WWW.DENTALLEARNING.NET VOLUME 4 | ISSUE 1 DENTAL LEARNING A PEER REVIEWED PUBLICATION Knowledge for Clinical Practice Current Protocols for Posterior Single Implant- supported Restorations Scott MacLean, DDS, FADI, FACD, FICD, FPFA

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Current Protocols for Posterior Single Implant-supported Restorations

ABSTRACT EDUCATIONAL OBJECTIVES Current options for posterior single implant-supported restora- The overall goal of this article is to provide the reader with tions allow for shorter treatment times and earlier restorative care information on posterior implant-supported restorations. After for patients. For all protocols, careful treatment planning is critical, completing this article, the reader should be able to: and is aided by the use of CT and/or CBCT imaging as well as 1. Describe anatomical and other considerations during implant software that helps the clinician with the identifi cation of relevant treatment planning; structures and with overall treatment planning. Primary implant 2. Review the use of software during implant treatment planning; stability, , and soft-tissue contouring are all af- 3. List and describe aspects of implant design that affect primary fected by the surgical phase, and soft tissues are affected by the implant stability; and restorative phase. Careful consideration should be given to these 4. Delineate abutment and retention options and the evidence aspects for all stages of implant therapy. for these.

ABOUT THE AUTHOR Scott MacLean, DDS, FADI, FACD, FICD, FPFA - Dr. reatment options for the replacement of missing Scott MacLean is currently a part-time clinical profes- teeth have expanded substantially since the sor at the Dalhousie University Dental Clinic. He was involved with the "Implant Elective” and the “Advanced Tintroduction of modern, root-form endosseous Restorative Elective" for over 10 years, and practices dental implants, which offer excellent long-term out- general dentistry in Halifax, Nova Scotia, with a large component of comes with suitable case selection and clinical care. The his practice focused on implant and esthetic dentistry. He was recently standard protocol 2 decades ago for all indications calibrated as number one out of 60 participants in an international required that implants were only placed in healed sockets speakers training program and has published articles internationally (ridges) and submerged to remain undisturbed during on implant dentistry. Dr. MacLean is the director of the AIM4 Excel- osseointegration (two-stage surgical technique). Since lence Atlantic Canada Seattle Study Club. He is a member of the then, implants have been developed and protocols International Congress of Oral Implantologists (ICOI), the Canadian Academy of Restorative (CARDP), the CAED, and evaluated that offer more rapid and less invasive treat- the American Academy of (AACD). He also has a ment without compromise or possibly even with im- YouTube following with a channel dedicated to implant dentistry called provements by becoming less invasive and more precise. “The YouTube Dentist.” He is a Fellow of the Academy of Dentistry International, the Pierre Fauchard Academy, the International College Current protocols for posterior single implants of Dentists and the American College of Dentists. AUTHOR DISCLO- Current protocols for posterior single implants include SURE: Dr. MacLean lectures for Nobel Biocare. He can be reached at immediate, early, or delayed implant placement relative Twitter@drscottmaclean.

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

to the time of tooth removal; submerged two-stage proce- CT scan studies,2,4 the greatest risk is at mandibular second dures or one-stage procedures using a healing abutment and molar sites and at least three times greater than other poste- avoiding the second surgery (required to uncover submerged rior sites. It is important for the clinician to understand the implants); and immediate, early, or delayed temporization relative position of arteries such as the submental artery to and/or loading. Single, implant-supported posterior restora- avoid very rare but important-to-understand complications. tions offer high survival and success rates with these proto- A small proportion of the population has an incisive branch cols when the individual case is carefully selected. of the mental nerve. This should be isolated on CT and dis- cussed with the patient prior to surgery. Lastly, posterior ridge Treatment Planning for Posterior Dental Implants resorption has implications for the fi nal occlusion in addition Case selection is important to avoid failures. There are to increasing the risk to anatomical structures—as the ridge few systemic health contraindications to implant therapy, and resorbs, it typically leads to a crossbite setup, especially if research supports treatment in patients with diabetes mel- maxillary ridge resorption also occurs. litus (unless uncontrolled), cardiac disease, or osteoporosis.1 It is generally recommended that a minimum of 2 mm Although smokers have been found to experience greater of bone height be preserved as a safety margin between the marginal bone loss than nonsmokers, smoking tobacco is also inferior alveolar nerve on the one end and between both the not considered a contraindication. A full medical history is es- site preparation drilling and the implant on the other.3 If this sential to consider all potential absolute and relative contrain- would not be possible, alternatives include dications. Local contraindications must be considered, includ- and delayed implant placement, the use of short implants ing but not limited to anatomical structures, lack of bone, and (or highly invasive specialist nerve repositioning), or provid- parafunctional habits. Anatomical considerations are critical ing an alternative treatment. when planning mandibular and maxillary implants. Maxillary Implants Mandibular Implants The most obvious anatomical landmark to consider is The inferior alveolar nerve is the most critical anatomical the position of the maxillary sinus. This tends to pneuma- landmark, and poor treatment planning can result in iatro- tize once the tooth has been extracted. If the sinus drops genic nerve injury during implant placement with outcomes too much, then bone grafting may be required to provide that include paresthesia, a complete absence of sensation, or adequate bone for primary implant stability. If bone grafting pain. Although 2-dimensional radiographs have historically is required, it is prudent to assess the patency of the ostium been used to assess anatomical structures and bone prior to (the entrance and exit point of the sinus entering into the implant placement, these cannot produce an accurate 3- middle meatus of the nasal cavity). Other areas of interest dimensional assessment. Risk assessment using computer- include the buccal undercut in the anterior maxilla; this ized tomography (CT scans) has shown that <6 mm of bone area can be palpated or reviewed using 3D images to plan separated the inferior alveolar canal from teeth in 73% and implant angulation and depth. Lastly, maxillary bone den- 53% of mandibular second and fi rst molars respectively, sity may be a concern. The bone has a thinner cortex and a and 65% of second bicuspids.2 larger spongy bone area than the mandible, which enhances The inferior alveolar canal including an anterior loop, blood supply to osteotomy sites but also may compromise as well as the position of the lingual and sublingual arteries, the stability of the bone. must be considered. Undercuts and/or anatomical concavities in the lingual area of the lower mandible may present a risk Treatment Planning, Anatomical Structures and Software for lingual plate perforation.3 Based on CBCT (virtual) and In addition to CT/CBCT, is now improv-

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ing the diagnostic and planning phases of implant treatment. mesio-distal bone length may necessitate use of a narrow Software is available that guides clinicians through the whole diameter implant or a different solution. treatment planning process after patient details and images have been uploaded. This software helps the clinician inspect Implant Depth and Angulation the anatomy using panoramic views, 3-D digital reconstruc- It is important to pre-operatively determine implant tions of the arch, thin slices, and cross-sectional slices from depth and angulation necessary to provide the inter-arch any point along the arch. For example, mapping out the path and intra-arch prosthetic space required for restoration and of the inferior dental nerve using these tools leads to a more adequate long-term strength. Although­ less critical in the accurate understanding of its position as well as the mental posterior region, the distance from the proposed restorative foramen and mental nerve. In addition the software can now contact point to the crestal bone should be considered. use a fusion technique to bring a digital scan of the wax-up A distance of more than 5 mm results in poor papillary and model into the CT/CBCT software to plan the implant form.5,6 Implant angulation is determined by the best com- placement based on the final prosthetics. This software can bination of safely utilizing available bone and soft tissue 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 Figure 1. Virtual implant superimposed in a 3-D view 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

TABLE 1. Dimensional recommendations for implant and bone Bone between implant and At least 2 mm key anatomical structures Bone lingual to the implant At least 2 mm

Bone buccal to the implant At least 2 mm Bone between implant and Figure 2. Cross-sectional diagrammatic view At least 1.5 mm adjacent teeth

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relative to the planned tooth cervical emergence from the ment relative to the occurrence of tooth extraction are sup- implant and axial trajectory toward the occlusal surface. ported for posterior implants: Nonsplinted implants should be placed such that they • Delayed implant placement, waiting 6 months for the will be loaded axially over the implant body, as any angula- alveolar ridge to completely heal tion would be detrimental and magnify the forces on non- • Immediate-delayed implant placement, waiting 2 splinted implants. The position of the screw channel is also months post-extraction before implant placement impacted by implant angulation. Ideally, the screw channel • Immediate implant placement at the time of tooth should be in the central fossa of a screw-retained crown. extraction. In addition, if the restoration will be cement-retained, it is In a 2010 Cochrane review, based on 2 randomized desirable to have an abutment screw channel that could be controlled clinical trials with implant in function for at accessed by cutting a channel through the implant crown if least 1 year, no statistically signifi cant differences in failure the abutment screw were to loosen. rates, complications, peri-implant bone levels, or esthetic With digital software, it is possible to view 3D models outcomes were found when comparing immediate versus and cross-sections, showing the anatomical dimensions and delayed implant placement.7 A more recent review by Lang angulation of an implant diagrammatically and virtually et al of 46 prospective studies with a mean follow-up of 2 (Figures 1 and 2). Prosthetic planning can be enhanced by years (minimum 1 year) estimated an average 2-year sur- using "smart fusion" technology. Clinicians can now scan vival rate of 98.4% (range 97.3% to 99%) and an average models and wax-ups of the patient’s arch in order to fuse 97.5% 4-year survival rate (p<0.05) for immediately placed these with a dicom-based CT scan. The fusion of the digital implants.8 These rates are similar to those observed with de- X-ray with the digital models shows the clinician the virtual layed placement. Ridge preservation bone grafting has been problems and concerns prior to surgery, and the implant recommended to help preserve the alveolar ridge following team can see the proposed relative position of the implant extractions in delayed placement cases, with some studies to the fi nal crown/bridge. This enables the planning team to showing reduced alveolar bone loss in grafted vs nongrafted place the implant so that the fi nal outcome is ideal based on sites.9-11 For ridge preservation, bone grafting typically takes both occlusion and bone volumes. Once the plan has been 5 months to heal prior to implant placement. created, a stereolythic surgical template can be fabricated to Immediate implant placement at the time of extraction aid placement of the implant in the ideal position, controlling reduces the number of surgical interventions, the length of both depth and angulation. During surgery the guide helps time before the patient has a functional loaded implant, and the surgeon place the implant in the position created on the reduces patient discomfort.12 It has been suggested that im- planning software. Anatomical landmarks such as the nerve mediate implant placement reduces crestal bone loss. Based and sinus can be visualized using this technology. on a recent review of clinical trials, however, no statistically Adjustments can be made in the software virtually until signifi cant differences in crestal bone levels were found in the optimal solution is found for a successful surgical and short-, medium-, or long-term follow-up studies.13 restorative outcome. Software also may allow the clinician When a tooth is extracted, the implant is usually smaller to perform a “virtual extraction” and examine the shape and and in a different position than the original tooth. For dimensions of the resulting “virtual socket.” Implants can then example, in the anterior the implant is placed in a lingual be virtually selected and placed in these sockets to determine position leaving a buccal jump gap anterior to the implant. implant size and suitable depth, bone height, width and vol- It has been recommended that this space be bone grafted ume, and implant angulation. to prevent collapse of the buccal plate. Bone grafting is recommended if the space between the implant and the Immediate vs Delayed Implant Placement socket wall is more than 2 mm.14 Whether immediate Three protocols regarding the timing of implant place- implant placement may help limit buccal mucosal recession

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is debatable. Outcomes from available studies are mixed osseointegration. Research has led to the conclusion that with findings of no statistically significant differences at 2 implant micromotion should ideally be limited to 100 μm years,15 less recession buccally than lingually in a 5-year and that implant micromovement in excess of 150 μm can study,16 and conclusions from one review that there were result in fibrous encapsulation and failure to osseointegrate, no statistically significant differences long-term.13 Lee et al while immediate implants can withstand micromovement found a 0.5 mm to 1 mm reduction in vertical and horizon- in the 50 μm to 150 μm range.25-28 As a point of reference, tal bone 4 to 12 months after immediate implant place- the lateral movement of natural teeth in a healthy dentition ment, correlated to the thickness of the buccal plate.17 ranges from 56 μm to 108 μm.29 For nonsplinted implants it is important to ensure that the implant has nonfunctional The Importance of Biotype loading – this implies no occlusal contact in CR, CO, MI, Facial mucosal recession was reported at a 2009 consen- or in excursive movements. To achieve primary stability in sus conference to be a greater risk with immediately placed extraction sockets, the osteotomy site should extend 3 mm implants, with risk factors including a thin biotype, thin or apical to the socket or there must be 3 mm of bone contact damaged facial bony wall, and positioning of the implant with the walls of the extraction site.28,30 This highlights the too far buccally.18,19 Crestal bone loss has been found to be importance of atraumatic extractions and selection of an greater where thinner buccal bone plate is present (≤1 mm) implant with dimensions suitable for a given extraction site. or where the jumping distance is ≤1 mm.20 There is some evidence that if the thickness of the mucosal tissue is <2.5 Implant Design and Primary Stability mm more bone loss is likely than with a thicker biotype. Implant designs have been modified over time to help Linkevicius et al concluded in their study that thinner soft increase primary implant stability. Thread designs have tissue at the crestal bone level significantly influences crestal been adjusted for width, depth, and pitch – a reduced pitch bone stability, especially when <2 mm thick where distance and increased thread compactness decreases micro- >1 mm of crestal bone loss may then occur compared to motion.31,32 In an implant design with a variable pitch, also thick biotype sites.21 incorporating variable thread angle depths, primary stability was increased with fewer threads. The increased thread pitch Peri-apical Pathology increases stability because the threads are deeper and vari- Immediate implant placement in sites with peri-apical able.33 Variable-thread implant designs, including with im- pathology has historically been debated. In a recent review, it mediate loading in healed sites, was assessed after 36 months was determined that this is not a contraindication if the site is of loading, by Arnhart et al. They found a survival rate in curetted prior to implant placement.22 Two separate large ret- evaluable subjects (n=127) of 97.7% for internal and 96.3% rospective studies by Fugazzotto23 and Bell24 were conducted. for external connection designs, with no statistically signifi- Fugazzotto placed 418 implants in sites with peri-apical pa- thology with a 97.8% survival rate and a mean follow-up of TABLE 2. Factors improving primary implant stability more than 5 years;23 Bell found a survival rate of 97.5% for 655 implants. No differences in survival rates were observed Increased thread compactness between sites with or without peri-apical pathology.24 The Thread pitch ability to achieve primary implant stability is still a prerequi- Variable thread design site, and curettage of the site prior to implant placement and post-operative antibiotics are recommended. Rough implant surfaces Higher bone density Primary Implant Stability Primary implant stability is an important factor for Intact socket walls in immediate implant placement cases

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cant difference and stable bone levels after initial healing.34 Implant Surface In patients receiving implants with variable-thread designs, Roughened implant surfaces were developed based on in partially edentulous mandibles and maxillae, the cumula- the concept of increasing the available surface area for tive survival rate was 97.7%. Additional factors infl uencing osseointegration. primary implant stability are discussed below (Table 2). Several types of roughened surfaces have been shown to offer successful outcomes for immediate, early, and delayed Primary loading (insertion) torque loading including in the posterior mandible and to increase os- There is a strong correlation between lower initial inser- seointegration.40-46 A 10-year study on implants with a porous tion torques and implant failures.35 In one study using ISQ oxidized microtexture surface (TiUnite®, Nobel Biocare) found measurements to assess primary implant stability, it was a cumulative survival rate of 98% for evaluable implants in found that stability may be lower for immediate implant healed sites and 96.5% for immediate implant placement, placement but that this difference was lost over time and with stable marginal bone levels and a total mean marginal did not affect outcomes.15 Research also supports immediate bone loss of 1.93 mm and 1.98 mm respectively.47 This surface loading if a primary loading torque of 40 Ncm to 45 Ncm has a high crystallinity and phosphorus ceramic-like qualities can be achieved during implant placement.28 Thread design and micropores for high osteoconductivity and fast anchorage infl uences the primary loading torque that can be achieved. of newly formed bone, with the objective of decreasing healing times. Microtextured rough surfaces are also suitable for the Immediate, Early, and Delayed Loading promotion of osseointegration in immediate implant place- Traditionally, implants were loaded 3 to 8 months after ment cases involving lower quality, soft bone as demonstrated placement (i.e., following osseointegration). Immediate and by outcomes in a 7-year study with a cumulative implant early loading of implants (1 week to 2 months post-place- survival rate of 97.1% where 76% were placed in soft bone ment) has been recommended to decrease treatment times. and the majority were posterior implants.48 High survival and success rates have been observed with immediate loading.36-38 In a review of 19 studies, an overall Platform Switching 95.5% survival rate after 12 months was observed, with no Platform switching has been proposed to help preserve statistically signifi cant differences in survival rates for im- crestal bone. mediate, early, or delayed single implant placement.37 A 2012 One review found no signifi cant differences in crestal bone review of immediately loaded implants in 9 studies (including preservation for switched and non-switched platforms,49 and single, FPDs, and removable restorations) cited an implant a small study of 32 implants found no differences in the pres- survival rate range from 95.8% to 100%, and success rates ence or level of infl ammatory cells and biomarkers associated for mandibular implants of 79% to 100%. The research- with bone loss after prolonged intraoral exposure of abut- ers concluded that immediate loading was predictable for ments.50 In contrast, a pilot study using CBCT scans found mandibular implants.38 Esposito et al reviewed clinical trials greater crestal bone loss at the abutment-implant interface with different loading times and occlusal vs nonocclusal load- level in a separate study.51 The conclusion from the systematic ing, and found no clinically relevant differences for implant review and meta-analysis by Atieh et al, based on 10 studies survival rates, prosthesis failure rates, or loss of crestal bone.39 with 1,239 implants, was that there was statistically signifi - Immediate loading protocols are supported in the litera- cantly less crestal bone loss associated with platform-switched ture if the implant has a minimum stability of 35 Ncm when implants than non-platform-switched implants (p<0.0001).52 challenged with further rotation and the healing structure is A recent study yielded a 100% survival rate, with statistically non-functionally loaded. If the implant is splinted to another signifi cantly less marginal bone loss with internal connection implant, then the loading capabilities can sometimes be full platform-switched than non-platform-switched external con- functional load. nection implants.53

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A minimum vertical thickness of 2.5 mm of soft tissue is in microleakage, and represent a risk for peri-implantitis.55 recommended for an adequate soft-tissue seal. Ensuring use of components with a tight fit is essential. The implant and abutment also share a mating hexagon at the Emergence Profile base of the conical connection. This is available for indexing The goal is to have an emergence profile that is not too purposes to enable orientation transfer between clinical and wide so that the buccal bone plate architecture is ideal, laboratory components and restorations. while also creating a soft-tissue seal to maintain bone. The Contentious debate has arisen over screw-retained vs emergence buccal lingually is often the limiting factor for cement-retained options. Wilson found that patients with peri- implant size since the width of the bone narrows after tooth implant disease often had cement trapped under the abutment loss, while the mesial distal length is typically not problem- areas of implants. Eighty-one percent of the patients with peri- atic. An emergence profile shaped like a wineglass with the implant disease had residual cement. Once the cement was shape leaving the implant platform and reaching the contact removed, in 74% the peri-implant disease resolved.56 point on a smooth angle similar to the posterior tooth In the past, if the implant was angled to the facial aspect, anatomy achieves these objectives. Using a wider implant then a typical screw-retained option through the occlusal helps to create this ideal emergence. The implant should surface was not possible. An abutment had to be fabricated be submerged sufficiently to maintain a minimum 2.5 mm and then a crown was made to cement over the screw chan- depth from the anticipated soft tissue crest to the implant nel exiting through the facial aspect. platform to provide adequate soft tissue volume and create Recently, angulated screw channels (ASC) have been an emergence profile that prevents food entrapment. If the designed to provide zirconia-based solutions allowing more implant is not placed deeply enough, then the emergence flexibility in securing the abutment. In the posterior region, profile leads to food impaction. this is particularly advantageous when limited work- ing space is available. ASC abutments have improved the Abutment Design and Placement conical internal implant-abutment interface by having a Stock abutments were originally available as straight abut- titanium adapter that supports the zirconia abutment. One ments, and angled abutments were introduced that gave more of the most important benefits is the strength of the mate- flexibility for implant placement to meet anatomical demands rial while reducing the cost. For porcelain-fused-to-gold and restorative requirements. One concern is the lack of cus- restorations the cost of the gold can be very high since the tomization impacting the ability to have crown margins at an restoration is not merely a shell but rather places the tooth appropriate level for esthetics as well as for cement cleanup and some bone as a solid core. Since gold is a commodity, at insertion. CAD/CAM ceramic custom abutments have the price vs zirconia can be quite a bit more. The zirconia increased treatment options and improved esthetics. has a yttrium stabilized structure with a 1400 MPa tensile The fit/seal between abutments and implants is critical, strength which is higher than for the gold alloys used in as is lack of rotation to prevent screw loosening. Abutment porcelain-fused-to-metal restorations. Furthermore many screw loosening was found to be uncommon in a review companies are moving towards monolithic zirconia which of 12 studies and 586 single implant restorations with eliminates the porcelain layering technique. The case pre- “complication-free” success rates of 97.3% for external sentation below demonstrates the use of a single implant- connections. For internal connections (1,113), this was supported platform-switched and screw-retained posterior 98.6%.54 There are various internal connections used restoration. today. Many implant systems have used the conical con- nection design to maximize the tight fit of the abutment Case Presentation to the implant and minimize any potential complications The patient was a 63-year-old man in excellent general due to bacterial leakage at this interface. Microgaps result health and with good periodontal health. He presented with

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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 3. Hopeless lower fi rst molar

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

Figure 5. Fractured root tip in the extraction site Figure 6. Socket following atraumatic extraction Note the preservation of soft tissue

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Figure 7. NobelGuide® surgical template Figure 8. Seating the implant with the implant driver 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 Figure 9. Post-placement radiograph using the free 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 Figure 10. A 5 mm-high healing abutment was placed during bone grafting the implant begins to engage, the objective is for seating

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Figure 11. Placement of the PEEK healing abutment Figure 12a. Soft tissue contour 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- Figure 12b and c. Impression coping seated 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- Figure 13. Soft tissue model plant position and a healing abutment was placed (Figures

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Figure 14a. CAD/CAM assessment of space Figure 15. Completed restoration with the porcelain layer over the zirconia abutment

Figure 14b. CAD/CAM planning of abutment on soft Figure 16a. Seated crown 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- Figure 16b. Seated crown after covering the screw access ics (amoxicillin 500 mg, 3 times a day) 24 hours before the channel

12 VOLUME 4 | ISSUE 1 Current Protocols for Posterior Single Implant-supported Restorations

treatment and would continue taking these 3 times per day the implant conical connection and serving as a precise for 7 days postoperatively. Osseointegration was allowed to friction-fi t pedestal base for the zirconia abutment. This adds occur for 3 months after the implant and PEEK healing abut- strength by using titanium instead of zirconia for the internal ment were placed before fabrication of the crown restoration connection that could be subjected to fl exural forces, while began. preserving biocompatibility. The precision fi t of the zirconia/ The PEEK healing abutment was removed and an open titanium adapter interface does not use or require a luting tray impression was performed using a fl ared impression agent, thereby eliminating the breakdown of an adhesive coping to pick up the soft tissue emer gence that was created bond as a potential risk. using the PEEK healing abutment (Figure 12a). Prior to the The clinician can choose layered porcelain over the zirco- impression an X-ray was used to confi rm the seating of the nia or monolithic zirconia, which means that the complete impression coping (Figures 12b and 12c). The remaining tis- crown is fabricated in one solid core of zirconia. When sue emergence was picked up with the impression coping and veneering porcelain is desired, the complete crown/abutment polyether injected around the impression coping. A color was is designed as full contour and then a cutback is made for the selected using the 3D Vita shade master guide and a “Vita veneering porcelain only. easyshade compact” tool. The lab technician poured the stone Since the channel is in zirconia it is easier to disguise model using a soft-tissue material around the replica (Figure when the restorative resin is placed compared to the darkness 13). This enables the technician to remove the soft tissue scan observed with metal substructures. By using the ASC crown, during scanning. The model was multiple-scanned using the the technician could move the channel to the ideal position. scanner (NobelProcera). The technician scans the position of Once the fi nal crown is designed, the dental technician uses the replica as well as the soft-tissue profi le. This ensures that a software tool to reduce the overall dimension by 1 mm. the emer gence of the PEEK healing abutment is visualized The fi nal design was sent via private secure internet (Nobel- on the scanned digital model. The technician used software Connect) to the centralized milling center (Figures 14a and (NobelProcera) to create a 3D model. 14b). The abutment was milled on a CNC milling machine Restoration had been planned using a one piece screw- and returned to the technician. The technician added the retained porcelain-to-zirconia restoration attached directly porcelain and delivered the fi nal contoured crown to the to the implant. This provides a robust restoration with full dental offi ce for fi nal delivery (Figure 15). control over emergence profi le and eliminates the use of a At the crown delivery appointment, the healing abut- separate abutment with a separate cemented crown. ment was re moved. The porcelain-veneered zirconia crown/ For this patient, an Angulated Screw Channel zirconia abut- abutment with adapter was inserted into the implant as one ment (NobelProcera) was used. This abutment provides the piece and fastened using the Omnigrip™ Clinical Screw and capability to insert and fasten abutment screws to proper torque Screwdriver specifi cations (35 Ncm) through a screw channel that can be The result was an esthetic and functional single lower fi rst angled up to 25 degree from the straight center axis. A screw- molar implant restoration (Figure 16). The patient was given driver and abutment screw interface designed for this purpose instructions and an appointment made for both (Omnigrip™, Nobel Biocare) enables the abutment screw to be a 1-week check and a 3-month implant maintenance visit. fully seated within the implant while being inserted through a channel that may be designed for approaches at angles of up to Conclusions 25 degrees from the implant center axis. Using the SmartFu- Posterior single implant restorations have proven to be sion™ process, such correction may not be required though successful and desirable treatment options. Current proto- it still may be useful for fi nesse in aligning a screw access hole cols give the clinician and patient options with respect to the precisely, for example, to avoid an opposing cusp. length of treatment, timing of phases, whether an immediate This abutment includes a titanium insert extending from replacement will be provided at the time of extraction, and

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30. Al-Harbi SA, Edgin WA. Preservation of soft tissue contours with immediate screw-retained provisional what restorative materials will be used. With suitable case 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- selection, high survival and success rates are found for this 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. design and its relationship therapy. Esthetic restorations that respect biological and 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 ™ functional requirements in the posterior region offer excel- implant. Available at: http://www.oralhealthgroup.com/news/case-report-of-an-immediate-placement-and- temporization-using-the-nobelactive-153-implant/1000229566/ lent solutions for patients. 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 References single-tooth implants. Int J Oral Maxillofac Implants. 2005;20(5):769-76. 1. Gómez-de Diego R, Mang-de la Rosa Mdel R, Romero-Pérez MJ, Cutando-Soriano A, López-Valverde- 36. Ribeiro FS, Pontes AE, Marcantonio E, Piattelli A, Neto RJ, Marcantonio E Jr. Success rate of immedi- Centeno A. Indications and contraindications of dental implants in medically compromised patients: update. ate nonfunctional loaded single-tooth implants: immediate versus delayed implantation. Implant Dent. Med Oral Patol Oral Cir Bucal. 2014;19(5):e483-9. 2008;17(1):109-17. 2. Froum S, Casanova L, Byrne S, Cho SC. Risk assessment before extraction for immediate implant place- 37. den Hartog L, Slater JJ, Vissink A, Meijer HJ, Raghoebar GM. Treatment outcome of immediate, early ment in the posterior mandible: a computerized tomographic scan study. J Periodontol. 2011;82(3):395-402. and conventional single-tooth implants in the aesthetic zone: a systematic review to survival, bone level, soft- 3. Greenstein G, Tarnow D. The mental foramen and nerve: clinical and anatomical factors related to dental tissue, aesthetics and patient satisfac-tion. J Clin Periodontol. 2008;35(12):1073-86. implant placement: a literature review. J Periodontol. 2006;77(12):1933-43. 38. Strub JR, Jurdzik BA, Tuna T. Prognosis of immediately loaded implants and their restorations: a system- 4. Lin MH, Mau LP, Cochran DL, Shieh YS, Huang PH, Huang RY. Risk assessment of inferior alveolar nerve atic literature review. J Oral Rehabil. 2012;39(9):704-17. injury for immediate implant placement in the posterior mandible: a virtual implant placement study. J Dent. 39. Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing teeth: differ- 2014;42(3):263-70. ent times for loading dental implants. Cochrane Database Syst Rev. 2013;3:CD003878. 5. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone 40. Cochran DL, Jackson JM, Jones AA, Jones JD, Kaiser DA, Taylor TD et al. A 5-year prospective multi- on the presence or absence of the interproximal dental papilla. J Periodontol. 1992;63(12):995-6. center clinical trial of non-submerged dental implants with a titanium plasma-sprayed surface in 200 patients. 6. Gastaldo J, Cury PR, Sendyk WR. Effect of the vertical and horizontal distances between adjacent implants J Periodontol. 2011;82(7):990-9. and between a tooth and an implant on the incidence of interproximal papilla. J Periodontol. 2004;75:1242-6. 41. Nelson K, Semper W, Hildebrand D, Özyuvaci H. A retrospective analysis of sandblasted, acid-etched 7. Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Timing of implant placement after tooth implants with reduced healing times with an observation period of up to 5 years. Int J Oral Maxillofac Impl. extraction: immediate, immediate-delayed or delayed implants? A Cochrane systematic review. Eur J Oral 2008;23(4):726-32. Implantol. 2010;3(3):189-205. 42. Balshe AA, Assad DA, Eckert SE, Koka S, Weaver AL. A retrospective study of the survival of smooth- and 8. Lang NP, Lui P, Lau KY, Li KY, Wong MCM. A systematic review on survival and success rates of implants rough-surface dental implants. Int J Oral Maxillofac Impl. 2009;24(6):1113-8. placed immediately into fresh extraction sockets after at least 1 year. Clin Oral Impl Res. 2012;23(Suppl. 43. Ivanoff CJ, Hallgren C, Widmark G, Sennerby L, Wennerberg A. Histologic evaluation of the bone integra- 5):39–66. tion of TiO(2) blasted and turned titanium microimplants in humans. Clin Oral Impl Res. 2001;12(2):128-34. 9. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L, Carda-ropoli G. Socket preservation using bovine 44. George KM, Choi YG, Rieck KL, Van Ess J, Ivancakova R, Carr AB. Immediate restoration with ti-unite bone mineral and collagen membrane: a randomized controlled clinical trial with histologic analysis. Int J implants: practice-based evidence compared with animal study outcomes. Int J Prosthodont. 2011;24(3):199- Perio Restor Dent. 2012;32(4):421-30. 203. 10. Horowitz RA, Mazor Z, Miller RJ, Krauser J, Prasad HS, Rohrer MD. Clinical evaluation alveolar ridge 45. Cordaro L, Torsello F, Roccuzzo M. Implant loading protocols for the partially edentulous posterior man- preservation with a beta-tricalcium phosphate socket graft. Compend Contin Educ Dent. 2009;30(9):588-90, dible. Int J Oral Maxillofac Implants. 2009;24 Suppl:158-68. 592, 594 passim. 46. Cannizzaro G, Leone M. Restoration of partially edentulous patients using dental implants with a microtex- 11. Barone A, Aldini NN, Fini M, Giardino R, Calvo Guirado JL, Covani U. Xenograft versus extraction tured surface: a prospective comparison of delayed and immediate full occlusal loading. Int J Oral Maxillofac alone for ridge preserva-tion after tooth removal: a clinical and histomorphometric study. J Periodontol. Implants. 2003;18(4):512-22. 2008;79(8):1370-7. 47. Degidi M, Nardi D, Piattelli A. 10-year follow-up of immediately loaded implants with TiUnite porous 12. Avila G, Galindo P, Rios H, Wang HL. Immediate implant loading: current status from available literature. anodized surface. Clin Implant Dent Relat Res. 2012;14(6):828-38. Implant Dent. 2007;16(3):235-45. 48. Glauser R. Implants with an oxidized surface placed predominately in soft bone quality and subjected 13. Ortega-Martínez J, Pérez-Pascual T, Mareque-Bueno S, Hernández-Alfaro F, Ferrés-Padró E. Immediate to immediate occlusal loading: results from a 7-year clinical follow-up. Clin Implant Dent Relat Res. implants following tooth extraction. A systematic review. Med Oral Patol Oral Cir Bucal. 2012;17 (2):e251-61. 2013;15(3):322-31. 14. Chen ST, Beagle J, Jensen SS, Chiapasco M, Darby I. Consensus statements and recommended clinical 49. Romanos GE, Javed F. Platform switching minimises crestal bone loss around dental implants: truth or procedures regarding surgical techniques. Int J Oral Maxillofac Implants. 2009;24 Suppl:272-8. myth? J Oral Rehabil. 2014;41(9):700-8. 15. Palattella P, Torsello F, Cordaro L. Two-year prospective clinical comparison of immediate replacement vs. 50. Dellavia C, Canullo L, Allievi C, Lang NP, Pellegrini G. Soft tissue surrounding switched platform implants: immediate restoration of single tooth in the esthetic zone. Clin Oral Implants Res. 2008;19:1148-53. an immunohistochemical evaluation. Clin Oral Implants Res. 2013;24(1):63-70. 16. Botticelli D, Renzi A, Lindhe J, Berglundh T. Implants in fresh extraction sockets: a prospective 5-year 51. Vera C, De Kok IJ, Chen W, Reside G, Tyndall D, Cooper LF. Evaluation of post-implant buccal bone follow-up clinical study. Clin Oral Implants Res. 2008;19:1226-32. resorption using cone beam computed tomography: a clinical pilot study. Int J Oral Maxillofac Implants. 17. Lee CT, Chiu TS, Chuang SK, Tarnow D, Stoupel J. Alterations of the bone dimension following im- 2012;27(5):1249-57. mediate implant placement into extraction socket: systematic review and meta-analysis. J Clin Periodontol. 52. Atieh MA, Ibrahim HM, Atieh AH. Platform switching for marginal bone preservation around dental 2014;41(9):914-26. implants: a systematic review and meta-analysis. J Periodontol. 2010;81(10):1350-66. 18. Chen ST, Buser D. Clinical and Esthetic Outcomes of Implants Placed in Postextraction Sites. Int J Oral 53. Pozzi A, Agliardi E, Tallarico M, Barlattani A. Clinical and radiological outcomes of two implants with Maxillofac Implants. 2009:24(Suppl):186-217. different prosthetic interfaces and neck configurations: randomized, controlled, split-mouth clinical trial.Clin 19. Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Impl Res. Implant Dent Relat Res. 2014;16(1):96-106. 2008;19(1):73-80. 54. Theoharidou A, Petridis HP, Tzannas K, Garefis P. Abutment screw loosening in single-implant restorations: 20. Ferrus J, Cecchinato D, Pjetursson EB, Lang NP, Sanz M, Lindhe J. Factors influencing ridge alterations a systematic review. Int J Oral Maxillofac Implants. 2008;23(4):681-90. following immediate implant placement into extraction sockets. Clin Oral Implants Res. 2010;21(1):22-9. 55. Rismanchian M, Hatami M, Badrian H, Khalighinejad N, Goroohi H. Evaluation of microgap size and 21. Linkevicius T, Apse P, Grybauskas S, Puisys A. The influence of soft tissue thickness on crestal bone microbial leakage in the connection area of 4 abutments with Straumann (ITI) implant. J Oral Implantol. changes around implants: a 1-year prospective controlled clinical trial. Int J Oral Maxillofac Implants. 2012;38(6):677-85. 2009;24(4):712-9. 56. Wilson TG Jr. The positive relationship between excess cement and peri-implant disease: a prospective 22. Álvarez-Camino JC, Valmaseda-Castellón E, Gay-Escoda C. Immediate implants placed in fresh sockets clinical endoscopic study. J Periodontol. 2009;80(9):1388-92. associated to periapical infectious processes. A systematic review. Med Oral Patol Oral Cir Bucal. 2013;18 57. Kolinski ML, Cherry JE, McAllister BS, Parrish KD, Pumphrey DW, Schroering RL. Evaluation of a variable- (5):e780-5. thread tapered implant in extraction sites with immediate temporization: a 3-year multicenter clinical study. J 23. Fugazzotto P. A Retrospective Analysis of Immediately Placed Implants in 418 Sites Exhibiting Periapical Periodontol. 2014;85(3):386-94. 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. Webliography 25. Tarnow D, Emtiaz SH, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous Atieh MA, Ibrahim HM, Atieh AH. Platform switching for marginal bone preservation around dental implants: arches: ten consecutive case reports with 1 to 5 year data. Int J Oral Maxillofac Implants. 1997;12(3):319–24. a systematic review and meta-analysis. J Periodontol. 2010;81(10):1350-66. Available at: http://www.joponline. 26. Brunski JB. In vivo bone response to biomechanical loading at the bone/dental-implant interface. Adv org/doi/abs/10.1902/jop.2010.100232?journalCode=jop. Dent Res. 1999;13:99-119. Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing teeth: different 27. Szmukler-Moncler S, Salama H, Reingewirtz Y, Dubruille JH. Timing of loading and effect of micromotion times for loading dental implants. Cochrane Database Syst Rev. 2013;3:CD003878. Available at: http://www. on bone dental implant interface: review of experimental literature. J Biomed Mater Res. 1998;43:192–203. ncbi.nlm.nih.gov/pubmed/23543525. 28. Garber DA, Salama H, Salama MA. Two-stage versus one-stage-is there really a controversy? J Periodon- Kim S-G (2011). Clinical complications of dental implants. In: Implant dentistry - a rapidly evolving practice, tol. 2001;72(3):417-21. Prof. Ilser Turkyilmaz (Ed.), ISBN: 978-953-307-658-4, InTech, Available from: http://www.intechopen.com/ 29. Misch C. Conteporary Implant Dentistry, 1st ed., p186. books/implant-dentistry-a-rapidly-evolving-practice/clinical-complications-of-dental-implants

14 VOLUME 4 | ISSUE 1 Current Protocols for Posterior Single Implant-supported Restorations

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1. Current protocols for posterior single implants include 6. The ______must be considered during implant treatment ______. planning. a. immediate, early, or delayed implant placement a. lingual mandibular undercut b. nonsubmerged or submerged osseointegration b. anterior loop of the inferior alveolar canal c. immediate, early, or delayed temporization and loading c. inferior alveolar nerve d. all of the above d. all of the above

2. Local contraindications include ______. 7. Ideally, there should be 1.5 mm of space from the implant a. lack of adequate bone to ______. b. parafunctional habits a. adjacent teeth c. proximity to anatomical structures b. metal surfaces d. all of the above c. adjacent implants d. the buccal bone plate

3. Implants should be placed such that they will be loaded ______over the implant body. 8. Software also may allow the clinician to ______. a. axially a. assess implant angulation and depth b. mesially b. perform a virtual extraction c. buccally c. examine a virtual socket d. diagonally d. all of the above

4. Less than 6 mm of bone separated the inferior alveolar canal 9. Linkevicius et al concluded in their study that thinner soft tissue from the mandibular rst molar in ______of cases at the crestal bone level signi cantly in uences crestal bone in one study. stability, especially when ______where >1 mm of crestal a. 43% bone loss may then occur compared to thick biotype sites. b. 53% a. <2 mm thick c. 63% b. >2 mm thick d. 73% c. <4 mm thick d. >4 mm thick

5. A review by Lang et al estimated an average 4-year survival rate of ______for immediately placed implants in the 10. With respect to the presence of peri-apical pathology, ______. mandible and maxilla. a. post-operative antibiotics are recommended a. 95% b. the ability to achieve primary implant stability is still a b. 95.5% prerequisite c. 97.5% c. curettage of the site prior to implant placement is required d. 99.5% d. all of the above

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CEQuiz

11. To achieve primary stability in extraction sockets ______. 16. ______is a concern with stock abutments. a. the osteotomy site should extend 3 mm apical to the a. Lack of customization socket b. Lack of compatibility b. there should be 4 mm lateral to the socket c. Cost c. there must be 3 mm of bone contact with the walls of the d. all of the above extraction site d. a or c 17. Microgaps result in microleakage and represent a risk for ______. a. caries 12. ______improve primary stability. b. a. Rough implant surfaces c. peri-implantitis b. Variable thread designs d. none of the above c. Higher bone densities d. all of the above 18. For cement-retained restorations, an abutment screw channel that could be accessed by cutting a channel through 13. Immediate loading protocols are supported in the literature the implant crown if the ______were to loosen is if the implant has a minimum stability of ______when desirable. challenged with further rotation and the healing structure is a. implant non-functionally loaded. b. abutment a. 25 Ncm c. abutment screw b. 30 Ncm d. restoration c. 35 Ncm d. 45 Ncm 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 14. Microtextured rough surfaces ______. implant placement based on ______. a. promote osseointegration a. surgical procedures b. are suitable for immediate implant placement cases involving b. the nal prosthetics lower quality, soft bone c. bone tolerance c. are designed to decrease healing times d. none of the above d. all of the above

20. A stereolythic surgical template can be fabricated to 15. Atieh et al concluded in their systematic review and meta- ______. analysis that there was statistically signi cantly less crestal a. aid placement of the implant in the ideal position bone loss associated with ______. b. control depth a. non-platform-switched implants c. control angulation b. platform-switched implants d. all of the above c. immediate loading d. delayed placement

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16 VOLUME 4 | ISSUE 1 Current Protocols for Posterior Single Implant-supported Restorations

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*E-mail: AGD Code: 690 *Telephone: License Renewal Date: EDUCATIONAL OBJECTIVES QUIZ ANSWERS 1. Describe anatomical and other considerations during the treatment planning process Fill in the circle of the appropriate 2. Review the use of software during implant treatment planning answer that corresponds to the 3. List and describe aspects of implant design that affect primary implant stability question on previous pages. 4. Delineate abutment and retention options and the evidence for these. 1. A B C D COURSE EVALUATION 2. A B C D Please evaluate this course using a scale of 3 to 1, where 3 is excellent and 1 is poor. 3. A B C D 1. Clarity of objectives ...... 3 2 1 4. A B C D 2. Usefulness of content ...... 3 2 1 5. A B C D 3. Benefi t to your clinical practice ...... 3 2 1 6. A B C D 4. Usefulness of the references ...... 3 2 1 7. A B C D 5. Quality of written presentation ...... 3 2 1 8. A B C D 6. Quality of illustrations ...... 3 2 1 9. A B C D 7. Clarity of quiz questions ...... 3 2 1 10. A B C D 8. Relevance of quiz questions ...... 3 2 1 11. A B C D 9. Rate your overall satisfaction with this course ...... 3 2 1 12. A B C D 10. Did this lesson achieve its educational objectives? Yes No 13. A B C D 11. Are there any other topics you would like to see presented 14. A B C D in the future? ______15. A B C D ______16. A B C D 17. A B C D COURSE SUBMISSION: Dental Learning, LLC A B C D 1. Read the entire course. 500 Craig Road, First Floor 18. 2. Complete this entire answer sheet in Manalapan, NJ 07726 19. A B C D either pen or pencil. *If paying by credit card, please note: 20. A B C D 3. Mark only one answer for each question. Master Card | Visa | AmEx | Discover 4. Mail answer form or fax to 732-303-0555. *Account Number Price: $29 CE Credits: 2 For immediate results: ______Save time and the environment 1. Read the entire course. *Expiration Date 2. Go to www.dentallearning.net/SIR-ce. by taking this course online. 3. 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