Prosthetic Aspects of Dental

Implants
 CONTENTS
 Treatment planning for implant restorations
 Basic restorative techniques
 Terminologies used in implant prosthesis
 Impression materials and components
 Impression procedures for edentulous patient , partially edentulous
patients
 Screw retained & Cemented restorations
 Aesthetic in dental implants
 References
 Treatment planning for implant
restorations

 Types of implant restoration

 Planning considerations
 Provisional restorations
 Treatment order
 Type of implant restoration
 • Fixed bridges
 • Overdentures
 • Single tooth restorations
 Planning considerations

 • Functional and aesthetic considerations

 • Evaluation of the edentulous ridge
 • Study casts and diagnostic set-ups
 • Implant numbers and spacing
 Study casts and diagnostic set-
ups
 Determines the number and position of the teeth to be
replaced and their occlusal relationship with the opposing
dentition.

 Temporary restoration

 Can be used to construct a stent or guide & surgical

placement of the implants

 The stent/guide can be positioned on the original cast and

with reference to the radiographs - decide upon the optimum
location, number, and type of implants.
 Provisional restorations

 It helps to establish the design of the final reconstruction

and is used by the patient throughout the treatment stages.
• Complete denture
• Partial denture
• Adhesive bridgework
• Fixed bridgework
Basic restorative techniques
 Provisional restorations
 • Abutment selection
 • Seating the abutment
 • Impression making
 • Laboratory techniques
 • Jaw relation registration
 • Try-in appointment
 • Framework try-in
 • Restoration insertion
 • Follow-up appointment
 Terminologies used in implant
prosthesis
 Parts of in implant

 Body or fixture

 Abutments

 Superstructure
An impression - transfer the position and design of the implant
or abutment to a master cast for prosthesis fabrication.

 FIXTURE –
Pure titanium with machined threads .
The top of the fixture has hexagonal design &
threads ..

 COVER SCREW- seals the coronal

potion of fixture during the interim period.
 Cover Screw is placed after stage 1
surgery into the top of the implant
to prevent bone, soft tissue, and
debris from invading the abutment
connecting area during healing.

Healing cap is placed to facilitate retention

of the surgical dressing after suturing
 Permucosal extension or healing
abutment - Extends the implant
above the soft tissue and results in
the development of permucosal seal
around the implant, placed after
stage 2 surgery for soft tissue
healing.

 Transfer coping : It is used to position an analog in

an impression and is defined by the portion of the
implant it transfers to the master cast, either the
implant body transfer coping or the abutment
transfer coping.
 Abutment is the portion of the implant

that supports or retains prosthesis or

the superstructure

Superstructure is defined as a metal

framework that fits the implant

abutment and provides retention for a

removable prosthesis
 Three categories of implant
abutment
 1. An abutment for screw retention

 2. An abutment for cement retention

 3. An abutment for attachment

 An indirect transfer coping uses an Reseating

impression material requiring elastic

properties.

 It is screwed into the implant or the

abutment body and remains in place when the

set impression is removed from the mouth.

 It is parallel sided or slightly tapered to allow

ease in removal.
 A direct transfer coping
Pick up
 Consists of a hollow transfer
component often square, and a
long central screw to secure it to
the abutment or implant body and
may be used as the pick up
impression coping.

 It takes advantage of impression

materials having rigid properties
and eliminate the error of
permanent deformation because
they remain within the impression
until the master model is poured
and separated.
 An implant analog is used in the fabrication of master cast to
replicate the retentive portion of the implant body or abutment.
(implant body analog, abutment body analog)

 After the master impression is obtained, the corresponding analogs

attached to the transfer coping and the assembly is poured in stone to
fabricate he master cast.
Prosthetic coping is a thin covering usually designed to fit the
abutment screw retention and serve as connection between the
abutment and prosthesis or superstructure.

 1. Remove the surgical pack.

 2. Unscrew the healing caps.
 3. Remove any remaining sutures

 4. Using radiographs, check if implants are

correctly placed.
 Abutment selection
 The abutment extends through the gingiva into the oral
cavity and it provides the support for the restoration.
 The simplest abutment is a titanium parallel sided cylinder
that extends from the implant head through into the oral
cavity by 1–2 mm.
 From the top of this cylinder, bridgework can be made
linking the abutments together
 In recent years the number of abutments available for
all implant systems has dramatically and confusingly
increased.

The main types are:

 • Single tooth abutments
 • Fixed bridgework abutments
 • Overdenture abutments
 Seating the abutment
 It is essential that full seating is ensured and as the abutment-
implant junction is commonly subgingival, checking with an
intra-oral radiograph may be needed.

 When full seating has been verified, the abutment screw can be
tightened to the manufacturer’s recommended level of force using
a torque wrench.

 When the level of torque force needed is high it is advisable to

hold the abutment with a counter-torque device.

 Plastic healing caps are available to cover the abutments once

they have been placed and the provisional restoration will need to
be adjusted to accommodate the additional components
 Impression Making
 The aim of an impression for implant restorations is to record the
implant positions in a master working cast.

 Many techniques …. …no consensus on any one way of making

the impression,

 Impression materials should be resilient enough to be removed

from undercuts without distortion & rigid enough to allow for
accurate seating of components into the impression and to
prevent movement of components during pouring of the
impression in dental stone

 Primary - irreversible hydrocolloid (alginate) in a stock tray.

 Extensive cases - custom tray

Few important points to remember for Imp Materials

 Greatest accuracy occurs if impression is poured immediately

 Polyether absorbs water so should not be stored in this
medium.
 Addition silicones are very stable
 Greatest dimensional change is seen with condensation
silicones
 Polysulfides shrink drastically after 24 hours
 Least amount of dimension changes occurs in addition
silicones and polyethers, so these should be used for final
impression.
Impression procedures for
Edentulous patient
 Remove the healing caps with the
internal hexagon screw driver.

 Rinse off debris and clean the

area around abutment.

 Place the tapered impression

copings using the frictional fit
screw driver.
 Select the appropriate size stock tray
normally used for natural dentition .

 The edentulous stock trays do not

provide space for impression copings.

 Make alginate impression

 Inspect the impression for accurate

reproduction of impression copings
and rinse saliva from the impression
 Connect abutment replicas to
each tapered impression copings

 Slip each replica coping unit into

the impression

 Use gentle vibration when

pouring the impression.
 Recover the cast and remove the
impression copings

 Completed diagnostic cast

 Connect the square impression

copings with the medium or long
length guide pins
 Block out the impression copings
with two thickness of base plate
wax.

 Be certain to leave the heads of the

guide pins exposed

 Lubricate the cast and adapt tray

resin on the cast
 Make a full arch custom tray and
leave the heads of the guide pins
exposed

 Enlarge the guide pin access holes

to approximately 5.0mm in
diameter.

 Finish the tray borders.

 Remove the healing caps and
connect the square impression
coping with medium guide pins.

 Try in the tray to verify intraorally.

 Inject impression material around

each impression coping and
surrounding tissues.
 Fill the impression tray with
remaining impression material.

 Seat the tray intraorally and wipe

excess impression material to
expose the guide pins.

 Inspect the impression for

accuracy and check for
impression material between
impression copings and abutment
cylinders.
 Connect abutment replicas to
each impression coping

 Bead the impression

 After completing the second

pour and the stone has set,
unscrew the guide pins.
 Separate the cast from the
impression

 Trim and complete the master

cast.
 During the nextappointment, using individual

custom trays with wax rims, the definitive

intermaxillary relationship determined..

 Face-bow transfer

 Articulator
 Impression technique for
implant supported over denture
 The base of the tissue borne over denture should be as large

as possible within the functional and anatomical limitations

to optimize the distribution of the occlusal forces.

 There are several methods for making impression to obtain

a master cast for fabrication of the overdentures.

Single impression technique
Double impression technique
 The metal superstructure is first
constructed and then secured in position
intraorally and a final impression is
made. The superstructure is reproduced
in stone in the master cast.
 This requires two impressions;
 One that transfers the position of either
the abutments or the implants to a
working cast and a final impression for
the fabrication of the prosthesis itself
There are two different method available to record
abutment impression

 Pick up impression coping technique at abutment

level

 Reseating technique.
 The pick-up implant impression
 Open faced impression tray- allows access to a
retaining screw that secures the impression coping to
the implant.
 The retaining screw must extend 2–3 mm above the
impression tray opening
 Impression material in injected around the impression
copings first and then the tray is seated in the mouth.
 After the impression material has set and before
removing the tray, the retaining screw is unscrewed
leaving the pick-up impression coping inside the
impression.
 The implant laboratory replica is then attached to the
coping before pouring the impression with dental stone
 Pick up impression coping
technique at abutment level
The re-seating impression coping
 Is used with a conventional impression tray
and syringing technique and the coping
remains in place on the implant after the
impression material has set and the
impression removed from the mouth
 The transfer coping is then unscrewed from
the implant and attached to the laboratory
replica outside the mouth and the
coping/replica is re-inserted into the
impression before pouring with dental stone.
 This technique is useful in clinical situations
where there is limited space to allow for
screwdrivers to undo the long retaining
screws of the pick-up technique
Single tooth impressions
Single tooth impression can be divided into

 Implant head

 Abutment level impression

 Impression of Implant head

 Most implant system provides a

premachined impression coping for
recording an impression of the head
of the implant.

 This is usually made up of two

pieces; the impression coping and
the guide pin. The impression coping
seats directly on to the implant head
and is retained with the guide pin.
 A polymeric standard stock tray
may be used and modified so that
the guide pin projects beyond the
adjacent teeth through he
impression tray.
 When set, the guide screw is
loosened and the impression tray is
removed from the mouth with the
coping picked up in the impression.
A working impression of the implant at a fixture level may
be taken for one of the three reasons

 1. To delay the decision on the type and size of the

abutment after the construction of the master model.
 2. To provide a master impression for constructing a one
piece prosthesis designed to fit directly on the Implants
 3. To construct a master cast for the use of prepable
abutments or custom made abutments
 Laboratory techniques
 Same as for conventional prosthodontic treatment.

 Casts are made - an accurate fit of the abutment

 Implant supported bridges can either be made using

conventional metal ceramic techniques or using denture
teeth set in acrylic resin
 Jaw relation registration

 Conventional jaw relation records are made for single

tooth and short span bridgework.

 The same principles for establishing occlusal plane,

freeway space and recording the retruded position are
applied - with the advantage that bases for occlusal rims
can be secured firmly to the abutments

 Articulator or face bow

 Try-in appointment
 From the records of the previous appointment the
laboratory are able to fabricate a try-in using
acrylic teeth set onto the resin bar or by waxing
up the entire set-up
 To check the appearance and occlusion as well as
phonetics and cleansibility of the final restoration.
 Single tooth restoration and short span bridges are
normally produced directly from the impression
stage and do not require try-in appointments.
 Occlusion
 For single tooth restorations or limited span bridges,
occlusal contacts need to be examined in light and heavy
contact.

 Full contact under initial occlusal contact- possibly be

overloaded.

 It is important that the restoration is not totally out of

occlusion - uncontrolled over eruption

 In the completely edentulous patients, implant retained

dentures should follow conventional occlusal concepts of
bilateral balanced or lingualised occlusion.
 Framework try-in

 For long span bridges it is important that the final

framework is tried in the mouth before the final fit
appointment. It is desirable to have a perfect passive fit of
the framework onto the abutments
 Restoration insertion

 Acrylic or porcelain can produce stress within the

framework which may effect fit ………

- procedures for framework try-in should therefore

be repeated to check the final fit.

 The occlusion and appearance need to be checked and the

patient given appropriate oral hygiene instruction.

 Screw retained or cement retained

 CEMENTATION
Temporary Cement
Luting consistency
Superstructure – supraocclusion
deflective occlusal
contact
affects stability
 Esthetics and Implant prosthesis

Crown form, dimension ,shape & gingival harmony – not

ideal

Smile line
Gingival discrepancy
Loss of papilla
Alveolar ridge defect
 Lab considerations
 Master cast considerations – authors recommend imp at
implant level & carrying out abutment selection on master
cast

Soft tissue topography can be directly transferred

The tissue collapses or expands depending on transfer
copings used

Transfer copings that are more accurate should be used for

aesthetic areas
Preparation of individual
abutment
 Abutment should be selected on master cast depending on
bone level, angulation of implant to crown, & size of
tooth that need to be replaced
 Finish lines can be subgingival or supragingival
 Ceramic abutments – more aesthetic appearance
 Suprastructure – PFM – std for implant supported
prosthesis
 Esthetic management of patients
in transitional phases:
Stage I –
 Following stage I – patients often
object to the lack of esthetics from
not wearing their removable
appliance for the initial healing
period

 In maxillary arch it may be

advantageous to place denture
immediately following surgery.
The relined denture can act as
surgical compression stent and
stabilize the flap post-operatively
 Single tooth replacement

transitional acrylic resin RPD

transitional fixed restoration –

bonded to adjacent natural teeth

or replacement tooth may be
luted on to orthodontic band
during the integration phase.
 Stage II: Provisional fixed bridge work has
many advantages when used after stage II
surgical procedure.

 Helps to evaluate the esthetics, tooth position,

lip support, pontic location, vertical
dimension and control gingival margin prior
to construction of final restoration.

 It prevents tissue growth over the abutment

and prevents debris accumulation in the area
of abutment retaining screw
 Provides patient with a degree of psychologic confidence.

 Oral hygiene procedure can be reinitiated at early stage.

 After stage II healing:

 Soft tissue around abutment in the stage 2 postoperative

period can recede

 At this point additional procedure can be carried out e.g.

tissue contouring / augmentation.
 Soft tissue management:

 Gingival graft augmentation

 Gingival papilla reconstruction

  improving esthetics in patients in patients with a
high smile line
 providing support for the lip profile of a “caved in”
upper lip
 improving speech and phonetics
 preventing food impaction

 Fabricate - an individual, custom tray must - finished bridge is

repositioned on the master model.
 Aeas to be captured in the impression`, i.e., facial aspect -
blocked out with wax.
 A minimum of three points (incisal stops) should contact the
tray to ensure its secure seating with the bridge.
 Ideally the impression will reproduce 3\4 of the circumference
of each implant post.
 On the master model obtained from the custom impression,
the margins of the desired gingival epithesis are marked
•Gingiva colored ceramics – if augmentation measures
are CI, small alveolar def & missing papilla can be
constructed by restorative measures.

•All ceramic gingival masks – local alveolar ridge

defect
Impression is made, custom tray – medium viscosity
polyether – color of gingiva determined by shade gide-
leucite reinforced glass ceramic is used.
•Gingival prosthesis- soft silicone material – they can be
fixed to the restoration with precision attachment
 Gingival prostheses
 Fixed or removable
 Acrylics, composite resins, silicones or porcelain-based
materials.
 Undercuts or dental attachments are used to secure
 References
Color atlas and text of – dental and maxillofacial implantology
mosby-wolfe John A Hobkrick, Roger M Watson

BDJ 1999

Dental implant prosthetics" Mosby. Carl E. Misch

“Dental implants the art and science” W.B. Saunder

Charles Babbush

“Implant dentistry” 2nd edition, Mosby. Carl E. Misch

Implants in dentistry. Saunders Michael, John Kent ,Luis

Introducing dental implants Churchill Livingstone John A

Hobkrick Roger M Watson