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The Final (And Most Difficult?) Step in Implant Placement: The Restoration

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Surgical placement of the dental implant is a complicated procedure and is often seen as the most difficult step in the implant to restoration process. A poorly placed implant not only significantly increases the likelihood of failure, but, assuming the implant does integrate, will also make the restoration difficult depending on angulation, location gingival margins and integrity of the bone.

For these reasons, an argument can be made that the most difficult step in the dental implant process is the restoration itself. As restorative dentists we are forced to work with what we are given after healing of the area(s) is complete. We have all encountered situations where the implant is too far to the buccal or lingual, too close to an adjacent tooth, there is a lack of interocclusal clearance, or we have to restore an implant where the threads are showing because it was not placed fully within the alveolus.

Because of these difficulties and our desire to ideally restore poorly and well-placed implants, many improvements have been made over time to make it easier to go from the implant to the final restoration. The consensus still remains it is best to avoid immediate loading of the implant to lessen the likelihood of failure, but advancements are being made to aid in integration, reducing the time it takes to get to completion. This will be discussed in a future blog.

Final impression protocols have remained fairly similar over the years regardless of the restoration using either an open or closed tray technique. Assuming we are placing an abutment supported crown, bridge or denture, once we produce a model with the analog(s) in place we can either use a stock abutment(s) or have custom abutment(s) made in the laboratory to support the restoration. The dozens of abutments available from every manufacturer of different collar height, width, angle and material have made it much easier to fabricate the final prosthetic.

Once the abutment is prepared and ready for placement in the mouth, I prefer to torque it in place and take a traditional crown and bridge impression of the final impression for the implant supported denture. Some prefer to have the abutment and crown fabricated together in the lab and seated at the same time. As with everything we do, it comes down to personal preference and the relationship with the lab. 

The implant supported denture is a wonderful service we can provide for our edentulous patients. Due to its great retention, patients are very seldom displeased.  The implant supported crown or bridge is a great alternative to a conventional bridge, and the only downside is hearing patients complain it takes too long to get the final restoration in place! 

The abutment supported crowns and bridges quickly replaced the original UCLA abutments because of superior esthetics. However, many restorative dentists began to notice a localized gingival inflammation around some cement-retained implant restorations. Research determined there are many situations where cement used to retain the final restoration became lodged subgingivally and, in many cases, led to significant periodontal issues and sometimes loss of the implant as well. For this reason, dentistry is moving back to the UCLA abutment, particularly by researchers funded by Nobel Biocare.

Regardless of the technique used to go from the implant to the final product, implant manufacturers are making it easier for us to fabricate very esthetic, healthy and functional restorations. This has allowed us to preserve adjacent teeth by preventing conventional bridge preparations while significantly improving  the quality of life for our edentulous patients.

Sean Grady, DDS, is a member of the Dental Product Shopper evaluator team and owns and operates a private practice, Grady Dental Care, in Johns Creek, Georgia.  Click here to join our team of product evaluators. 

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