
The most significant disadvantage of periapical radiographs is their
susceptibility to unpredictable magnification of anatomic structures,
which does not allow reliable measurements.15 Foreshortening or
elongation can be minimized by the use of paralleling technique.
However, distortion is particularly accentuated in edentulous areas,
where missing teeth and resorption of the alveolus necessitate receptor
placement at significant angulation in relation to the long axis of
the teeth and alveolar bone. Additionally, periapical radiographs are
two-dimensional representations of three-dimensional objects and
do not provide any information of the buccal-lingual dimension
of the alveolar ridge. Structures that are distinctly separated in the
buccal-lingual dimension appear to be overlapping. Also, the periapical
image is limited by the size of film or sensor being used. Often, it
is not possible to image the entire height of the remaining alveolar
ridge, and when extensive mesial-distal areas need to be evaluated,
multiple periapical radiographs are required.
Periapical radiographs are useful screening images that offer a
detailed view of a small area of the alveolar arch. Limitations that
must be considered include the possibility of distortion and the
two-dimensional representation of anatomic structures.
Occlusal Radiographs
Occlusal radiographs are intraoral projections that offer easy, eco-
nomic, low-radiation dose and high-resolution images covering a
larger area than periapical projections.20 Depending on receptor
placement and the angulation of the x-ray tube, occlusal radiographs
can provide an image of the mandibular width or can depict an
extended area of the edentulous ridge. Occlusal radiographs have
753
 CHAPTER 76  Diagnostic Imaging for the Implant Patient 753.e1

Abstract
Radiographic imaging is a valuable tool in the assessment of patients
receiving dental implants. Two- and three- dimensional imaging
approaches are utilized to provide an accurate assessment of the
anatomy of the osseous structures of the craniofacial complex. In
this chapter, we discuss the advantages and disadvantages of standard
intraoral and extraoral projections and complex imaging modalities
such as multi-slice computed tomography (MSCT) and cone-beam
computed tomography (CBCT). We also provide a disciplined and
methodical approach toward assessment of the available radiographs
to maximize their usefulness towards improved outcomes.

Key Words
radiographs
periapical
panoramic
CBCT
MSCT
surgical guides
754 Part 4  Oral Implantology

TABLE 76.1  Advantages and Disadvantages of the Various Radiographic Projections

Modality Advantages Disadvantages
Periapical and occlusal High resolution and detail, easy acquisition, low Unpredictable magnification, small imaged area, 2D
radiography radiation exposure, relatively inexpensive representation of anatomy
Panoramic radiography Easy to acquire, images the full dentoalveolar Unpredictable magnification, unequal magnification in vertical
ridge, low radiation dose, relatively inexpensive and horizontal dimensions, 2D representation of anatomy,
not detailed
Lateral cephalometric Easy to acquire, predictable magnification, low Limited use in area of midline, 2D representation of anatomy
radiography radiation dose, relatively inexpensive
Multislice computed 3D representation, no magnification, sufficient Requires special equipment, expensive, higher radiation dose
tomography detail, digital format, images whole arch
Cone-beam computed 3D representation, no magnification, sufficient Requires special equipment, relatively expensive
tomography detail, digital format, images whole arch, low
radiation dose
2D, Two-dimensional; 3D, three-dimensional.

TABLE 76.2  Radiation Dose (Effective Dose in µSv) Received

From Common Projections During Evaluation of the Implant
Patient Data
Modality Effective Dose (µSv)
Full-mouth x-ray (FMX) series 177
Panoramic 20
Limited field-of-view CBCT 47
Medium field-of-view CBCT 98
Large field-of-view CBCT 117
Fig. 76.2  Panoramic radiograph. Both jaws are visualized on the same
MSCT, Maxillofacial 913 image. An overall assessment of superoinferior and mesial–distal dimensions
CBCT, Cone-beam computed tomography; CT, computed tomography; MSCT, multislice
of the alveolar ridge can be formulated. Tooth and root positions relative
computed tomography. to planned implant sites can be evaluated. Important anatomic structures,
Adapted from Mallya SM: Principles of cone beam computed tomography. In Fayad M, such as the maxillary sinus and mandibular canal, can be identified.
Johnson BR, editors: 3D imaging in endodontics: a new era in diagnosis and treatment.
Median effective doses for standard exposure protocols were derived from collation of
data from several reports in the literature.
the same limitations of distortion and overlapping anatomy as periapi-
cal radiographs.
Occlusal radiographic projections offer an initial assessment of
the implant patient, and they provide an overview of the mandibular
width or can visualize larger areas of alveolar ridge compared with
periapical radiographic projections.

Fig. 76.1  The periapical radiograph offers a high-resolution, detailed
image of the edentulous area. Healing of the extraction socket with dense
bone (socket sclerosis) can be seen (small white arrows). Some anatomic
structures, such as the maxillary sinus (large white arrow) and the zygomatic
process of the maxilla (black arrow), can also be visualized.
Panoramic Radiographs
Panoramic radiographs are often used in the evaluation of the implant
patient because they offer several advantages over other modalities.16
Panoramic radiographs deliver low radiation doses (see Table 76.2)
to provide a broad picture of both arches and thus allow assessment
of longer edentulous spans, angulation of existing teeth and occlusal
plane, and important anatomy in implant treatment planning such
as the maxillary sinus, nasal cavity, mental foramen, and mandibular
canal (Fig. 76.2). Panoramic units are widely available and easy to
operate, and dentists are familiar with the anatomy and pathology
depicted by the images. Similar to intraoral projections, panoramic
images are two-dimensional and thus do not offer diagnostic informa-
tion for the buccal–lingual width of the alveolar arch.
Panoramic images appear intuitively familiar. However, they
combine characteristic physical and radiographic principles that
make them distinct from other intraoral and extraoral radiographs.
Although outside the scope of this chapter, familiarity with the principles
 CHAPTER 76  Diagnostic Imaging for the Implant Patient 755

underlying panoramic radiography is central for understanding, and

thus compensating for, the limitations and constraints of the images.
The reader is referred to other textbooks for detailed discussion of
this topic.7,10 Briefly, the existence of ghost shadows, unpredictable
horizontal and vertical magnification, distortion of structures outside
the focal trough, projection geometry generated by the negative vertical
angulation of the x-ray beam, and the propensity to patient-positioning
errors do not allow consistently detailed and accurate measurements
to be generated. As a result, panoramic radiographs do not provide
the highly detailed images that are generated by intraoral radiographs.
Measurement distortion is more prevalent and varies across the
radiographic image. On average, panoramic radiographs are 25%
magnifications of actual size. Implant manufacturers often provide
transparency sheets with implant size outlines of 25% magnification.
However, it is important to appreciate that the 25% magnification is
an estimate. The actual magnification may range from 10% to 30%
in different areas within the same image and depends greatly on
patient positioning during panoramic radiography. For this reason,
precise measurements on panoramic projections are not possible.
Nonetheless, panoramic radiographs offer an overall view of the
maxilla and mandible that can be used to estimate bone measurements
and evaluate the approximate relationships between teeth and other
anatomic structures. More precise diagnostic imaging should be used
to measure the proximity of critical anatomic structures, such as the Fig. 76.3  Schematic diagram of the anatomic area imaged with large
maxillary sinus or the mandibular canal, to proposed implant positions. (green), medium (blue), and limited (magenta) field of view cone-beam
Panoramic projections provide useful information for the initial computed tomography.
assessment of the implant patient. However, because of magnification
and distortion errors, panoramic radiographs should not be used for
detailed measurements of proposed implant sites. An important feature of the various CBCT units is the field of view
(FOV) describing the extent of the imaged volume. CBCT units are
typically categorized as large FOV (greater than 15 cm), medium FOV
Cross-Sectional Imaging (8 to 15 cm), and limited FOV systems (less than 8 cm). Fig. 76.3
Cross-sectional diagnostic imaging modalities include MSCT and depicts schematically the anatomic area covered by large, medium,
CBCT. Conventional tomography also provides cross-sectional images and limited FOV scans. In general, large FOV units image a more
with predictable magnification and has been used in the assessment extensive anatomic area, deliver a higher radiation exposure to the
of the implant patient. However, with the introduction and expansion patient, and produce lower-resolution images (Fig. 76.4). Conversely,
of CBCT imaging, conventional tomography is becoming obsolete limited FOV units image a small area of the face, deliver less radiation,
and is not described in this chapter. and produce a higher-resolution image (Fig. 76.5).
CBCT scans offer several advantages for evaluation of the implant
Cone-Beam Computed Tomography patient, compared with two-dimensional (2D) imaging. True cross
Cone-beam computed tomography (CBCT) is an imaging modality sections offer a precise and detailed evaluation of the height and width
that offers significant advantages for the evaluation of implant of the alveolar ridge. The images can be adjusted and printed without
patients.5,14 CBCT was introduced to dentistry in the late 1990s,1,12 magnification, facilitating measurements directly on the prints or films
and several CBCT units are commercially available for imaging of with standard rulers (i.e., not magnified). Vertical and horizontal rulers
the craniofacial complex. The x-ray source and the detector are adjacent to each section allow the clinician to check for magnification
diametrically positioned and make a 180- to 360-degree rotation and make direct measurements. The digital format allows for image
around the patient’s head within the gantry. The x-ray beam is col- enhancement tools, rapid communication between the radiologist and
limated and the resultant beam is cone or pyramid shaped. Typically, the surgeon, and generation of multiple copies of the images. Various
a single complete rotation, 180 to 500 basis projections of the region anatomic structures can be visualized and analyzed at all three coordinate
of interest, is generated. The computer uses these images to generate axes, so that their superoinferior, anteroposterior, and buccolingual
a digital, three-dimensional map of the face. Once this map is gener- location can be identified with precision. CBCT images the entire
ated, multiplanar reconstructions—axial, coronal, sagittal, or oblique arch, or even both arches, so several edentulous areas can be visualized
sections of various thicknesses—can be reconstructed from the data. with a single examination. The bone and soft-tissue contrast and resolu-
tion are appropriate for the diagnostic task.
In summary, CBCT scanning is a valuable imaging modality for
KEY FACT three-dimensional and cross-sectional evaluation of the implant patient.
CBCT offers significant advantages for the evaluation of implant patients. It has similar advantages and disadvantages as CT scanning. The
The field of view (FOV) is an important feature that describes the extent most significant difference is that CBCT imaging delivers much less
of the imaged volume from large FOV (greater than 15 cm) to medium radiation exposure to the patient.
FOV (8 to 15 cm) and limited FOV (less than 8 cm). Limited FOV units
Multislice Computed Tomography
image a small area, delivering less radiation and producing a higher-
resolution image Multislice CT (MSCT) was widely used in the evaluation of the
implant patient.3,6 However, with the advent of CBCT, utilization of
756 Part 4  Oral Implantology

C
Fig. 76.4  Cone-beam computed tomography images for the evaluation of the edentulous space at the area
of missing tooth #30 before implant placement using a large field-of-view unit (NewTom 3G, Verona, Italy,
distributed by AFP Imaging, Elmsford, New York). Note the tooth-shaped marker used. (A) A series of “panoramic”
reconstructions through the alveolar ridge reveals the relationship of the marker to the adjacent teeth. The top
“panoramic” view is 12 mm thick so as to depict most of the extent of the alveolar ridge and adjacent teeth.
The middle “panoramic” image is 1 mm thick through the area of the mandibular canal. Note that adjacent
teeth are out of the plane of the section and thus not depicted on the image. The bottom “panoramic” view is
the same as the middle one, but the position of the mandibular canal has been depicted by the red line. (B)
Scout axial view and series of cross sections through the area of the marker. The bottom row shows the same
axial slices as the top row. However, the position of the red line drawn on the panoramic view is also depicted
to help localization of the mandibular canal. The height and width of the alveolar ridge have been measured
in a selected section. (C) Three-dimensional reconstructions provide an overall impression of the bone contours
and shape of the alveolar ridge. Note the small exostosis on the lingual surface of the alveolar ridge.

MSCT has been reduced significantly. However, MSCT is an excellent
choice for evaluation of the implant patient if CBCT scanning is not
available.4
Typical dental views reconstructed from a MSCT scan include a
scout view (see Fig. 76.6A) as well as axial (Fig. 76.6B), panoramic
(Fig. 76.6C), and cross-sectional (Fig. 76.6D) views of the jaws.
Appropriate axial slices through the alveolar ridge of interest are
selected as scout views. The curvature of the maxillary or mandibular
ridge is then drawn on the axial slices, and panoramic images along
the drawn line are created. Finally, cross-sectional slices, typically
at every 1 to 2 mm and perpendicular to the drawn curvature, are
created. In addition to these flat, two-dimensional views, complex,
three-dimensional images with surface rendering can also be gen-
erated from the CT data (Fig. 76.6E). These images can provide
useful information about the alveolar ridge defects that are easy to
comprehend.

A1 A2
B1 B2
Fig. 76.5  Cone-beam computed tomography images for the evaluation
of the edentulous space at the area of missing tooth #4 (A) and missing
tooth #30 (B) using a limited field-of-view scan (3D Accuitomo, J. Morita
Corporation, Suita City, Osaka, Japan, distributed by J. Morita USA, Inc.,
Irvine, California). Sagittal and cross-sectional slices are shown. Although
the anatomic area imaged is limited, the resolutions of the images are high.
(A) Implant site #4 (maxillary right second premolar) in anterior–posterior
(A1) and buccolingual (A2) cross-sectional views. (B) Implant site #30
(mandibular right first molar) in anterior–posterior (B1) and buccolingual
(B2) cross-sectional views.
MSCT offers the same advantages and disadvantages as MSCT.
However, the two modalities have basic differences that result from
the different physical principles used during image acquisition.
MSCT scans offers a greater contrast resolution, or the ability to
distinguish two objects with small density differences. In contrast,
CBCT scans have a limited capacity to separate muscle from fat
or connective tissue compared with MSCT scans. Fortunately, the
diagnostic tasks in implant treatment planning do not require high-
contrast resolution. Because bone has a much higher radiodensity
than surrounding soft tissues, both CBCT and MSCT clearly depict
bone morphology and internal trabecular architecture. One of the most
significant advantages of CBCT scanning versus MSCT scanning is
the significantly lower radiation dose delivered to the patient9,21,22
(Table 76.2).
MSCT scanning requires specialized equipment and setting.
Radiologists and technicians need to be knowledgeable of the anatomy,
anatomic variants, and pathology of the jaws, as well as considerations
pertinent to implant treatment planning, so that optimal views will
be provided. An MSCT scan delivers a much higher radiation dose
to the patient than the other modalities used during implant treatment
planning13 (Table 76.2). Because a CT scan images the whole arch,
radiation is delivered to the entire imaged area, regardless of how
many or how few sites are actually needed. Metallic restorations
can cause beam-hardening artifacts that impair the diagnostic quality
CHAPTER 76  Diagnostic Imaging for the Implant Patient 757
of the images. This is particularly challenging in patients with heavily
restored dentition. In general, the cost of MSCT is significantly
higher than that of CBCT or the other standard intraoral and extraoral
projections.
In summary, MSCT scanning offers many advantages during
implant treatment planning, including accurate cross-sectional imaging
and three-dimensional visualization of anatomic structures. High
dose to the patient and artifacts caused by metallic restorations are
concerns that should be considered.
Interactive “Simulation” Software Programs
Implant treatment planning can be greatly enhanced by the use of
specialized software. In addition to measuring the quantity and
quality of bone in potential implant sites, these programs use CT
(MSCT or CBCT) scan data to simulate placement of implant and
restorations. Using a database of commercially available implant
images, the length, width, angulation, and position of implants
can be “simulated” in the desired positions and evaluated relative
to other structures in three dimensions. In cases of alveolar ridge
deficiency or defects, or when sinus bone augmentation is indicated,
the additional bone volume needed can be evaluated and quanti-
fied. The restoration of the implants can also be simulated and the
distribution of mechanical forces onto the implant and adjacent bone
predicted.
Software programs specialized in implant treatment planning,
such as SIM/Plant (Materialise/Columbia Scientific, Glen Burnie,
Maryland), can acquire information directly from CBCT or CT scan
data. The clinician can use the reformatted images on a personal
computer in an interactive manner to identify anatomic structures,
simulate implant placement positions, and better appreciate relation-
ships between planned implant positions and teeth or anatomic
structures (Fig. 76.7). InVivo5 planning software (Anatomage, San
Jose, California) acquires data directly from CBCT or CT scan DICOM
(Digital Imaging and Communications in Medicine) files without
the need for reformatting. The clinician can evaluate the case on a
personal computer in an interactive manner to identify anatomic
structures, simulate implant placement positions, and better appreciate
relationships between planned implant positions and teeth or anatomic
structures. Once implant positions are confirmed, a computer-generated
surgical guide is produced to facilitate the surgical placement of
implants in the planned positions (Fig. 76.8).
Patient Evaluation
Evaluation of the implant patient should be disciplined and objective.
Specific questions that can affect implant placement and outcome
should be considered and examined carefully and explicitly. The
advantages and disadvantages of various radiographic projections
should be considered and radiographic modalities chosen based on
necessary information for the particular patient. The objectives for
any radiographic evaluation, regardless of imaging technique used,
should include an evaluation to (1) exclude pathology, (2) identify
anatomic structures, and (3) measure the quantity, quality, and location
of available bone.
! CLINICAL CORRELATION
All diagnostic images, regardless of technique, should be evaluated
to identify or exclude pathology and to identify normal anatomic
structures.
Text continued on p. 762
758 Part 4  Oral Implantology

A B C

D E

Fig. 76.6  Multislice computed tomography (MSCT) examination for evaluation of edentulous maxilla before
implant placement. (A) Scout view of the patient’s head; axial sections through the area of interest are indicated.
(B) Axial slice through the markers is used to display the orientation of the panoramic and cross-sectional
images through the alveolar ridge. (C) Panoramic views through the alveolar ridge demonstrate the relation of
the markers to adjacent teeth. (D) Cross-sectional slices through the area of the markers reveal the height and
buccolingual dimension of the alveolar ridge, as well as the relation of the markers to the ridge. (E) Three-
dimensional reconstructions provide an overall impression of the bone contours and shape of the alveolar ridge.
 CHAPTER 76  Diagnostic Imaging for the Implant Patient 759

10

12
5 10 13
7

A B

7 10
5 12 12
13 5 7 10 13

C D
Fig. 76.7  SIM/Plant images. The SIM/Plant software program allows clinicians to measure bone height,
width, density, and volume on a personal computer. Scan data are reformatted for interactive evaluation and
manipulation. Implant positions can be simulated on the patient’s scan data before surgery, allowing the surgeon
to anticipate areas of deficiency. (A) Cross-sectional image through simulated implant in anterior maxilla, site
#10. (B) Panoramic projection of multiple simulated implant positions, #5, 7, 10, 12, and 13. (C) Axial view of
simulated implants. (D) Three-dimensional image of maxilla with simulated implants.
760 Part 4  Oral Implantology

B
Fig. 76.8  InVivo5 simulation images. The InVivo5 software program allows clinicians to plan implant treatment
and simulate virtual implant positions directly from DICOM scan data on a personal computer. (A) Cross section
and axial images with three-dimensional simulation of implant positions. (B) Model mockup for computer-generated
surgical guide.
 CHAPTER 76  Diagnostic Imaging for the Implant Patient 761

D E

F G H
Fig. 76.8, cont’d (D–E) Surgical guide that was created from a simulated plan. (F−H) Periapical radiographs
demonstrating the accurate position and alignment of implants that were placed using a computer-generated
surgical guide.
762 Part 4  Oral Implantology

B
Fig. 76.9  Cone-beam computed tomography examination of the posterior left maxilla. Top row (A) shows
reconstructed “panoramic” and coronal sections of the alveolar ridge. Note the thickened mucoperiosteal lining
of the floor of the left maxillary sinus (white arrow). The patient has chronic maxillary sinusitis. Bottom row
(B) shows conventional panoramic, reconstructed “panoramic,” coronal, and axial sections of the alveolar ridge
at the area of the missing first maxillary molar. A large radiolucent lesion at the edentulous alveolar ridge
elevates the floor of the maxillary sinus and occupies most of the sinus. Biopsy revealed a keratocystic odontogenic
tumor that was an incidental finding in this asymptomatic patient.

Exclude Pathology
Healthy bone is a prerequisite for successful osseointegration and
long-term implant success. The first step in the radiographic evaluation
of the implant site is to establish the health of the alveolar bone
and other tissues imaged within a particular projection. Local and
systemic diseases that affect bone homeostasis can preclude, modify,
or alter the placement of implants. Retained root fragments, residual
periodontal disease, cysts, and tumors should be identified and resolved
before implant placement. Systemic diseases, such as osteoporosis and
hyperparathyroidism, alter bone metabolism and might affect implant
osseointegration. Areas of poor bone quality should be identified and,
if indicated, adjustments to the treatment plan incorporated. Maxil-
lary sinusitis, polyps, or other sinus pathology should be diagnosed
and treated when implants are considered in the posterior maxilla,
especially if sinus bone augmentation procedures are planned
(Fig. 76.9).
Identify Anatomic Structures
Several important anatomic structures are found close to desired
areas of implant placement in the maxilla and mandible (Box 76.1).
Familiarity with the radiographic appearance of these structures is
important during treatment planning and implant placement. Their
exact localization is central to prevent unwanted complications and
unnecessary morbidity. Important anatomic structures in the maxilla
include the floor and anterior wall of the maxillary sinus, incisive
foramen, floor and lateral wall of the nasal cavity, and canine fossa.
Important anatomic structures in the mandible that should be rec-
ognized include the mandibular canal, anterior loop of the mandibular
canal, mental foramen, anterior extension of the canal, and subman-
dibular fossa. The existence of anatomic variants, such as incomplete
healing of an extraction site, sinus loculation, division of mandibular
canal (Fig. 76.10), or absence of a well-defined corticated canal,
should also be recognized. See Chapter 58 for important periodontal
and implant surgical anatomy.
BOX 76.1  Anatomic Structures Pertinent to Treatment
Planning of the Implant Patient
Maxilla
Maxillary sinus (floor and anterior wall)
Nasal cavity (floor and lateral wall)
Incisive foramen
Canine fossa
Canalis sinuosus
Mandible
Mandibular canal
Anterior loop of the mandibular canal
Anterior extension of the mandibular canal
Mental foramen
Submandibular fossa
Retromolar canal
Lingual inclination of the alveolar ridge
! CLINICAL CORRELATION
Several important anatomic structures need to be identified in the jaws
prior to implant placement. Violation of structures such as nerves may
cause serious complications. Familiarity with the radiographic appearance
of vital structures is important, and the existence of anatomic variants
should also be recognized.
Assess Bone Quantity, Quality, and Volume
The primary goal of diagnostic imaging for potential implant patients
is to evaluate the available bone volume for implant placement in
desired anatomic locations. The clinician should estimate and verify
exact adequate height, width, and density to the recipient bone while
 CHAPTER 76  Diagnostic Imaging for the Implant Patient 763

A C

B D
Fig. 76.10  Cone-beam computed tomography examination of the area of missing tooth #19 before implant
placement. (A) Panoramic view of the area of interest depicts an accessory mandibular canal. (B) Same panoramic
view with the accessory mandibular canal colored blue and the main canal colored red. (C) Cross-sectional
views through the area of missing tooth #19. (D) Same cross-sectional images depicting the blue and red
markings. Note that the position of the markings coincides with the position of the accessory and main mandibular
canals (compare parts C and D).

avoiding damage to critical anatomic structures. Failure to accurately

assess the location of important anatomic structures can lead to
unnecessary complications. For example, inadvertent penetration
and damage to the inferior alveolar nerve can result in serious
immediate-term (profuse bleeding), short-term, and long-term (nerve
paresthesia/anesthesia) complications. The height and width of the
alveolar bone should be accurately detailed. Depending on the
technique, diagnostic imaging can estimate or measure the coronal–
apical height, the buccal–lingual width, and the mesial–distal spacing
available for implants that will be placed in proximity to teeth or
relative to other planned implants. A
This task can be simple in cases with good bone quality and
sufficient bone volume in the desired implant location(s). However,
in cases with moderate to severe bone resorption, alveolar defects,
or recent extraction sites, obtaining a clear and accurate diagnostic
image can be more challenging. The diagnostic imaging may reveal
inadequate bone volume for the proposed implant(s) and indicate
a need for bone augmentation or, depending on the severity of the
deficiency, preclude the patient from the possibility of implant
therapy (Fig. 76.11). When ridge augmentation is deemed neces-
sary, radiographic evaluation prior to and after surgery informs
treatment planning and ensures grafting integrity and quality
(Fig. 76.12). B
In addition to the amount, the quality of the available bone should
also be evaluated. A uniform, continuous cortical outline and a lacy, Fig. 76.11  Radiographic evaluation of a patient with congenitally missing
maxillary lateral incisors before implant placement. (A) Panoramic radiograph
well-defined trabecular core reflect the normal bone homeostasis
reveals sufficient height and mesial-lateral width of the alveolar ridge. (B)
necessary for appropriate bone response around the implant. Thin Cross-sectional conventional tomography of the edentulous areas reveals
or discontinuous cortex, sparse trabeculation, large marrow spaces, a narrow (<4 mm) buccal-lingual width of the alveolar ridge that needs to
and altered trabecular architecture should be noted because they be addressed by modifications in the treatment planning, such as bone
might predict poor implant stabilization and less desirable response augmentation.
of the bone. Poor bone quality may necessitate modifications of the
treatment planning, such as waiting longer for healing (osseointegra-
tion) to maximize bone-to-implant contact before loading.
764 Part 4  Oral Implantology
A B
C D
Fig. 76.12  Radiographic evaluation of a patient with missing left maxillary
second premolar and first molar. Initial cone-beam computed tomography
(CBCT) reveals an atrophic alveolar ridge (A) with inadequate height for
implant placement (B). Also note the thickened mucoperiosteum at the floor
of the maxillary sinus. CBCT after sinus grafting for ridge augmentation
shows the uniformly opaque grafting area blending with alveolar trabeculation
and a smooth sinus floor elevation (C), which provides adequate dimensions
for implant placement (D).
Evaluate Relation of Alveolar Ridge With Existing
Teeth and Desired Implant Position
Accurate placement (spatial position and angulation relative to adjacent
teeth and occlusal plane) will greatly affect the restorative success
and long-term prognosis of the implant (see Chapters 75 and 77).
A significant variable during the preimplant evaluation is the relation
of the desired implant position relative to the existing teeth, alveolar
crest, and occlusal plane. Angled or custom abutments can accom-
modate slight variations in implant position and implant inclination.
However, more significant deviations should be avoided.
Prolonged tooth loss is usually associated with atrophy of the
alveolar ridge and, in the case of the maxilla, with pneumatization
of the sinus floor toward the alveolar crest. Traumatic extractions
can compromise the buccal or lingual cortex and alter the shape and
buccolingual ridge dimension. Anatomic variants, such as lingual
inclination of the alveolus or narrow ridges, should be considered
during treatment planning of the implant patient (Fig. 76.13).
An important part of diagnostic imaging must include an evaluation
of the available bone relative to the “prosthetically driven” implant
position. This aspect of the patient evaluation is best accomplished
with diagnostic models, wax-up of planned tooth replacement, and
radiographic markers in the desired tooth positions during imaging.
Steel balls, brass tubes, and gutta-percha have all been used to establish
the proposed tooth positions relative to the existing alveolar bone.
The use of these nonanatomic markers is helpful for evaluating bone
height and width in specific anatomic locations. However, they do
not accurately represent the tooth contours and do not allow the
A B
C D
Fig. 76.13  Radiographic evaluation of a patient with an edentulous
posterior left mandible before implant placement. Panoramic (A) and periapical
(B) radiographs demonstrate sufficient height of the alveolar ridge with little
or no resorption. Cone-beam computed tomography sections (C–D) reveal
significant lingual inclination of the alveolar ridge with lingual concavity
that is not depicted on conventional radiographs.
clinician to estimate variations in implant position and angulation
relative to the position and emergence of the planned tooth replace-
ment. Therefore it is more desirable and beneficial to use radiopaque
tooth-shaped markers so that the existing alveolar bone can be
evaluated relative to the entire tooth position/contours (Fig. 76.14;
see also Fig. 76.5). This is particularly important for anterior, aesthetic
implant cases. Patients should always be imaged with radiographic
guides (markers).
KEY FACT
An important part of diagnostic imaging must include an evaluation of
the available bone relative to the “prosthetically driven” implant position.
It is most beneficial to assess the prosthetic position in scans using
radiopaque tooth-shaped markers so the proper contours of the proposed
restoration can be appreciated.
Clinical Selection of Diagnostic Imaging
Radiography is an important diagnostic tool for the evaluation of
the implant patient. However, radiographic imaging alone is insuf-
ficient. It is important to correlate diagnostic information with a
good clinical examination. Conversely, a clinical examination is
insufficient to provide the information needed to plan implant treatment
for a patient without some radiographic imaging.
Clinical Examination
Before taking any radiographs, a complete clinical examination of
the implant patient is required. This should include the etiology and
duration of tooth loss, any history of traumatic extraction, and a
review of records and radiographs, if available. A clinical assessment
of the edentulous area, covering mucosa, adjacent and opposing
teeth, and occlusal plane, should be performed. Temporomandibular
function, mandibular maximal opening, and protrusive and lateral
movements should be evaluated.
 CHAPTER 76  Diagnostic Imaging for the Implant Patient 765

B
Fig. 76.14  (A) Panoramic view of partially edentulous maxilla with tooth-shaped markers in areas of missing
teeth (potential implant sites). (B) Cross-sectional views from a cone-beam computed tomography examination
before implant placement in the right maxilla. Appropriately sized and shaped tooth markers placed in the
prosthetically desired locations of the planned restorations for the missing teeth help evaluate the existing
alveolar ridge relative to the prospective tooth positions and contours.
766 Part 4  Oral Implantology

A B
Fig. 76.15  Intraoperative periapical radiographs are valuable in assessing the proximity of adjacent teeth.
(A) The 2-mm guide pin is used to determine the direction of the osteotomy site and its proximity to the adjacent
root. (B) After angle correction, the osteotomy sites are completed to length with the final drill. Here the 3-mm
guide pins confirm the correct angulation and spacing of the final osteotomy site preparation before implant
placement.

and the poor performance and potential failure of a misplaced implant,

Screening Radiographs
At this point, an overall assessment of the health of the jaws should
be performed. The American Academy of Oral and Maxillofacial
Radiology recommends panoramic radiography as the initial evaluation
of the dental implant patient, supplemented with periapical radiographs
as needed.17 Periapical radiographs provide a high-resolution image
of the alveolus and the surrounding structures, including adjacent
teeth. For extended edentulous areas, panoramic, lateral cephalometric,
and occlusal radiographs can be used to estimate bone height and
width. Any pathology of the bone at the prospective implant site,
as well as of the surrounding structures, should be identified and
treated as indicated.
KEY FACT
The American Academy of Oral and Maxillofacial Radiology recommends
panoramic radiography as the initial evaluation of the dental implant
patient, supplemented with periapical radiographs as needed. The organiza-
tion also recommends that radiographic examination of any potential
implant site should include cross-sectional imaging orthogonal to the site
of interest.
Fabrication of Radiographic and Surgical Guides
Once the health of the soft and hard tissues is established, casts
should be taken and a detailed analysis performed. The clinician
should decide on the number of implants and their desired location.
Next, a radiographic guide should be fabricated, usually with clear
acrylic. The position of the desired implants is indicated by the use
of radiopaque objects such as metallic balls, cylinders, or rods;
gutta-percha; or composite resin. If CT imaging might be performed,
the use of metallic markers should be avoided. The design of such
a guide greatly enhances the diagnostic information provided by the
radiographs because it correlates the radiographic anatomy with the
exact position of the proposed implant location.
Cross-Sectional Imaging
The American Academy of Oral and Maxillofacial Radiology recom-
mends that radiographic examination of any potential implant site
should include cross-sectional imaging orthogonal to the site of
interest.17 The potential morbidity of a compromised anatomic structure
combined with the wide availability of tomographic facilities, favor
the use of cross-sectional imaging in most cases of implant treatment
planning. It is crucial that the cross sections are perpendicular to
the curvature of the mandible and parallel to the planned implant.
Improper patient positioning can lead to an overestimation of the
height and width of the available bone. If the surgeon believes that
sections were performed at the wrong angulation, new images should
be requested. This might necessitate reexposure of the patient.
Intraoperative and Postoperative
Radiographic Assessment
Various radiographic modalities can provide valuable information
during implant placement. Because of the ease of acquisition and
high resolution, periapical radiographs are most commonly used.
Intraoperative radiographs can be taken during surgery to evaluate
proximity to important anatomic structures. Sequential periapical
radiographs guide the clinician to visualize changes in direction and
depth of the drilling procedure and parallelism to adjacent teeth and
other implants (Fig. 76.15). Digital radiographs are particularly
advantageous during an intraoperative assessment of implant place-
ment; images appear on the screen almost instantaneously and can
be manipulated to extract the most pertinent diagnostic information
(see Chapter 33).
Implant osseointegration, and the level of peri-implant alveolar
bone are major determinants of implant prognosis. Panoramic and
periapical radiographs offer a fast, easy, and low-radiation depiction
of the implant and surrounding tissues and aid in the assessment of
implant success. To obtain an accurate assessment of peri-implant
bone height, the x-ray beam should be directed perpendicular to the
implant. In the case of threaded implants, the implant threads should
be distinguishable and not overlapping (Fig. 76.16A).
A 1.2-mm marginal bone loss during the first year after implant
placement and 0.1 mm per year afterward are expected; however,
further bone loss is considered abnormal.2 Pathologic bone loss could
be localized along the full extend of the implant (peri-implant bone
loss) or around the crestal part of the implant (“saucerization”), and
it could reflect poor osseointegration, peri-implantitis, or unfavorable
stress distribution (Fig. 76.16B–C).
In select cases, when poor implant placement (Fig. 76.17) or
compromise of vital anatomic structures (Fig. 76.18) is suspected,
advanced imaging (CBCT, CT, or conventional tomography) provides
 A B

C
Fig. 76.16  Radiographic follow-up after implant placement in three different patients. (A) Periapical radiograph
of three implants in the posterior right mandible. “Normal” bone remodeling around the anterior two implants
and slight horizontal bone loss/remodeling around the molar/posterior implant is present. (B) Periapical radiograph
of two implants in the left posterior mandible. Severe bone loss (50% of implant length) is seen around the
anterior implant, whereas mild bone loss/bone remodeling is observed around the posterior implant. A moderate
buccal cantilever in the restoration likely contributed to an adverse occlusal load and the resultant bone loss
observed in this case. (C) Panoramic radiograph of maxillary and mandibular implants in an edentulous patient
prior to implant loading. The mandibular implants do not show signs of bone loss and appear to be osseointegrated.
All maxillary implants show signs of moderate-to-severe peri-implant bone loss, and the success of osseointegration
is questionable.

Fig. 76.17  Radiographic follow-up after

implant placement. (A) Panoramic radiograph
suggests mild-to-moderate bone loss around
the neck of all implants. This is especially true
for the implants in the left maxilla. These
implants appear to be angled, and the distal
implant is positioned more apical. The over- A
denture bar is not completely seated on the
left implants. Note that superimposed overlap-
ping anatomic structures in this panoramic
radiograph impair the ability to clearly visualize
and assess bone loss around implants. (B)
Cross-sectional (B1) and sagittal cone-beam
computed tomography (B2) images of the
anterior implant in the left maxilla. Poor implant
placement beyond the buccal cortex of the
alveolar ridge (cross section) and peri-implant
bone loss (sagittal) are revealed.

B1 B2
768 Part 4  Oral Implantology

Conclusion
Many radiographic projections are available for the evaluation of
implant placement, each with advantages and disadvantages. The
clinician must follow sequential steps in patient evaluation, and
radiography is an essential diagnostic tool for implant design and
successful treatment of the implant patient. Selection of appropriate
radiographic modalities will provide the maximum diagnostic
information, help avoid unwanted complications, and maximize
treatment outcomes while delivering an “as low as reasonably
achievable” radiation dose to the patient.11

Case Scenarios are found on the companion website

www.expertconsult.com.

Fig. 76.18  Cone-beam computed tomography sagittal and cross-sectional References

images clearly demonstrate penetration of the implant into the mandibular
canal. References for this chapter are found on the companion
website www.expertconsult.com.

a three-dimensional evaluation of the oral structures in relation to the

implants. This information can be very important for proper assessment
and treatment planning. The treating dentist should recognize relevant
signs and symptoms and order appropriate imaging as soon after
implant placement as possible. Implant removal, if necessary, would
be less complicated before advanced osseointegration.
 CHAPTER 76  Diagnostic Imaging for the Implant Patient 768.e1

CASE SCENARIO 76.1 

Patient:  38-year-old male
Chief Complaint:  “My upper right back tooth had recent sharp pain after
I used my teeth to cut some copper wires at work.”
Background Information
The patient is an electrician who presented to your office with an 11-mm
narrow probing depth localized to the disto-buccal line angle of tooth #3.
All clinical parameters suggest possible fracture. In an attempt to save
this tooth, you have decided to use cone-beam computed tomography
(CBCT) to perform an Endo survey in attempt to locate any fractures.
Clinical Findings:  A coronal section of a CBCT image for this tooth has
identified a neurovascular bundle structure (circled in red) found on the
lateral wall of the maxillary sinus.

CASE-BASED QUESTIONS SOLUTION AND EXPLANATION

1. The neurovascular bundle structure (circled in red) is identified as Answer: D
the _______ artery. Explanation: Intraosseous vessels are present throughout the jaws. It is
A. descending palatine artery important to identify the location, especially if planning a surgical
B. infraorbital artery procedure in the area. The posterior superior alveolar artery passes
C. maxillary artery through the lateral wall of the sinus.
D. posterior superior alveolar artery
E. sphenopalatine artery
2. The neurovascular bundle structure (circled in red) consists of a Answer: D
nerve from which cranial nerve? Explanation: The trigeminal nerve (CN V) supplies the tissues on the
A. Olfactory nerve (CN I) lateral side of face.
B. Optic nerve (CN II)
C. Oculomotor nerve (CN III)
D. Trigeminal nerve (CN V)
E. Facial nerve (CN VII)
3. The above-identified nerve originates from the brain and exits the Answer: A
skull through which foramina? Explanation: See anatomy.
A. Foramen rotundum
B. Foramen ovale
C. Foramina of the cribriform plate
D. Superior orbital fissure
E. Stylomastoid foramen
768.e2 Part 4  Oral Implantology

CASE SCENARIO 76.2 

Patient:  68-year-old female
Chief Complaint:  “I had my upper right tooth extracted due to a huge
cavity about 5 months ago. I would like to have it replaced as soon as
possible because I can no longer smile confidently.”
Background Information
Cone-beam computed tomography (CBCT) is an important tool for
assessing bone quality, quantity, and volume; excluding pathology; and
identifying important anatomic structures. CBCT data in DICOM format
for the #4 edentulous site was obtained from the patient’s restorative
dentist.
Current Findings:  Normal periapical demonstrates the extraction socket
has healed completely. Sagittal and coronal sections of the potential
implant site #4 are provided below.

CASE-BASED QUESTION SOLUTION AND EXPLANATION

1. Identify the structure circled in red. Answer: B
A. Abnormal anatomic structure Explanation: See anatomy.
B. Greater palatine artery
C. Posterior superior alveolar artery
D. Normal trabeculation bone pattern
E. None of the above

References
1. Arai Y, Tammisalo E, Iwai K, et al: Development of compact computed
tomographic apparatus for dental use, Dentomaxillofac Radiol 28:245,
1999.
2. Benson BW, Shetty V: Dental implants. In White SC, Pharoah MJ,
editors: Oral radiology: principles and interpretation, ed 6, St. Louis,
2009, Mosby.
3. Cavalcanti MG, Yang J, Ruprecht A, et al: Validation of spiral computed
tomography for dental implants, Dentomaxillofac Radiol 27:329, 1998.
4. Bushberg JT, Seibert JA, Leiholdt E, et al: The essential physics of medical
imaging, ed 3, Philadelphia, 2011, Lippincott Williams & Wilkins.
5. Hatcher DC, Dial C, Mayorga C: Cone beam CT for pre-surgical
assessment of implant sites, J Calif Dent Assoc 31:824, 2003.
6. Kraut RA: Utilization of 3D/dental software for precise implant site
selection: clinical reports, Implant Dent 1:134, 1992.
7. Langland OE, Langlais RP, Preece JW: Panoramic and special imaging
techniques. Principles of dental imaging, ed 2, Baltimore, 2002, Lippincott
Williams & Wilkins.
8. Ludlow JB, Davies-Ludlow LE, White SC: Patient risk related to common
dental radiographic examinations: The impact of 2007 International
Commission on Radiological Protection recommendations regarding
dose calculation, J Am Dent Assoc 139:1237, 2008.
9. Ludlow JB, Ivanonic M: Comparative dosimetry of dental CBCT devices
and 64-slice CT for oral and maxillofacial radiology, Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 106:106, 2008.
10. Mallya SM, Lurie AG: Panoramic imaging. In White SC, Pharoah MJ,
editors: Oral radiology: principles and interpretation, ed 7, St. Louis,
2013, Mosby.
11. Michel R, Zimmerman TL: Basic radiation protection considerations
in dental practice, Health Phys 77:S81, 1999.
CHAPTER 76  Diagnostic Imaging for the Implant Patient 768.e3
12. Mozzo P, Procacci C, Tacconi A, et al: A new volumetric CT machine for
dental imaging based on the cone-beam technique: preliminary results,
Eur Radiol 8:1558, 1998.
13. Scaf G, Lurie AG, Mosier KM, et al: Dosimetry and cost of imaging
osseointegrated implants with film-based and computed tomography,
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 83:41, 1997.
14. Schulze D, Heiland M, Blake F, et al: Evaluation of quality of refor-
matted images from two cone-beam computed tomographic systems, J
Craniomaxillofac Surg 33:19, 2005.
15. Sewerin IP: Errors in radiographic assessment of marginal bone height
around osseointegrated implants, Scand J Dent Res 98:428, 1990.
16. Truhlar RS, Morris HF, Ochi S: A review of panoramic radiography
and its potential use in implant dentistry, Implant Dent 2:122, 1993.
17. Tyndall DA, Brooks SL: Selection criteria for dental implant site imaging:
a position paper of the American Academy of Oral and Maxillofacial
Radiology, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 89:630,
2000.
18. Tyndall DA, Price JB, Tetradis S, et al: Position statement of the American
Academy of Oral and Maxillofacial Radiology on selection criteria for
the use of radiology in dental implantology with emphasis on cone beam
computed tomography, Oral Surg Oral Med Oral Pathol Oral Radiol
113(6):817, 2012.
19. Whaites E: Periapical radiography. Essentials of dental radiography
and radiology, ed 3, London, 2002, Churchill Livingstone.
20. White SC, Pharoah MJ: Intraoral radiographic examinations. Oral
radiology: principles and interpretation, ed 6, St. Louis, 2009, Mosby.
21. White SC, Pharoah MJ: Radiation safety and protection. Oral radiology:
principles and interpretation, ed 6, St. Louis, 2009, Mosby.
22. White SC, Mallya SM: Update on the biological effects of ionizing
radiation, relative dose factors and radiation hygiene, Aust Dent J 57(Suppl
1):2, 2012.

Prosthetic Considerations for Implant Treatment
Todd R. Schoenbaum | Evelyn Chung | Ting-Ling Chang | Perry R. Klokkevold
CHAPTER OUTLINE
Implant Considerations Management of Partially Edentulous
Abutment/Prosthesis Considerations Implant Treatment in the Aesthetic
for Single Units Zone
For online-only content on fully edentulous prosthetic considerations, go to the companion website at www.expertconsult
.com.
Ultimately, successful implant treatment requires a team of clinicians
dedicated to excellence in surgical and the prosthetic aspects of the
process. This chapter reviews the critical aspects of prosthetic implant
treatment proven to maximize long-term functional, biologic, and
aesthetic success.
Implant Considerations
Understanding the Anticipated Load on the
System and Its Relation to Implant Diameter
Selecting the appropriate implants for the partially edentulous patient
depends in part on the anticipated loads of that particular tooth location.
The larger the anticipated loads, the more robust the implant must be to
properly support the prosthesis. Notably, for any given implant design,
larger-diameter implants result in stronger prostheses.14 The implant
connection design also plays a significant role and will be discussed
later. However, the prosthetic advantages of a larger-diameter implant
must be balanced with the surgical needs for sufficient (~1.5 mm)
surrounding bone. In some locations, this constraint will present itself
in the mesiodistal dimension, whereas in others the constraint will
come from the buccolingual dimension of the alveolar ridge.
The anticipated load on the implant is affected by its position in
the arch. The more posterior the implant is in the arch, the higher
the anticipated load. Estimates have been made relating to the ratio
of load from anterior to posterior,45 but such generalizations over-
simplify the complexity of the system. Although a tooth located
more posteriorly will receive at least twice the load forces (and
therefore require a larger implant diameter), there are several other
factors that will influence the result. Anterior–posterior position in
the arch is part of this consideration, but so are the number and
integrity of the teeth distal to the implant position. A first molar
implant with good second molars will receive significantly less force
than that same molar with no other molar support.
Often overlooked, the size of the muscles of mastication can
provide cursory evidence regarding just how much force a patient
is able to produce on his or her dentition. Patients with very large
muscles will generate greater forces on their teeth and implants.
However, excessive forces do not always show up as attrition. These
forces can be delivered in a largely vertical vector with little to no
CHAPTER 77 
Fully Edentulous: Prosthetic
Considerations (e-only)
Conclusion
horizontal component. This information should be checked and
recorded at the initial patient examination. Patients with a history
of cracked or broken teeth and crowns should be expected to place
heavier loads on the implants used to replace them.
In the evaluation of the implant patient, special attention should
be given to the arch opposing the location of expected implant
treatment. If the opposing dentition is a removable appliance, then
the implant will receive significantly lower forces.48,53 Conversely,
if the opposing dentition is implant-supported fixed restorations, the
forces are likely to be quite high. This phenomenon is largely due
to the lack of a periodontal ligament (PDL) around the implants. If
the implant is opposing a removable appliance, it should be determined
if there is any likelihood of converting to a fixed implant-supported
prosthesis. If this is the case, then the implant in question should be
planned with increased loads in mind.
Occlusal guards have long been employed to protect the dentition
and prostheses against excessive forces and destructive wear habits.
As implants lack the “cushioning effect” that the PDL provides to
natural teeth, the occlusal guard can provide the patient with an
added layer of protection against overloading of the implant system.
The limiting factor with occlusal guards is patient compliance.
Clinicians looking for a more quantified approach to evaluating
the loads placed on teeth and implants might consider digital occlusal
analysis systems.
! CLINICAL CORRELATION
The anticipated load on the implant is affected by its position in the arch.
The more posterior the implant, the higher the anticipated load. Estimates
have been made relating to the ratio of load from anterior to posterior,
but such generalizations oversimplify the complexity of the system. Although
a tooth located more posteriorly will receive at least twice the load forces,
there are several other factors that will influence the result. Other important
factors to consider are the number of implants, the stability of the sur-
rounding dentition, and individual mastication forces.
Larger-diameter implants create stronger prosthetics and are less
likely to fracture.14 The use of larger implants becomes more important
769
 CHAPTER 77  Prosthetic Considerations for Implant Treatment 769.e1

Abstract
Succesful implant treatment requires a knowledgeable and skilled
team of clinicians and technicians. At every step in the process,
careful consideration must be given to the approach with the best
prognosis for the given patient and their proposed treatment. This
chapter focuses on the restorative/prosthodontic aspects of implant
treatment. It will provide useful information to the entire treatment
team based on the best available evidence.

Keywords
implant prosthetics
implant restorations
abutments
partially edentulous
fully edentulous
770 Part 4  Oral Implantology
under the following circumstances: enlarged masseter/temporalis
muscles, a history of broken teeth and crowns, distal-most tooth in
the arch, opposing other implants, and patients unwilling to wear
an occlusal guard. However, the prosthetic advantages of larger
platform implants must be balanced with the realities of the surgical
site. In locations with space constraints, other prosthetic modalities
may be employed to mitigate the anticipated risks. Innovations in
implant connections, manufacturing tolerances, and alloys have
created more and more robust systems that will improve the ability
to withstand excessive forces.
Narrow-diameter implants have proven to be a reliable and useful
approach to compromised spaces (<7 mm).71 This constraint can be
mesiodistal due to adjacent teeth or implants, or it can be buccolingual
due to inadequate volume of the alveolar ridge. Use of such implants
is best reserved for sites with low expected loads and constrained
spaces, namely the incisors of both jaws.
Number of Implants
Partially edentulous patients with multiple adjacent missing teeth
can present some unique challenges. If we use 4 mm as the diameter
of a “regular” implant, and the guideline of 1.5 mm of circumferential
peri-implant bone, we can quickly estimate the amount of space
required for implants by multiplying 7 mm times the number of
missing teeth.135 Or more simply, one tooth requires 7 mm of
mesiodistal space; two teeth require 14 mm, three teeth require 21 mm,
and so on (Fig. 77.1). This is an oversimplification of the planning
process, but makes initial estimations of treatment options easier.
Not every missing tooth needs an implant. Two implants with a
three-unit fixed dental prosthesis (FDP) have proven to be quite
reliable in many situations.90 Material selection is key; weaker and
unproven materials should be used with extreme caution. Gold alloy
porcelain-fused-to-metal (PFMs) and zirconia-based FDPs have good
(but not perfect) track records. Lithium disilicate materials (and
recent derivatives) are not well tested for multiunit FDPs. The use
of a pontic between two implants has aesthetic advantages in relation
to the volume of the peri-implant tissues. This topic will be covered
Fig. 77.1  Implants benefit from the presence of 1.5 mm of bone circum-
ferentially. A “normal” diameter implant is ~4 mm. For treatment planning
purposes, each implant should have 7 mm of space mesial–distally at the
bone crest, two implants would need 14 mm, and so on.
more in depth during the discussion on implants in the
aesthetic zone.
Cantilevers off one or more implants can be a creative solution
to complicated implant treatment planning situations. Such a design
is certainly less durable than a noncantilevered approach, but it does
have its place. Cantilever FDPs are best reserved to replace multiple
missing incisors in patients with nonexcessive occlusal forces.119
The use of a cantilever pontic should be avoided in most posterior
situations, unless multiple implants are splinted and the length of
the cantilever is deemed acceptable.
Narrow-diameter implants can be implemented in areas with
reduced dimensions, but only to a point. Narrower implants are
inherently more fragile and more apt to suffer from catastrophic
failure. Their minimal dimensions will make more aesthetic prosthetic
materials (i.e., zirconia abutments) a riskier option. Although manu-
facturers will continue to produce smaller and smaller implants, their
use in patients should be considered cautiously until proven to be
successful.
When space constraints push the clinician to select smaller and
riskier implants, alternative options should be seriously considered:
orthodontics, tooth-borne FDPs (Fig. 77.2), bone augmentation, and
additional extractions. Though the last option may sound overly
aggressive, it can be the best choice in scenarios where adequate
space cannot be created. This most commonly presents as a single
missing mandibular incisor. The two missing incisors can then be
replaced with a single implant. In this scenario the implant can be
placed centrally between the two missing teeth or off to one side
with a larger cantilever (Fig. 77.3). The centrally located implant
will reduce the stress due to the decreased length of the cantilever,
but the offset implant may allow for the creation of a more natural
gingival architecture around the pontic.
Implant-Abutment Connection
Of all the variations in implant designs, perhaps none is as important
to prosthetic success as the connection design. The design of an
implant abutment junction (IAJ) will influence everything from
incidence of screw loosening, to maintenance of the hard and soft
tissues, to leakage inside the implant. The implant(s) should be
selected for a particular scenario based on a thorough consideration
of the connection that best suits the case. There is no “one size fits
all” solution. Certain connections are well suited for fully edentulous
patients but are poor choices for a single unit, whereas another
connection might be well proven in complicated aesthetic treatments
but do poorly under heavy loads.
Currently available dental implants are classified into three types
(Fig. 77.4) based on their abutment connection design: external
connection, internal connection, and solid body (the abutment is
contiguous with the implant body).
The external connection implant is commonly referred to as an
“external hex” implant due to the presence of a raised hexagon
connection on most versions of this design. The external connection
is one of the older connection designs still in common use today. It
offers the advantages of an extremely extensive array of prosthetic
products to address even the most complicated of clinical presentations.
It is a robust implant and rarely suffers from fracture of the implant
body itself. This is a well-tested and widely accepted implant design.4,5
It is well suited to the restoration of fully edentulous patients desiring
a fixed restoration. The wide platform of the implant creates a stable
base, whereas the relatively short connection (0.7 mm tall) allows
for easy correction of nonparallel implants.
The primary drawback of the external connection implant is screw
loosening.40,41,61,64 The short connection height does little to share
the forces between the abutment and the implant body. Even if the
 CHAPTER 77  Prosthetic Considerations for Implant Treatment 771

Fig. 77.2  It is important to understand that implants are not the only way to replace missing teeth. In this
example a ceramic Maryland bridge is used to replace the upper left lateral incisor.

A
B

C D E
Fig. 77.3  Replacement of two consecutive missing teeth presents a unique challenge. Mesial–distal space
requirements often preclude the use of two adjacent implants. The implant can be placed centrally (A–B) or in
the position of one of the missing roots (C–E).

hex portion is engaged, there is still very little vertical wall height
to transfer the oblique forces of the prosthesis. Inevitably, these
forces are transferred largely to the abutment screw, which stretches
and deforms under load. Over time this will result in the need to
tighten and replace the screws. This problem is significantly reduced
with prostheses supported by multiple implants. It is primarily a
problem with single tooth replacements on the external connection
implant.
KEY FACT
Perhaps the most important implant design factor relative to prosthetic
success is the implant-abutment connection design. The design of an
implant abutment junction (IAJ) will influence everything from incidence
of screw loosening, to maintenance of the hard and soft tissues, to leakage
inside the implant.
Compared with more modern implant designs, the external con-
nection loses more crestal bone.a This is a multifactorial problem,
but it is due in large part to the constant opening and closing of the
IAJ under load.55,95,106 This leads to bacterial infiltrate being pumped
into and out of the internal aspects of the implant5,59 and directly
into the peri-implant tissues (Fig. 77.5). A move away from the
external connection has mitigated (but not eliminated) both screw
loosening and excessive crestal bone loss.
The internal connection (in all its variations) has become the
implant of choice for most partially edentulous rehabilitations due
to improved reliability compared with the external hex design.49 For
most systems, it is a misnomer to call it an “internal hex.” The
geometry of the connection itself comes in many variations including
hexagons, octagons, 12-pointed stars, trilobes, circles with four flat
References 7, 8, 13, 20, 25, 26, 44, 46, 58, 104, 115, 134, 136.
a
772 Part 4  Oral Implantology
sides, seven-splines, and others. The number of sides to the connection
allows the user various positions from which to orient a stock
manufacturer abutment. Some manufacturers prescribe which lobe
or point of the implant connection should be oriented buccally to
address this. Although more sides on the connection allow for more
flexibility in positioning a stock abutment, this does increase the
difficulty of correctly aligning a custom abutment. There is no
overwhelming, independent, peer-reviewed evidence that any one
internal connection geometry is superior to all the others.
Many implant systems have begun to incorporate a tapered element
into the implant abutment connection. The rationale for incorporating
a taper into the connection is to further stabilize the IAJ,88 thus
minimizing leakage, abutment movement, and loosening of screws.
Fig. 77.4  Most currently available implants can be classified as one of
three types: external connection, internal connection, or solid body. The
external hex connection is primarily indicated for full-arch treatments. The
solid body implant must be placed in the ideal position, as there is no way
to correct the position with the abutment. The internal connection implant
(of which there are many varieties) is indicated for most partially edentulous
treatments. Note the abutment engagement areas, as highlighted in red.
A B
Fig. 77.5  All two-piece implants have hollow internal spaces. Under functional loads, the junction between
the implant and the abutment will open slightly and allow saliva, oral flora, and nutrients into the internal
aspects of the implant (A). In this oxygen-free environment, anaerobes will proliferate. They will be pumped
into the peri-implant tissues and may be partially responsible for typical peri-implant bone loss or inflammation
of the peri-implant tissues (B).
This concept comes from the world of machining tools, like lathes
and drill presses. For some unknown reason, the dental profession
has taken to referring to any tapered connection implant as a “Morse
taper,” though few implant designs meet the very specific specifications
of any Morse taper variation (~1.5-degree taper).
Regardless, upon fully torquing the abutment screw, implants
with a very narrow taper do create a better seal and will have better
long-term stability of the abutment and the screw. Both are advantages
in terms of maintenance and persevering the peri-implant tissues at
a maximum level. Some tapered connection implant systems even
require a special tool to remove the abutments, as after screw removal
the components can have such a strong friction fit.
When wide diameter external connection implants were introduced,
they remained compatible with the abutments from the narrower
implants. Some clinicians and scientists began experimenting with
using these narrow abutments on wider implants; they referred to
these connections as “platform switched.”74 This term has come to
encompass any implant that has an abutment that is narrower than
the implant neck (Fig. 77.6). The preponderance of evidence suggests
that the platform-shifted design maintains bone at a higher level
than that of a nonplatform switched design.b The reasons for this
effect are less leakage at the IAJ (most are tapered connections),9,38,73,92
less screw loosening,101,110 less stress on the peri-implant bone,29,52,85,86
and movement of the nonosseointegrating surface of the abutment
away from the bone. The latter concept creates a horizontal space
on the implant for supracrestal connective tissue to establish a cir-
cumferential peri-implant seal, thereby allowing the bone to maintain
its position at a higher level without having to remodel to a lower
position.111,112
The only potential downside to a platform-switched implant system
is that the abutment is narrower and therefore more prone to breakage.
Data on this concern are sparse, but it stands to reason that for any
material (in particular zirconia), the thinner it is, the more easily it
will suffer fracture. Many manufacturers have begun to address this
problem by offering their zirconia abutments with a titanium insert
that interfaces with the implant body (Fig. 77.7). This has the benefit
of placing the more fragile zirconia outside the implant and prevents
the possibility of the zirconia wearing the implant connection
prematurely.
b
References 7, 8, 13, 20, 25, 26, 44, 46, 58, 104, 115, 134, 136.
 CHAPTER 77  Prosthetic Considerations for Implant Treatment
A B
C wide or wider than the head of the
Fig. 77.7  Zirconia abutments are useful to minimize any changes to the
color of the peri-implant tissues and allow the use of semitranslucent
prosthetic materials. Most manufacturers have developed zirconia abutments,
which have a titanium base as shown here. This may make the abutments
stronger and will eliminate the failure of the zirconia inside the implant
body. Such failures are difficult to resolve successfully.
The internal aspect of the implant is hollow to allow for the screw
and the abutment connection. However, these spaces inside the implant
can serve as a pathogenic reservoir if or when the IAJ leaks.9,73,92
This internal chamber is anaerobic, body temperature, and when the
IAJ leaks it will become filled with oral bacteria, saliva, and nutrients.
The chamber is then fertile breeding ground for anaerobic bacteria
and their by-products. Continued movement between the abutment
773
Fig. 77.6  The platform switched
implant design (A, right) has an
abutment that is narrower than the
head of the implant (B). The major-
ity of evidence suggests that this
design better preserves bone than
implants, which use abutments as
implant (C).
and the implant will pump the bacterial exudate into the fragile
peri-implant tissues. It appears that this is one of the primary causes
of “normal” bone loss around implants. Excessive amounts of pumping
may be culpable in idiopathic incidences of peri-implant mucositis
and peri-implantitis. Therefore clinicians should opt for implants
and abutments that have been shown (over extended periods of time)
to reduce the micro-gap and leakage. This is best accomplished with
a narrow tapered connection and abutments with titanium interfaces
milled by the implant manufacturer. There are additional factors to
consider in selecting the appropriate implant for any given scenario,
but efforts to minimize the loss of peri-implant tissues is best
accomplished with this treatment modality.
The last type of implant connection to address is the “solid body”
implant, or an implant in which the abutment and the implant are
one contiguous piece. Such implants have been available for some
time but have never gained significant popularity. The challenge
with solid body implants is not surgical, and they may in fact be
better for the peri-implant tissues because there is no microgap and
no leakage. The problem is prosthetic. For these implants, there is
no screw-retained option for the prosthesis, and the cement margin
is determined at the time of placement. The abutment can be prepped
to move the margin apically if absolutely necessary, but there is no
reasonable way to move the margin coronally. This presents a serious
problem when the gingiva has any significant papilla adjacent to the
implant, as the cement margin that is placed perhaps 1 mm subgingival
on the facial aspect may now be 3 to 7 mm subgingival at the mesial
and distal aspect (Fig. 77.8). With no option for a screw-retained
restoration, the restoring clinician is now tasked with fully removing
cement far too deep subgingival and will inevitably leave cement
774 Part 4  Oral Implantology
Fig. 77.8  Solid body (and tissue-level) implants present a unique prosthetic
challenge due to the margin being on the implant body itself. This often
results in mesial and distal margins that are far too deep to reliably remove
cement. As such, restorations for tissue-level implants should generally be
screw retained. Unfortunately, restorations on solid body implants can only
be cemented. Extreme care must be used with solid body implants.
behind. This residual cement is likely to induce inflammatory reactions
and loss of bone, soft tissue, and perhaps the implant itself.72,145
The solid body implant offers no recourse should the abutment
break. This is of particular concern as the use of solid body zirconia
implants becomes more prevalent. Should the abutment on the solid
body implant break, the implant must either be extracted or abandoned.
Special care should be taken with solid body implants to avoid
overprepping the abutment area, leading to weakness and increased
risk of fracture.
There are a few esoteric implant-abutment connections on the
market as well, including press-fit, cemented abutments (where the
abutment is cemented into the implant), and others. These will not
be discussed here due to space constraints and their relative obscurity
at the current time.
Abutment/Prosthesis Considerations for
Single Units
Retention Method for Partially Edentulous
Treatment: Cemented Prostheses, Screw-Retained
Porcelain-Fused-to-Metal Options, Screw-Retained
Full Contour Zirconia, and Hybrid Designs
When treatment planning a partially edentulous case for restoration
with an implant, one of the major prosthetic decisions to be made
is whether to have a crown that is cemented to an abutment or a
crown that is contiguous with the abutment and screwed directly to
the implant. For the sake of discussion here, the screw-retained
option will be defined as a cast gold alloy abutment with appropriate
support of feldspathic porcelain that will be layered directly on it
(sometimes referred to as UCLA abutments). Variations of the
screw-retained crown will be discussed later. Many clinicians have
developed personal preferences for screw or cement-retained crowns
based on their experiences and failures. Much of an individual clini-
cian’s anecdotal experience likely has much to do with the skill of
his or her technician when considering screw-retained PFMs. Here
we will consider the peer-reviewed evidence to determine the evidence-
based advantages and disadvantages of each type of retention.
For most single tooth replacements, either screw or cement-retained
crowns have proven to have very high levels of long-term
TABLE 77.1  Major Versus Minor Complications in Implant
Prosthetics
Major Complications Minor Complications
Implant failure Screw loosening
Atypical peri-implant bone loss Chipped porcelain not requiring
prosthesis replacement
Persistent inflammation of the soft De-cementation of the
tissue prosthesis
Infection of the peri-implant tissues
Failure of the porcelain requiring
replacement of the prosthesis
Loss of the prosthesis
Fractured screws or abutments
success,90,113,124,139 provided that the clinician and technician follow
critical guidelines. In some clinical scenarios, one type of retention
is the overwhelmingly superior choice, but this does not reflect the
majority of cases.
It is important to understand the difference between major and
minor complications (Table 77.1). Minor complications are issues
that can be resolved with little effort or increased risk, such as loose
screws, minor porcelain fracture, and reversible peri-implant mucositis.
Major complications are loss of the implant, peri-implantitis, severe
bone loss, fractured screws, significant porcelain failure, and loss
of the prosthesis.
Screw-retained restorations have a long history of clinical success.
Their introduction in 198878 allowed clinicians to create more aesthetic
restorations than were possible with the available alternatives of the
time, and in less vertical space. They can be used in areas with limited
interocclusal distances due to their construction design. They can be
created with metal occlusal or palatal surfaces for patients with high
functional demands. They can have the porcelain carried to within
1 mm of the head of the implant for improved aesthetics. The primary
disadvantages of the screw-retained restoration are significantly more
prosthetic complicationsc: porcelain fracture (Fig. 77.9),68,94,113 screw
loosening,d increased bone loss,33,54,60,75,94 increased lab costs, and the
need for ideal implant angulation. Minor areas of porcelain fracture
can be predictably remedied with contouring and polishing. Larger
fractures will require replacement of the entire prosthesis, as porcelain
cannot be repaired after prolonged exposure to the oral environment.
A dedicated technician could strip all the porcelain off the metal
framework in an attempt to save the costs of a new abutment and
alloy, but it may very well be that the reason for the fracture in the
first place was a poorly designed framework. As such, it is advisable
to fabricate an entirely new prosthesis should the porcelain fail. Screw
loosening has been established repeatedly as significantly more common
in screw-retained restorations, in spite of the fact that cemented restora-
tions generally use the same screw and torque specifications. The
reason for this phenomenon is not exactly known, though it is likely
due to poorly casted abutment interfaces, increased preload due to
nonpassive frameworks,89,125,138 the historic use of weaker gold alloy
screws, or damage to the interface during divestment (Fig. 77.10) or
finishing. Technicians must exercise care when creating a screw-retained
restoration to ensure the integrity of the abutment interface. The UCLA
abutment should have a machined interface made by the manufacturer
References 28, 34, 39, 76, 90, 105, 113, 144.
c
References 16, 34, 39, 76, 90, 99, 113, 143.
d
 CHAPTER 77  Prosthetic Considerations for Implant Treatment 775

A B
Fig. 77.9  Screw-retained PFM restorations have been shown to have significantly more prosthetic complications,
most commonly failure of the porcelain and loose abutment screws. Failure of the porcelain is best addressed
by replacement. The new prosthesis will need a more robust framework design or alternative materials.
(A) Screw-retained PFM crowns with fractured porcelain. (B) Screw-retained PFM bridge being replaced after
screws loosened.

through a crucial aesthetic or functional area. This situation is most

Fig. 77.10  During the fabrication of a screw-retained PFM, the technician
must exercise extreme care in creation of the framework so as not to damage
the interface area as shown here. The damaged interface will produce a
poor-fitting prosthesis leading to increased leakage and screws that loosen
more frequently.
to ensure the integrity of the fit between the abutment and the implant.
Because the screw access channel must exit the crown, this option is
best reserved for when the implant angulation exits directly through
the occlusal surface in posterior regions and through the palatal/lingual
surface in the anterior regions.
KEY FACT
For most single tooth implant crowns, both screw and cement-retained
methods have proven to be highly successful over the long term provided
that the clinician and technician follow critical guidelines. In some clinical
scenarios, one type of retention is the overwhelmingly superior choice,
but this does not reflect the majority of cases.
The common alternative to the screw-retained crown is the
cement-retained crown. This system is made up of an abutment
(titanium, gold alloy, or zirconia) that is screwed into the implant
and a crown that will be cemented to the abutment. The cement-
retained crown allows the restoration of implants that are not placed
ideally without having to manage a screw access channel exiting
common in the aesthetic zone. When implants are placed angled
such that and their line of draw exits through the facial surface of
the crown, it becomes aesthetically prohibitive to use a “normal”
screw-retained crown (Fig. 77.11). There are some workarounds that
will be discussed briefly later.
Some clinicians prefer cement-retained restorations because the
cementation process is familiar and comfortable. However, the
cementation process is not to be taken lightly, as residual cement is
one of the major causes (but not the only cause) of peri-implantitis.1,15,72,145
Cementation details will be discussed later, but note that no attempt
should be made to cement an implant crown when margins are more
than 1 mm subgingival (Fig. 77.12).83,84 Cement-retained implant
crowns have the main advantage of being far more durable than the
screw-retained alternative, a fact confirmed in multiple
reviews.90,113,124,144,146 Porcelain failure of screw-retained crowns has
been reported to be as high as 38%, compared with just 4% for
cement-retained crowns at an average of 5 years.94 For this reason
cement-retained implant crowns are indicated in scenarios of higher
loads (i.e., molars, patients with enlarged masseters). Should the
patient break the cemented crown, retrieval of the remaining abutment
is greatly simplified. Drilling through even an intact cemented crown
to access the screw channel is a relatively simple matter, akin to
endodontic access. Lastly, there is the issue of lab cost. The cemented
restorations typically lead to far less expensive lab bills compared
with the screw-retained PFM options, though the cost of the latter
varies significantly with the market price for gold alloy.
One of the reasons cited for selecting a screw-retained restoration
is the ease of retrievability. There is a valid concern that should
something fail, the cemented crown is more difficult to remove.
Although it may seem obvious, removal of the cemented crown is
hardly more difficult than for a screw-retained crown (Fig. 77.13).120
The differences are drilling the access through porcelain or metal
instead of composite and the location of access may be difficult to
discern. Most clinicians are fairly adept at cutting through porcelain,
but locating the access channel can be a slight challenge. Most often,
the access is fairly easy to locate based off simple radiographs. More
sophisticated approaches to recording the location of the access have
been proposed, from stents,56 to guides,141 to occlusal markings (Fig.
77.14).116,122 During the era of weaker abutment screws and external
connection implants, screw loosening was a common problem. As
776 Part 4  Oral Implantology
A B
C toward facial surface. (C) Provisional restoration with abutment screws
Fig. 77.12  For cemented implant restorations, the abutment must be
designed such that the cementation margin is no deeper than 1 mm below
the gingival margin. In all but the flattest of ridges, this can only be
accomplished with a custom-milled abutment.
such, replacement of the screws was a common maintenance requirement
and a screw-retained restoration was ideal. Modern implant connections
rarely suffer from loose screws, even for single-unit implants.90,105
There are a few other crown retention variations that should be
mentioned. One is the full-contour zirconia, screw-retained crown
This crown is similar in design to the cast gold, screw-retained
crown, but it has no feldspathic layering porcelain, and the substructure
is zirconia. Though relatively new to market, these restorations may
prove to maintain many of the advantages of the screw-retained
Fig. 77.11  In the aesthetic zone, ungrafted alveolar ridges may result
in implants angled out to the facial. This results in a relative contraindica-
tion to screw retention. With most implant systems, implants angled
out through the facial surface will need to be restored with a cement-
retained option. Lateral view (A) and occlusal view (B) of maxillary
anterior implants with abutment screws showing long-axis projection
projecting through facial surface.
Fig. 77.13  Removal and replacement of failed cement-retained implant
crowns are relatively straightforward procedures with most implant designs.
The clinician estimates the long access of the implant with radiographs
and by palpating the ridge and then simply drills into the screw access
through the crown material. The abutments/crowns may still be cemented
together and can be removed as one piece.
system while eliminating its major complication—porcelain fracture.
Not all manufacturers offer this restoration, and some variants do
not offer a titanium insert to protect the implant from wear and
zirconia failure. The titanium insert should be used whenever possible.
Some manufacturers offer this restoration with a screw channel that
can be angled up to 25 degrees to allow for screw-retained restorations
even when the implant is not in the long access of the crown. The
screw-retained zirconia option is relatively new and not fully tested
in clinical trials. Implement with caution.
Another option is the hybrid crown (sometimes referred to as a
screwmentable crown). This system consists of a crown that is
 CHAPTER 77  Prosthetic Considerations for Implant Treatment
cemented to a stock titanium abutment (Fig. 77.15), but the cementa-
tion is performed in the laboratory where excess cement can be
easily removed. The screw access is predrilled into the crown. This
system offers the advantages of minimal risk of retained cement,
minimal risk of porcelain fracture when stronger ceramics are used,
and a lower lab cost than cast gold alloys. This system is relatively
new and not fully tested; in clinical trials implement with caution.
Lastly, there is the option of lingual set screws. This system is
most commonly employed in the anterior areas of the mouth when
Fig. 77.14  Placement of an occlusal/palatal marker during fabrication of
the crown can make finding the screw access more predictable should
removal become necessary.
A B
C base crown. (B) Crown view of titanium base crown. (C) Titanium base
777
the implants are angled too far toward the facial for a traditional
screw-retained restoration and the clinician is uncomfortable with
a cemented option. The challenges with lingual set screws are
increased lab costs, difficulty in locating technicians competent in
the technique, leakage between the crown and the abutment, and
challenging screw access.
Abutment Material Selection
In most bone-level implant designs, the junction between the abutment
and the implant is near the crestal bone. In this area the connective
tissue and the junctional epithelium may be in intimate contact with
the abutment. As such, the abutment material and accuracy of the
fit play a critical role in preserving the peri-implant bone and soft
tissue. Some abutments better preserve the peri-implant tissues than
others. The most relevant options for currently available definitive
abutment materials are titanium, titanium with a titanium nitride
coating, full-contour zirconia, zirconia with a titanium base, and
gold alloy (Fig. 77.16). Other less common options include lithium
disilicate and chrome-cobalt alloys.
The most rigorous study examining bone and soft tissue reactions
to abutment materials found histologic evidence that titanium pre-
served 1.5 mm more soft tissue and 1 mm more bone compared
with the fully cast gold alloy abutment.2 However, it should be noted
that this study was performed in the canine mandible and that when
a titanium interface was used in conjunction with a cast gold abutment,
there was less bone loss than with the gold alone. It stands to reason
that some of the bone and soft tissue loss with gold abutments may
have more to do with the less accurate fit of a cast restoration than
to the influence of the material itself. More recent clinical studies
and reviews have questioned these findings, with gold and titanium
showing an equivalent biologic response.79,137 However, the latter
Fig. 77.15  The hybrid crown design consists of a titanium base that
is connected to a full contour ceramic (generally zirconia) crown. In the
laboratory, the technician follows a specific protocol to cement the
titanium base to the ceramic crown. This design produces a screw-retained
restoration that should be less prone to the problems of a PFM, though
few long-term data are yet available. (A) Abutment view of titanium
crown in lab model.
778 Part 4  Oral Implantology

A B

C D

E Fig. 77.16  Implant abutments are available in a variety of materials. (A) Titanium. (B) Titanium with a
titanium nitride coating. (C) Full contour zirconia. (D) Zirconia with a titanium base. (E) Gold alloy.

were done with radiographic analysis rather than the histologic
measurements of the former. As a whole, the data are not yet con-
clusive on the biocompatibility of the abutment material and its
clinical effects on the tissues. Titanium has been repeatedly shown
to perform better on a histologic level than gold alloys, but the
difference may be of little clinical significance. What is clear is that
the interface between the abutment and the implant must be as accurate
as possible. This will ensure minimal leakage, minimal screw loosen-
ing, and better maintenance of the peri-implant tissues. Abutments
that require casting of the implant interface portion cannot match
the fit accuracy of the machined interface.19
The strength of the abutment is critical in maintaining long-term
success with minimal technical complications. Titanium and gold
alloy abutments have a long track record of outstanding strength.
Some studies have even shown failure of the implant before failure
of the titanium abutment.131 The primary concern regarding strength
is related to zirconia abutments.
Zirconia abutments can be used with little risk of fracture in
many clinical scenarios,91 but there are a few caveats. The zirconia
abutment should have an implant interface component made of
titanium (Fig. 77.17).131 This minimizes the risk of wear to the implant
body, and should the zirconia fracture, it is outside the implant where
it is much easier to treat. The zirconia abutment should not be used
in cases with extreme loads (i.e., molars, patients with enlarged
muscles of mastication, long span FDPs). The zirconia abutments
should be made by a reputable manufacturer. Evidence has shown
that the manufacturer can have a huge impact on the strength of the
material.69 The abutment walls should be sufficiently thick, no less
than 0.7 mm. Every effort should be made to avoid cutting the zirconia
after it has been sintered.
Lastly we must consider the effect of the abutment material on
the color of the soft tissue. Gray-colored metallic abutments will
darken the tissue more than zirconia abutments, but the effect is not
as great as might be expected. Zirconia abutments still cause a
 CHAPTER 77  Prosthetic Considerations for Implant Treatment
Fig. 77.17  Zirconia implant abutments should be fabricated with a titanium
base. This has multiple advantages: increased strength, less complicated
failures, and less wear of the internal surface of the implant.
Fig. 77.18  Gold color coating of titanium abutments produces less graying
of the soft tissue. This coating is made from titanium nitride or titanium
oxide.
significant and perceptible darkening of the soft tissue, confirmed
in multiple studies.17,70,82 Some manufacturers and clinicians have
developed techniques to anodize or coat titanium abutments to create
gold or pink shades. These may offer some improvement of soft
tissue aesthetics. The gold-colored abutments (Fig. 77.18) allow
predictable use of semi-translucent ceramics with minimal shade
change. The thickness of the overlying tissue has been shown to
have a greater influence on the perceived color of the gingiva over
an implant than the material used. Thick tissues have an almost
nonperceptible color shift, whereas with thin tissues the shift is
always perceptible, even with zirconia abutments.63
KEY FACT
It is clear that the interface between the abutment and the implant must
be as accurate as possible. An accurate IAJ fit will ensure minimal leakage,
minimal screw loosening, and better maintenance of the peri-implant
tissues. Clinicians should understand and appreciate that abutments with
casting of the implant interface portion cannot match the fit accuracy of
the machined interface.
779
Fig. 77.19  Even in the aesthetic zone, the abutment margins should not
be placed deeper than 1 mm subgingivally. The margins should be clearly
visible circumferentially. This will minimize the risk of cement-induced
peri-implantitis.
Abutment Design and Emergence Profile
The design and contours of the abutment play a key role in the shape
and dimensions of the peri-implant tissues. If the abutment is
overcontoured it will ultimately lead to a loss of bone and soft tissue.
This is a common problem when technicians design and shape the
abutment without the soft tissue mask on the model. Such overcon-
toured abutments may require surgery to deliver because the tissue
prevents complete seating of the restoration. Alternatively, the restora-
tion can be reshaped to reduce or eliminate impingement on tissues.
The emergence profile of the abutment is the area of the abutment
between the head of the implant and the soft tissue margins. More
data are showing that undercontouring the emergence profile helps
to protect and maintain the peri-implant bone and soft tissue.111
The “platform switch” style implant helps to create the narrowed
abutment design due to the smaller diameter of the connection
interface. In most scenarios, the abutment should be designed
to emerge from the implant in a narrowed hourglass shape. The
narrowed design may allow for increased blood flow around the
implant and provide sufficient room for the soft tissues without bone
remodeling.121,135
Understanding the effects the emergence profile has on the shape
and position of the soft tissue is critical for implant treatment in the
aesthetic zone.117,127 By selectively over- or undercontouring the
emergence zone, the soft tissue can be positioned with a high degree
of accuracy.132 More on this technique will be described in the next
section with the use of aesthetic zone provisional restoration.
For cement restorations, arguably the most critical aspect of the
abutment design is the placement of the margins. The peri-implant
soft tissue is never perfectly flat, and as such custom abutments are
almost universally indicated to avoid deep subgingival margins with
the risk of retained cement and the resulting peri-implantitis. The
only way for a stock abutment to be used with minimal risk is to
select one with completely supragingival margins, but this can be
aesthetically unacceptable. If a common stock abutment is selected
to hide the titanium, with a facial margin 1 mm subgingival, in most
scenarios the margin at the mesial and distal papilla will be 4 mm
or more subgingival. Both in vitro and in vivo studies have shown
that for margins beyond 1 mm subgingival, significant amounts of
cement will always be left behind.83,84 No attempt should ever be
made to cement restorations on implants with margins more than
1 mm subgingival (Fig. 77.19). A custom abutment can be easily
designed to address the natural scalloping of the gingiva. It is fab-
ricated by milling or casting, though casting of custom abutments
780 Part 4  Oral Implantology

A B
Fig. 77.20  When margins are placed deeper than 1 mm, it is inevitable that cement will be left subgingivally.
Regardless of cement type, cement left subgingivally will result in significant loss of bone and soft tissue. Here,
a large amount of residual cement has caused catastrophic loss of bone and soft tissue (peri-implantitis). These
implants ultimately required extraction and significant reconstruction to treat. (A) Clinical view. (B) Abutment
removed.

for cement-retained crowns is no longer the best option due to

increased costs, increased screw loosening,e and the less accurate
fit at the implant.19

! CLINICAL CORRELATION
The thickness of the overlying tissue has been shown to have a greater
influence on the perceived color of the gingiva over an implant than the
abutment/restorative material used. The color shift is almost imperceptible
under thick tissues, whereas it is nearly always noticeable when covered
by thin tissues, even with zirconia abutments.

Milled custom abutments can be made out of titanium or zirconia.

When prescribing these abutments, it is critical to communicate to
the technician where the margins should be placed. If left unstated,
many technicians will opt to place them deep subgingivally. Several
studies83,84 have clearly shown that cement cannot be predictably
removed at depths greater than 1 mm subgingival. If the margins
are any deeper than 1 mm, significant amounts of cement will be
left behind and will likely start the process of peri-implantitis (Fig.
77.20). It is common for clinicians and technicians to place the
margins deeper than 1 mm subgignival in aesthetic cases in an attempt
to hide the titanium abutment if recession should occur. This strategy
is unwise and will inevitably result in retained cement. The correct
approach is to shape the tissue with a provisional, allow it to mature,
and place the margin no deeper than 1 mm. The abutment could
also be made of zirconia and stained to resemble the root surface.
Clinicians should be aware of the significant strength variations in
zirconia abutments based on the manufacturer.69
! CLINICAL CORRELATION
No attempt should ever be made to cement restorations on an implant
abutment with margins more than 1 mm below the gingival margin. A
custom abutment can be easily designed to address the natural scalloping
References 16, 34, 39, 76, 90, 99, 113, 143.
e
Fig. 77.21  Many in vitro studies have shown that splinting of adjacent
implants helps to share occlusal forces between the implants. However,
several clinical trials have shown no clinically significant difference in bone
levels between splinted and nonsplinted restorations at 3, 5, and 10 years
of use.
of the gingiva. The probability of leaving (missing) excess cement trapped
below the gingival margin is extremely high and problematic. Studies
have clearly shown that cement cannot be removed at depths greater
than 1 mm subgingival.
Splinting Adjacent Implants
The rational for splinting adjacent implants (Fig. 77.21) stems from
various finite element analysis (FEA)10,12,142,148 and photo-elastic gel
(PEG) experiments.51 These in vitro studies repeatedly confirm that
multiple implants produce less acute forces in the peri-implant bone
when splinted compared with multiple individual restorations.
However, we do not have a clear notion of how much stress is
acceptable for the peri-implant bone and at what threshold we might
expect pathologic bone loss. The clinician must consider the length
and diameter of the implants as well as the quality and quantity of
the bone when determining if multiple implants should be splinted
together.
 CHAPTER 77  Prosthetic Considerations for Implant Treatment 780.e1

the screw access (eFig. 77.3). With either technique, 3-4 mm of

Covering the Screw Access space must be left coronally in screw-retained restorations to allow
After placement and proper torquing of the abutment screw, there space for a robust composite seal. For cement-retained restorations,
is the need to cover the screw access channel. The ideal material either material can be placed to the top of the abutment screw. It is
for this is one that does not inhibit future access to the abutment advisable to clean the screw access beforehand with a strong
screw and provides a seal to inhibit leakage into the abutment. chlorhexidine solution (eFig. 77.4) and dry thoroughly.
Traditionally this has been done with a cotton pellet, a technique
adapted from the temporary procedure used in endodontics. However,
unlike a root canal temporary, the screw cover in an implant abutment
will be left in place for many years.
The challenge in implants is that the internal aspect of the implant
and the abutment are hollow, body temperature, dark, and oxygen
free. Upon functioning, the abutment will move slightly in the implant,
and the fluids and bacteria from the oral environment will fill this
hollow chamber. Ultimately, proliferation of certain bacterial strains
inside the implant may play a role in the presence of peri-implantitis.21-24
Obviously, placing a cotton pellet into this environment for any
extended period of time is a poor idea. It provides no seal and is an
ideal environment for the proliferation of pathogenic bacteria (i.e.,
Parvimonas micra) (eFig. 77.1).
Reasonable and tested alternatives include gutta-percha, polytet-
rafluoroethylene (PTFE) tape (also known as Teflon or “plumber’s”
tape), and polyvinyl siloxane (PVS) impression material. Gutta percha
has been shown to provide a good seal27,93 but can be challenging
to remove without the use of an endodontic heat instrument. PTFE
eFig. 77.1  Cotton has been a commonly used material to directly cover
tape and PVS look to be reasonable alternatives,98,102,108 but further the abutment screw. However, the internal aspect of two-piece implants
testing is needed to determine their long-term success and clinical will have saliva and oral flora filling this area, leading to the proliferation
effects. To use PTFE tape, a long portion (~10 cm) is sterilized then of vast amounts of anaerobic bacteria. The cotton provides an ideal substrate
rolled up and condensed into the screw access (eFig. 77.2). Alter- for the bacteria and leads to foul odors and tastes coming from the implant
natively, light body PVS impression material can be injected into under function.
780.e2 Part 4  Oral Implantology

A B

C D

eFig. 77.2  PTFE tape (“plumber’s tape”) is a good alternative to cotton

(A). It is easy to remove, protects the screw, and does not promote
bacterial growth. It is rolled into rope or “cigar” shape and fully condensed
into access after torquing the screw (B–D). A 2- to 4-mm space should
E be left above the condensed PTFE. (E) This is then covered with a bonded
layer of opaque composite.
 CHAPTER 77  Prosthetic Considerations for Implant Treatment 780.e3

A B
eFig. 77.3  PVS impression material also works well to cover the abutment screw, though it is best suited
for use with cemented restorations. The material is dispensed into the screw access starting at the bottom
and back-filling to the top (A). The excess is then wiped off before setting and cementation of the crown. The
PVS plus is easy to remove should the need arise (B).

eFig. 77.4  Chlorhexidine-soaked pellets or brushes are used to clean prior to covering the screw access.
Common chlorhexidine is made as a 0.12% solution, though 2% is preferable when available.
 CHAPTER 77  Prosthetic Considerations for Implant Treatment
Splinted restorations are advisable when the foundation is
compromised (i.e., short or narrow implants, compromised bone).87,147
This will allow the stronger or better supported implants to “assist”
the others. The compromise here is that if the weaker implant fails,
an entirely new prosthesis may need to be fabricated, usually at a
significant expense.
The rationale for splinting adjacent implants involves the intention
of “sharing the forces,” a concept derived from the in vitro studies
of the early 2000s cited earlier. The implication is that clinically we
would see fewer implant failures and less bone loss over extended use
with splinted restorations. Long-term in vivo randomized controlled
trials (RCTs)30,42,140 have tested this hypothesis in order to quantify
the differences in bone loss and implant failure with splinted versus
nonsplinted restorations. In the partially edentulous RCT, at 10 years
the mean difference in bone loss between splinted and nonsplinted
restorations for 132 implants was a mere 0.1 mm.140 This could
hardly be considered clinically significant under most scenarios. In
the fully edentulous study with two mandibular implants retaining a
full denture, the differences at 3 years were statistically insignificant
at most sites and only about 0.5 mm at the most significantly dif-
ferent sites.42 A prospective split mouth, in vivo trial examining
bone levels around splinted and not-splinted restorations showed no
significant difference at 36 months.30 Until better evidence shows
otherwise, “sharing forces” in an attempt to reduce bone loss is not
a proper consideration for whether or not adjacent implants should
be splinted. These data are not necessarily in conflict with the early
in vitro experiments, they simply illustrate that higher forces do
not necessarily result in more bone loss and that it is difficult to
extrapolate data from FEAs and PEGs to clinical realities. Depending
on the type of bone and implant, there is likely a threshold below
which increased forces will not result in significant bone loss over
extended use. Conversely, despite the lack of significance found in
these studies, there may be scenarios in which clinical judgment
warrants splinting adjacent implants such as multiple implants placed
in the posterior maxilla in type IV bone opposing an intact natural
dentition or implants.
The downside to splinted restorations is largely related to long-
term repair and replacement costs. With patients having implants that
must maintain a prosthesis for 30, 40, or 50 years, it is appropriate
to consider that the prosthesis will require replacement throughout
its life. Most commonly, this is related to porcelain failure on screw-
retained PFM FDPs.94 After a PFM restoration has been in the mouth
for any significant period of time, porcelain failure cannot simply be
repaired. The restoration must be fully stripped or replaced. Practically
speaking, it can be a challenge to find a laboratory willing and
able to strip and restack porcelain, and most will opt for complete
replacement of the prosthesis. Essentially this has doubled, tripled, or
quadrupled the cost of replacement. If an individual unit suffers the
same complication, only the unit affected needs to be replaced. Issues
related to patient autonomy and desires need to be considered in the
replacement of multiple adjacent missing teeth. Some patients may
tolerate splinted restorations, whereas others may desire individual
units. Oral hygiene techniques and ease of cleansibility will vary
between restoration types as well.
KEY FACT
Until evidence shows otherwise, “sharing forces” is not a valid reason to
splint adjacent implants. These data are not necessarily in conflict with
the early in vitro experiments, they simply illustrate that higher forces do
not necessarily result in more bone loss and it is difficult to extrapolate
data from finite element analysis and photo-elastic gel studies to clinical
realities.
781
Indications for splinting adjacent implants include significant
off-axis forces (i.e., canine replacement), multiple adjacent external
hex implants, poor bone, and diminutive implants.50
Management of Partially Edentulous Implant
Treatment in the Aesthetic Zone
Diagnosis and Treatment Planning
Treatment of the partially edentulous patient in the aesthetic zone
is one of the more challenging prosthetic scenarios. The “aesthetic
zone” is not simply canine to canine in the maxilla. Each patient
must be individually evaluated for lip position and movement (Fig.
77.22) to determine the appropriate level of aesthetic consideration
necessary.
The primary challenge in this treatment is the peri-implant soft
tissues.18 If patients show soft tissue during lip movement, then
particular attention should be paid to the creation and preserva-
tion of natural appearing gingiva. First, there must be sufficient
thickness of the gingiva. Thin tissue biotypes are more prone to
recession, peri-implant mucositis, papilla loss, and graying.65,80,81,107,149
The surgical team may need to employ various techniques prior
to, or at the time of, implant placement to increase the tissue
thickness.
During the treatment planning phase, the clinical team should
consider the shape and position of the soft tissue on all teeth or
implants in the area. If any of these positions are planning to be
modified, the corresponding implant position may change as well.
Management of potential changes to the tissue color can be
challenging, as there is a shift in the gingiva around implants to a
gray tone.17 This can be somewhat managed with the use of UCLA
or zirconia abutments, though research has clearly shown that there
can still be a perceptible color shift with these more aesthetic materials
(delta E >3.9).62 Though zirconia abutments are weaker than titanium,
they have shown comparable survival rates for single units in vivo.150
Some technicians have begun experimenting with the use of fluoresc-
ing glazes over the emergence zone of zirconia abutments to decrease
the color shift. Some manufacturers and clinicians have coated the
titanium abutments with a gold or pink color, again in an attempt
to mitigate color changes.
The greatest challenge of implants in the aesthetic zone is papilla
management. Implants, even with contemporary designs (i.e., platform
switch, conical connections), cannot maintain crestal bone height as
much as a healthy tooth. The implant is very different than the natural
tooth because it does not have periodontal ligament (and its blood
supply) or supracrestal inserting connective tissue fibers. The clinical
appearance (i.e., height and fullness) of the papilla between an implant
and a tooth ultimately depends on the periodontal attachment level
of the adjacent tooth and not the level of bone adjacent to the implant.
Should the papilla fail to meet desires and expectations, the open
gingival embrasure is generally best managed through additional
surgery or closing the space with restorations.132 Although there have
been good attempts to solve the problem of deficient papilla with
pink prosthetics, it is all but impossible to resolve it in a manner
that is both aesthetically convincing and hygienic in the partially
edentulous patient.
Although there will be variations in papilla height adjacent
to or between implants, the average papilla height adjacent to a
single implant is 4.2 mm.66 Between adjacent, unrestored natural
teeth, the average papilla height is at least 5 mm.130 Between adja-
cent (external hex) implants, the average papilla is only 3.4 mm
(Table 77.2).128
The preceding figures are averages and do not represent the actual
value for what is possible for any given patient. The key to predictable,
782 Part 4  Oral Implantology

A B

C D
Fig. 77.22  Implant treatment in the aesthetic zone is more challenging than in the functional zone. It is
important to keep in mind that the aesthetic zone differs for each patient. It should be evaluated though a
series of basic photos: right, center, and left at maximum smile (A–C), and with lips at rest (D). In this patient
the aesthetic zone clearly includes the anterior teeth and all premolars.

TABLE 77.2  Anticipated Papilla Height Tissue Shaping and Management

Between Between Following integration of the implant and maturation of the soft tissue,
Between Tooth and Adjacent there may be the need to correct slight malpositions of the peri-implant
Natural Teeth Implant Implants tissues. This can be done through modification of the implant abutment,
Average expected ≥5 mm (Tarnow, 4.2 mm (Kan, 3.4 mm but it should not be done repeatedly to avoid increased tissue changes
papilla height 1992)130 2003)66 (Tarnow, that lead to bone loss. Significant deficiencies of tissue may be
(from crest of 2003)128 difficult to correct, whereas others may be able to be addressed with
bone) additional surgery.
The emergence profile of the provisional restoration can be
added to or contoured back to manipulate the soft tissue position.
Applying additional contour will move the gingiva apically, whereas
successful treatment in the aesthetic zone is the implant-retained undercontouring will allow the tissue to drape more coronally. The
provisional restoration. This will allow the clinical team and the patient abutment can also be modified to apply pressure to the base of the
to truly test the four key criteria of aesthetics, phonetics, function, papilla, thus forcing the tip coronally,132 but this technique should be
and hygiene. Revisions and alterations are much easier to accomplish used with caution around implants due to a diminished blood supply
with provisionals as compared with the definitive prosthesis. and fragility of the soft tissue.111 The clinician should minimize
the number of reattachments to the head of the implant, as this
will weaken the integrity of the tissues and create additional bone
FLASH BACK loss.3,112
The greatest challenge of implants in the aesthetic zone is papilla manage- Ideally all contours of the soft tissues should be designed in
ment. Although there have been good attempts to solve the problem of the patient’s mouth, and the four keys (aesthetics, phonetics,
deficient papilla with pink prosthetics, it is all but impossible to resolve function, and hygiene) should be tested and approved. If done
it in a manner that is both aesthetically convincing and hygienic in the correctly, the transition from the patient to the technician is seam-
partially edentulous patient. less with the provisional serving as a blueprint for the definitive
prosthesis.
 CHAPTER 77  Prosthetic Considerations for Implant Treatment
Implant-Retained Provisional Restorations
The implant-retained provisional restoration is a critical tool in the
treatment of partially edentulous patients. It can be fabricated in the
laboratory or directly in the mouth (eTable 77.1). As stated previously,
the provisional restoration allows the clinical team and the patient
to determine if the proposed treatment will meet expectations.
Regardless of the definitive restoration design, the implant provisional
should be screw retained because the use of cement should be avoided
in fresh surgical sites, and the ability to remove, modify, and replace
the restoration is essential. The emergence zone of the provisional
must be smooth and well polished. The apical most 2 mm of the
provisional should be clean titanium (not polyetheretherketone
[PEEK], composite, or acrylic) (eFig. 77.5) due to its well proven
effects on the soft tissues2 and minimal risk of breakage.
eTABLE 77.1  Fabrication of the Implant-Retained Provisional
Restoration
1. Clean the provisional abutment, apply opaquing composite resin;
polymerize.
2. Attach titanium provisional abutment to the implant; verify
complete seating.
3. Adjust the composite shell crown to fit over or around the
abutment.
4. Apply bonding agent and flowable composite to the shell intaglio
and the surface of the abutment.
5. Carefully place the shell onto the abutment in the correct position
and polymerize.
6. Remove the abutment/shell from the implant; steam clean, dry, and
apply bonding agent.
7. Use flowable composite to fill in the emergence area.
8. Most scenarios will benefit from the creation of an undercontoured
emergence profile.
9. Finish and polish; ensure that the apical 2 mm portion of the
provisional restoration is clean and polished titanium.
10. Deliver the provisional restoration to the implant and tighten to the
appropriate setting.
11. Cover the screw access.
eFig. 77.5  The screw-retained provisional restoration is a critical tool in
the treatment of aesthetic zone implant cases. It will support and shape
the soft tissue while allowing in vivo evaluation of function, hygiene, phonet-
ics, and aesthetics. It should be designed such that the apical 1.5 to 2 mm
portion of the restoration is in highly polished titanium.
782.e1
The main advantage of the implant-retained provisional restoration
is its use in preserving and supporting the peri-implant tissue con-
tours.11,126,133 This scenario presents itself when an implant is placed
and restored with the provisional immediately at the time of extraction—
a technique commonly called “immediate provisionalization” or
“immediate loading.” Immediate loading requires sufficient stability
of the implant, the ability to keep the restoration out of occlusion/
excursion, stable maximum intercuspal position (MIP), and patient
cooperation. There appears to be little change in implant failure when
these criteria are carefully followed. The main advantage of immediate
loading is the preservation of the papilla25,31,32,35 and decreased bone
loss.114 It is much easier to preserve papilla than to regenerate.
At the time of implant placement, the provisional should be
designed with the goals of protecting the surgical site and maximizing
the potential volume of the peri-implant tissues. To accomplish these
goals, it should have a smooth, titanium emergence that is no wider
than the implant itself. This will help to promote blood supply to
the area and any graft that may have been placed. It should not
blanch the tissue or compress the papilla at this stage. It should
emerge from the implant narrow and gradually transition to the
contour of the crown near the gingival margin. Should the implants
be angled to the facial, a screw-retained provisional can still be
predictably used.
To fabricate the restoration, the following items are needed
(eFig. 77.6):
• Titanium provisional abutment (not PEEK)
• Abutment screw
• Crown form (composite, natural tooth, or crown)
Prior to the appointment, the titanium abutment should be
sandblasted with 50 micron aluminum oxide, covered with an
appropriate opaquing resin (generally A1), and polymerized.
Some titanium temporary abutments are incorrectly designed with
a flared portion directly exiting from the junction with the implant.117
This puts unnecessary pressure on the per-implant tissues and will
force the peri-implant bone to remodel to a more apical position.121
This area of the abutment can and should be removed prior to the
procedure (eFig. 77.7).
The crown form can be fabricated from composite resin in the
laboratory on a model. Alternatively, the patient’s existing natural
tooth or current crown may be used. Material-specific bonding
procedures should be implemented to ensure adhesion. Acrylic
materials could be used as well, but delivery and manipulation can
be difficult in the surgical environment.
Following the placement and stability check of the implant, the
provisional abutment is attached, checked for full seating, and hand
tightened. The crown form is then adjusted to fit over or around
the provisional abutment (eFig. 77.8). If the angulation is through
the facial, the abutment itself must be marked, removed, cut, and
repositioned. It is critical that the crown form easily fits into the exact
desired position over or around the abutment. Both the crown and the
abutment are cleaned, bonding agent applied, and both are lined with
flowable composite (eFig. 77.9). The crown is then positioned and the
composite polymerized. Upon removal, there will be sharp, unfilled,
and undercut areas (eFig. 77.10). The provisional is thoroughly cleaned
and fresh bonding agent applied. Composite is then used to fill and
shape the emergence area (eFig. 77.11). It should now be placed
back onto the implant to ensure there is no blanching and that there
is some degree of open gingival embrasures to allow for swelling and
papilla migration (eFig. 77.12). The provisional should be removed,
polished, and carefully examined. At this stage, the surgeon may opt
to complete the grafting procedure, prior to delivery of the provisional.
It should be checked to ensure that there is absolutely no contact in
MIP or throughout the excursive movements (eFig. 77.13).
782.e2 Part 4  Oral Implantology

A B
eFig. 77.6  Prior to fabricating the provisional restoration in the mouth, the titanium (not PEEK) abutment
should be coated with a layer of opaque composite resin (A). A provisional shell needs to be fabricated from
composite resin as well (B).

A B
eFig. 77.7  Temporary abutments from some manufacturers have a flared area that comes directly off the
head of the implant. This is a flawed design and the flared area should be removed prior to use with a heatless
stone (A). Once removed, the area should be no wider than the implant and must be polished (B).

eFig. 77.8  To fabricate the provisional, the titanium abutment is connected
to the implant, and the composite shell is adjusted to fit around/over it. For
lateral incisors, the shell will often have to be made into a three-quarter
crown form to fit around the abutment. Special care must be taken to ensure
that the shell easily fits into the proper position.
eFig. 77.9  Using composite bonding agent and flowable composite, the
shell is positioned and bonded to the titanium abutment. In immediate
placement sites, care must be given to ensuring that blood does not con-
taminate the bonding interface.
 CHAPTER 77  Prosthetic Considerations for Implant Treatment 782.e3

eFig. 77.10  After polymerizing the flowable composite, the abutment eFig. 77.12  The provisional restoration is delivered onto the implant and
and shell are removed together. They should be steam cleaned and thoroughly torqued to an appropriate value. The ideal provisional should produce little
dried. The open and undercut areas are covered with bonding agent, and to no blanching of the peri-implant tissues and have open gingival embrasures
flowable composite is used to fill the emergence area. to allow for papillary development.

eFig. 77.11  The finished screw-retained provisional should have 2 mm

of polished titanium at the base, and it should flow into a smooth, narrow
emergence area.

eFig. 77.13  The provisional restoration in immediate load cases should

be designed to be fully out occlusion in maximum intercuspal position (MIP)
and throughout the excursive range. Patients are instructed to not chew on
the provisional.
 CHAPTER 77  Prosthetic Considerations for Implant Treatment 783

A Case Scenario is found on the companion website

Conclusion
www.expertconsult.com.
Successful implant treatment requires a team of clinicians and
technicians dedicated to excellence in surgical and prosthetic aspects.
A thorough understanding of the prosthodontic restoration of implants
References
from implant-abutment connections to hard and soft tissue interfaces
and compatibility with the implant/abutment/restoration is essential. References for this chapter are found on the companion
This chapter reviewed the critical aspects of prosthetic implant website www.expertconsult.com.
treatment proven to maximize long-term functional, biologic, and
aesthetic success.
 CHAPTER 77  Prosthetic Considerations for Implant Treatment
eTABLE 77.2  Fabrication of Indirect Custom Impression Copings
Custom impression copings can be fabricated indirectly in the lab.57 The
indirect technique is well suited for three or more units. Fabrication
of indirect custom impression copings involves the following steps:
1. Remove and clean the provisional restoration.
2. Attach appropriate analogs.
3. Submerge in impression material.
4. Mark the orientation of the facial surfaces.
5. Remove the provisional restoration.
6. Attach narrow impression copings.
7. Fill the emergence zone with a low-shrinkage resin.
8. Mark the facial surface and tooth number for each coping.
9. Return to the patient and place the impression copings on the
appropriate implant with the facial surface oriented correctly.
10. Verify seating with radiographs.
11. Make the impression.
eTABLE 77.3  Fabrication of Direct Custom Impression Copings
For one or two implant units, the custom impression copings can be
fabricated directly in the mouth.118 Fabrication of direct custom
impression copings involves these steps:
1. Remove the provisional restoration.
2. Quickly attach narrow impression coping.
3. Fill the emergence zone with a dual-cure resin.
4. Polymerize.
5. Verify seating with radiographs.
6. Make the impression.
Customized Impression Copings
To ensure that the technician is fabricating the definitive abutment
and crown on a model that exactly replicates the current patient
condition, a customized impression coping should be used (eTables
77.2 and 77.3). The customized impression coping replicates or
preserves the existing tissue contours in the final impression. Without
the use of a custom impression coping, the soft tissue will collapse
and deform during the impression, leaving the technician guessing
about where to put margins or how to shape the emergence zone.
Fully Edentulous: Prosthetic Considerations
Edentulous Maxilla
Prosthetic options for the patient with an edentulous maxilla include
a conventional complete denture, an implant-assisted denture, or an
implant-supported fixed prosthesis. However, a conventional complete
denture does not provide the comfort and quality of life that many
patients desire. An implant-assisted or implant-supported prosthesis
can provide stability, retention, and comfort, and can restore the
patient’s confidence, especially in patients with one or more of the
following conditions:
1. Poor ridge form with a marginally stable conventional maxillary
denture. Two or four implants provide greater stability and security
of a maxillary denture in function when the maxillary ridge is
severely resorbed and lacks resistance to lateral forces.
2. Lack of posterior support with an intact mandibular anterior
dentition. Implants in the maxilla can offset the potentially
destructive effects on the premaxillary region when a mandible
with natural anterior teeth and missing posterior teeth opposes
an edentulous maxilla. In this situation the lack of posterior support
783.e1
20 mm
10 mm
eFig. 77.14  Diagram demonstrating the anterior-posterior (A-P) implant
spread. It is defined as the distance from the middle of the most anterior
implant to the distal edge of the most posterior implant.
leads to a condition often referred to as combination syndrome,
in which overclosure of the jaws with mandibular anterior teeth
causes destruction of the edentulous anterior maxilla.
3. Palatal coverage is not tolerated. Some patients prefer a palateless
denture, which may enhance their sensations of taste and texture
or may simply provide a psychological advantage. Some patients
prefer a palateless denture because the proximity of the denture
with the soft palate induces a gag reflex. Patients with large
palatal tori (see Fig. 58.19A) can also benefit from a palateless
maxillary denture. A minimum of four implants with adequate
anterior-posterior (A-P) spread allows the fabrication of an
implant-assisted overdenture without palatal coverage.
4. High functional expectations and strong preference on fixed
prosthodontic tooth replacement treatment option. Patients with
a failing natural dentition, especially those who have never used
a removable prosthesis, often strongly prefer the implant-supported
fixed prosthesis treatment modality to meet their specific expecta-
tions and to allow a smoother transition. With modern rough
surface implants and computer-aided design/computer-assisted
manufacture (CAD/CAM) technology, immediate restoration of
function and aesthetics with implant-supported fixed prostheses
offers great benefits and patient satisfaction in carefully selected
cases.96
The design of a maxillary implant-retained prosthesis is greatly
influenced by the anatomy of the maxilla. Most notably, the maxillary
sinus limits the height of bone available for implant placement in
the posterior region. As a result, implant placement is confined to
the anterior region, and the A-P spread that can be achieved is often
limited (eFig. 77.14). If the A-P spread is inadequate to provide
support, a full-palatal-coverage overlay denture is recommended.
Most edentulous patients are best served with an implant-assisted
overlay denture. Lower cost, improved hygiene access, better lip
support and predictable speech articulation are additional benefits
that favor the use of an overlay denture in the edentulous maxilla
over an implant-supported fixed prosthesis. The four-implant–assisted,
palateless overlay denture ideally addresses the needs of most patients
(eFig. 77.15). Many patients who are edentulous in the maxilla have
lost a significant amount of structure in the premaxillary region
resulting in a lack of support for the upper lip. An implant-assisted
maxillary overdenture is preferred over an implant-supported fixed
783.e2 Part 4  Oral Implantology

A B

D
eFig. 77.15  Implant-assisted overlay denture. (A) Clinical photograph of a four-implant bar in the maxilla
designed to retain a palateless overlay denture. (B) Photograph of the clip and attachment design of a palateless
overlay denture. Anterior Hader clip attaches to anterior bar, and posterior extracoronal resilient attachments
(ERAs) fasten to female connectors at posterior ends of the bar. (C) Cross section of Hader bar clip attached
to the anterior bar (inset). View of overdenture bar with Hader clip (left) and ERA (right) attached. These plastic
components will be embedded in the overdenture as in part B. (D) Axis of rotation and function of the resilient
attachment. When posterior occlusal forces (solid vertical arrow) are applied, the denture rotates around the
bar clip anteriorly (curved arrow), and resilient attachment (arrow) allows the denture to be compressed to
primary denture-support areas posteriorly (open arrow).

prosthesis for this patient population because the labial flange can
provide the needed lip support to optimize the aesthetic outcomes.
The usual resorption pattern of the alveolus places the gingival margin
of a fixed restoration too far superiorly, too far palatally, or both.
Even if the patient has a low enough smile line to hide the appearance
of long crowns and deficient soft tissue height, a lack of lip support
just beneath the nose can be unsightly with fixed prostheses.
For patients who prefer an implant-supported fixed prosthesis
(and do not require additional lip support), six or more implants
arranged in an appropriate arc of curvature with at least 2 cm of A-P
spread are required (see eFig. 77.14). In this situation, the fixed
prosthesis can be fabricated with distal extension cantilevers up to
half the A-P spread provided it does not exceed 10 mm.
Transition from terminal dentition to complete edentulism always
presents the biggest challenge for patients with failing remaining
teeth. In the past, many patients were reluctant and unable to benefit
from the dental implants due to multiple surgeries, lengthy treatment
time, and the psychological fears of losing all their natural teeth and
getting used to an immediate removable prosthesis. However, advances
in modern implant designs, implant surfaces, and CAD/CAM technol-
ogy have broadened the implant applications due to high primary
stability, precision planning, and optimal implant placement. Emerging
evidence showed high patient-reported satisfaction and a comparable
implant success rate of immediate implant placement and immediate
loading compared with the delayed loading protocols.6,36,43,103,109,129
With careful patient selection and appropriate training, the experienced
clinician can shorten the treatment time, provide immediate restoration
of function and aesthetics, and mitigate the psychological impact of
complete edentulism with immediate loading of implant-supported
fixed prostheses96 (eFig. 77.16A–B).
 CHAPTER 77  Prosthetic Considerations for Implant Treatment 783.e3

A B

C D

E F

G H
eFig. 77.16  (A–E) Pretreatment: A 60-year-old male patient presented with failing dentition due to rampant
caries. This patient chose immediate implant placement and an immediate loading treatment option due to his
specific expectations. Immediate restoration of aesthetics and function was his top priority. Notice the extensive
caries, heavy plaque build-up, and severe occlusal plane discrepancy and crowding of remaining dentition.
(F–H) Post-op: Full mouth extractions of 22 teeth, bone reduction, and immediate placement of 11 implants (six
on the maxilla and five on the mandible) were completed in one surgery with CAD/CAM bone reduction guide
and implant surgical guide. Then CAD/CAM PMMA fixed provisional prostheses were connected onto five
maxillary implants and four mandibular implants, respectively, as shown on the post-op panoramic x-ray. Lower
insertion torque values were noted on implants at #11 and 22 positions at the time of surgery, and the decision
was made to exclude these two implants from the immediate loading protocol. (I and J) The patient was very
satisfied with the transition from his terminal dentition to implant-supported fixed provisional prostheses.
Continued
783.e4 Part 4  Oral Implantology
I J
eFig. 77.16, cont’d
That being stated, caution should be exercised in choosing
immediate treatment until methods have proven successful, especially
in the maxillary arch. Parel and Phillips100 identified several common
primary factors in maxillary implant failure scenarios based on a
retrospective study of the all-on-four implant concept. They found
the number of maxillary implant failures was about five to six times
the number of failed mandibular implants. Through this process of
patient profiling, they concluded that opposing natural dentition,
male gender, lack of bone density, the distal implant site, and
parafunctional habits were sufficiently frequent occurrences in failure
situations to suggest that either the use of additional implants or
delayed loading and the provision of a complete denture as an interim
prosthesis may be more appropriate in the management of patients
identified as being high risk. Secondary factors such as bone avail-
ability (volume) and smoking were less common in failure situations.
These factors, when considered and evaluated presurgically, can be
helpful in treatment planning with regard to the appropriate number
of implants necessary and the possible loading sequence for optimal
integration and prosthesis success.
The use of CAD/CAM technologies for digital workflow from
the virtual implant treatment planning, image-guided implant surgery,
to the manufacturing prosthetic frameworks on dental implants is
noticeably increasing. While embracing the exciting technology
advancement in implant dentistry, clinicians must be mindful of
the limitations, and the overall possible accuracy of the CAD/
CAM technology depends on the accuracy of the individual steps
of the production process. Flügge and colleagues47 showed that
the registration accuracy in commercial virtual implant planning
software is significantly influenced by the preprocessing of imported
data, by the user, and by the number of restorations resulting in
clinically nonacceptable deviations encoded in image-guided
implant surgery drilling guides. This study emphasized that the
automatic segmentation in the implant planning software was
significantly less accurate compared with the manual segmentation
by the users, especially in patients with multiple preexisting dental
restorations.
Edentulous Mandible
Similar to the edentulous maxilla, prosthetic options for patients
with an edentulous mandible include a conventional complete denture,
an implant-assisted denture, or an implant-supported prosthesis. A
mandibular complete denture is more problematic for patients than
a maxillary complete denture, especially for patients with a severely
resorbed (atrophic) mandibular ridge. The lack of stability and
retention makes it challenging for patients to control the denture.
The addition of implants offers unprecedented control (i.e., stability
and retention) for a complete, removable prosthesis.
Bar
Hader
clip
Metal housing
eFig. 77.17  Cross section of a Hader bar with clip. Note that the minimal
height of the Hader bar is 2.5 mm and about 1.2 mm for the plastic clip
and the metal housing. We should also allow room for acrylic for the retention
of these components.
Implant-assisted overlay dentures are designed so that most of the
masticatory load is borne by the primary denture-support areas (i.e.,
retromolar pad, buccal shelf). A common practice is to place two
implants in the anterior mandible with a connecting bar. One or two
clips retain the denture to the bar (eFig. 77.17). When occlusal forces
are applied, the denture rotates around the bar (anterior axis of rotation)
and depresses slightly in the posterior aspect, directing the forces to
the primary denture-bearing areas (eFig. 77.18). The implants provide
stability and retention while bearing minimal stress from occlusal
loads. Individual attachments secured to each implant can also offer
a simple prosthetic alternative (eFig. 77.19) to the bar and clip design.
However, it is more critical for implants with individual attachments
to be parallel to one another to facilitate a proper path of insertion
and to minimize stress during prosthetic seating and function.
For patients who prefer an implant-supported fixed prosthesis,
four, five, or six implants arranged in an appropriate arc of curvature
with at least 1 cm of A-P spread are required (see eFig. 77.14). In
this situation, the fixed prosthesis can be fabricated with distal
extension cantilevers up to twice the A-P spread (eFig. 77.20).
Many patients prefer a fixed option for psychological reasons,
but the mastication efficiency provided by a fixed versus removable
prosthesis does not appear to be significant.67 Evidence suggests that
such fixed restorations tend to stop resorption of the body of the
posterior mandible and in some cases enable regeneration of the
bone in this region.
 CHAPTER 77  Prosthetic Considerations for Implant Treatment 783.e5

A B

C D
eFig. 77.18  Implant-assisted overlay denture. (A) Clinical view of an overdenture in occlusion. (B) Photograph
of a mandibular overlay denture (tissue-bearing surface) designed for an implant bar attached to two implants
in the anterior mandible. Two Hader clips are embedded in the anterior acrylic. (C) Clinical view of a bar attached
to two implants in the anterior mandible. (D) Illustration demonstrating how the axis of rotation allows denture
to rotate around the bar. When the patient applies occlusal force posteriorly, the overlay denture rotates around
the bar, and the load is absorbed by primary denture-bearing surfaces posteriorly.

A B
eFig. 77.19  Individual attachments can be used on each implant to assist in retention of the mandibular
overdenture. (A) Clinical view of the anterior mandible with individual ball attachments on two implants. (B)
Tissue-bearing surface of the mandibular overdenture showing individual female attachments embedded in the
denture. (Courtesy Dr. Sal Esposito, Beachwood, Ohio.)
783.e6 Part 4  Oral Implantology

Anterior-posterior spread is
the distance from the
center of the most anterior
implant(s) to the distal
surface of the most
posterior implants.

The AP spread required for

an implant-supported
prosthesis is:
Maxilla = 2 cm
6+ implants
Mandible = 1 cm
4+ implants

Cantilever
length

A B

eFig. 77.20  Cantilever length relative to A-P spread of implant distribution. (A) Clinical view of an implant-
supported restoration replacing mandibular teeth. Notice that the restoration is supported by five implants in
the anterior and has cantilever extensions in the posterior segments. (B) Study model view of a similar mandibular
implant-supported restoration with posterior cantilever extensions. Cantilever length, in the edentulous mandible,
should not exceed twice the A-P spread.
 CHAPTER 77  Prosthetic Considerations for Implant Treatment 783.e7

CASE SCENARIO 77.1 

Patient:  29-year-old Caucasian female, ASA 1.
Chief Complaint:  “I have pain and swelling around my implant.”
Background Information
Patient reports having the mandibular left central incisor replaced with
an implant about 1 12 years ago. She did not have symptoms until recently
when the gum over the implant became tender and swollen.
Current Findings:  Exam reveals that probing depths range from 2 to
3 mm. Dentition is intact except for the mandibular left lateral incisor,
which is replaced with an implant. There is a 7- to 8-mm pocket on the
labial area with moderate erythema and edema. The tissues easily retract
away from the implant revealing excess cement. The implant crown is
positioned facial to the adjacent teeth.

A B

CASE-BASED QUESTIONS SOLUTION AND EXPLANATION

1. What is the diagnosis? Answer: A
A. Peri-implantitis Explanation: There is attachment loss, bone loss, and peri-implant
B. Peri-implant mucositis inflammation most likely precipitated by excess cement.
C. Normal peri-implant health
D. Periodontal abscess
2. What are the etiologic factors? Answer: C
A. Smoking Explanation: It has been well documented that excess cement cannot be
B. Poor oral hygiene detected or removed when >1 mm subgingival.
C. Cementing an implant crown with margins that are more than
1 mm subgingival
D. Unknown systemic disease
3. What prosthetic measures can be taken to avoid this problem? Answer: C
A. Use a screw-retained restoration Explanation: Using a screw-retained restoration or using a custom
B. Use a custom abutment that keeps the cement margins ≤ 1 mm abutment that creates crown margins within 1 mm of the gingival
from the gingival margin margin will avoid or minimize the likelihood of excess cement being
C. Both of the above extruded into the subgingival tissues.
D. This problem is unavoidable
783.e8 Part 4  Oral Implantology
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127. Su H, González-Martín O, Weisgold A, et al: Considerations of implant
abutment and crown contour: critical contour and subcritical contour,
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128. Tarnow D, Elian N, Fletcher P, et al: Vertical distance from the crest
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 CHAPTER 77  Prosthetic Considerations for Implant Treatment
129. Tarnow DP, Emtiaz S, Classi A: Immediate loading of threaded implants
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130. Tarnow DP, Magner AW, Fletcher P: The effect of the distance from
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zirconia and titanium abutments with internal and external implant–
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132. Urban IA, Klokkevold PR, Takei HH: Papilla reformation at single-tooth
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133. Van Nimwegen WG, Goené RJ, Van Daelen AC, et al: Immediate
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134. Vandeweghe S, De Bruyn H: A within-implant comparison to evaluate
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136. Vela-Nebot X, Rodríguez-Ciurana X, Rodado-Alonso C, et al: Benefits
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SECTION II:  SURGICAL PROCEDURES
CHAPTER 78 
Basic Implant Surgical Procedures
Perry R. Klokkevold
CHAPTER OUTLINE
General Principles of Implant Surgery
Two-Stage “Submerged” Implant Placement
One-Stage “Nonsubmerged” Implant Placement
Conclusion
Editors’ note: An animation (slide show) has been added by the editors
as a supplement to the chapter. It was produced by My Dental Hub as
a patient education tool and covers the basic elements in a conceptual
manner. It is not intended to be a procedural guide for dental
professionals.
The surgical procedures for the placement of nearly all endosseous
dental implants currently used are based on the original work of
Professor Per-Ingvar Brånemark and colleagues in Sweden in the
1960s and 1970s.4,5 Their landmark research evaluated the biologic,
physiologic, and mechanical aspects of the titanium screw-shaped
implant, subsequently known commercially as the Nobelpharma
“Brånemark” implant system and currently manufactured by Nobel
Biocare. The original Brånemark implant was a parallel-walled,
cylindrically shaped, threaded implant with an external hex connection
and a machined surface. Since their introduction, many designs of
root form implants have been developed, modified, and studied.
The same fundamental principles of atraumatic, precise implant site
preparation applies to all implant systems. Briefly, this includes a
gentle surgical technique and progressive, incremental preparation
of the bone for a precise fit of the implant at the time of placement.
This chapter outlines the basic surgical procedures for the place-
ment of endosseous dental implants using either one-stage or two-stage
protocols. The principles described here are intentionally generic
and meant to serve as guidelines that are applicable to most common
implant systems (Video 78.1). Each implant system is designed with
specific armamentarium and recommendations for use (e.g., drilling
speeds), and it is advisable to follow the detailed protocols provided
by the manufacturer. For the presentation of a dental implant case,
see Video 78.2.
General Principles of Implant Surgery
Patient Preparation
Most implant surgical procedures can be done in the office using
local anesthesia. Conscious sedation (oral or intravenous) may be
indicated (see Chapter 38) for some patients. The risks and benefits
of implant surgery specific to the patient’s situation and needs should
be thoroughly explained prior to surgery. A written, informed consent
should be obtained for the procedure.
784
Implant Site Preparation
Some basic principles must be followed to achieve osseointegration
with a high degree of predictability3,4,7 (Box 78.1). The surgical site
should be kept aseptic, and the patient should be appropriately prepared
and draped for an intraoral surgical procedure. Prerinsing with
chlorhexidine gluconate for 1 to 2 minutes immediately before the
procedure will aid in reducing the bacterial load present around the
surgical site. Every effort should be made to maintain a sterile surgical
field and to avoid contamination of the implant surface. Implant
sites should be prepared using gentle, atraumatic surgical techniques
with an effort to avoid overheating the bone.
Successful osseointegration occurs predictably for submerged4 and
nonsubmerged11 dental implants when proven clinical guidelines are
followed. Well-controlled studies of patients with good plaque control and
appropriate occlusal forces have demonstrated that root form, endosseous
dental implants show little change in bone height around the implant
over years of function.1 After initial bone remodeling in the first year
(1 to 1.5 mm of resorption described as “normal remodeling around
an externally hexed implant”),1 the bone level around healthy function-
ing implants remains stable for many years afterward. The average
annual crestal bone loss after the first year in function is expected to be
0.1 mm or less. Hence, implants offer a predictable solution for tooth
replacement.
Regardless of the surgical approach, the implant must be placed
in healthy bone with good primary stability to achieve osseointegra-
tion, and an atraumatic technique must be followed to avoid damage
to bone. Drilling of the bone without adequate cooling generates
excessive heat, which injures bone and increases the risk of failure.12
The anatomic features of bone quality (dense compact versus loose
trabecular) at the recipient site influences the interface between bone
and implant.9 Compact bone offers a much greater surface area for
bone-to-implant contact than cancellous bone. Areas of the jaw
exhibiting thin layers of cortical bone and large cancellous spaces,
such as the posterior maxilla, have lower success rates than areas
of dense bone.9 The best results are achieved when the bone-to-implant
contact is intimate at the time of implant placement.
One-Stage Versus Two-Stage Implant
Placement Surgery
Currently, most threaded endosseous implants can be placed using
either a one-stage (nonsubmerged) or a two-stage (submerged)
 CHAPTER 78  Basic Implant Surgical Procedures 784.e1

Abstract
Surgical procedures for the placement of endosseous dental implants
follow the same basic implant surgical procedures that were developed
by P.I. Branemark and co-workers in Sweden in the 1960s and 1970s.
It is essential to understand and follow these basic guidelines to
predictably achieve osseointegration. Fundamental protocols must
be followed for implant placement, regardless of whether implants
are placed using a one-stage approach or a two-stage approach with
a subsequent implant exposure surgery. These fundamentals apply
to all implant systems. This chapter reviews the basic principles of
implant surgery. Case presentations are used to demonstrate these
important concepts.
Keywords
implant surgery
implant site preparation
osteotomy preparation
one-stage surgery
two-stage surgery
sequential drilling
implant placement
flap closure
suturing

BOX 78.1  Basic Principles of Implant Therapy to Achieve
Osseointegration
1. Implants must be sterile and made of a biocompatible material
(e.g., titanium).
2. Implant site should be prepared under sterile conditions.
3. Implant site should be prepared with an atraumatic surgical
technique that avoids overheating of the bone during preparation
of the recipient site.
4. Implants should be placed with good initial stability.
5. Implants should be allowed to heal without loading or
micromovement (i.e., undisturbed healing period to allow for
osseointegration) for 2 to 4 or 4 to 6 months, depending on the
bone density, bone maturation, and implant stability.
A B C lingually to the level of the mucogingival junction. A narrow, sharp ridge
Fig. 78.1  One-stage implant versus two-stage implant surgeries. (A)
One-stage surgery with the implant designed so that the coronal portion of
the implant extends through the gingiva. (B) One-stage surgery with implant
designed to be used for two-stage surgery. A healing abutment is connected
to the implant during the first-stage surgery. (C) In the two-stage surgery,
the top of the implant is completely submerged under gingiva.
protocol. In the one-stage approach, the implant or the abutment
emerges through the mucoperiosteum/gingival tissue at the time of
implant placement, whereas in the two-stage approach, the top of
the implant and cover screw are completely covered with the flap
closure (Fig. 78.1). Implants are allowed to heal, without loading
or micromovement, for a period of time to allow for osseointegration.
In two-stage implant surgery, the implant must be surgically exposed
following a healing period. Some implants, referred to as “tissue
level,” are specifically designed with the coronal portion of the implant
positioned above the crest of bone and extending through the gingival
tissues at the time of placement in a one-stage protocol (Fig. 78.1A).
Other implant systems, referred to as “bone level,” are designed to
be placed at the level of bone and require a healing abutment to be
attached to the implant at the time of placement to be used in a
one-stage approach8 (Fig. 78.1B).
A one-stage surgical approach simplifies the procedure because
a second-stage exposure surgery is not necessary. The two-stage,
submerged approach is advantageous for situations that require
simultaneous bone augmentation procedures at the time of implant
placement because membranes can be submerged, which will
minimize postoperative exposure. Mucogingival tissues can be
augmented if desired at the second-stage surgery in a two-stage
protocol or as part of the one-stage protocol. Fundamental differences
in flap management for these two surgical techniques are described
separately.
CHAPTER 78  Basic Implant Surgical Procedures 785
A B
C D
Fig. 78.2  Tissue management for a two-stage implant placement. (A)
Crestal incision is made along the crest of the ridge, bisecting the existing
zone of keratinized mucosa. (B) Full-thickness flap is raised buccally and
can be surgically reduced/contoured to provide a reasonably flat bed for
the implant. (C) Implant is placed in the prepared osteotomy site. (D) Tissue
approximation achieves primary flap closure without tension.
Two-Stage “Submerged” Implant Placement
In the two-stage implant surgical approach, the first-stage or implant
placement surgery ends by suturing the soft tissues together over
the implant cover screw so that it remains submerged and isolated
from the oral cavity. In areas with dense cortical bone and good
initial implant support, the implants are left to heal undisturbed for
a period of 2 to 4 months, whereas in areas of loose trabecular bone,
grafted sites, and sites with lesser implant stability, implants may
be allowed to heal for periods of 4 to 6 months or more. Longer
healing periods are indicated for implants in sites with less bone
support. During healing, osteoblasts migrate to the surface and form
bone adjacent to the implant (osseointegration).6 Shorter healing
periods are indicated for implants placed in good quality (dense)
bone and for implants with an altered surface microtopography (e.g.,
acid etched, blasted, or etched and blasted). Readers are referred to
online material and other resources for more information about implant
surface microtopography.
In the second-stage (exposure) surgery, the implant is uncovered
and a healing abutment is connected to allow emergence of the
abutment through the soft tissues. Once healed, the restorative dentist
then proceeds with the prosthodontic aspects of the implant therapy
(impressions and fabrication of prosthesis).
The following paragraphs describe the steps for osteotomy
preparation and the first-stage implant placement surgery of the
two-stage protocol. Figs. 78.2 and 78.3 illustrate the procedures via
diagrams, and Fig. 78.4 depicts the procedures with clinical
photographs.
786 Part 4  Oral Implantology

A B C D

E F G H
Fig. 78.3  Implant site preparation (osteotomy) for a 4-mm diameter, 10-mm length screw-type, threaded
(external hex) implant in a subcrestal position. (A) Initial marking or preparation of the implant site with a round
bur. (B) Use of a 2-mm twist drill to establish depth and align the implant. (C) Guide pin is placed in the
osteotomy site to confirm position and angulation. (D) Pilot drill is used to increase the diameter of the coronal
aspect of the osteotomy site. (E) Final drill used is the 3-mm twist drill to finish preparation of the osteotomy
site. (F) Countersink drill is used to widen the entrance of the recipient site and allow for the subcrestal
placement of the implant collar and cover screw. Note: An optional tap (not shown) can be used following this
step to create screw threads in areas of dense bone. (G) Implant is inserted into the prepared osteotomy site
with a handpiece or handheld driver. Note: In systems that use an implant mount, it is removed prior to placement
of the cover screw. (H) The cover screw is placed and soft tissues are closed and sutured.

A remote incision with a layered suturing technique may be used

Flap Design, Incisions, and Elevation
Flap management for implant surgery varies slightly, depending on
the location and objective of the planned surgery. There are different
incision/flap designs, but the most common is the crestal flap design.
The incision is made along the crest of the ridge, bisecting the
existing zone of keratinized mucosa (see Figs. 78.2A and 78.4B).
to minimize the incidence of bone graft exposure when extensive bone
augmentation is planned. The crestal incision, however, is preferred
in most cases, because closure is easier to manage and typically
results in less bleeding, less edema, and faster healing.10
A full-thickness flap is raised (buccal and lingual) up to or slightly
beyond the level of the mucogingival junction, exposing the alveolar
 CHAPTER 78  Basic Implant Surgical Procedures 787

A B

C D

E F

G H
Fig. 78.4  Clinical view of stage-one implant placement surgery. (A) Partial edentulous ridge; presurgical and
prosthodontic treatment has been completed. (B) Mesial sulcular and distal vertical incisions are connected by
a crestal incision. Notice that bands of gingival collars remain adjacent to the distal molar tooth. (C) Minimal
flap reflection is used to expose the alveolar bone. Sometimes a ridge modification is necessary to provide a
flap recipient bed. (D) Buccal flap is partially dissected at the apical portion to provide a flap extension. This is
a critical step to ensure a tension-free closure of the flap after implant placement. (E) It is important to use the
surgical stent to determine the mesial-distal and buccal-lingual dimensions and proper angulation of the implant
placement. (F) Frequent use of the guide pins ensures parallelism of the implant placement. (G) After placement
of two Nobelpharma implants, the cover screws are placed. The cover screws should be flush with the rest of
the ridge to minimize the chance of exposure. This is especially important if the patient will wear a partial
denture during the healing phase. (H) Suturing completed. Both regular interrupted and inverted mattress sutures
are used intermittently to ensure tension-free, tight closure of the flaps.
788 Part 4  Oral Implantology
Fig. 78.5  Sequence of drills used for standard-diameter (4-mm) implant
site osteotomy preparation: round, 2-mm twist, pilot, 3-mm twist, and
countersink. Bone tap (not shown here) is an optional drill that is sometimes
used in dense bone before implant placement.
ridge of the implant surgical sites (see Figs. 78.2B and 78.4C).
Elevated flaps may be sutured to the buccal mucosa or the opposing
teeth to keep the surgical site open during the surgery. The bone at
the implant site must be thoroughly debrided of all granulation tissue.
For a “knife-edge” alveolar process with sufficient alveolar bone
height and distance from vital structures (e.g., inferior alveolar nerve),
a large round bur is used to recontour or flatten the bone to provide a
wider, level surface for the implant site preparation (see Fig. 78.2B).
However, if the vertical height of the alveolar bone is limited (e.g.,
<10 mm), the knife-edge alveolar bone height should be preserved.
Bone augmentation procedures can be used to increase the ridge
width while preserving alveolar bone height (see Chapter 79).
Implant Site Preparation
Once the flaps are reflected and the bone is prepared (i.e., all granula-
tion tissue removed and knife-edge ridges flattened), the implant
osteotomy site can be prepared. A series of drills are used to prepare
the osteotomy site precisely and incrementally for an implant (Fig.
78.5). A surgical guide or stent is inserted, checked for proper
positioning, and used throughout the procedure to direct the proper
implant placement (see Fig. 78.4E).
Round Bur
A small round bur (or spiral drill) is used to make the initial penetration
into bone for the implant site. The surgical guide is removed, and
the initial marks are checked for their appropriate buccal-lingual
and mesial-distal location, as well as the positions relative to each
other and adjacent teeth (see Fig. 75.9). Slight modifications may
be necessary to adjust spatial relationships and to avoid minor ridge
defects. Any changes should be compared with the prosthetically
driven surgical guide positions. Each marked site is then prepared
to a depth of 1 to 2 mm with a round drill, breaking through the
cortical bone and creating a starting point for the 2-mm twist drill
(see Fig. 78.3A).
The 2-mm Twist Drill
A small twist drill, usually 2 mm in diameter and marked to indicate
various lengths (i.e., corresponding to the implant sizes), is used
next to establish the depth and align the long axis of the implant
recipient site (see Fig. 78.3B). This drill may be externally or internally
irrigated. In either case, the twist drill is used at a speed of approxi-
mately 800 to 1500 rpm, with copious irrigation to prevent overheating
of the bone. Additionally, drills should be intermittently and repeatedly
“pumped” or pulled out of the osteotomy site while drilling to expose
them to the water coolant and to facilitate clearing bone debris from
the cutting surfaces. In other words, clinicians should pump the drill
(up and down) intermittently and avoid using a constant “push” of
the drill in the apical direction only.
When multiple implants are being placed next to one another, a
guide pin should be placed in the prepared sites to check alignment,
parallelism, and proper prosthetic spacing throughout the preparation
process (see Fig. 78.3C). The relationship to neighboring vital
structures (e.g., nerve and tooth roots) can be determined by taking
a periapical radiograph with a guide pin or radiographic marker in
the osteotomy site (see Fig. 76.15). Implants should be positioned
with approximately 3 mm between one another to ensure sufficient
space for interimplant bone and soft-tissue health and to facilitate
oral hygiene procedures. Therefore the initial marks should be sepa-
rated by at least 7 mm (center to center) for 4 mm standard-diameter
implants. Incrementally more space is needed for wide-diameter
implants (see Fig. 75.9).
The 2-mm twist drill is used to establish the final depth of the
osteotomy site corresponding to the length of each planned implant.
The clinician should also evaluate the bone quality (density) with
this drill while preparing the osteotomy to assess the need for
modifying subsequent drills used (Box 78.2). If the vertical height
of the bone was reduced during the initial ridge preparation, this
must be taken into account when preparing the site for a predetermined
implant length. For example, if it appears that the implant will be
too close to a vital structure, such as the inferior alveolar nerve
canal, the depth of the implant osteotomy site and length of the
implant may need to be reduced.
The next step is to use a series of drills to incrementally increase
the width of the osteotomy site to accommodate the planned implant
diameter. The styles, shapes, and final diameter of the drills will
differ slightly among different implant systems, but their general
purpose is to prepare a recipient site with a precise diameter (and
depth) for the selected implant without unduly traumatizing the
surrounding bone. It is important to use copious irrigation and a
“pumping” action for all drilling.
KEY FACT
A series of drills will be used (speeds determined by manufacturer)
sequentially to prepare osteotomy sites. It is essential to prepare sites
with copious irrigation to prevent overheating of the bone. Additionally,
drills should be intermittently and repeatedly “pumped” or pulled out of
the osteotomy site while drilling to expose them to the water coolant and
to facilitate clearing bone debris from the cutting surfaces.
Pilot Drill
Following the 2-mm twist drill, a pilot drill with a noncutting
2-mm–diameter “guide” at the apical end and a cutting 3-mm–diameter
(wider) midsection is used to enlarge the osteotomy site at the coronal
end, thus facilitating the insertion of the subsequent drill in the
sequence (see Fig. 78.3D).
The 3-mm Twist Drill
The final drill in the osteotomy site preparation for a standard-diameter
(4 mm) implant is the 3-mm twist drill. It is the last drill used to widen
the site along the entire depth of the osteotomy from the previous
diameter (2 mm) to final diameter (3 mm). This final drill in the

BOX 78.2  Clinical Advice to Enhance Precision of Final
Implant Site Preparation
Clinical Situation 1
If the final drill stops advancing in the apical direction before
reaching the desired depth, the added hand pressure necessary to
achieve the proper depth can cause wobbling and funneling of the
recipient site. This is especially true with “cannon” drills (used for
cylindrical implants). To minimize this effect, a smaller-diameter drill
should be used to prepare the site slightly deeper (e.g., 0.5 mm or
less). This narrower drill allows the desired depth to be reached
without affecting the side walls and facilitates a more precise
osteotomy preparation with the final drill. It is also important to use
drills that are sharp, especially for dense bone.
Clinical Situation 2
If the final drill is inserted at an inaccurate angle, the result is
funneling of the coronal portion of the implant site. To minimize this
potential problem, when drilling multiple implant sites, the operator
should always keep a direction indicator in an adjacent site. For
single-implant sites, the adjacent teeth and surgical guide should
serve as direction indicators. When dealing with dense bone, a
precise recipient site can be achieved more predictably if there is
minimal diameter change from drill to drill. For example, switching
from 3 to 5 mm is much less precise than proceeding from 3 to 3.3 to
4.2 to 5 mm.
Clinical Situation 3
If the bone is “soft” (e.g., loose trabecular bone), it may be
advantageous to underprepare the osteotomy site. A slightly
underprepared site can be accomplished by using the final drill to a
shallower depth than the previous drill (e.g., half the depth of the
osteotomy site). This avoids removing too much bone and increases
the implant stability or tightness at the time of placement. Another
method to achieve an underprepared site is to use a drill with a
slightly smaller diameter as the final drill in the preparation (e.g., a
2.75-mm drill as the final drill rather than a 3-mm or a 3.25-mm
version as the final drill for a 4-mm implant).
sequence finishes preparing the osteotomy site and consequently is
the step that dictates whether the implant will be stable or not (see
Fig. 78.3E). It is critically important that the final diameter drilling
be accomplished with a steady hand, without wobbling or changing
direction so that the site is not overprepared. Finally, depending on
bone density, the diameter of this final drill may be slightly increased
or decreased to enhance implant support (see Box 78.2).
Countersink Drill (Optional)
When it is desirable to place the cover screw at or slightly below
the crestal bone, countersink drilling is used to shape or flare the
crestal aspect of the osteotomy site allowing the coronal flare of the
implant head and cover screw to fit within the osteotomy site (see
Fig. 78.3F). As with all drills in the sequence, copious irrigation and
gentle surgical techniques are used.
Bone Tap (Optional)
As the final step in preparing the osteotomy site in dense cortical
bone, a tapping procedure may be necessary (not shown on Fig.
78.3). With self-tapping implants being almost universal, there is
less need for a tapping procedure in most sites. However, in dense
cortical bone or when placing longer implants into moderately dense
bone, it is prudent to tap the bone (create threads in the osteotomy
site) before implant placement to facilitate implant insertion and to
reduce the risk of implant binding (see Fig. 78.3G).
CHAPTER 78  Basic Implant Surgical Procedures 789
! CLINICAL CORRELATION
When faced with a very soft, poor-quality bone (e.g., loose trabecular
bone in the posterior maxilla), tapping is not necessary or recommended
(see Box 78.2). It is better to allow the threaded implant to “cut” its own
path into the osteotomy site.
Bone tapping and implant insertion are both done at very slow
speeds (e.g., 20 to 40 rpm). All other drills in the sequence are used
at higher speeds (800 to 1500 rpm).
It is important to create a recipient site that is accurate in size
and angulation. In partially edentulous cases, limited jaw opening
or proximity to adjacent teeth may prevent appropriate positioning
of the drills in posterior edentulous areas. In fact, implant therapy
may be contraindicated in some patients because of a lack of interoc-
clusal clearance, lack of interdental space, or a lack of access for
the instrumentation. Therefore a combination of longer drills and
shorter drills, with or without extensions, may be necessary. Anticipat-
ing these needs before surgery facilitates the procedure and improves
the results.
! CLINICAL CORRELATION
In areas with loose trabecular bone, such as the posterior maxilla, it may
not be necessary to tap the site. If bone is especially loose, it may be
beneficial to underprepare the site. For example, the final drill could be
omitted to increase the implant stability.
Implant Placement
Implants are inserted with a handpiece rotating at slow speeds (e.g.,
25 rpm) or by hand with a wrench. Insertion of the implant must
follow the same path or line as the osteotomy site. When multiple
implants are being placed, it is helpful to use guide pins in the other
sites to have a visual guide for the path of insertion.
Flap Closure and Suturing
Once the implants are inserted and the cover screws secured (see
Fig. 78.4G), the surgical sites should be thoroughly irrigated with
sterile saline to remove debris and clean the wound. Proper closure
of the flap over the implant is essential. One of the most important
aspects of flap management is achieving good approximation and
primary closure of the tissues in a tension-free manner (see Fig.
78.3H). This is achieved by incising the periosteum (innermost layer
of full-thickness flap), which is nonelastic. Once the periosteum is
released, the flap becomes very elastic and is able to be stretched
over the implant without tension. One suturing technique that
consistently provides the desired result is a combination of alternating
horizontal mattress and interrupted sutures (see Fig. 78.4H). Horizontal
mattress sutures evert the wound edges and approximate the inner,
connective tissue surfaces of the flap to facilitate closure and wound
healing. Interrupted sutures help to bring the wound edges together,
counterbalancing the eversion caused by the horizontal mattress
sutures.
The clinician should choose an appropriate suture for the given
patient and procedure. For patient management, it is sometimes
simpler to use a resorbable suture that does not require removal
during the postoperative visit (e.g., 4-0 chromic gut suture). However,
when moderate-to-severe postoperative swelling is anticipated, a
nonresorbable suture is recommended to maintain a longer closure
period (e.g., 4-0 monofilament suture). These sutures require removal
at a postoperative visit.
790 Part 4  Oral Implantology

middle of the keratinized tissue and full-thickness flap reflection can

Postoperative Care
Simple implant surgery in a healthy patient usually does not require
antibiotic therapy. However, antibiotics (e.g., amoxicillin, 500 mg
three times a day [tid]) can be prescribed if the surgery is extensive
or if the patient is medically compromised. Postoperative swelling
is likely after flap surgery. This is particularly true when the periosteum
has been incised (released). As a preventive measure, patients should
apply cold packs over the first 24 to 48 hours. Chlorhexidine gluconate
oral rinses can be prescribed to facilitate plaque control, especially
in the days after surgery when oral hygiene is typically poorer.
Adequate pain medication should be prescribed (e.g., ibuprofen, 600
to 800 mg tid).
Patients should be instructed to maintain a relatively soft diet
after surgery. Then, as healing progresses, they can gradually return
to a normal diet. Patients should also refrain from tobacco and alcohol
use after surgery. Provisional restorations, whether fixed or removable,
should be checked and adjusted to minimize trauma to the surgical
area.
be used to expose implants.
Partial-Thickness Repositioned Flap
If a minimal zone of keratinized tissue exists at the implant site, a
partial-thickness flap technique can be used to fulfill the objective
of the second-stage surgery (exposing the implant) while increasing
the width of keratinized tissue. The initial incision is made
within the zone of keratinized tissue so that it becomes the outer
edge of the reflected split-thickness flap. Vertical releasing incisions
are used on both the mesial and the distal end of the flap (Fig.
78.7A–B). A partial-thickness flap is then raised in such a manner
that a nonmobile, firm periosteum remains attached to the underlying
bone. The flap, containing a narrow band of keratinized tissue, is
then repositioned to the facial side of the emerging head of the
implant and sutured to the periosteum with a fine needle and resorbable
suture such as a 5-0 gut suture (Fig. 78.8). If the initial amount of
keratinized tissue is less than 2 mm, the flap may be started at the
labial edge of the keratinized tissue allowing that zone to remain on

Second-Stage Exposure Surgery

For implants placed using a two-stage “submerged” protocol, a
second-stage exposure surgery is necessary. Box 78.3 lists the objec- BOX 78.3  Objectives of Second-Stage Implant Surgery
tives for second-stage implant exposure surgery. The need for a zone
1. To expose the submerged implant without damaging the
of keratinized tissue surrounding implants is desirable, as one
surrounding bone
long-term study indicated that the presence of keratinized tissue is
2. To control the thickness of the soft tissue surrounding the implant
strongly correlated with soft- and hard-tissue health.2
3. To preserve or create attached keratinized tissue around the
implant
Simple Circular “Punch” or Crestal Incision
4. To facilitate oral hygiene
In areas with sufficient zones of keratinized tissue, the gingiva covering 5. To ensure proper abutment seating
the head of the implant can be exposed with a circular or “punch”
6. To preserve soft-tissue aesthetics
incision (Fig. 78.6). Alternatively, a crestal incision through the

A B

C D
Fig. 78.6  Clinical view of second-stage implant exposure surgery in a case with adequate keratinized tissue.
(A) Simple circular “punch” incision used to expose implant when sufficient keratinized tissue is present around
the implant. (B) Implant exposed. (C) Healing abutment attached. (D) Final restoration in place, achieving an
aesthetic result with a good zone of keratinized tissue.
 CHAPTER 78  Basic Implant Surgical Procedures 791

A B C

D E F

G H
Fig. 78.7  Clinical view of second-stage implant exposure surgery in a case with inadequate keratinized
tissue. (A) Two endosseous implants were placed 4 months previously and are ready to be exposed. Note the
narrow band of keratinized tissue. (B) Two vertical incisions are connected by crestal incision. If facial keratinized
tissue is insufficient, it is necessary to locate the crestal incision more lingually so that there is at least 2 to
3 mm of keratinized band. (C) Buccal partial-thickness flap is sutured to the periosteum apical to the emerging
implants. (D) Gingival tissue coronal to the cover screws is excised using the gingivectomy technique. (E) Cover
screws are removed, and heads of the implants are cleared. (F) Abutments are placed. Visual inspection ensures
intimate contact between the abutments and the implants. (G) Healing at 2 to 3 weeks after second-stage
surgery. (H) Four months after the final restoration. Note the healthy band of keratinized attached gingiva around
the implants.

A B C
Fig. 78.8  Illustration depicting the use of a split-thickness flap that is repositioned to the labial surface to
preserve and increase the amount of keratinized tissue. (A) Partial-thickness flap is created from the lingual
aspect of the crest toward the labial surface to preserve the keratinized tissue on the crest (over the implant).
Note: This tissue might be excised in a simple implant exposure. (B) The split-thickness flap is repositioned to
the labial surface. (C) The flap is sutured to the periosteum at a more apical position preserving the amount of
keratinized tissue (arrows). Finally, the remaining connective tissue over the cover screw (B) is excised with a
sharp blade to expose the implant. Care should be taken to avoid removing keratinized tissue from the lingual
aspect of the implant.
792 Part 4  Oral Implantology

the lingual aspect of the implant. A partial-thickness flap is apically

displaced and sutured to the periosteum without exposing the alveolar
bone (see Fig. 78.7C). A free gingival graft may be harvested from
the palate and sutured to the periosteum on the labial surface of the
implants to increase the zone of keratinized tissue (not shown).
After the flap is repositioned and secured with periosteal sutures,
the excess tissue coronal to the cover screw is excised, usually with
a surgical blade (see Fig. 78.8B). However, if removal of this tissue
would jeopardize the amount of remaining keratinized tissue around
the lingual aspect of the implant, a similar partial-thickness flap can
be elevated and repositioned on the lingual side as well. Extra care
must be taken when creating a split-thickness flap on the lingual
surface of mandibular sites because the tissue is often very thin.
A B
Alternatively, a full-thickness lingual flap will be safer and will serve
a similar purpose of preserving keratinized tissue on the lingual
surface of the implant.
A sharp blade is used to eliminate all tissues coronal to the cover
screw (see Fig. 78.7D). The cover screw is then removed, the head
of the implant is thoroughly cleaned of any soft- or hard-tissue
overgrowth, and the healing abutments or standard abutments are
placed on the implant (see Fig. 78.7E–F). The fit of the healing
abutments to the implants can often be visually evaluated. However,
if it is not possible to visualize clearly the intimate connection between
the implant and the abutment, an intraoral periapical x-ray film should
be taken to confirm complete seating. Bone may need to be removed C D
around the top of the implant to get the abutment to seat properly. Fig. 78.9  Tissue management for a one-stage implant placement. (A)
Readers are referred to online material for a discussion of bone Crestal incision made along the crest of the ridge, bisecting the existing
profiling. zone of keratinized mucosa. (B) Full-thickness flap is raised buccally and
lingually to the level of the mucogingival junction. A narrow, sharp ridge
can be surgically reduced or contoured to provide a reasonably flat bed for
KEY FACT the implant. (C) Implant is placed in the prepared osteotomy site. (D) Tissues
are adapted around the neck of the implant to achieve flap closure with
In sites with limited keratinized tissue, a partial-thickness flap can be the implant protruding through the soft tissues.
utilized to preserve and reposition the keratinized tissue. A partial-thickness
flap is apically displaced and sutured to the periosteum. In cases without
keratinized tissue, a free gingival graft may be harvested from the palate initial implant support, the implants are left to heal undisturbed for
and sutured to the periosteum on the labial surface of the implants to a period of 2 to 4 months, whereas in areas of loose trabecular bone,
increase the zone of keratinized tissue. grafted sites, or minimal implant support, they may be allowed to
heal for periods of 4 to 6 months or more).
In the one-stage surgical approach, the implant or the healing
Postoperative Care abutment protrudes approximately 2 to 3 mm from the bone crest,
Once the implant is exposed and soft tissues are sutured, it is important and the flaps are adapted around the implant/abutment. As with the
to remind the patient of the need for good oral hygiene around the second-stage surgical procedures described, the soft tissues may
implant and adjacent teeth. Care should be taken during oral hygiene be thinned, repositioned, or augmented at the implant placement
procedures to avoid dislodging any repositioned or grafted soft tissues. surgery to increase the zone of keratinized tissue surrounding the
Direct pressure or movement directed toward the soft tissue from a implant.
provisional prosthesis can delay healing and should be avoided.
Tissues should be monitored regularly, and the provisional prosthesis Flap Design, Incisions, and Elevation
should be adjusted as needed. Impressions for the final prosthesis The flap design for the one-stage surgical approach is always a
fabrication can begin about 2 to 6 weeks after implant exposure crestal incision bisecting the existing keratinized tissue (see Fig.
surgery, depending on healing and maturation of soft tissues. Fig. 78.9). Vertical incisions may be needed at one or both ends to facilitate
78.7 (parts G and H) shows the postoperative results in a clinical access to the bone or osteotomy site. Tissues can be thinned in
case after 2 to 3 weeks and 4 months, respectively. posterior areas if desired but are generally not thinned in anterior
aesthetic areas. Full-thickness flaps are elevated facially and
lingually.
One-Stage “Nonsubmerged” Implant
Placement Implant Site Preparation
In the one-stage implant surgical approach, a second implant exposure Implant site preparation for the one-stage approach is identical in
surgery is not needed because the implant is exposed (per gingival) principle to the two-stage implant surgical approach. The primary
from the time of implant placement (Fig. 78.9). In the standard difference is that the coronal aspect of the implant or the healing
(classic) implant protocol, the implants are left unloaded and abutment (two-stage implant) is placed approximately 2 to 3 mm
undisturbed for a period similar to that for implants placed in the above the bone crest and the soft tissues are approximated around
two-stage approach (i.e., in areas with dense cortical bone and good the implant/implant abutment.
 CHAPTER 78  Basic Implant Surgical Procedures 793

Flap Closure and Suturing Conclusion

The keratinized edges of the flap are sutured with single interrupted
sutures around the implant. Depending on the clinician’s preference,
the wound may be sutured with resorbable or nonresorbable sutures.
When keratinized tissue is abundant, scalloping around the implant
provides better flap adaptation.
It is essential to understand and follow basic guidelines to predictably
achieve osseointegration. Fundamental protocols must be followed
for implant placement (stage one) and implant exposure surgery
(stage two). These fundamentals apply to all implant systems.

Postoperative Care
A Case Scenario is found on the companion website
The postoperative care for the one-stage surgical approach is similar
www.expertconsult.com.
to that for the two-stage surgical approach except that the cover
screw or healing abutment is exposed to the oral cavity. Patients are
advised to avoid chewing in the area of the implant. Prosthetic
appliances should not be used if direct chewing forces can be References
transmitted to the implant, particularly in the early healing period
(first 4 to 8 weeks). When removable prosthetic appliances are used, References for this chapter are found on the companion
website www.expertconsult.com.
they should be adequately relieved and a soft-tissue liner should be
applied.

CASE SCENARIO 78.1 
Patient:  60-year-old Hispanic female
Chief Complaint:  “I’m ready for my implant.”
Background Information
The patient has controlled hypertension. She is currently taking Atenolol.
She is a nonsmoker. Tooth #3 was extracted with socket preservation 1
year ago. A sinus lift/bone augmentation procedure was completed 4
months after extraction due to a limited (4-mm) vertical height of
CASE-BASED QUESTIONS
1. You plan to place a 5 × 10 mm implant in site #3. How should the
osteotomy be prepared?
A. Overprepare the osteotomy site by using a 5-mm drill as the
final drill.
B. Complete the osteotomy site with a 4-mm drill, but perform
bone tapping to facilitate implant insertion.
C. Underprepare the osteotomy site by using a 3.75-mm drill as the
final drill.
D. Prepare the osteotomy site with reduced speeds (< 800 rpm) to
avoid overheating the bone.
2. Which of the following promotes bone-to-implant contact?
A. Machined surface implant
B. Roughened surface implant
C. Bone-level implant
D. Tissue-level implant
3. If the patient did not have adequate keratinized tissue, when could
soft tissue augmentation be performed?
A. Prior to implant placement
B. During the second stage of the procedure
C. Following delivery of final prosthesis
D. All of the above
CHAPTER 78  Basic Implant Surgical Procedures 793.e1
native bone. Now, 8 months later, the patient presents for implant
placement.
Current Findings:  Generalized healthy gingiva with history of moderate
chronic periodontitis. Edentulous site #3 has adequate ridge width,
mesial-distal dimension, and interocclusal space. There is a good zone of
keratinized, attached tissue. Cone beam computed tomography (CBCT)
scan reveals good healing and consolidation of bone grafted sinus. The
native bone is type 3, with a loose trabecular pattern.
SOLUTIONS AND EXPLANATIONS
Answer: C
Explanation: The posterior maxilla has softer, loose trabecular bone,
which reduces bone-to-implant contact. Overpreparing the osteotomy
will remove an unnecessary amount of bone, making it more difficult to
achieve primary implant stability. Bone tapping should only be
performed in dense cortical bone. Additionally, osteotomy sites should
be prepared at 800 to 1500 rpm with a pumping motion and copious
water irrigation to prevent overheating the bone.
Answer: B
Explanation: Implants with roughened surface topography (e.g.,
sandblasted or acid etched) increase the surface area of the implant to
promote increased implant-to-bone contact and may result in shorter
healing time.
Answer: D
Explanation: Soft tissue augmentation can be performed at any time.
However, the need for bone augmentation prior to or during implant
placement may dictate that a free gingival graft be performed first to
provide adequate keratinized tissue for flap management and suturing.
793.e2 Part 4  Oral Implantology
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