The Basics of Implant Dentistry with Alfred Nelson

According to Thomas D. Taylor, DDS, MSD, an estimated 1.5% of teeth are replaced with dental implants. The other 98.5% are replaced with conventional prosthodontic methods. Based on his 75-minute lecture on  "The Basics of Implant Dentistry," Certified Dental Technician (CDT) and Manager of our Amsterdam Division, Alfred Nelson clearly defines key terminology, sequencing of processes, and shares the best practices for implementation in this article.

Dental implant mapping

​WHO IS ALFRED NELSON?

Alfred Nelson, CDT, owned and operated the prestigious Amsterdam Dental Lab of Philadelphia, PA for 50 years. He’s cultivated a reputation in the dental community by creating premium, high-quality restorations with a strong concentration in implant dentistry. A name synonymous with quality in implant dentistry, Amsterdam Dental Lab has been at the forefront of our industry, setting the benchmark for cutting-edge innovation. He now spearheads and manages Amsterdam Dental Lab as a division of The Dental Lab specializing in premium in-house restorations. With an extensive career as a Lab Owner and Implant Specialist, Al has lectured internationally, been published in the top peer-reviewed journals such as Practical Periodontics and Aesthetic Dentistry (PPAD) and Journal of International Relations and Development  (JIRD), held a faculty position at the University of Pennsylvania and assisted in product development for some of the leading brands in dentistry like Zimmer Biomet.

Dental implant

​GLOSSARY FOR KEY TERMINOLOGY

• Dental implant - a tooth root replacement made of titanium.
  
• Titanium - the main metal from which implants are made. It is a strong, lightweight, and highly corrosion-resistant metal element.
  
• Abutment - a component that replaces the coronal portion of the tooth. The prosthesis is attached to this.
  
• Screw - a component that holds an abutment to the implant.
  
• Single-stage surgery - the surgical placement of an implant leaving the healing screw or healing abutment exposed eliminating the need for a second surgery.
  
• Second-stage surgery - surgery following implant placement involving the uncovering of implants and placement of healing abutments
  
• Impression coping - a component used to record the position of an implant or abutment with an impression.
  
• Transfer impression coping- an impression coping that is transferred back to the impression as it does not pull in the impression.
  
• Pick-up impression coping - an impression coping that is picked up in the impression as it is removed from the mouth.
  
• Implant platform - the interface or coronal surface of the implant

Color-coded implant platforms

• Driver - an instrument that places the screw or abutment.
• Torque - a turning or twisting force.
• Torque driver - a driver that can deliver specified amounts of torque.
• Newton Centimeter (Ncm) - the measurement unit of torque. For implant restorations, the range is usually 10-35 Ncm
• Laboratory analog - a replica of the implant for laboratory use.
• Attachment - the component that functions by attaching a denture to an abutment or bar.
  Soft tissue cast - a master model with soft artificial “gums.”
• Connection - the structural mechanism of connecting the abutment to the implant. It can be external or internal.
• External hex - connection is on top of the platform, external to the implant body
  Internal connection - connection is inside of the implant body
• Collar height - the height from the platform up to the functioning portion of an abutment.
  

4mm, 2mm, 2mm, 3mm collar heights

4mm, 2mm, 2mm, 3mm collar heights

​TYPES OF ABUTMENTS

Healing abutments are used to provide a path from the implant through the tissue during healing. Its roles are to shape and tighten the gum tissue and prevent food or bacteria from settling around the implant. They are available as a one-piece, two-piece, encode, or custom. One-piece healing abutments connect into a dental implant without an additional retaining screw. Two-piece healing abutments are comprised of an internal bore and a second component that attaches to the first on the exterior surface. Encode abutments are a type of healing abutment from Zimmer Biomet that have markings that allow them to be used in place of an impression coping or a scan body. Lastly, custom healing abutments can be designed to make up for offset or angled implant placement while preserving the anatomical shape.

Moreover, temporary abutments take the form of performance posts or temporary cylinders. They are used for the fabrication of an interim restoration. They aid in healing the surrounding tissue while providing an attachment point for the dental implant. They may be removed for a permanent abutment to take its place.

Restorative abutments are components between the implant and the definitive restoration that  provides retention, support, stability, and optimal positioning. They can be secured through cementation or be screw-retained. 

A pre-fabricated abutment is a final abutment that is attached to the implant via a screw. The final prosthesis is then attached to the abutment. A hexed UCLA abutment is a type of pre-fabricated abutment that engages implant hex and has a tactile “click” finger feature with 4four robust fingers for maintaining the “click” after casting. The abutment is loaded into the crown and placed in the implant. Once the fingers “click” into place, the crown is removed, leaving the abutment attached to the implant

Pre-angled abutments correct angulation and restore proper restorative contours. They are used when implants are not parallel to adjacent teeth or contiguous implants. They also offer 12 potential positions due to the 12-point internal connection. 

Lastly, a Locator® abutment is an overdenture abutment indicated for 2-4 implants. They are designed to be used with overdentures or partial dentures retained by implants in the mandible or maxilla. 

Locator overdenture abutment collar heights

HOW TO WORK UP A CASE

Cases begin with a patient interview, followed by a series of exams and evaluations before diagnostic casts and wax-ups can be made. Then, implant surgical guides are mapped, fabricated, and presented in the treatment plan.

1. The patient interview must cover the chief complaint and go over the history of the complaint.
2. Examinations and evaluations are performed. A dental examination is conducted to assess the presence and condition of the teeth as well as the condition of the residual ridges. A periodontal examination is done to assess probing, attachment, and mobility. An occlusal exam, temporomandibular (TMJ) exam, and soft tissue evaluation are performed. A radiographic evaluation is done using periapical radiographs, panoramic radiographs, or computed tomography (CT) scans. Based on the assessments, the restorative dentist will prioritize implant placement, implant prosthetic platform, soft tissue availability, occlusion, temporization options, treatment time, and abutment selection when it comes to diagnostics.
3. Diagnostic casts and wax-ups are fabricated. With a focus on evaluating interocclusal distance, the restorative dentist will communicate to the patient what the final restoration will look like using the construction of radiographic and surgical stents.
4. ​Mapping and fabrication of the implant placement guides are done. The implant surgical guide is the only way to communicate the desired position of the dental implant to the surgeon.  If there is no guide, then the restorative dentist has no say in the position of the implant. Implant surgical guides allow for ideal implant placement, which in turn allows for ideal restoration. Mapping can predictably place multiple implants side by side if the appropriate amount of distance is present between them and have an interdental papilla. The treatment plan should allow for 3mm between dental implants and 1.5mm between dental implants and teeth to enable blood supply and biologic width.
5. The treatment plan is presented to discuss the plan, the treatment sequence, and fees. This is also the time to obtain consent for the treatment.

Diameter driven treatment planning: maxilla

Diameter driven treatment planning: mandible

​SEQUENCING FOR A PARTIAL EDENTULISM CASE

1. Consultation and gathering of diagnostic information.
2. The second consultation consists of the treatment plan presentation and scheduling of appointments.
3. Preparation of the patient for implant placement. Provisional restorations are created if needed. The surgical guide for dental implants is created and the mouth is prepared with restorative dentistry, orthodontics if needed, or grafting if not to be done at the time of implant placement.
4. The implant is placed. Healing times depend on the bone. Good quality bone allows for immediate to 8-week loading. Fair bones heal in about 8 to 12 weeks. Poor bone or grafts take 4 to 6 months to heal. Provisional restoration if needed is placed.
5. During the restorative phase, the implant impression is made in about an hour. In the laboratory, the abutment type is selected and the restoration is created.
6. The delivery phase takes place 2 to 4 weeks after the impression. The abutment is placed and the patient is radiographed before the screw is torqued to place. The occlusion and interdental contacts are then evaluated. Finally, the restoration is cemented.
7. During the maintenance phase, prophylaxis and bruxism appliances are used.

Diagnostic wax up

Implant placement guide

Surgical guide in CAD/CAM software

Surgical guide in CAD/CAM software

​WHAT IS A HIDDEN IMPLANT PATIENT?

Any patient with a beating heart is a potential implant patient. Edentulism is a major public health problem and it fulfills the World Health Organization's (WHO) definition of a physical impairment because important body parts have been lost. It also fulfills the WHO’s definition of a disability because two important body functions have been lost.

The McGill Consensus Statement on Overdentures states that as a minimal treatment objective on the mandibular, two-implant overdentures are the first choice standard of care for edentulous patients.

Patients with a single edentulous space that are missing anterior or posterior teeth have the option of replacing that space with fixed partial dentures. They can be done with one or two crowns and an implant.

Single edentulous space

Patients with multiple edentulous spaces can undergo tooth for tooth replacements. Implants can be used to restore individual teeth and to restore a fixed partial denture. Removable partial dentures can also be replaced with implants.

Completely edentulous patients have a variety of treatment options that will enable the preservation of the bone and soft tissue while restoring their confidence in their prosthetics. Options that require two implants include Locator®, O-ring, and Dal-Ro. Four implants can be used for bar-supported overdentures, such as distal extension ERA or bredent attachments. Five or more implants can support fixed implant overdentures like spark erosion prostheses and bone-anchored bars.

Patients with retained deciduous teeth or congenitally missing secondary teeth can have the mesial-distal diameter of the tooth reduced to match that of a secondary premolar.

Multiple edentulous spaces

Congenitally missing premolar

​Patients treated with crowns and bridges, or patients with endodontically-treated teeth are able to replace fixed partial dentures with crowns and replace missing teeth with implants, or they can extract teeth with failing root canal treatments and replace them with dental implants rather than treat them with apicoectomy.

Patients with periodontal disease can also be ideal for dental implants. Periodontal disease must be treated and controlled and occlusal relationships must be stable. For teeth with questionable or poor prognoses, implants should be discussed as a definitive treatment option.

Implant-supported overdenture

HOW TO TALK TO PATIENTS ABOUT IMPLANTS

Make implants the standard of care. Implants should be discussed in all situations with all patients. They should be understood by front office personnel, assistants, and hygienists as patients often hear of implants before the doctor ever sees them. 

Do not speak of fees until the patient fully understands the benefits of implant dentistry and don’t be concerned with insurance regarding implants - or any dental treatment. It’s wrong to diagnose the patient’s wallet or to allow insurance to dictate treatment. The present doctor should also not make any financial arrangements. Compromising treatment under any circumstances should not be done.

​HOW CAN THE DENTAL LAB HELP?

The Dental Lab is a full-service dental laboratory specializing in implant restorations. With over 35 years of experience plus Al’s expertise, The Dental Lab is a powerhouse for restorative products and services. Call us today to learn more information at 215-293-9760.

Sources:
Healing Abutment Care
Some issues related to evidence-based implantology
Temporary Abutment

Keywords:
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