IMPLANT DESIGN CONSIDERATIONS

To achieve not only predictable osseointegration but also a functional and

esthetic restoration, each implant system needs to have nine essential
design features. Each characteristic and its purpose are explained in detail
in this article.

1.Implant Material

Fig. 1

Gold, carbon, titanium and zirconia have been utilized as implant material.
Titanium (Fig.1, right) has proven to be the choice of material due to
excellent biocompatibility and strength properties. Titanium is produced
in different grades of purity and  in some cases alloyed with other metals
to enhance material properties. Manufacturers use different grades of
titanium for their implants. Grade 5 (Ti-6Al-4V) titanium is 78% stronger
than its next weaker Grade 4 cousin. 

2.Outside Thread Design

Fig. 2

Proper implant design should allow for a high primary stability in the
receptor site to facilitate osseointegration. The tighter the implant surface is
in contact with the bone at the time of placement the more predictable its
success will be. Early versions of implants (Calcitek®, Spline) were
produced without outside thread pattern (Fig.2, left) by some implant
manufacturers. This design quickly fell out of favor due to a reduced BIC
(Bone to Implant Contact) and primary stability concerns. Modern implants
are designed with a outside thread pattern in various configurations.
 Fig. 3

The thread geometry itself may be designed as a common V-thread (Fig.3,

"A", Zimmer®, Tapered Screw-Vent), trapezoid (Fig.3, "B", NobelActive™),
square (FIG.3, "C", BioHorizons®) or buttress (Fig.3, "D", Straumann®)
profile. Each manufacturer can produce scientific studies supporting their
preferred thread geometry in regards to stress distribution capabilities and
cutting efficiency.

Fig. 4

Threads may be machined as a single (Fig.4, "A", BioHorizons®, external

hex), double (Fig.4, "B", Implant Direct™, Legacy™) or triple lead thread
(Fig.4, "C", Zimmer®, Screw-Vent). This feature has no bearing on
osseointegration, BIC or stress distribution. It simply increases the speed at
which the implant is driven in to the osteotomy at the time of insertion.

Thread pitch is the distance from the crest of one thread to the next. The
smaller the thread pitch (Fig.1, right) the greater the number of threads and
the greater the surface area of the implant. More threads equal better
stress distribution and greater primary stability.

Fig. 5

Thread depth can be even along the length of the implant or vary. A
diminishing or non existing thread depth (Fig.5, left) towards the apical of
the implant will reduce its self tapping capability and potentially diminish
primary stability compared to a deep thread implant (Fig.5, right) design
due to the reduced BIC.

3.Body Geometry

Fig. 6
The implant geometry (Fig.6) may be machined with a parallel, parallel with
a tapered apex or tapered body. A parallel body geometry provides the
greatest surface area and stress distribution while a tapered body may be
more suitable in situations with limited apical space due to anatomical
constraints, but sacrifices surfaces area. Parallel body implants with a
tapered apex try to bridge the advantages and disadvantages of purely
parallel and tapered implant geometries.

4.Surface Treatment

Fig. 7

To further enhance osseointegration, the outer surface of the implant that is

in direct contact with the surrounding bone should be roughened to
increase the surface area. Resorbable media blasting followed by acid
etching (Fig.7, center) are currently the most common modes of surface
roughening. Some implants are titanium (TPS) or hydroxylapatite
(HA) plasma sprayed (Fig.7, right). Both intended to aid osseointegration.
HA and TPS coated implants are mostly used in poor quality bone such as
type D4 bone.

5.Implant Length

Fig. 8

Implants are offered in several lengths (Fig.8). 5mm implants are currently
the shortest implants on the market while Biomet 3i™ offers the longest at
20mm, excluding zygoma implants. The longer the implant the greater the
surface area and stress distribution. Length beyond 15mm has little
beneficial effect.

6.Implant Diameter
 Fig. 9

Choice of Implant diameter (Fig.9) is a important factor in stress distribution

and greater surface area. The BioHorizon® Laser-Lok®3.0 implant is
currently the smallest three component (implant, abutment, screw) implant
system on the market while the 8mm Rescue® implant from MegaGen is
the widest. Different platform diameters will allow for a more suitable
emergence profile congruent with the tooth to be replaced. A Diameter
greater than 6mm may be detrimental due to a stress shielding effect.

If all the above criteria are met within an implant system, the chances for
successful and predictable osseointegration are significantly increased. But
osseointegration alone does not portend a predictable, long lasting and
functional prosthesis. For a successful restoration after osseointegration, it
is also important to look at factors that have a favorable influence on the
fabrication, delivery, function, esthetics and maintenance of the final
restoration.

7.Abutment Indexing

Fig. 10

The implant should have a built in indexing design such as an external or

internal hex at the connecting surface to the abutment. Indexing aides in
proper implant position registration and transfer through impression taking
to restoration fabrication and delivery of the prosthesis. An internal indexing
design is favored because the screw head of the abutment screw can be
designed to seat closer to the head of the implant (Fig.10, right). Effectively
lowering the stack height of the components and allowing greater freedom
in abutment design and favorable stress distribution from
prosthesis/abutment to the implant. A internal indexing feature can be
designed with a grater length (up to 1.5mm) as compared to a external
indexing feature (up to 1mm). The greater length of the indexing feature
gives not only better tactile feed back when seating the
abutment/restoration but also provides greater torsional resistance.
8.Abutment Screw

Fig. 11

A removable and replaceable abutment screw (Fig.11) that holds the

abutment securely connected to the head of the implant is a design
necessity because of potential future screw failure. A screw down
connection design will also allow for a simplified disassembly in case of
prosthesis failure or prosthesis design changes in the future. Screws are
implant brand specific and may vary in design and torque requirements
from implant diameter to implant diameter within a given brand and
abutment material. The majority of fixation screws are torqued
to 30Ncm and up. Screw heads are designed for various tool connections
from square (Robertson) to multiple hex dimensions and more recent
Torx™ (hexalobular) configurations. Some manufacturers plate their
screws with gold (Biomet 3i™), titanium nitride (Keystone) or carbon (Nobel
Biocare™) to reduce friction during the torque procedures, effectively
increasing pre-loading of the screw.

9.Abutment Material

Fig. 12

Abutments (Fig.12) should be produced a wide variety of styles and

materials: straight, angled, different collar height, lengths, emergence
profile diameters and UCLA type to allow the greatest freedom and choice
to create the most ideal and cost effective abutment for the most ideal
restoration even in a less than perfect implant placement situation.
Abutment material choice has become an important factor because of
consumer demand for high esthetics and "metal free" restorations. A
implant system that offers abutments manufactured out of titanium and
zirconia will meet the demands of even the most discerning patient.
Zirconia abutments may be produced with a friction fit or pre-bonded
titanium implant interface and as a through and through zirconia abutment.
Smaller (3.3mm to 3.5mm) implant/abutment interface (platform) diameter
zirconia abutments may only be suitable for small, single anterior
restorations due to strength concerns.

To summarize the most important elements, titanium grade, screw thread

design, roughened surface, geometry, choice of length, several diameters,
indexing, separate and replaceable 30N-cm abutment screw, the ability to
manufacture custom abutments out of titanium and zirconia can lead to a
more predictable and highly esthetic final restoration. Additional features
may improve implant and component handling and are discussed in
the expanded design article.

EXPANDED DESIGN CONSIDERATIONS

To further augment the basic features, we can add nice to have but not
necessary features.  Local (within one hour driving distance) manufacturer
representatives can be a great resource on technical issues and be
physically in the office to lend a hand in the beginning when the surgeon is
getting used to the handling of the implant system. This is a great value
since the representative can showcase all the features, essentially
accelerating your learning curve significantly.

1. Platform switching

Fig. 1

This is a much debated feature/benefit with scant scientific evidence

(Lazzara RJ, Porter SS, Int J Periodontics Restorative Dent. 2006 Feb;26
(1):9-17) but copious favorable field reports. The abutment platform is
designed, on purpose or accident, smaller than the implant platform (Fig.1
left). Resulting in less initial bone atrophy around the implant and in some
instances bone growth over the implant post implant insertion. One theory
is the medialised movement of the micro gap between implant and
abutment results in a decreased bacteria proximity to bone cells since the
micro gap can act as a bacteria harbor. No scientific studies have been
undertaken to define key factors on what dimensions qualify as platform
switching and benefits. How many millimeters wide should the medialised
junction between abutment and implant be? Does the platform have to be
perpendicular to the long axis of the implant or can it be sloping and what
angle of slope is acceptable?

2.Multi use coping

A feature that can save a significant amount of money and cut down on the
multitude of parts needed is a fixture mount or implant carrier that comes
pre attached to the implant body that can also be used as an impression
coping and final abutment.

3.Solid zirconia abutment

To maximize the versatility and esthetics of zirconia abutments the

connecting interface of the abutment should have no metal reinforcement
pre bonded to the abutment. A through and through zirconia abutment is
therefore more desirable because this will allow the technician to bake
porcelain directly to the abutment to create a more ideal emergence profile
or fabricate a all ceramic screw retained restoration.

4.Color coding

Color coding of the actual components makes for easy identification and
can substantially reduce the risk of part mix ups and resulting remakes.