DENTAL LEARNING Implant_(Nobel)CE WEB.pdf · dental implants, which offer excellent long-term...

Current Protocols forPosterior Single Implant-supported RestorationsScott MacLean, DDS, FADI, FACD, FICD, FPFA

Knowledge for Clinical Practice

WWW.DENTALLEARNING.NET

A PEER-REVIEWED PUBLICATIONA PEER-REVIEWED PUBLICATION

DENTAL LEARNINGVOLUME 4 | ISSUE 1

INSIDEEarn 2

CECredits

Written fordentists, hygienists

and assistants

Integrated Media Solutions Inc./DentalLearning.net is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental profession-als in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. Integrated Media Solutions Inc./DentalLearning.net designates this activity for 2 continuing education credits.

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement.2/1/2012 - 1/31/2016 Provider ID: # 346890AGD Subject Code: 690

Dental Learning, LLC is a Dental Board of California CE Provider. The California Provider # is RP5062. All of the infor-mation contained on this certi� cate is truthful and accurate. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type. This course meets the Dental Board of Califor-nia’s requirements for 2 units of continuing education. CA course code is 02-5062-15007.

DENTAL LEARNING www.dentallearning.net

EDUCATIONAL OBJECTIVES

The overall goal of this article is to provide the reader with information on posterior implant-supported restorations. After completing this article, the reader should be able to:

1. Describe anatomical and other considerations during implant treatment planning;

2. Review the use of software during implant treatment planning;3. List and describe aspects of implant design that affect primary

implant stability; and4. Delineate abutment and retention options and the evidence

for these.

Current options for posterior single implant-supported restora-tions allow for shorter treatment times and earlier restorative care for patients. For all protocols, careful treatment planning is critical, and is aided by the use of CT and/or CBCT imaging as well as software that helps the clinician with the identifi cation of relevant structures and with overall treatment planning. Primary implant stability, osseointegration, and soft-tissue contouring are all af-fected by the surgical phase, and soft tissues are affected by the restorative phase. Careful consideration should be given to these aspects for all stages of implant therapy.

ABSTRACT

Treatment options for the replacement of missing teeth have expanded substantially since the introduction of modern, root-form endosseous

dental implants, which offer excellent long-term out-comes with suitable case selection and clinical care. The standard protocol 2 decades ago for all indications required that implants were only placed in healed sockets (ridges) and submerged to remain undisturbed during osseointegration (two-stage surgical technique). Since then, implants have been developed and protocols evaluated that offer more rapid and less invasive treat-ment without compromise or possibly even with im-provements by becoming less invasive and more precise.

Current protocols for posterior single implantsCurrent protocols for posterior single implants include

immediate, early, or delayed implant placement relative

SPONSOR/PROVIDER: This is a Dental Learning, LLC continuing education activity. COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from NOBEL BIOCARE. DESIGNATION STATEMENTS: Dental Learning, LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dental Learning, LLC designates this activity for 2 CE credits. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2012 - 1/31/2016. Provider ID: # 346890. EDUCATIONAL METHODS: This course is a self-instructional journal and web activity. Information shared in this course is based on current information and evidence. REGISTRATION: The cost of this CE course is $29.00 for 2 CE credits. PUBLICATION DATE: February 2015. EXPIRA-TION DATE: January 2018. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, participants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most current information available from evidence-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the � eld related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Casey Warner, does not have a leadership or commercial inter-est in any products or services discussed in this educational activity. She can be reached at [email protected]. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/REFUND POLICY: Any participant who is not 100% satis� ed with this course can request a full refund by contacting Dental Learning, LLC, in writing. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected]. Go Green, Go Online to www.dentallearning.net take your course. © 2015

Current Protocols for

Posterior Single Implant-supported Restorations

ABOUT THE AUTHOR

Scott MacLean, DDS, FADI, FACD, FICD, FPFA - Dr. Scott MacLean is currently a part-time clinical profes-sor at the Dalhousie University Dental Clinic. He was involved with the "Implant Elective” and the “Advanced Restorative Elective" for over 10 years, and practices

general dentistry in Halifax, Nova Scotia, with a large component of his practice focused on implant and esthetic dentistry. He was recently calibrated as number one out of 60 participants in an international speakers training program and has published articles internationally on implant dentistry. Dr. MacLean is the director of the AIM4 Excel-lence Atlantic Canada Seattle Study Club. He is a member of the International Congress of Oral Implantologists (ICOI), the Canadian Academy of Restorative Prosthodontics (CARDP), the CAED, and the American Academy of Cosmetic Dentistry (AACD). He also has a YouTube following with a channel dedicated to implant dentistry called “The YouTube Dentist.” He is a Fellow of the Academy of Dentistry International, the Pierre Fauchard Academy, the International College of Dentists and the American College of Dentists. AUTHOR DISCLO-SURE: Dr. MacLean lectures for Nobel Biocare. He can be reached at Twitter@drscottmaclean.

CE EditorFIONA M. COLLINS

Managing EditorJULIE CULLEN

Creative DirectorMICHAEL HUBERT

Art DirectorMICHAEL MOLFETTO

Copyright 2015 by Dental Learning, LLC. No part of this publication may be reproduced or transmitted in any form without prewritten permission from the publisher.

500 Craig Road, Floor One, Manalapan, NJ 07726

DENTAL LEARNING

to the time of tooth removal; submerged two-stage proce-dures or one-stage procedures using a healing abutment and avoiding the second surgery (required to uncover submerged implants); and immediate, early, or delayed temporization and/or loading. Single, implant-supported posterior restora-tions offer high survival and success rates with these proto-cols when the individual case is carefully selected.

Treatment Planning for Posterior Dental ImplantsCase selection is important to avoid failures. There are

few systemic health contraindications to implant therapy, and research supports treatment in patients with diabetes mel-litus (unless uncontrolled), cardiac disease, or osteoporosis.1

Although smokers have been found to experience greater marginal bone loss than nonsmokers, smoking tobacco is also not considered a contraindication. A full medical history is es-sential to consider all potential absolute and relative contrain-dications. Local contraindications must be considered, includ-ing but not limited to anatomical structures, lack of bone, and parafunctional habits. Anatomical considerations are critical when planning mandibular and maxillary implants.

Mandibular ImplantsThe inferior alveolar nerve is the most critical anatomical

landmark, and poor treatment planning can result in iatro-genic nerve injury during implant placement with outcomes that include paresthesia, a complete absence of sensation, or pain. Although 2-dimensional radiographs have historically been used to assess anatomical structures and bone prior to implant placement, these cannot produce an accurate 3-dimensional assessment. Risk assessment using computer-ized tomography (CT scans) has shown that <6 mm of bone separated the inferior alveolar canal from teeth in 73% and 53% of mandibular second and fi rst molars respectively, and 65% of second bicuspids.2

The inferior alveolar canal including an anterior loop, as well as the position of the lingual and sublingual arteries, must be considered. Undercuts and/or anatomical concavities in the lingual area of the lower mandible may present a risk for lingual plate perforation.3 Based on CBCT (virtual) and

CT scan studies,2,4 the greatest risk is at mandibular second molar sites and at least three times greater than other poste-rior sites. It is important for the clinician to understand the relative position of arteries such as the submental artery to avoid very rare but important-to-understand complications.A small proportion of the population has an incisive branch of the mental nerve. This should be isolated on CT and dis-cussed with the patient prior to surgery. Lastly, posterior ridge resorption has implications for the fi nal occlusion in addition to increasing the risk to anatomical structures—as the ridge resorbs, it typically leads to a crossbite setup, especially if maxillary ridge resorption also occurs.

It is generally recommended that a minimum of 2 mm of bone height be preserved as a safety margin between the inferior alveolar nerve on the one end and between both the site preparation drilling and the implant on the other.3 If this would not be possible, alternatives include bone grafting and delayed implant placement, the use of short implants (or highly invasive specialist nerve repositioning), or provid-ing an alternative treatment.

Maxillary ImplantsThe most obvious anatomical landmark to consider is

the position of the maxillary sinus. This tends to pneuma-tize once the tooth has been extracted. If the sinus drops too much, then bone grafting may be required to provide adequate bone for primary implant stability. If bone grafting is required, it is prudent to assess the patency of the ostium (the entrance and exit point of the sinus entering into the middle meatus of the nasal cavity). Other areas of interest include the buccal undercut in the anterior maxilla; this area can be palpated or reviewed using 3D images to plan implant angulation and depth. Lastly, maxillary bone den-sity may be a concern. The bone has a thinner cortex and a larger spongy bone area than the mandible, which enhances blood supply to osteotomy sites but also may compromise the stability of the bone.

Treatment Planning, Anatomical Structures and SoftwareIn addition to CT/CBCT, digital dentistry is now improv-

Current Protocols for Posterior Single Implant-supported Restorations


4 VOLUME 4 | ISSUE 1

ing the diagnostic and planning phases of implant treatment. Software is available that guides clinicians through the whole treatment planning process after patient details and images have been uploaded. This software helps the clinician inspect the anatomy using panoramic views, 3-D digital reconstruc-tions of the arch, thin slices, and cross-sectional slices from any point along the arch. For example, mapping out the path of the inferior dental nerve using these tools leads to a more accurate understanding of its position as well as the mental foramen and mental nerve. In addition the software can now use a fusion technique to bring a digital scan of the wax-up and model into the CT/CBCT software to plan the implant placement based on the final prosthetics. This software can further produce a surgical template that enables the surgeon to place the implant at the ideal depth and angulation based on fusion of the X-ray and the model used in the planning process.

Bone Height, Width, and Length Besides maintaining adequate safety margins for structures

at risk of injury, ideally there should be 2 mm of bone on the buccal and lingual surfaces of the ridge and 1.5 mm of space from the implant to adjacent teeth (Table 1). In the absence of sufficient buccal and lingual ridge width, perforation of the plate may occur, the bony wall may be so thin that bone fenestration occurs post-placement, or implant positioning may not meet biologic width requirements and result in poor gingival form. (It may be necessary to do bone grafting many months prior to implant placement to have ideal width of bone around the implant.) Care also must be taken to ensure that the implant does not impact roots due to a general or lo-cal lack of mesio-distal width. A substantial lack of adequate

mesio-distal bone length may necessitate use of a narrow diameter implant or a different solution.

Implant Depth and Angulation It is important to pre-operatively determine implant

depth and angulation necessary to provide the inter-arch and intra-arch prosthetic space required for restoration and adequate long-term strength. Al though less critical in the posterior region, the distance from the proposed restorative contact point to the crestal bone should be considered. A distance of more than 5 mm results in poor papillary form.5,6 Implant angulation is determined by the best com-bination of safely utilizing available bone and soft tissue

Figure 1. Virtual implant superimposed in a 3-D view

Figure 2. Cross-sectional diagrammatic view

TABLE 1. Dimensional recommendations for implant and bone

Bone between implant and key anatomical structures At least 2 mm

Bone lingual to the implant At least 2 mm

Bone buccal to the implant At least 2 mm

Bone between implant and adjacent teeth At least 1.5 mm


5February 2015

relative to the planned tooth cervical emergence from the implant and axial trajectory toward the occlusal surface.

Nonsplinted implants should be placed such that they will be loaded axially over the implant body, as any angula-tion would be detrimental and magnify the forces on non-splinted implants. The position of the screw channel is also impacted by implant angulation. Ideally, the screw channel should be in the central fossa of a screw-retained crown. In addition, if the restoration will be cement-retained, it is desirable to have an abutment screw channel that could be accessed by cutting a channel through the implant crown if the abutment screw were to loosen.

With digital software, it is possible to view 3D models and cross-sections, showing the anatomical dimensions and angulation of an implant diagrammatically and virtually (Figures 1 and 2). Prosthetic planning can be enhanced by using "smart fusion" technology. Clinicians can now scan models and wax-ups of the patient’s arch in order to fuse these with a dicom-based CT scan. The fusion of the digital X-ray with the digital models shows the clinician the virtual problems and concerns prior to surgery, and the implant team can see the proposed relative position of the implant to the fi nal crown/bridge. This enables the planning team to place the implant so that the fi nal outcome is ideal based on both occlusion and bone volumes. Once the plan has been created, a stereolythic surgical template can be fabricated to aid placement of the implant in the ideal position, controlling both depth and angulation. During surgery the guide helps the surgeon place the implant in the position created on the planning software. Anatomical landmarks such as the nerve and sinus can be visualized using this technology.

Adjustments can be made in the software virtually until the optimal solution is found for a successful surgical and restorative outcome. Software also may allow the clinician to perform a “virtual extraction” and examine the shape and dimensions of the resulting “virtual socket.” Implants can then be virtually selected and placed in these sockets to determine implant size and suitable depth, bone height, width and vol-ume, and implant angulation.

Immediate vs Delayed Implant PlacementThree protocols regarding the timing of implant place-

ment relative to the occurrence of tooth extraction are sup-ported for posterior implants:

• Delayed implant placement, waiting 6 months for the alveolar ridge to completely heal

• Immediate-delayed implant placement, waiting 2 months post-extraction before implant placement

• Immediate implant placement at the time of tooth extraction.

In a 2010 Cochrane review, based on 2 randomized controlled clinical trials with implant in function for at least 1 year, no statistically signifi cant differences in failure rates, complications, peri-implant bone levels, or esthetic outcomes were found when comparing immediate versus delayed implant placement.7 A more recent review by Lang et al of 46 prospective studies with a mean follow-up of 2 years (minimum 1 year) estimated an average 2-year sur-vival rate of 98.4% (range 97.3% to 99%) and an average 97.5% 4-year survival rate (p<0.05) for immediately placed implants.8 These rates are similar to those observed with de-layed placement. Ridge preservation bone grafting has been recommended to help preserve the alveolar ridge following extractions in delayed placement cases, with some studies showing reduced alveolar bone loss in grafted vs nongrafted sites.9-11 For ridge preservation, bone grafting typically takes 5 months to heal prior to implant placement.

Immediate implant placement at the time of extraction reduces the number of surgical interventions, the length of time before the patient has a functional loaded implant, and reduces patient discomfort.12 It has been suggested that im-mediate implant placement reduces crestal bone loss. Based on a recent review of clinical trials, however, no statistically signifi cant differences in crestal bone levels were found in short-, medium-, or long-term follow-up studies.13

When a tooth is extracted, the implant is usually smaller and in a different position than the original tooth. For example, in the anterior the implant is placed in a lingual position leaving a buccal jump gap anterior to the implant. It has been recommended that this space be bone grafted to prevent collapse of the buccal plate. Bone grafting is recommended if the space between the implant and the socket wall is more than 2 mm.14 Whether immediate implant placement may help limit buccal mucosal recession



is debatable. Outcomes from available studies are mixed with findings of no statistically significant differences at 2 years,15 less recession buccally than lingually in a 5-year study,16 and conclusions from one review that there were no statistically significant differences long-term.13 Lee et al found a 0.5 mm to 1 mm reduction in vertical and horizon-tal bone 4 to 12 months after immediate implant place-ment, correlated to the thickness of the buccal plate.17

The Importance of BiotypeFacial mucosal recession was reported at a 2009 consen-

sus conference to be a greater risk with immediately placed implants, with risk factors including a thin biotype, thin or damaged facial bony wall, and positioning of the implant too far buccally.18,19 Crestal bone loss has been found to be greater where thinner buccal bone plate is present (≤1 mm) or where the jumping distance is ≤1 mm.20 There is some evidence that if the thickness of the mucosal tissue is <2.5 mm more bone loss is likely than with a thicker biotype. Linkevicius et al concluded in their study that thinner soft tissue at the crestal bone level significantly influences crestal bone stability, especially when <2 mm thick where >1 mm of crestal bone loss may then occur compared to thick biotype sites.21

Peri-apical Pathology Immediate implant placement in sites with peri-apical

pathology has historically been debated. In a recent review, it was determined that this is not a contraindication if the site is curetted prior to implant placement.22 Two separate large ret-rospective studies by Fugazzotto23 and Bell24 were conducted. Fugazzotto placed 418 implants in sites with peri-apical pa-thology with a 97.8% survival rate and a mean follow-up of more than 5 years;23 Bell found a survival rate of 97.5% for 655 implants. No differences in survival rates were observed between sites with or without peri-apical pathology.24 The ability to achieve primary implant stability is still a prerequi-site, and curettage of the site prior to implant placement and post-operative antibiotics are recommended.

Primary Implant Stability Primary implant stability is an important factor for

osseointegration. Research has led to the conclusion that implant micromotion should ideally be limited to 100 μm and that implant micromovement in excess of 150 μm can result in fibrous encapsulation and failure to osseointegrate, while immediate implants can withstand micromovement in the 50 μm to 150 μm range.25-28 As a point of reference, the lateral movement of natural teeth in a healthy dentition ranges from 56 μm to 108 μm.29 For nonsplinted implants it is important to ensure that the implant has nonfunctional loading – this implies no occlusal contact in CR, CO, MI, or in excursive movements. To achieve primary stability in extraction sockets, the osteotomy site should extend 3 mm apical to the socket or there must be 3 mm of bone contact with the walls of the extraction site.28,30 This highlights the importance of atraumatic extractions and selection of an implant with dimensions suitable for a given extraction site.

Implant Design and Primary StabilityImplant designs have been modified over time to help

increase primary implant stability. Thread designs have been adjusted for width, depth, and pitch – a reduced pitch distance and increased thread compactness decreases micro-motion.31,32 In an implant design with a variable pitch, also incorporating variable thread angle depths, primary stability was increased with fewer threads. The increased thread pitch increases stability because the threads are deeper and vari-able.33 Variable-thread implant designs, including with im-mediate loading in healed sites, was assessed after 36 months of loading, by Arnhart et al. They found a survival rate in evaluable subjects (n=127) of 97.7% for internal and 96.3% for external connection designs, with no statistically signifi-

TABLE 2. Factors improving primary implant stability

Increased thread compactness

Thread pitch

Variable thread design

Rough implant surfaces

Higher bone density

Intact socket walls in immediate implant placement cases


7February 2015

cant difference and stable bone levels after initial healing.34

In patients receiving implants with variable-thread designs, in partially edentulous mandibles and maxillae, the cumula-tive survival rate was 97.7%. Additional factors infl uencing primary implant stability are discussed below (Table 2).

Primary loading (insertion) torqueThere is a strong correlation between lower initial inser-

tion torques and implant failures.35 In one study using ISQ measurements to assess primary implant stability, it was found that stability may be lower for immediate implant placement but that this difference was lost over time and did not affect outcomes.15 Research also supports immediate loading if a primary loading torque of 40 Ncm to 45 Ncm can be achieved during implant placement.28 Thread design infl uences the primary loading torque that can be achieved.

Immediate, Early, and Delayed LoadingTraditionally, implants were loaded 3 to 8 months after

placement (i.e., following osseointegration). Immediate and early loading of implants (1 week to 2 months post-place-ment) has been recommended to decrease treatment times.

High survival and success rates have been observed with immediate loading.36-38 In a review of 19 studies, an overall 95.5% survival rate after 12 months was observed, with no statistically signifi cant differences in survival rates for im-mediate, early, or delayed single implant placement.37 A 2012 review of immediately loaded implants in 9 studies (including single, FPDs, and removable restorations) cited an implant survival rate range from 95.8% to 100%, and success rates for mandibular implants of 79% to 100%. The research-ers concluded that immediate loading was predictable for mandibular implants.38 Esposito et al reviewed clinical trials with different loading times and occlusal vs nonocclusal load-ing, and found no clinically relevant differences for implant survival rates, prosthesis failure rates, or loss of crestal bone.39

Immediate loading protocols are supported in the litera-ture if the implant has a minimum stability of 35 Ncm when challenged with further rotation and the healing structure is non-functionally loaded. If the implant is splinted to another implant, then the loading capabilities can sometimes be full functional load.

Implant Surface Roughened implant surfaces were developed based on

the concept of increasing the available surface area for osseointegration.

Several types of roughened surfaces have been shown to offer successful outcomes for immediate, early, and delayed loading including in the posterior mandible and to increase os-seointegration.40-46 A 10-year study on implants with a porous oxidized microtexture surface (TiUnite®, Nobel Biocare) found a cumulative survival rate of 98% for evaluable implants in healed sites and 96.5% for immediate implant placement, with stable marginal bone levels and a total mean marginal bone loss of 1.93 mm and 1.98 mm respectively.47 This surface has a high crystallinity and phosphorus ceramic-like qualities and micropores for high osteoconductivity and fast anchorage of newly formed bone, with the objective of decreasing healing times. Microtextured rough surfaces are also suitable for the promotion of osseointegration in immediate implant place-ment cases involving lower quality, soft bone as demonstrated by outcomes in a 7-year study with a cumulative implant survival rate of 97.1% where 76% were placed in soft bone and the majority were posterior implants.48

Platform SwitchingPlatform switching has been proposed to help preserve

crestal bone. One review found no signifi cant differences in crestal bone

preservation for switched and non-switched platforms,49 and a small study of 32 implants found no differences in the pres-ence or level of infl ammatory cells and biomarkers associated with bone loss after prolonged intraoral exposure of abut-ments.50 In contrast, a pilot study using CBCT scans found greater crestal bone loss at the abutment-implant interface level in a separate study.51 The conclusion from the systematic review and meta-analysis by Atieh et al, based on 10 studies with 1,239 implants, was that there was statistically signifi -cantly less crestal bone loss associated with platform-switched implants than non-platform-switched implants (p<0.0001).52

A recent study yielded a 100% survival rate, with statistically signifi cantly less marginal bone loss with internal connection platform-switched than non-platform-switched external con-nection implants.53



A minimum vertical thickness of 2.5 mm of soft tissue is recommended for an adequate soft-tissue seal.

Emergence ProfileThe goal is to have an emergence profile that is not too

wide so that the buccal bone plate architecture is ideal, while also creating a soft-tissue seal to maintain bone. The emergence buccal lingually is often the limiting factor for implant size since the width of the bone narrows after tooth loss, while the mesial distal length is typically not problem-atic. An emergence profile shaped like a wineglass with the shape leaving the implant platform and reaching the contact point on a smooth angle similar to the posterior tooth anatomy achieves these objectives. Using a wider implant helps to create this ideal emergence. The implant should be submerged sufficiently to maintain a minimum 2.5 mm depth from the anticipated soft tissue crest to the implant platform to provide adequate soft tissue volume and create an emergence profile that prevents food entrapment. If the implant is not placed deeply enough, then the emergence profile leads to food impaction.

Abutment Design and Placement Stock abutments were originally available as straight abut-

ments, and angled abutments were introduced that gave more flexibility for implant placement to meet anatomical demands and restorative requirements. One concern is the lack of cus-tomization impacting the ability to have crown margins at an appropriate level for esthetics as well as for cement cleanup at insertion. CAD/CAM ceramic custom abutments have increased treatment options and improved esthetics.

The fit/seal between abutments and implants is critical, as is lack of rotation to prevent screw loosening. Abutment screw loosening was found to be uncommon in a review of 12 studies and 586 single implant restorations with “complication-free” success rates of 97.3% for external connections. For internal connections (1,113), this was 98.6%.54 There are various internal connections used today. Many implant systems have used the conical con-nection design to maximize the tight fit of the abutment to the implant and minimize any potential complications due to bacterial leakage at this interface. Microgaps result

in microleakage, and represent a risk for peri-implantitis.55 Ensuring use of components with a tight fit is essential. The implant and abutment also share a mating hexagon at the base of the conical connection. This is available for indexing purposes to enable orientation transfer between clinical and laboratory components and restorations.

Contentious debate has arisen over screw-retained vs cement-retained options. Wilson found that patients with peri-implant disease often had cement trapped under the abutment areas of implants. Eighty-one percent of the patients with peri-implant disease had residual cement. Once the cement was removed, in 74% the peri-implant disease resolved.56

In the past, if the implant was angled to the facial aspect, then a typical screw-retained option through the occlusal surface was not possible. An abutment had to be fabricated and then a crown was made to cement over the screw chan-nel exiting through the facial aspect.

Recently, angulated screw channels (ASC) have been designed to provide zirconia-based solutions allowing more flexibility in securing the abutment. In the posterior region, this is particularly advantageous when limited work-ing space is available. ASC abutments have improved the conical internal implant-abutment interface by having a titanium adapter that supports the zirconia abutment. One of the most important benefits is the strength of the mate-rial while reducing the cost. For porcelain-fused-to-gold restorations the cost of the gold can be very high since the restoration is not merely a shell but rather places the tooth and some bone as a solid core. Since gold is a commodity, the price vs zirconia can be quite a bit more. The zirconia has a yttrium stabilized structure with a 1400 MPa tensile strength which is higher than for the gold alloys used in porcelain-fused-to-metal restorations. Furthermore many companies are moving towards monolithic zirconia which eliminates the porcelain layering technique. The case pre-sentation below demonstrates the use of a single implant-supported platform-switched and screw-retained posterior restoration.

Case Presentation The patient was a 63-year-old man in excellent general

health and with good periodontal health. He presented with


9February 2015

a lower fi rst molar with failed endodontic therapy and an abscess, as well as excessive occlusal loading (Figure 3). The tooth was deemed to be nonrestorable and it was decided that it would be extracted, followed by immediate implant placement. The CT scan revealed adequate bone and it was determined that it would be possible to achieve primary implant stability.

Treatment planning was restoratively driven, aided by digital software. This lets the clinician see many key treat-ment planning points in 3D views. Fusion of the scanned model over the CT image aids planning of the depth and angulation of the implant based on the prosthetic position of the fi nal crown, letting the clinician see the ideal posi-

Figure 4a. Digital software for treatment planning Figure 4b. Depth and angulation of proposed implant

Figure 3. Hopeless lower fi rst molar

Figure 5. Fractured root tip in the extraction site Figure 6. Socket following atraumatic extraction

Note the preservation of soft tissue



tion of the screw channel, thickness of the soft tissue, bone dimensions, and position of the inferior alveolar nerve rela-tive to the available space (Figures 4a and 4b). Once these structures are visualized a surgical guide can be made using stereolithography, and used during surgery to to guide the implant into the ideal angulation and depth.

Following atraumatic extraction, the bone socket was debrided using a curette and then irrigated with saline (Figures 5 and 6).

A 2.0 mm guided pilot drill was used in the surgical guide to establish the position of the tip of the implant in the extraction site (Figure 7). Once the drill was placed to depth, the guide was removed and the depth was measured using the free gingival margin as the reference point by placing a 2 mm drill back in the osteotomy and placing a drill guide on the drill. Once this depth was determined the site was widened using other twist drills (keeping in mind that the osteotomy preparation needs to be undersized to establish initial stability of the implant in the bone beyond the extraction socket). Next, a 2.4-2.8 diameter twist drill was used to establish the full depth of the osteotomy. Note that the osteotomy was prepared to full depth with drills <4.0 mm diameter and then just the first entry point to the bone was prepared to 4 mm diameter since the tip of the implant is also 4 mm. It is important to widen only the top of the site with this drill sufficiently to provide an entry purchase point to insert the apical tip of the implant. Once the implant begins to engage, the objective is for seating

Figure 7. NobelGuide® surgical template Figure 8. Seating the implant with the implant driver

Figure 9. Post-placement radiograph

Figure 10. A 5 mm-high healing abutment was placed during bone grafting


11February 2015

to continue in the preserved 2.8 mm diameter channel and ultimately the 2.4 mm diameter apical site preparation for fi nal seating. An undersized osteotomy is a key strategy for achieving implant stability of greater than 35 Ncm.

A 5.5 mm diameter, 13 mm length implant (NobelActive Wide Platform, Nobel Biocare) was placed into the osteotomy, establishing the apical tip into a minimum of 3 mm depth of bone while staying a minimum of 2 mm away from the nerve (Figure 8). The 5.5 mm wide implant has a widely spaced and deep dual thread with a progressively increasing vertical thread profi le design. This thread design, the 4 mm wide implant tip, and the TiUnite® rough surface are designed to enhance initial implant stability, and its effi cacy has been shown for immedi-ate implant placement at time of extraction followed with stable bone remodeling, including for single implants that were immediately temporized and in function.33,57 The widest part of this implant is intended to be placed below the bone crest and the implant then has a reverse taper ending with a 5.1 mm platform. The combination of this back taper and platform shift abutment design emerging within this reduced diameter allows for more soft tissue volume between adjacent implants or with an adjacent tooth. By increasing implant diameter from the standard 4.3 mm, fatigue strength is doubled (580 N vs. 290 N). After seating to the desired depth, the implant resisted further rotation or insertion when 70 Ncm was applied to confi rm initial stability.

A periapical radiograph was taken to confi rm the im-plant position and a healing abutment was placed (Figures

Figure 11. Placement of the PEEK healing abutment Figure 12a. Soft tissue contour

Figure 12b and c. Impression coping seated

Figure 13. Soft tissue model



9 and 10). Allograft bone particles were then used to fill the remaining socket to the top of the implant. The healing abutment was placed before the allograft to prevent al-lograft particles from entering the internal screw channel of the implant.

Next, a polyetheretherketone (PEEK) healing abutment with a 4 mm height was placed to shape the soft tissues and help create the emergence profile from the time of surgery (Figure 11). The soft tissue was sutured both anterior and posterior to this healing abutment, after which vinylpolysi-loxane impression material was placed to cover the screw channel opening. The patient had started a course of antibiot-ics (amoxicillin 500 mg, 3 times a day) 24 hours before the

Figure 16a. Seated crownFigure 14b. CAD/CAM planning of abutment on soft tissue model

Figure 15. Completed restoration with the porcelain layer over the zirconia abutment

Figure 16b. Seated crown after covering the screw access channel

Figure 14a. CAD/CAM assessment of space


13February 2015

treatment and would continue taking these 3 times per day for 7 days postoperatively. Osseointegration was allowed to occur for 3 months after the implant and PEEK healing abut-ment were placed before fabrication of the crown restoration began.

The PEEK healing abutment was removed and an open tray impression was performed using a fl ared impression coping to pick up the soft tissue emer gence that was created using the PEEK healing abutment (Figure 12a). Prior to the impression an X-ray was used to confi rm the seating of the impression coping (Figures 12b and 12c). The remaining tis-sue emergence was picked up with the impression coping and polyether injected around the impression coping. A color was selected using the 3D Vita shade master guide and a “Vita easyshade compact” tool. The lab technician poured the stone model using a soft-tissue material around the replica (Figure 13). This enables the technician to remove the soft tissue scan during scanning. The model was multiple-scanned using the scanner (NobelProcera). The technician scans the position of the replica as well as the soft-tissue profi le. This ensures that the emer gence of the PEEK healing abutment is visualized on the scanned digital model. The technician used software (NobelProcera) to create a 3D model.

Restoration had been planned using a one piece screw-retained porcelain-to-zirconia restoration attached directly to the implant. This provides a robust restoration with full control over emergence profi le and eliminates the use of a separate abutment with a separate cemented crown.

For this patient, an Angulated Screw Channel zirconia abut-ment (NobelProcera) was used. This abutment provides the capability to insert and fasten abutment screws to proper torque specifi cations (35 Ncm) through a screw channel that can be angled up to 25 degree from the straight center axis. A screw-driver and abutment screw interface designed for this purpose (Omnigrip™, Nobel Biocare) enables the abutment screw to be fully seated within the implant while being inserted through a channel that may be designed for approaches at angles of up to 25 degrees from the implant center axis. Using the SmartFu-sion™ process, such correction may not be required though it still may be useful for fi nesse in aligning a screw access hole precisely, for example, to avoid an opposing cusp.

This abutment includes a titanium insert extending from

the implant conical connection and serving as a precise friction-fi t pedestal base for the zirconia abutment. This adds strength by using titanium instead of zirconia for the internal connection that could be subjected to fl exural forces, while preserving biocompatibility. The precision fi t of the zirconia/titanium adapter interface does not use or require a luting agent, thereby eliminating the breakdown of an adhesive bond as a potential risk.

The clinician can choose layered porcelain over the zirco-nia or monolithic zirconia, which means that the complete crown is fabricated in one solid core of zirconia. When veneering porcelain is desired, the complete crown/abutment is designed as full contour and then a cutback is made for the veneering porcelain only.

Since the channel is in zirconia it is easier to disguise when the restorative resin is placed compared to the darkness observed with metal substructures. By using the ASC crown, the technician could move the channel to the ideal position. Once the fi nal crown is designed, the dental technician uses a software tool to reduce the overall dimension by 1 mm. The fi nal design was sent via private secure internet (Nobel-Connect) to the centralized milling center (Figures 14a and 14b). The abutment was milled on a CNC milling machine and returned to the technician. The technician added the porcelain and delivered the fi nal contoured crown to the dental offi ce for fi nal delivery (Figure 15).

At the crown delivery appointment, the healing abut-ment was re moved. The porcelain-veneered zirconia crown/abutment with adapter was inserted into the implant as one piece and fastened using the Omnigrip™ Clinical Screw and Screwdriver

The result was an esthetic and functional single lower fi rst molar implant restoration (Figure 16). The patient was given oral hygiene instructions and an appointment made for both a 1-week check and a 3-month implant maintenance visit.

ConclusionsPosterior single implant restorations have proven to be

successful and desirable treatment options. Current proto-cols give the clinician and patient options with respect to the length of treatment, timing of phases, whether an immediate replacement will be provided at the time of extraction, and



what restorative materials will be used. With suitable case selection, high survival and success rates are found for this therapy. Esthetic restorations that respect biological and functional requirements in the posterior region offer excel-lent solutions for patients.

References1. Gómez-de Diego R, Mang-de la Rosa Mdel R, Romero-Pérez MJ, Cutando-Soriano A, López-Valverde-Centeno A. Indications and contraindications of dental implants in medically compromised patients: update. Med Oral Patol Oral Cir Bucal. 2014;19(5):e483-9.2. Froum S, Casanova L, Byrne S, Cho SC. Risk assessment before extraction for immediate implant place-ment in the posterior mandible: a computerized tomographic scan study. J Periodontol. 2011;82(3):395-402.3. Greenstein G, Tarnow D. The mental foramen and nerve: clinical and anatomical factors related to dental implant placement: a literature review. J Periodontol. 2006;77(12):1933-43.4. Lin MH, Mau LP, Cochran DL, Shieh YS, Huang PH, Huang RY. Risk assessment of inferior alveolar nerve injury for immediate implant placement in the posterior mandible: a virtual implant placement study. J Dent. 2014;42(3):263-70.5. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol. 1992;63(12):995-6.6. Gastaldo J, Cury PR, Sendyk WR. Effect of the vertical and horizontal distances between adjacent implants and between a tooth and an implant on the incidence of interproximal papilla. J Periodontol. 2004;75:1242-6.7. Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Timing of implant placement after tooth extraction: immediate, immediate-delayed or delayed implants? A Cochrane systematic review. Eur J Oral Implantol. 2010;3(3):189-205.8. Lang NP, Lui P, Lau KY, Li KY, Wong MCM. A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year. Clin Oral Impl Res. 2012;23(Suppl. 5):39–66.9. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L, Carda-ropoli G. Socket preservation using bovine bone mineral and collagen membrane: a randomized controlled clinical trial with histologic analysis. Int J Perio Restor Dent. 2012;32(4):421-30.10. Horowitz RA, Mazor Z, Miller RJ, Krauser J, Prasad HS, Rohrer MD. Clinical evaluation alveolar ridge preservation with a beta-tricalcium phosphate socket graft. Compend Contin Educ Dent. 2009;30(9):588-90, 592, 594 passim.11. Barone A, Aldini NN, Fini M, Giardino R, Calvo Guirado JL, Covani U. Xenograft versus extraction alone for ridge preserva-tion after tooth removal: a clinical and histomorphometric study. J Periodontol. 2008;79(8):1370-7. 12. Avila G, Galindo P, Rios H, Wang HL. Immediate implant loading: current status from available literature. Implant Dent. 2007;16(3):235-45.13. Ortega-Martínez J, Pérez-Pascual T, Mareque-Bueno S, Hernández-Alfaro F, Ferrés-Padró E. Immediate implants following tooth extraction. A systematic review. Med Oral Patol Oral Cir Bucal. 2012;17 (2):e251-61.14. Chen ST, Beagle J, Jensen SS, Chiapasco M, Darby I. Consensus statements and recommended clinical procedures regarding surgical techniques. Int J Oral Maxillofac Implants. 2009;24 Suppl:272-8.15. Palattella P, Torsello F, Cordaro L. Two-year prospective clinical comparison of immediate replacement vs. immediate restoration of single tooth in the esthetic zone. Clin Oral Implants Res. 2008;19:1148-53.16. Botticelli D, Renzi A, Lindhe J, Berglundh T. Implants in fresh extraction sockets: a prospective 5-year follow-up clinical study. Clin Oral Implants Res. 2008;19:1226-32.17. Lee CT, Chiu TS, Chuang SK, Tarnow D, Stoupel J. Alterations of the bone dimension following im-mediate implant placement into extraction socket: systematic review and meta-analysis. J Clin Periodontol. 2014;41(9):914-26.18. Chen ST, Buser D. Clinical and Esthetic Outcomes of Implants Placed in Postextraction Sites. Int J Oral Maxillofac Implants. 2009:24(Suppl):186-217. 19. Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Impl Res. 2008;19(1):73-80.20. Ferrus J, Cecchinato D, Pjetursson EB, Lang NP, Sanz M, Lindhe J. Factors influencing ridge alterations following immediate implant placement into extraction sockets. Clin Oral Implants Res. 2010;21(1):22-9. 21. Linkevicius T, Apse P, Grybauskas S, Puisys A. The influence of soft tissue thickness on crestal bone changes around implants: a 1-year prospective controlled clinical trial. Int J Oral Maxillofac Implants. 2009;24(4):712-9.22. Álvarez-Camino JC, Valmaseda-Castellón E, Gay-Escoda C. Immediate implants placed in fresh sockets associated to periapical infectious processes. A systematic review. Med Oral Patol Oral Cir Bucal. 2013;18 (5):e780-5.23. Fugazzotto P. A Retrospective Analysis of Immediately Placed Implants in 418 Sites Exhibiting Periapical Pathology: Results and Clinical Considerations. Int J Oral Maxillofac Implants. 2012;27:194–202.24. Bell CL, Diehl D, Bell BM, Bell RE. The immediate placement of dental implants into extraction sites with periapical lesions: a retrospective chart review. J Oral Maxillofac Surg. 2011;69:1623-7.25. Tarnow D, Emtiaz SH, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1 to 5 year data. Int J Oral Maxillofac Implants. 1997;12(3):319–24.26. Brunski JB. In vivo bone response to biomechanical loading at the bone/dental-implant interface. Adv Dent Res. 1999;13:99-119.27. Szmukler-Moncler S, Salama H, Reingewirtz Y, Dubruille JH. Timing of loading and effect of micromotion on bone dental implant interface: review of experimental literature. J Biomed Mater Res. 1998;43:192–203.28. Garber DA, Salama H, Salama MA. Two-stage versus one-stage-is there really a controversy? J Periodon-tol. 2001;72(3):417-21.29. Misch C. Conteporary Implant Dentistry, 1st ed., p186.

30. Al-Harbi SA, Edgin WA. Preservation of soft tissue contours with immediate screw-retained provisional implant crown. J Pros Dent. 2007;98(4):329-32.31. Akkocaoglu M, Uysal S, Tekdemir I, Akca K, Cehreli MC. Implant design and intraosseous stability of im-mediately placed implants: a human cadaver study. Clin Oral Implants Res. 2005;16(2):202–9. 32. Steigenga JT, al-Shammari KF, Nociti FH, Misch CE, Wang HL. Dental implant design and its relationship to long term implant success. Implant Dent. 2003;12(4):306–17.33. MacLean S. Case report of an immediate placement and temporization using the NobelActive implant. Available at: http://www.oralhealthgroup.com/news/case-report-of-an-immediate-placement-and-temporization-using-the-nobelactive-153-implant/1000229566/34. Arnhart C, Kielbassa AM, Martinez-de Fuentes R, Goldstein M, Jackowski J, Lorenzoni M, et al. Com-parison of variable-thread tapered implant designs to a standard tapered implant design after immediate loading. A 3-year multicentre randomised controlled trial. Eur J Oral Implantol. 2012 Summer;5(2):123-36.35. Ottoni JM, Oliveira ZF, Mansini R, Cabral AM. Correlation between placement torque and survival of single-tooth implants. Int J Oral Maxillofac Implants. 2005;20(5):769-76.36. Ribeiro FS, Pontes AE, Marcantonio E, Piattelli A, Neto RJ, Marcantonio E Jr. Success rate of immedi-ate nonfunctional loaded single-tooth implants: immediate versus delayed implantation. Implant Dent. 2008;17(1):109-17.37. den Hartog L, Slater JJ, Vissink A, Meijer HJ, Raghoebar GM. Treatment outcome of immediate, early and conventional single-tooth implants in the aesthetic zone: a systematic review to survival, bone level, soft-tissue, aesthetics and patient satisfac-tion. J Clin Periodontol. 2008;35(12):1073-86.38. Strub JR, Jurdzik BA, Tuna T. Prognosis of immediately loaded implants and their restorations: a system-atic literature review. J Oral Rehabil. 2012;39(9):704-17.39. Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing teeth: differ-ent times for loading dental implants. Cochrane Database Syst Rev. 2013;3:CD003878. 40. Cochran DL, Jackson JM, Jones AA, Jones JD, Kaiser DA, Taylor TD et al. A 5-year prospective multi-center clinical trial of non-submerged dental implants with a titanium plasma-sprayed surface in 200 patients. J Periodontol. 2011;82(7):990-9.41. Nelson K, Semper W, Hildebrand D, Özyuvaci H. A retrospective analysis of sandblasted, acid-etched implants with reduced healing times with an observation period of up to 5 years. Int J Oral Maxillofac Impl. 2008;23(4):726-32.42. Balshe AA, Assad DA, Eckert SE, Koka S, Weaver AL. A retrospective study of the survival of smooth- and rough-surface dental implants. Int J Oral Maxillofac Impl. 2009;24(6):1113-8.43. Ivanoff CJ, Hallgren C, Widmark G, Sennerby L, Wennerberg A. Histologic evaluation of the bone integra-tion of TiO(2) blasted and turned titanium microimplants in humans. Clin Oral Impl Res. 2001;12(2):128-34.44. George KM, Choi YG, Rieck KL, Van Ess J, Ivancakova R, Carr AB. Immediate restoration with ti-unite implants: practice-based evidence compared with animal study outcomes. Int J Prosthodont. 2011;24(3):199-203.45. Cordaro L, Torsello F, Roccuzzo M. Implant loading protocols for the partially edentulous posterior man-dible. Int J Oral Maxillofac Implants. 2009;24 Suppl:158-68.46. Cannizzaro G, Leone M. Restoration of partially edentulous patients using dental implants with a microtex-tured surface: a prospective comparison of delayed and immediate full occlusal loading. Int J Oral Maxillofac Implants. 2003;18(4):512-22.47. Degidi M, Nardi D, Piattelli A. 10-year follow-up of immediately loaded implants with TiUnite porous anodized surface. Clin Implant Dent Relat Res. 2012;14(6):828-38. 48. Glauser R. Implants with an oxidized surface placed predominately in soft bone quality and subjected to immediate occlusal loading: results from a 7-year clinical follow-up. Clin Implant Dent Relat Res. 2013;15(3):322-31. 49. Romanos GE, Javed F. Platform switching minimises crestal bone loss around dental implants: truth or myth? J Oral Rehabil. 2014;41(9):700-8. 50. Dellavia C, Canullo L, Allievi C, Lang NP, Pellegrini G. Soft tissue surrounding switched platform implants: an immunohistochemical evaluation. Clin Oral Implants Res. 2013;24(1):63-70. 51. Vera C, De Kok IJ, Chen W, Reside G, Tyndall D, Cooper LF. Evaluation of post-implant buccal bone resorption using cone beam computed tomography: a clinical pilot study. Int J Oral Maxillofac Implants. 2012;27(5):1249-57.52. Atieh MA, Ibrahim HM, Atieh AH. Platform switching for marginal bone preservation around dental implants: a systematic review and meta-analysis. J Periodontol. 2010;81(10):1350-66.53. Pozzi A, Agliardi E, Tallarico M, Barlattani A. Clinical and radiological outcomes of two implants with different prosthetic interfaces and neck configurations: randomized, controlled, split-mouth clinical trial. Clin Implant Dent Relat Res. 2014;16(1):96-106. 54. Theoharidou A, Petridis HP, Tzannas K, Garefis P. Abutment screw loosening in single-implant restorations: a systematic review. Int J Oral Maxillofac Implants. 2008;23(4):681-90.55. Rismanchian M, Hatami M, Badrian H, Khalighinejad N, Goroohi H. Evaluation of microgap size and microbial leakage in the connection area of 4 abutments with Straumann (ITI) implant. J Oral Implantol. 2012;38(6):677-85. 56. Wilson TG Jr. The positive relationship between excess cement and peri-implant disease: a prospective clinical endoscopic study. J Periodontol. 2009;80(9):1388-92.57. Kolinski ML, Cherry JE, McAllister BS, Parrish KD, Pumphrey DW, Schroering RL. Evaluation of a variable-thread tapered implant in extraction sites with immediate temporization: a 3-year multicenter clinical study. J Periodontol. 2014;85(3):386-94.

WebliographyAtieh MA, Ibrahim HM, Atieh AH. Platform switching for marginal bone preservation around dental implants: a systematic review and meta-analysis. J Periodontol. 2010;81(10):1350-66. Available at: http://www.joponline.org/doi/abs/10.1902/jop.2010.100232?journalCode=jop.Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing teeth: different times for loading dental implants. Cochrane Database Syst Rev. 2013;3:CD003878. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23543525.Kim S-G (2011). Clinical complications of dental implants. In: Implant dentistry - a rapidly evolving practice, Prof. Ilser Turkyilmaz (Ed.), ISBN: 978-953-307-658-4, InTech, Available from: http://www.intechopen.com/books/implant-dentistry-a-rapidly-evolving-practice/clinical-complications-of-dental-implants


15February 2015

1. Current protocols for posterior single implants include ______________.a. immediate, early, or delayed implant placementb. nonsubmerged or submerged osseointegrationc. immediate, early, or delayed temporization and loadingd. all of the above

2. Local contraindications include ____________.a. lack of adequate boneb. parafunctional habitsc. proximity to anatomical structuresd. all of the above

3. Implants should be placed such that they will be loaded _______________ over the implant body.a. axially b. mesiallyc. buccallyd. diagonally

4. Less than 6 mm of bone separated the inferior alveolar canal from the mandibular � rst molar in _____________ of casesin one study.a. 43%b. 53%c. 63%d. 73%

5. A review by Lang et al estimated an average 4-year survival rate of ___________ for immediately placed implants in the mandible and maxilla.a. 95% b. 95.5%c. 97.5% d. 99.5%

6. The _____________must be considered during implant treatment planning.a. lingual mandibular undercutb. anterior loop of the inferior alveolar canalc. inferior alveolar nerved. all of the above

7. Ideally, there should be 1.5 mm of space from the implant to ____________.a. adjacent teeth b. metal surfacesc. adjacent implantsd. the buccal bone plate

8. Software also may allow the clinician to ______________.a. assess implant angulation and depthb. perform a virtual extractionc. examine a virtual socketd. all of the above

9. Linkevicius et al concluded in their study that thinner soft tissue at the crestal bone level signi� cantly in� uences crestal bone stability, especially when _____________ where >1 mm of crestal bone loss may then occur compared to thick biotype sites. a. <2 mm thickb. >2 mm thick c. <4 mm thickd. >4 mm thick

10. With respect to the presence of peri-apical pathology, ________.a. post-operative antibiotics are recommended b. the ability to achieve primary implant stability is still a

prerequisitec. curettage of the site prior to implant placement is requiredd. all of the above

CEQuizTo complete this quiz online and immediately download your CE verifi cation document, visit www.dentallearning.net/SIR-ce, then log into your account (or register to create an account). Upon completion and passing of the exam, you can immediately download your CE verifi cation document. We accept Visa, MasterCard, Discover, and American Express.

Scan the QR code to take the test on your tablet or smartphone.



11. To achieve primary stability in extraction sockets _____________.a. the osteotomy site should extend 3 mm apical to the

socket b. there should be 4 mm lateral to the socketc. there must be 3 mm of bone contact with the walls of the

extraction sited. a or c

12. ______________ improve primary stability.a. Rough implant surfacesb. Variable thread designsc. Higher bone densitiesd. all of the above

13. Immediate loading protocols are supported in the literature if the implant has a minimum stability of _______________ when challenged with further rotation and the healing structure is non-functionally loaded.a. 25 Ncmb. 30 Ncm c. 35 Ncmd. 45 Ncm

14. Microtextured rough surfaces _____________.a. promote osseointegrationb. are suitable for immediate implant placement cases involving

lower quality, soft bone c. are designed to decrease healing timesd. all of the above

15. Atieh et al concluded in their systematic review and meta-analysis that there was statistically signi� cantly less crestal bone loss associated with _____________.a. non-platform-switched implantsb. platform-switched implants c. immediate loadingd. delayed placement

16. _____________ is a concern with stock abutments.a. Lack of customizationb. Lack of compatibilityc. Costd. all of the above

17. Microgaps result in microleakage and represent a risk for _________.a. cariesb. periodontal diseasec. peri-implantitisd. none of the above

18. For cement-retained restorations, an abutment screw channel that could be accessed by cutting a channel through the implant crown if the ___________ were to loosen is desirable.a. implant b. abutmentc. abutment screwd. restoration

19. A fusion technique can be used to bring a digital scan of the wax-up and model into the CT/CBCT software to plan the implant placement based on __________.a. surgical proceduresb. the � nal prostheticsc. bone toleranced. none of the above

20. A stereolythic surgical template can be fabricated to __________________.a. aid placement of the implant in the ideal positionb. control depthc. control angulationd. all of the above

CEQuiz

Scan the QR code to take the test on your tablet or smartphone.

17February 2015


www.dentallearning.net/SIR-ceCE ANSWER FORM (E-mail address required for processing)

*Name: Title: Speciality

*Address: NPI No.

*City: *State: *Zip: AGD Identifi cation No.

*E-mail:

*Telephone: License Renewal Date:

Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected]. COURSE EVALUATION and PARTICIPANT FEEDBACK: We encourage participant feedback pertaining to all courses. Please be sure to complete the evaluation included with the course. INSTRUCTIONS: All questions have only one answer. Participants will receive confi rmation of passing by receipt of a verifi cation certifi cate. Verifi cation certifi cates will be processed within two weeks after submitting a completed examination. EDUCATIONAL DISCLAIMER: The content in this course is derived from current information and research based evidence. Any opinions of effi cacy or perceived value of any products mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily refl ect those of Dental Learning. Completing a single continuing education course does not provide enough information to make the participant an expert in the fi eld related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST: All participants scoring at least 70% on the examination will receive a CE verifi cation certifi cate. Dental Learning, LLC is an ADA CERP recognized provider. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Please contact Dental Learning, LLC for current terms of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. Dental Learning, LLC is a California Provider. The California Provider number is RP5062. The cost for courses ranges from $19.00 to $90.00. RECORD KEEPING: Dental Learning, LLC maintains records of your successful completion of any exam. Please contact our offi ces for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within fi ve business days of request. Dental Learning, LLC maintains verifi cation records for a minimum of seven years. CANCELLATION/REFUND POLICY: Any participant who is not 100% satisfi ed with this course can request a full refund by contacting Dental Learning, LLC in writing or by calling 1-888-724-5230. Go Green, Go Online to www.dentallearning.net to take this course. © 2015

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

QUIZ ANSWERSFill in the circle of the appropriate answer that corresponds to the question on previous pages.

EDUCATIONAL OBJECTIVES1. Describe anatomical and other considerations during the treatment planning process2. Review the use of software during implant treatment planning3. List and describe aspects of implant design that affect primary implant stability4. Delineate abutment and retention options and the evidence for these.

If you have any questions, please email Dental Learning at [email protected] or call 888-724-5230.

COURSE SUBMISSION: 1. Read the entire course.2. Complete this entire answer sheet in

either pen or pencil.3. Mark only one answer for each question.4. Mail answer form or fax to 732-303-0555. For immediate results:1. Read the entire course.2. Go to www.dentallearning.net/SIR-ce.3. Log in to your account or register to create an

account.4. Complete course and submit for grading to

receive your CE verifi cation certifi cate.

A score of 70% will earn your credits.

Dental Learning, LLC500 Craig Road, First FloorManalapan, NJ 07726

*If paying by credit card, please note:Master Card | Visa | AmEx | Discover

*Account Number

______________________________________________

*Expiration Date

______________________________________________

The charge will appear as Dental Learning, LLC.

If paying by check, make check payable to Dental Learning, LLC.

ALL FIELDS MARKED WITH AN ASTERISK (*) ARE REQUIRED

AGD Code: 690

Price: $29 CE Credits: 2Save time and the environment by taking this course online.

COURSE EVALUATIONPlease evaluate this course using a scale of 3 to 1, where 3 is excellent and 1 is poor.

1. Clarity of objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

2. Usefulness of content . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

3. Benefi t to your clinical practice . . . . . . . . . . . . . . . . . . . . 3 2 1

4. Usefulness of the references . . . . . . . . . . . . . . . . . . . . . . 3 2 1

5. Quality of written presentation . . . . . . . . . . . . . . . . . . . . 3 2 1

6. Quality of illustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

7. Clarity of quiz questions . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1

8. Relevance of quiz questions . . . . . . . . . . . . . . . . . . . . . . 3 2 1

9. Rate your overall satisfaction with this course . . . . . . . . 3 2 1

10. Did this lesson achieve its educational objectives? Yes No

11. Are there any other topics you would like to see presented in the future? __________________________________________________________________________

_______________________________________________________________________________________

DENTAL LEARNING Implant_(Nobel)CE WEB.pdf · dental implants, which offer excellent long-term...

Documents

Transcript of DENTAL LEARNING Implant_(Nobel)CE WEB.pdf · dental implants, which offer excellent long-term...