P

ROSTHETIC PHASE IN IMPLANTS

INTRODUCTION
In recent years, prosthodontics has undergone a significant transformation due to the emergence of
implant dentistry, providing patients with groundbreaking options for replacing lost teeth and
reconstructing oral structures. The advent of implant-supported prosthetic restorations has ushered in
a new era of treatment possibilities for edentulous patients, offering not only functional rehabilitation
but also remarkable enhancements in esthetics and quality of life 1. At the heart of this transformative
process lies the prosthetic phase of implant treatment, an intricate and multifaceted stage that
encompasses a myriad of factors ranging from meticulous treatment planning to the final delivery of a
functional and esthetically pleasing restoration.

The significance of the prosthetic phase cannot be overstated, as it represents collaborative effort
involving various dental specialists, including prosthodontists, oral surgeons, periodontists, and dental
technicians, each contributing their expertise to ensure the success of the treatment. This phase is
characterized by its complexity, requiring a comprehensive understanding of biomechanical
principles, occlusal dynamics, soft tissue management, and patient-specific factors, all of which
influence the ultimate outcome of implant therapy. Several types of prosthetic designs and materials
are available nowadays for implant-supported fixed prostheses, depending on their type: interim
(provisional) or definitive (final). 2, 3

At its core, the prosthetic phase is guided by the principles of restorative dentistry, with a focus on
achieving harmonious integration between the implant-supported restoration and the patient's existing
dentition, facial morphology, and occlusal function 4. This entails meticulous attention to detail at
every stage of the treatment process, from the initial diagnosis and treatment planning to the
fabrication and delivery of the final prosthesis5.

One of the fundamental challenges in the prosthetic phase is the selection of appropriate implant
components and restorative materials, taking into account factors such as implant design, abutment
morphology, esthetic requirements, and biomechanical considerations 6. With the proliferation of
implant systems and prosthetic options in the market, clinicians are faced with the task of navigating a
complex landscape of choices, each with its own advantages, limitations, and indications 7.
Furthermore, advancements in digital dentistry have revolutionized the prosthetic workflow, offering
new avenues for enhanced precision, efficiency, and esthetic outcomes. Computer-aided design and
manufacturing (CAD/CAM) technologies, intraoral scanning systems, and virtual implant planning
software have transformed the way implant-supported restorations are designed, fabricated, and
delivered, offering clinicians unprecedented control and predictability in treatment outcomes 8.

Despite these advancements, challenges persist in this phase, ranging from technical complications
such as implant misfit and screw loosening to biological issues such as peri-implant inflammation and
soft tissue recession9. Addressing these challenges requires a multidisciplinary approach, with close
collaboration between clinicians and dental laboratory technicians to achieve optimal outcomes and
long-term success.

This dissertation endeavors to undertake a comprehensive appraisal of the prosthetic armamentarium

in implant dentistry, elucidating the clinical indications, advantages, and limitations of different
prosthetic modalities. By drawing insights from existing literature, clinical case studies, and patient
experiences, this research seeks to shed light on the nuances of prosthetic decision-making, providing
practitioners with a roadmap for navigating the complexities of implant prosthodontics and delivering
personalized, evidence-based care to their patients.

In conclusion, the exploration of prosthetic options in implant dentistry underscores the

transformative potential of interdisciplinary collaboration in modern dental practice. By unraveling
the multifaceted landscape of implant-supported prostheses, this dissertation aims to empower
prosthodontic practitioners with the knowledge and insights necessary to navigate the evolving
landscape of implant dentistry, thereby advancing the frontiers of oral rehabilitation and improving
the quality of life for patients worldwide.

REVIEW OF LITERATURE:

Carl E. Misch in (1989)10 put forward five prosthetic choices for implant dentistry. The initial three
options constitute fixed prostheses (FPs), which can replace partial (one or several teeth) or complete
dentitions and can be either cemented or screw-retained. Their purpose is to convey the visual
appearance of the eventual prosthesis to all members of the implant team. These options are
determined by the extent of replacement of both hard and soft tissue structures, as well as the aesthetic
considerations within the esthetic zone. A common feature among all fixed options is that they cannot
be removed by the patient. The remaining two types of final implant restorations are removable
prostheses (RPs), which rely on the level of implant support rather than the appearance of the
prosthesis.

FP-1 Fixed prosthesis; replaces only the crown; looks like a natural tooth

FP-2 Fixed prosthesis; replaces the crown and a portion of the root; crown contour appears normal
in the occlusal half but is elongated or hyper-contoured in the gingival half

FP-3 Fixed prosthesis; replaces missing crowns and gingival color and portion of the edentulous
site; prosthesis most often uses denture teeth and acrylic gingiva, but may be porcelain to metal

RP-4 Removable prosthesis; overdenture supported completely by implant

RP-5 Removable prosthesis; overdenture supported by both soft tissue and implant

Carr AB et al (1996)11 In this study he reviews the fundamental concepts related to the use of screws
and presents data describing the effect of fabrication, finishing, and polishing procedures on as-
received preload for implant cylinders. Specifically, this study measured and compared preload
produced when using as-received gold cylinders (the reference or gold standard), and cast cylinders
produced from premade gold and plastic cylinders in the as-cast condition and following post cast
finishing and polishing manipulations. The results reveal that preload in the gold screw-gold cylinder-
abutment joint can be affected by the casting process, and that the choice of cylinder type, casting
alloy, investment, and finishing/polishing technique may affect the resultant preload as compared to
as-received joint conditions. The data from this study indicate that when plastic patterns are used as
part of the framework, finishing and polishing of implant cylinder components should provide an
increased preload compared to no such manipulations. Also, if maximum preload is desired, the use of
premade metal cylinders offers an advantage over plastic patterns in both preload magnitude and
precision.

Becker W et al in (1997)12 Perform their study on "Alveolar bone anatomic profiles as measured
from dry skulls". The purpose of this study was to evaluate the relationship of alveolar bone
morphology to tooth shape and form. The mean number of dehiscences for flat and scalloped skulls
was 0.5. The average number of dehiscences for pronounced scalloped was 1. There were no
significant differences when tooth shapes were compared with bone anatomy. Pronounced scalloped
anatomic profiles were slightly narrower when compared with the other groups.
Nicholson L (1997)13 In his article "Transfer index of multiple angulated abutments in the restoration
of an edentulous maxilla", describes a procedure for fabricating an index to accurately transfer the
ideal position of several 17-degree angulated abutments from the master cast to the mouth in a
predictable way. After the final try-in, evaluation of the space available and angulation of the implants
is made to choose the appropriate abutments within the contours of the final restoration. A customized
index was also developed to accurately transfer the position of those 17- degree angulated abutments
from the master cast to the mouth in a precise manner.

Byrne D et al in (1998)14 perform their study to assess the adaptation of premachined, cast, and
laboratory modified pre-machined abutments to implants at two sites: abutment/implant interface and
screw to screw seat. There are six combinations of abutments and implants were studied: CeraOne
abutments joined to Nobel Biocare implants; STR (Implant Innovations Inc.) abutments joined to 31
implants; Cast UCLA (31) abutments subjected to porcelain firing cycles and joined to 31 implants;
Cast UCLA abutments subjected to porcelain firing cycles and joined to Nobel Biocare implants;
UCLA pre-machined abutments cast with gold palladium alloy and subjected to porcelain firing
cycles (later joined to 31 implants); and UCLA pre-machined abutments joined to 31 implants. Each
group contained five assemblies. The adaptation of abutments to implants was closer and the amounts
of contact larger for assemblies with pre-machined and laboratory modified pre-machined abutments
than for those with cast abutments. So conclusion was that the finishing of custom-made abutments
requires further refinement.

Barzilay I in (1999)15 presented a clinical report "Maintenance of gingival contour during

prosthodontic procedures". He describes a simple and quick method of temporarily maintaining the
tissue profile. The method described in his report will maintain any gingival contour. However, care
must be taken that when removing the registration, material is not inadvertently left behind in the
implant, which may create an impediment to seating of the fixation screw.

El-Askary AS (2000)16 In his clinical report titled "Autogenous and allogenous bone grating
techniques to maximize aesthetics " describe that the corticocancellous graft is one of the predictable
methods in restoring bony defects because it produces proper bone framing around the implant, even
after remodelling. The use of Autogenous bone grafts has shown advantages over the use of
allogenous ones. We prefer to use Autogenous bone grafts in situations of extensive bone loss, and
allogenous bone grafts when small fenestration, labial dehiscence, or extraction sockets are present.
Accurate grafting procedures, whether allogenous or Autogenous, should be undertaken with caution
to obtain the desired osseous support for the implant at the required position that enables the
prosthodontist to restore both function and esthetics.

Chaimattayompol N et al in (2001)17 in their article "Use of a cross-mounting buccal index to help

transfer the spatial relationships of an interim prosthesis to the definitive implant-supported
prosthesis", describe a new method for the fabrication of an index for definitive implant abutment
selection, framework design, and fabrication. After the interim removable restoration is esthetically
and functionally accepted by the patient and dentist, it can be used as a surgical guide during implant
placement as well as a guide for abutment selection, framework design, and fabrication. The concepts
used in the fabrication of the cross-mounting buccal index include having a reference point,
maintaining the vertical dimension of occlusion, and supplying the ability for cross mounting.

Jeong YT et al in (2001)18 performed their study to evaluate screw joint stability through the analysis
of fitness at the mating thread surfaces between implant and screw after tightening screws made of
different materials. In titanium alloy screw, irregular contact and relatively large gap was present at
mating thread surface. Also in teflon-coated titanium screw, incomplete seating and only partially
contact was present at the mating thread surface. In gold-plated gold-palladium alloy screw, relatively
close and tight contact without the presence of large gap was present by existing of gold coating at the
mating thread surfaces. In gold alloy screw, relatively small gap between the mating components was
seen. This result suggested that gold plated gold-palladium alloy screw and gold alloy screw achieved
a greater degree of contact at the mating thread surfaces compared to titanium alloy screw and teflon-
coated titanium alloy screw.

Chaimattayompol N et al in (2002)19 in their article "Transforming an existing fixed provisional

prosthesis into an implant-supported fixed provisional prosthesis with the use of healing abutments",
focuse on the treatment phase in which teeth and/or transitional implants supporting a provisional
fixed partial denture are removed. The described technique makes use of healing abutments to support
a modified provisional fixed partial denture. This protocol ensures patient comfort and allows proper
soft tissue healing before definitive implant abutment selection. It also eliminates the placement of
interim implant abutments.
Grossmann Y et al in (2002)20 described the treatment options to correct severe implant
misalignment vary depending on clinical parameters but usually include the following:

(1) Implant removal,

(2) Transformation of the implant into a "sleeper," and

(3) Restoration with the misaligned implant.

They described the prosthetic restoration of implants in positions that compromised routine restorative
procedures. Prosthetic treatment included a separate impression for each implant, fabrication of
specifically designed custom abutments, transfer to a common working cast for finalization
procedures, and FPD fabrication. This treatment yielded a clinically stable result.

Finger IM et al in (2003)21 stated that the indications for implant dentistry continue to increase,
enabling the restoration of partially and totally edentulous patients with greater success and
predictability. Recent goals for implant dentistry include simplifying the involved procedures,
reducing the duration of therapy for the patient and clinician, and enabling the use of conventional
prosthodontic techniques for implant-supported restorations. Their article reviews key developments
in implantology and highlights the various design characteristics of internal abutment connection
implants, demonstrating their clinical application in a detailed case presentation.

Park CL at el in (2004)22 In their article regardless of the type of performed restoration, in most
cases, a screw connection is employed between the abutment and implant. For this reason, implant
screw loosening has remained a problem in restorative practices. The purpose of this study was to
compare the surface of coated/plated screws with titanium and gold alloy screws and to evaluate the
physical properties of coated/plated material after scratch tests via FE-SEM (field emission scanning
electron microscopy) investigation. GoldTite, titanium screws provided by 3i (Implant Innovation,
USA) and TorTite, titanium screws by Steri-Oss (Nobel Biocare, USA) and gold screws and titanium
screws by AVANA (Osstem Implant, Korea were selected for this study. The surface, crest, and root
of the abutment screws were observed by FE-SEM. A micro-diamond needle was also prepared for
the scratch test. Each abutment screw was fixed, and a scratch on the surface of the head region was
made at constant load and thereafter the fine trace was observed with FE-SEM. The surface of
GoldTite was smoother than that of other screws and it also had abundant ductility and malleability
compared with titanium and gold screws. The scratch tests also revealed that teflon particles were
exfoliated easily in the screw coated with teflon. The titanium screw had rough surface and low
ductility. The clinical use of gold-plated screws is recommended as a means of preventing screw
loosening.

Neves FD et al (2004)23 in their study entitled "Analysis of influence of lip line and lip support in
aesthetics and selection of maxillary implant-supported prosthesis design". The lip line and lip support
influence aesthetics and selection of implant-supported prosthetic designs for maxillary edentulous
patients. They describe a procedure to analyse the influence of lip line and lip support on the
aesthetics of an existing maxillary complete denture, revealing potential limitations when planning a
fixed implant-supported prosthesis.

Jivraj S et al in (2006)24 stated that the predictability of successful osseointegrated implant

rehabilitation of the edentulous jaw as described by Branemark et al., introduced a new era of
management for the edentulous predicament. Implant rehabilitation of the edentulous maxilla remains
one of the most complex restorative challenges because of the number of variables that affect both the
aesthetic and functional aspect of the prosthesis. Among the prosthesis designs used to treat the
edentulous maxilla are fixed or removable implant-supported restorations. Since the aesthetic
requirements and preoperative situation of each patient varies, considerable time must be spent on
accurate diagnosis to ensure patient desires are satisfied and predictable outcomes are achieved. The
purpose of this article is to compare the treatment options and prosthesis designs for the edentulous
maxilla. Emphasis will be placed on diagnosis and treatment planning. Criteria will be given to guide
the practitioner in deciding whether a fixed or removable restoration should be placed. This objective
will be accomplished through the review of cases with regard to varying design considerations and
factors that influence the decision-making process.

Rosner O et al in (2006)25 In their article "Use of a provisional restoration as a radiographic guide

prior to implant placement", describe that the radiographic imaging using radiographic guides
provides necessary data required for the clinician to accurately select implant dimensions, as well as
to plan implant placement, position, and angulation in advance. They presented a novel approach in
which the provisional restoration serves as the radiographic template, thus eliminating the
disadvantages and difficulties involved in the duplication processes.

Chee W et al in (2006)26 stated that the Implant supported restorations can be attached to implants
with screws or can be cemented to abutments which are secured to implants with screws. Screw
retained implant restorations are the authors' preferred method of securing restorations to implants.
They discuss the advantages and disadvantages of each method of retention will be covered under the
following headings: Aesthetics, Retrievability, Retention, Implant placement, Passivity, Provisionals,
Occlusion, Immediate loading, Impression procedures, Long term treatment planning.

Hagiwara Y et al (2007)27 In their article "The use of customized implant frameworks with gingiva-
colored composite resin to restore deficient gingival architecture", describe a technique for fabricating
cement-retained crowns over a customized gingiva coloured composite resin screw-retained implant
infrastructure. This prosthetic design is not significantly influenced by unsuitable implant position,
alignment, or angulation. Consequently, the cement-retained crowns can be reproduced in an
esthetically and functionally appropriate morphology, regardless of where the screw-access openings
are located in the infrastructure.

Oh WS et al in (2008)28 in their article “Use of a thermoplastic vacuum-formed matrix for secure

engagement of an implant surgical template”, describe a method of using a thermoplastic sheet to
engage the remaining dentition, which serves as a matrix to which the acrylic resin DRPD will attach,
and permits stable and secure intraoral placement of the denture for successful implant placement.

Zitmann NU et al in (2008)29 discussed that as in any dental treatment procedure, a thorough patient
assessment is a prerequisite for adequate treatment planning including dental implants. Patient
assessment included the following aspects: (1) evaluation of patient's history, his/her complaints,
desires and preferences; (2) extra-and intra-oral examination with periodontal and restorative status of
the remaining dentition; (3)obligatory prerequisites were a panoramic radiograph and periapical
radiographs (at least from the adjacent teeth) for diagnosis and treatment planning. Additional
tomographs are required depending on the anatomic situation and the complexity of the planned
restoration; (4) study casts are needed especially in more complex situations also requiring a
diagnostic set-up, which can be tried-in and transferred into a provisional restoration as well as into a
radiographic and surgical template. The current review clearly revealed the necessity for a thorough,
structured patient assessment. Following an evaluation, a recommendation is given for implant
therapy or, if not indicated, conventional treatment alternatives can be presented.

Oguz Eraslan et al in (2010)30 in their study showed that the use of a concave design in the pontic
frameworks of fixed partial dentures increases the von Mises stress levels on implant abutments and
supporting bone structure. However, the veneering porcelain element reduces the effect of the
framework and compensates for design weaknesses.

Gary Orentlicher et al in (2019)31 have noted that recently introduced treatment approaches for
complete-arch cases involve utilizing three implants along with off-the-shelf metal bars and adjustable
abutments. Additionally, techniques utilizing stackable bone reduction guides, implant placement
guides, and digitally planned provisional restorations, created prior to implant surgery, have expanded
treatment options. Digital technologies, employing 3D assessment for dental implants through optical
scanning, CT-guided software programs, and specialized surgical and laboratory tools, enable precise
and reliable treatment outcomes.

The adoption of CT-guided methodology streamlines surgical and restorative processes while
adhering to fundamental principles of implant dentistry, such as accurate diagnosis and patient
selection.

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