What is the process and recommended care for dental implant restoration?

Dental Implant Restoration: Process and Recommended Care

Dental implant restoration requires a systematic approach beginning with comprehensive diagnostic imaging using CBCT to assess bone volume, followed by precise implant placement with proper 3D positioning, adequate osseointegration time (typically 8 weeks for bone healing), and final restoration using high-strength materials with meticulous moisture control and adhesive protocols. 1

Pre-Surgical Planning and Assessment

Diagnostic imaging is mandatory to evaluate residual bone and anatomical structures before proceeding with implant placement. 1

• Use cone-beam computed tomography (CBCT) to develop a three-dimensional view of residual bone while minimizing radiation exposure 1
• Assess the height of the subantral bony ridge (residual bone height), which is the main driver in planning implant therapy 1
• Evaluate local and systemic variables through comprehensive clinical and radiographic examination 1

Eliminate all oral infections before implant surgery to reduce bacterial risk and improve outcomes. 1

• Complete periodontal treatment before implant surgery to prevent future peri-implant diseases 1
• Remove plaque biofilm and treat dental caries prior to implant placement 1
• Allow acute or chronic infections or fistulae at extraction sites to resolve completely 1

Surgical Timing and Technique

For post-extraction sites, early implant placement at 4-8 weeks is recommended rather than immediate placement, as this allows critical healing processes to occur. 1

The advantages of waiting 4-8 weeks include:

• Bundle bone resorption is complete, reducing future dimensional changes 1
• Spontaneous soft tissue thickening occurs (up to sevenfold increase), providing better flap thickness and vascularity 1
• New bone formation occurs at the apical portion of the socket, facilitating easier implant bed preparation 1
• Infections resolve, reducing bacterial risk 1

Implant positioning must follow the "comfort and danger zones" concept for optimal esthetic outcomes. 1

• Position the implant shoulder approximately 1.5 mm palatal to the future point of emergence 1
• Maintain 3-4 mm distance between the implant shoulder and future mucosal margin on the mid-facial aspect 1
• Use bone level implants based on platform switching concept for better bone maintenance 1

Osseointegration and Healing Period

The bone healing period is typically set at 8 weeks before proceeding with final restoration. 1

• Implant stability is a prerequisite for successful clinical outcomes 1
• Use resonance frequency analysis (Osstell system) to evaluate osseointegration at various time points 1
• Consider extended healing time or temporary crowns with lower occlusal force in compromised patients 1

Restoration Materials and Design

Use monolithic or micro-veneered restorations utilizing high-strength zirconia for optimal durability and longevity. 1, 2

For ceramic framework materials:

• Employ unveneered shoulders 1
• Maximize connector areas by reducing embrasure size 1
• Consider monolithic designs that can be milled and adhesively cemented to titanium base abutments extra-orally 2

Critical Adhesive and Cementation Protocol

Absolute moisture control is mandatory for resin-based materials and resin-modified glass ionomer cement (RMGIC), as moisture contamination is a primary cause of restoration failure. 3, 4

Surface Preparation

• Sandblast titanium base abutments with 50-μm Al₂O₃ to achieve optimal adhesive retention 2, 4
• Ensure all surfaces are completely dry before applying adhesive materials 3, 2
• Apply the least amount of adhesive necessary to avoid pooling in margins 2, 4

Material Selection Based on Moisture Control

• Use resin-based materials or RMGIC only when complete dryness can be achieved 3
• Traditional glass ionomer cement (GIC) should only be used when optimal moisture control cannot be achieved, as it tolerates moisture during setting 3
• Select appropriate resin cement, as this plays a crucial role in clinical success, particularly for titanium-base abutment concepts 2

Never proceed with adhesive cementation if complete dryness cannot be achieved, as this is a primary cause of restoration failure. 3

Occlusal Considerations for Cantilever Restorations

When using cantilever units in posterior regions, implement meticulous occlusal analysis and planning to prevent mechanical complications. 1, 2

• Cantilever units should only contact in maximum intercuspal position on flat surfaces, not oblique surfaces 1, 2
• Keep cantilever units out of contact in all excursive positions 1, 2
• Leave cantilever units slightly out of occlusion when opposing an implant-supported restoration 1
• Ensure contact in maximum intercuspation when occluding against a natural tooth or tooth-supported restoration 1

Be aware that implant-supported cantilever fixed dental prostheses show higher incidence of prosthetic complications (risk ratio 2.56), requiring careful patient selection and follow-up. 2

Post-Restoration Maintenance

Include all implant patients in a regular periodontal maintenance program to prevent peri-implant diseases and ensure long-term success. 1

• Monitor for gingival enlargement, particularly in patients taking calcium channel blockers or immunosuppressants 1
• Maintain proper periodontal control to avoid complications around implants 1
• Quantify implant stability at various time points to project long-term prognosis 1