Implant Restorations: A Step–by–Step Guide, Third Edition offers clinicians a practical, step–by–step approach to treatment planning and restoring dental implants. This highly illustrated, case–based book demonstrates how to treat the most commonly encountered treatment scenarios by describing the procedures, techniques, and sequences required in clear, concise language and in an easy–to–use format. The book takes the theory of implant restoration, using as its basis two different implant systems, and places it directly in the operatory, concentrating in detail on each stage of the actual clinical procedures involved in treating different patients. It integrates implant treatment with the realities of running a successful restorative practice. Building on the work of the second edition, the third edition of this successful text reflects the advances of implant prosthetics over the intervening years, providing new cases, exploring new techniques and technology, and demonstrating updated system components and armamentarium.
Implant Restorations: A Step–by–Step Guide follows a logical structure of three sections. The first section introduces implant restorative dentistry, how to develop an implant restorative practice, the issues involved, and the technical components of two different implant systems, diagnosis, and treatment planning. The central section of the book devotes separate chapters to in–depth descriptions of several types of patients that the restorative dentist may encounter, ranging from basic to more challenging cases. Every step of each procedure is described and illustrated with clinical photographs. Laboratory work orders are presented for use with commercial dental laboratories. The final section discusses record–keeping, patient compliance, hygiene regimes and follow–up, and provides the reader with an outline of best–practice procedural protocols.
An excellent and accessible guide on the most burgeoning subject in modern dental practice by one of its most experienced clinicians, Implant Restorations: A Step–by–Step Guide, Third Edition will appeal to prosthodontists, general dentists, implant surgeons, dental students, dental assistants, hygienists, and dental laboratory technicians.
Key Features
- Step–by–step format for quick and clear reference
- Highly illustrated with full color throughout
- Focuses on the practical aspects of actual clinical procedures
- Profiles several common basic and more advanced cases in a simple, concise, and straightforward manner
- Advises on procedural protocols, treatment planning, and sequencing
- Includes single–unit and implant–supported denture prostheses
Table of Contents
Contributors xiii
Foreword xv
Acknowledgments xvii
1 Introduction to Implant Dentistry 1
Introduction 1
Purpose of Textbook 1
Economics of Implant Dentistry 2
Predictability of Fixed Prosthodontics 2
Development of Prognosis for Teeth: Extract or Maintain 4
The Heavily Restored Tooth 4
The Furcation–Involved Tooth 5
The Periodontal–Prosthesis Patient 6
Difficult Aesthetic Cases 8
Development of Prognosis for the Dentition 11
Summary 13
2 Implants and Implant Restorative Components 17
Introduction 17
Implants 17
Implant/Abutment Connections 20
External Implant/Abutment Connections 20
Internal Implant/Abutment Connections 22
Healing Abutments 25
EP® Healing Abutments 25
CADCAM Healing Abutments 27
Impression Copings 30
Implant Impression Copings 30
Pickup Impression Copings 31
Transfer Impression Copings 32
Abutment Impression Copings 32
Abutments 33
Standard Abutments 33
Locat or® Overdenture Abutments 34
DIEM® Immediate Occlusal Loading (IOL®) Abutments 34
GingiHue® Posts 34
ZiReal® Posts 36
UCLA Abutments 38
CADCAM Abutments (BellaTek Laboratory Designed Abutments) 40
Multiunit Abutments 44
Screws (Clinical) 46
Cylinders 47
Definitive Cylinders 47
DIEM® Immediate Occlusal Loading Abutment Cylinders 47
Interim Cylinders 48
DIEM® Immediate Occlusal Loading
Abutment Temporary Cylinders (Biomet 3i) 48
Temporary Coping Multiunit Titanium Cylinders (Nobel Biocare) 49
Drivers and Placement Instruments 49
Large Hex Drivers 49
Large Hex Driver Tips 50
Square Drivers 50
Square Driver Tips 51
Abutment Drivers 51
Abutment Driver Tips 51
Laboratory Components 51
Implant Analogs 52
Abutment Analogs 52
Try–In Screws 53
Abutment Holders 54
3 Diagnosis and Treatment Planning in Implant Restorative Dentistry 57
Patient Selection 57
Medical History 58
Diagnostic Procedures 58
Radiographs 58
CT Scans 59
Diagnostic Casts 62
Physical Examination 63
Extraoral Examination 63
Intraoral Examination 64
Diagnostic Articulator Mounting 65
Diagnostic Wax Patterns 65
Surgical Guides 66
Implant Bone Volume 67
Implant Restorative Volume 69
Treatment Planning 72
Edentulous Patients 73
Overdentures 73
Fixed Hybrid Implant–Retained Prostheses–Edentulous Mandible 75
Fixed Hybrid Implant–Retained Prostheses–Edentulous Maxillae 76
Partially Edentulous Patients 77
Treatment Goals 78
Screw–Retained Restorations 79
Cement–Retained Restorations 81
Implant Loading Protocols 81
Two–Stage Surgical Protocol 81
Single–Stage Surgical Protocol 83
Early Loading 83
Immediate Occlusal Loading 84
Immediate Nonocclusal Loading 84
Patient Consultation 85
Principles 85
Informed Consent 85
Implant Coordinators 85
Summary 86
4 Treatment of a Patient with an Edentulous Mandible Implant–Retained Bar Overdenture and Resilient Attachments 91
Literature Review 91
Clinical Case Presentation 97
Appointment 1: Initial Examination (1 Hour) 97
Radiographs 97
Physical Examination 98
Diagnostic Casts 98
Diagnosis 99
Appointment 2: Consultation Restorative Dentist/Patient (3/4 Hour) 99
Treatment Options 100
Appointment 3: Consultation Restorative Dentist/Surgeon (1/2 Hour) 100
Prosthesis Design 100
Type/Number/Size of Implants 100
Implant/Abutment Connection 100
Surgical Guide 100
Surgical Protocol 101
Healing Abutment Selection 101
Implant Restorative Wish List 101
Appointment 4: Implant Placement (1 Hour) 101
One–/Two–Stage Surgical Protocol 101
Appointments 5 and 6: Follow–Up
Appointments (1/2 Hour Each) 104
Tissue Conditioning 104
Appointment 7: Implant–Level Impression (1 Hour) 105
Pickup Implant Impression Copings 106
Definitive Border–Molded Impression 106
Laboratory Work Order/Procedures 107
Appointment 8: Jaw Relation Records and Tooth Selection (1/2 Hour) 109
Clinical Procedures 109
Laboratory Procedures 110
Appointment 9: Wax Try–In (1 Hour) 111
Clinical Procedures 111
Evaluation of Jaw Relation Records 112
Patient Approval 112
Fabrication of CADCAM Framework for Mandibular Bar–Retained Overdenture 112
Virtual Design of Framework 117
Milled Framework 117
Laboratory Evaluation of Framework/Master Cast Fit 118
Appointment 10: Framework Try–In (3/4 Hour) 118
Clinical One–Screw Test 119
Appointment 11: Insertion (1 Hour) 120
Insert Bar 120
Torque Abutment Screws 120
Insert Mandibular Overdenture and Maxillary Complete Denture 120
Occlusion 121
Postinsertion Instructions 121
Follow–Up Appointments 122
One–Year Follow–Up Appointment 122
Costs/Fees/Profitability 122
5 Treatment of a Patient with a Partially Edentulous Mandible Using Intraoral Scanning (IOS) of a CADCAM Healing Abutment 125
Literature Review 125
Replacement of Individual Teeth 125
Single–Unit Implant Restorations 127
Computer–Aided Design/Computer–Aided Manufacturing (CADCAM) Healing Abutments 128
Intraoral Scanning 134
Models from Digital Impressions 135
Clinical Case Presentation 135
Appointment 1: Initial Examination (3/4 Hour) 135
Diagnostic Casts 136
Diagnoses 136
Appointment 2: Consultation Restorative Dentist/Patient (1/2 Hour) 136
Treatment Options 137
Appointment 3: Consultation Restorative Dentist/Surgeon (1/2 Hour) 139
Type/Size of Implant 139
Abutment/Prosthesis Design 139
Implant/Abutment Connection 140
Surgical Protocol 141
Healing Abutment Selection 141
Implant Restorative Wish List 141
Appointment 4: Extraction and Implant Placement (1 Hour) 141
Extraction and immediate implant placement protocol 141
CADCAM Healing Abutment Placement 141
Appointment 5: Restorative Follow–Up Appointments (1/4 1/2 Hour) [10 days; 4 weeks; 8 weeks] 142
Appointment 6: Reevaluation and Determination of Impression Date (1/2 Hour) 142
Appointment 7: CADCAM Healing Abutment Scan (Restorative Office) (1/2 Hour) 142
Clinical Procedures 142
Laboratory Procedures 143
Appointment 8: CADCAM Abutment and All–Ceramic Crown Insertion Appointment (3/4 Hour) 143
Abutment Placement 143
Radiographic Verification and Crown Try–In 144
Torque 144
Cementation 145
Appointment 9: Follow–Up Appointments 148
1 Week/6 Months 148
1–Year Recall Clinical and Radiographic Evaluation 149
6 Retreatment of a Patient with a Fractured Implant–Retained Fixed Partial Denture in the Posterior Maxilla–CADCAM Abutments and a New Fixed Partial Denture (Cement Retained) 151
Literature Review 151
Clinical Case Presentation 156
Appointment 1: Initial Examination (3/4 Hour) 156
Diagnostic Casts 156
Diagnosis 156
Appointment 2: Consultation Restorative Dentist/Patient (1/2 Hour) 157
Treatment Options 157
Laboratory Procedures 157
Appointment 3: Removal of Existing Prosthesis/Abutments; Implant Impression (1 Hour) 158
Implant–Level Impression 158
Laboratory Procedures/Work Orders 159
Appointment 4: Bisque Bake Try–In (3/4 Hour) 163
Removal of Preexisting Prosthesis and Abutments 163
Try–In CADCAM Abutments 163
Try–In Bisque Bake FPD 163
Appointment 5: Insertion Appointment (3/4 Hour) 165
Removal of Preexisting Abutments and Fixed Partial Denture 165
CADCAM Abutment Placement 166
Torque 166
Fixed Partial Denture Cementation 167
Appointment 6: Follow–Up Appointments (1/2 Hour) 167
2 Weeks/6 Months 167
1–Year Recall Clinical and Radiographic Evaluations 168
Costs/Fees/Profitability 170
7 Accelerated Treatment Protocol of a Patient with Edentulous Jaws and CADCAM Titanium
Framework/Fixed Hybrid Prostheses 173
Literature Review 173
Original Treatment Protocol 175
Accelerated Treatment Protocol 177
Clinical Case Presentation 4 Months Post Extractions, Implant Placement, and Immediate Occlusal Loading 177
Appointment 1: Evaluate Aesthetics, Jaw Relation Records, Abutment–Level Impressions (3 Hours) 177
Radiographic Examination (CBCT) 177
Extraoral Physical Evaluation 177
Intraoral Physical Examination 177
Clinical Assessment 177
Jaw Relation Records 179
Removal of Interim Prostheses/Alginate Impressions for Diagnostic Casts 179
Assess Implant/Abutment Stability and Clinical Osseointegration 179
Abutment–Level Impressions 181
Articulator Mountings 183
NobelProcera® Protocol for CADCAM Titanium Frameworks 191
Biomet 3i Protocol for CADCAM Titanium Frameworks 191
CAD for the Maxillary and Mandibular Frameworks 194
Laboratory Evaluation of CADCAM Frameworks 195
Denture Setup on CADCAM Frameworks 197
Appointment 2: CADCAM Framework, Wax Try–In, Verification of Jaw Relation Records, and Aesthetics (1 Hour) 198
Clinical One–Screw Test 199
Verification of Jaw Relation Records and Aesthetics 199
Laboratory Procedures 200
Appointment 3: Insertion of Definitive, Screw–Retained Hybrid Prostheses (1 Hour) 201
Torque Abutment Screws 202
Occlusion 202
Oral Hygiene Instructions 202
Appointments 4 and 5: Prosthetic Follow–Up Appointments: 1 Week and 6 Months (1/2 Hour Each) 203
Appointment 6: One–Year Recall with Radiographs (1 Hour) 204
Radiographic Evaluation 204
Clinical Examination 205
Future Recall Appointments 205
8 Treatment of a Patient with an Edentulous Mandible with an Immediate Occlusal Loading Protocol (DIEM® 2) 209
Literature Review 209
Introduction 209
The Preosseointegration Era 210
The Osseointegration Era 211
Immediate Occlusal Loading in the Edentulous Mandible 212
Immediate Occlusal Loading in Edentulous Maxillae 213
DIEM® Protocol 214
DIEM®2 Protocol 215
Clinical Case Presentation 216
Appointment 1: Initial Examination 216
Chief Complaint 216
Radiographs 216
Physical Examination 217
Diagnoses 218
Prognosis 219
Appointment 2: Consultation with Patient (1 Hour) 219
Treatment Options 219
Diagnostic Impressions 220
Appointment 3: Definitive Maxillary Impression and Jaw Relation Record (1 Hour) 220
Definitive Maxillary Complete Denture Impression 220
Articulator Mounting 222
Appointment 4: Wax Try–In (1/2 Hour) 222
Number/Size of Implants 222
Prosthesis Design 224
Implant/Abutment Connection 224
Laboratory Procedures/Work Orders for Processing Dentures 225
Surgical Work–Up and Protocol 226
Ball Clasps 226
Appointment 5: Preoperative Surgical Review Office Visit (1/2 Hour) 227
Appointment 6: Insertion of Maxillary Complete Denture, Mandibular Extractions, Alveolectomy,
and Implant Placement/Immediate Occlusal Loading for Mandibular Full–Arch Prosthesis 228
Surgical Protocol (2 Hours) 228
Surgical Guidelines for Immediate Occlusal Loading 230
Abutment Selection 234
Prosthetic Guidelines for Immediate Occlusal Loading 234
Postoperative Instructions 239
Appointment 7: Prosthetic Follow–Up Appointments (1/2 Hour) 239
24–Hour Follow–Up Appointment (1/2 Hour) 239
1–Week Follow–Up Appointment (1/2 Hour) 239
4–Week Follow–Up Appointment (1/2 Hour) 240
12–Week Follow–Up Appointment (1/2 Hour) 240
9 Treatment of an Edentulous Patient with an Accelerated Treatment Protocol and Immediate Occlusal Loading Protocol (All–on–4 ) 243
Literature Review 243
Clinical Case Presentation 245
Appointments 1 and 2: Initial Examination, Articulator Mounting, and Wax Try–In 245
Chief Complaint 245
History of the Present Illness 245
Radiographs (CT Scan) 245
Physical Examination 246
Diagnostic Casts, Articulator Mounting, and Diagnostic Wax Try–In 247
Diagnosis 250
Assessment 250
Treatment Options 251
Prognosis 251
Appointment 3: Consultation Restorative Dentist/Patient 252
Appointment 4: Consultation Prosthodontist/Surgeon 252
Number/Size of Implants 252
Prosthesis Design 253
Implant/Abutment Connection 254
Surgical Work–Up and Protocol 256
Laboratory Procedures for Processing the Maxillary and Mandibular Prostheses 256
Appointment 5: Implant/Prosthesis Placement 259
Maxillary Surgical Protocol 259
Maxillary Prosthetic Protocol 262
Mandibular Surgical Protocol 271
Mandibular Prosthetic Protocol 273
Postoperative Instructions 279
Prosthetic Follow–Up Appointments 280
1–Week Appointment 280
10 Immediate Nonocclusal Loading Provisional Restoration: Intraoral Scanning, CADCAM Abutment, and Definitive Restoration Maxillary Central Incisor 283
Literature Review 283
Clinical Case Presentation 286
Appointment 1: Initial Clinical Visit (3/4 Hour) 286
History of the Present Illness 286
Radiographs 286
Physical Examination 287
Diagnostic Casts 287
Surgical Guide 287
Diagnoses 288
Prognosis 288
Appointment 2: Consultation Restorative Dentist/Patient (1/2 Hour) 288
Appointment 3: Consultation Restorative Dentist/Surgeon (1/2 Hour) 288
Size and Type of Implant 288
Implant/Abutment Connection 291
Surgical Protocol 292
Interim Abutment 292
Implant Restorative Wish List 292
Appointment 4: Extraction, Implant, and Interim Abutment Placement (Surgical Office: 1 Hour) 292
Extraction and Implant Placement 292
Insertion Torque 293
Appointment 5: Restorative Appointment INOL Provisional Restoration (Same Day: 3/4 Hour) 293
Interim Abutment Placement 294
Abutment Preparation 294
Immediate Nonocclusal Loading Provisional crown (INOL–No Centric/Eccentric Contacts) 294
Dietary and Oral Hygiene Instructions 296
Appointment 6: Reevaluation Appointment 24 Hours (1/2 Hour) 297
History 297
Clinical Examination 297
Appointment 7: Reevaluation Appointment 2 Weeks (1/2 Hour) 297
History 297
Clinical Examination 297
Appointment 8: Reevaluation Appointment 10 Weeks (1/2 Hour) 297
History 297
Clinical Examination 297
Appointment 9: CADCAM Healing Abutment Impression (16 Weeks: 1 Hour) 298
History 298
Clinical Examination 298
Abutment Selection 298
Remove INOL Provisional Restoration/ Interim Abutment and Place CADCAM Healing Abutment 299
BellaTek Encode Healing Abutment Intra Oral Scan 300
Appointment 10: CADCAM Abutment and Crown Insertion (3/4 Hour) 303
Interim Abutment and Provisional Crown Removal 303
Definitive Abutment Placement 303
Radiographic Verification 304
Torque 304
Crown Try–In 304
Cementation 305
Postoperative Instructions 306
Appointment 11: 2–Week Follow–Up Appointment (1/4 Hour) 306
11 Computed Tomography (CT)–Guided Surgery/Immediate Occlusal Loading with a Full–Arch Prosthesis in the Edentulous Mandible 309
Literature Review 309
Immediate Occlusal Loading 309
Tilted Implants 310
Diagnostic Imaging 310
Computed Tomography (CT) 313
Interactive Computed Tomography (ICT) 314
Interactive Computer Software 314
Computer–Guided Surgery 315
Overview of Ct–Guided Surgical and Prosthetic Protocols 316
Surgical Guides 316
Master Tubes 317
Prosthetic Laboratory Kit: Implant Analog Mounts 317
Surgical Kit Components 317
Fabrication of Master Cast for Immediate, Fixed Provisional Prosthesis 319
Abutment Selection for Fixed, Screw–Retained Provisional Prostheses 320
Fabrication of a Screw–Retained Provisional Prosthesis 321
Appointment 1: Clinical Patient Presentation 323
Preoperative Radiographs 324
Diagnosis 325
Assessment 325
Treatment Plan 326
Construction of Wax Dentures 326
Appointment 2: Clinical Try–In of the Wax Dentures 329
Fabrication of CT Scanning Appliance 330
Appointment 3: Intraoral Ct Scan and Treatment Plan 332
Fabrication of Master Cast with Implant Analogs 332
Laboratory Abutment Selection and Placement 335
Fabrication of Metal Framework for the Provisional Prosthesis 336
Fabrication of the Provisional Prosthesis 339
Appointment 4: Surgical and Prosthetic Treatment 342
Surgical Implant Placement 342
Clinical Abutment Placement 343
Insertion of Provisional Prosthesis 344
Appointment 5: Postoperative Visit 346
12 Review of Concepts for Designing and Fabricating Metal Implant Frameworks for Hybrid Implant Prostheses 349
Introduction 349
Historical Perspective 349
Original Framework Designs for Fixed Hybrid Prostheses 350
Passively Fitting Implant Frameworks 352
Prosthetic Complications Associated with Fixed Implant Frameworks 352
Physical Properties of Metals Used in Fixed Implant Frameworks 353
Cast Noble Alloys 353
Cast Base Metal Alloys 353
Milled Titanium Frameworks 353
Milled Zirconium Frameworks 353
Design Considerations 356
The Rationale For Cantilever Length 357
A/P Spread and the All–on–4 Protocol 358
Guidelines for Implant–Retained Hybrid Frameworks 358
Conclusions 359
Index 363
Authors
Carl Drago, DDS, MS, is a Diplomate of the American Board of Prosthodontics (ABP) and serves as the Clinical Science Editor of the Journal of Prosthodontics, the journal of the American College of Prosthodontists. His private practice near Milwaukee, WI, is limited to fixed, removable, and implant prosthodontics. Dr. Drago is the clinical director of Eon Clinics in Waukesha, WI and is an adjunct associate professor at the Marquette University School of Dentistry. He has held positions as Assistant Professor at the University of Texas Dental School at San Antonio and Associate Professor in the Department of Restorative and Prosthetic Dentistry at the Ohio State University College of Dentistry in Columbus, OH. He has published more than 75 papers on various subjects including laboratory and clinical procedures in conventional and implant prosthodontics. Dr. Drago has also written three textbooks on dental implants, including Implant Laboratory Procedures: A Step by Step Guide, published by Wiley Blackwell.
