Title Details

Carl Drago, DDS, MS, is a Diplomate of the American Board of Prosthodontics (ABP) and serves as the Clinical Science Editor of the Journal of Prosthodontics, the journal of the American College of Prosthodontists. His private practice near Milwaukee, WI, is limited to fixed, removable, and implant prosthodontics. Dr. Drago is the clinical director of Eon Clinics in Waukesha, WI and is an adjunct associate professor at the Marquette University School of Dentistry. He has held positions as Assistant Professor at the University of Texas Dental School at San Antonio and Associate Professor in the Department of Restorative and Prosthetic Dentistry at the Ohio State University College of Dentistry in Columbus, OH. He has published more than 75 papers on various subjects including laboratory and clinical procedures in conventional and implant prosthodontics. Dr. Drago has also written three textbooks on dental implants, including Implant Laboratory Procedures: A Step by Step Guide, published by Wiley Blackwell.

Contributors xiii

Foreword xv

Acknowledgments xvii

1 Introduction to Implant Dentistry 1

Introduction 1

Purpose of Textbook 1

Economics of Implant Dentistry 2

Predictability of Fixed Prosthodontics 2

Development of Prognosis for Teeth: Extract or Maintain 4

The Heavily Restored Tooth 4

The Furcation-Involved Tooth 5

The Periodontal-Prosthesis Patient 6

Difficult Aesthetic Cases 8

Development of Prognosis for the Dentition 11

Summary 13

2 Implants and Implant Restorative Components 17

Introduction 17

Implants 17

Implant/Abutment Connections 20

External Implant/Abutment Connections 20

Internal Implant/Abutment Connections 22

Healing Abutments 25

EP® Healing Abutments 25

CADCAM Healing Abutments 27

Impression Copings 30

Implant Impression Copings 30

Pickup Impression Copings 31

Transfer Impression Copings 32

Abutment Impression Copings 32

Abutments 33

Standard Abutments 33

Locat or® Overdenture Abutments 34

DIEM® Immediate Occlusal Loading (IOL®) Abutments 34

GingiHue® Posts 34

ZiReal® Posts 36

UCLA Abutments 38

CADCAM Abutments (BellaTek™ Laboratory Designed Abutments) 40

Multiunit Abutments 44

Screws (Clinical) 46

Cylinders 47

Definitive Cylinders 47

DIEM® Immediate Occlusal Loading Abutment Cylinders 47

Interim Cylinders 48

DIEM® Immediate Occlusal Loading

Abutment Temporary Cylinders (Biomet 3i) 48

Temporary Coping Multiunit Titanium Cylinders (Nobel Biocare) 49

Drivers and Placement Instruments 49

Large Hex Drivers 49

Large Hex Driver Tips 50

Square Drivers 50

Square Driver Tips 51

Abutment Drivers 51

Abutment Driver Tips 51

Laboratory Components 51

Implant Analogs 52

Abutment Analogs 52

Try-In Screws 53

Abutment Holders 54

3 Diagnosis and Treatment Planning in Implant Restorative Dentistry 57

Patient Selection 57

Medical History 58

Diagnostic Procedures 58

Radiographs 58

CT Scans 59

Diagnostic Casts 62

Physical Examination 63

Extraoral Examination 63

Intraoral Examination 64

Diagnostic Articulator Mounting 65

Diagnostic Wax Patterns 65

Surgical Guides 66

Implant Bone Volume 67

Implant Restorative Volume 69

Treatment Planning 72

Edentulous Patients 73

Overdentures 73

Fixed Hybrid Implant-Retained Prostheses-Edentulous Mandible 75

Fixed Hybrid Implant-Retained Prostheses-Edentulous Maxillae 76

Partially Edentulous Patients 77

Treatment Goals 78

Screw-Retained Restorations 79

Cement-Retained Restorations 81

Implant Loading Protocols 81

Two-Stage Surgical Protocol 81

Single-Stage Surgical Protocol 83

Early Loading 83

Immediate Occlusal Loading 84

Immediate Nonocclusal Loading 84

Patient Consultation 85

Principles 85

Informed Consent 85

Implant Coordinators 85

Summary 86

4 Treatment of a Patient with an Edentulous Mandible Implant-Retained Bar Overdenture and Resilient Attachments 91

Literature Review 91

Clinical Case Presentation 97

Appointment 1: Initial Examination (1 Hour) 97

Radiographs 97

Physical Examination 98

Diagnostic Casts 98

Diagnosis 99

Appointment 2: Consultation Restorative Dentist/Patient (3/4 Hour) 99

Treatment Options 100

Appointment 3: Consultation Restorative Dentist/Surgeon (1/2 Hour) 100

Prosthesis Design 100

Type/Number/Size of Implants 100

Implant/Abutment Connection 100

Surgical Guide 100

Surgical Protocol 101

Healing Abutment Selection 101

Implant Restorative Wish List 101

Appointment 4: Implant Placement (1 Hour) 101

One-/Two-Stage Surgical Protocol 101

Appointments 5 and 6: Follow-Up

Appointments (1/2 Hour Each) 104

Tissue Conditioning 104

Appointment 7: Implant-Level Impression (1 Hour) 105

Pickup Implant Impression Copings 106

Definitive Border-Molded Impression 106

Laboratory Work Order/Procedures 107

Appointment 8: Jaw Relation Records and Tooth Selection (1/2 Hour) 109

Clinical Procedures 109

Laboratory Procedures 110

Appointment 9: Wax Try-In (1 Hour) 111

Clinical Procedures 111

Evaluation of Jaw Relation Records 112

Patient Approval 112

Fabrication of CADCAM Framework for Mandibular Bar-Retained Overdenture 112

Virtual Design of Framework 117

Milled Framework 117

Laboratory Evaluation of Framework/Master Cast Fit 118

Appointment 10: Framework Try-In (3/4 Hour) 118

Clinical One-Screw Test 119

Appointment 11: Insertion (1 Hour) 120

Insert Bar 120

Torque Abutment Screws 120

Insert Mandibular Overdenture and Maxillary Complete Denture 120

Occlusion 121

Postinsertion Instructions 121

Follow-Up Appointments 122

One-Year Follow-Up Appointment 122

Costs/Fees/Profitability 122

5 Treatment of a Patient with a Partially Edentulous Mandible Using Intraoral Scanning (IOS) of a CADCAM Healing Abutment 125

Literature Review 125

Replacement of Individual Teeth 125

Single-Unit Implant Restorations 127

Computer-Aided Design/Computer-Aided Manufacturing (CADCAM) Healing Abutments 128

Intraoral Scanning 134

Models from Digital Impressions 135

Clinical Case Presentation 135

Appointment 1: Initial Examination (3/4 Hour) 135

Diagnostic Casts 136

Diagnoses 136

Appointment 2: Consultation Restorative Dentist/Patient (1/2 Hour) 136

Treatment Options 137

Appointment 3: Consultation Restorative Dentist/Surgeon (1/2 Hour) 139

Type/Size of Implant 139

Abutment/Prosthesis Design 139

Implant/Abutment Connection 140

Surgical Protocol 141

Healing Abutment Selection 141

Implant Restorative Wish List 141

Appointment 4: Extraction and Implant Placement (1 Hour) 141

Extraction and immediate implant placement protocol 141

CADCAM Healing Abutment Placement 141

Appointment 5: Restorative Follow-Up Appointments (1/4–1/2 Hour) [10 days; 4 weeks; 8 weeks] 142

Appointment 6: Reevaluation and Determination of Impression Date (1/2 Hour) 142

Appointment 7: CADCAM Healing Abutment Scan (Restorative Office) (1/2 Hour) 142

Clinical Procedures 142

Laboratory Procedures 143

Appointment 8: CADCAM Abutment and All-Ceramic Crown Insertion Appointment (3/4 Hour) 143

Abutment Placement 143

Radiographic Verification and Crown Try-In 144

Torque 144

Cementation 145

Appointment 9: Follow-Up Appointments 148

1 Week/6 Months 148

1-Year Recall Clinical and Radiographic Evaluation 149

6 Retreatment of a Patient with a Fractured Implant-Retained Fixed Partial Denture in the Posterior Maxilla-CADCAM Abutments and a New Fixed Partial Denture (Cement Retained) 151

Literature Review 151

Clinical Case Presentation 156

Appointment 1: Initial Examination (3/4 Hour) 156

Diagnostic Casts 156

Diagnosis 156

Appointment 2: Consultation Restorative Dentist/Patient (1/2 Hour) 157

Treatment Options 157

Laboratory Procedures 157

Appointment 3: Removal of Existing Prosthesis/Abutments; Implant Impression (1 Hour) 158

Implant-Level Impression 158

Laboratory Procedures/Work Orders 159

Appointment 4: Bisque Bake Try-In (3/4 Hour) 163

Removal of Preexisting Prosthesis and Abutments 163

Try-In CADCAM Abutments 163

Try-In Bisque Bake FPD 163

Appointment 5: Insertion Appointment (3/4 Hour) 165

Removal of Preexisting Abutments and Fixed Partial Denture 165

CADCAM Abutment Placement 166

Torque 166

Fixed Partial Denture Cementation 167

Appointment 6: Follow-Up Appointments (1/2 Hour) 167

2 Weeks/6 Months 167

1-Year Recall Clinical and Radiographic Evaluations 168

Costs/Fees/Profitability 170

7 Accelerated Treatment Protocol of a Patient with Edentulous Jaws and CADCAM Titanium
Framework/Fixed Hybrid Prostheses 173

Literature Review 173

Original Treatment Protocol 175

Accelerated Treatment Protocol 177

Clinical Case Presentation 4 Months Post Extractions, Implant Placement, and Immediate Occlusal Loading 177

Appointment 1: Evaluate Aesthetics, Jaw Relation Records, Abutment-Level Impressions (3 Hours) 177

Radiographic Examination (CBCT) 177

Extraoral Physical Evaluation 177

Intraoral Physical Examination 177

Clinical Assessment 177

Jaw Relation Records 179

Removal of Interim Prostheses/Alginate Impressions for Diagnostic Casts 179

Assess Implant/Abutment Stability and Clinical Osseointegration 179

Abutment-Level Impressions 181

Articulator Mountings 183

NobelProcera® Protocol for CADCAM Titanium Frameworks 191

Biomet 3i Protocol for CADCAM Titanium Frameworks 191

CAD for the Maxillary and Mandibular Frameworks 194

Laboratory Evaluation of CADCAM Frameworks 195

Denture Setup on CADCAM Frameworks 197

Appointment 2: CADCAM Framework, Wax Try-In, Verification of Jaw Relation Records, and Aesthetics (1 Hour) 198

Clinical One-Screw Test 199

Verification of Jaw Relation Records and Aesthetics 199

Laboratory Procedures 200

Appointment 3: Insertion of Definitive, Screw-Retained Hybrid Prostheses (1 Hour) 201

Torque Abutment Screws 202

Occlusion 202

Oral Hygiene Instructions 202

Appointments 4 and 5: Prosthetic Follow-Up Appointments: 1 Week and 6 Months (1/2 Hour Each) 203

Appointment 6: One-Year Recall with Radiographs (1 Hour) 204

Radiographic Evaluation 204

Clinical Examination 205

Future Recall Appointments 205

8 Treatment of a Patient with an Edentulous Mandible with an Immediate Occlusal Loading Protocol (DIEM® 2) 209

Literature Review 209

Introduction 209

The Preosseointegration Era 210

The Osseointegration Era 211

Immediate Occlusal Loading in the Edentulous Mandible 212

Immediate Occlusal Loading in Edentulous Maxillae 213

DIEM® Protocol 214

DIEM®2 Protocol 215

Clinical Case Presentation 216

Appointment 1: Initial Examination 216

Chief Complaint 216

Radiographs 216

Physical Examination 217

Diagnoses 218

Prognosis 219

Appointment 2: Consultation with Patient (1 Hour) 219

Treatment Options 219

Diagnostic Impressions 220

Appointment 3: Definitive Maxillary Impression and Jaw Relation Record (1 Hour) 220

Definitive Maxillary Complete Denture Impression 220

Articulator Mounting 222

Appointment 4: Wax Try-In (1/2 Hour) 222

Number/Size of Implants 222

Prosthesis Design 224

Implant/Abutment Connection 224

Laboratory Procedures/Work Orders for Processing Dentures 225

Surgical Work-Up and Protocol 226

Ball Clasps 226

Appointment 5: Preoperative Surgical Review Office Visit (1/2 Hour) 227

Appointment 6: Insertion of Maxillary Complete Denture, Mandibular Extractions, Alveolectomy,
and Implant Placement/Immediate Occlusal Loading for Mandibular Full-Arch Prosthesis 228

Surgical Protocol (2 Hours) 228

Surgical Guidelines for Immediate Occlusal Loading 230

Abutment Selection 234

Prosthetic Guidelines for Immediate Occlusal Loading 234

Postoperative Instructions 239

Appointment 7: Prosthetic Follow-Up Appointments (1/2 Hour) 239

24-Hour Follow-Up Appointment (1/2 Hour) 239

1-Week Follow-Up Appointment (1/2 Hour) 239

4-Week Follow-Up Appointment (1/2 Hour) 240

12-Week Follow-Up Appointment (1/2 Hour) 240

9 Treatment of an Edentulous Patient with an Accelerated Treatment Protocol and Immediate Occlusal Loading Protocol (All-on-4™) 243

Literature Review 243

Clinical Case Presentation 245

Appointments 1 and 2: Initial Examination, Articulator Mounting, and Wax Try-In 245

Chief Complaint 245

History of the Present Illness 245

Radiographs (CT Scan) 245

Physical Examination 246

Diagnostic Casts, Articulator Mounting, and Diagnostic Wax Try-In 247

Diagnosis 250

Assessment 250

Treatment Options 251

Prognosis 251

Appointment 3: Consultation Restorative Dentist/Patient 252

Appointment 4: Consultation Prosthodontist/Surgeon 252

Number/Size of Implants 252

Prosthesis Design 253

Implant/Abutment Connection 254

Surgical Work-Up and Protocol 256

Laboratory Procedures for Processing the Maxillary and Mandibular Prostheses 256

Appointment 5: Implant/Prosthesis Placement 259

Maxillary Surgical Protocol 259

Maxillary Prosthetic Protocol 262

Mandibular Surgical Protocol 271

Mandibular Prosthetic Protocol 273

Postoperative Instructions 279

Prosthetic Follow-Up Appointments 280

1-Week Appointment 280

10 Immediate Nonocclusal Loading Provisional Restoration: Intraoral Scanning, CADCAM Abutment, and Definitive Restoration Maxillary Central Incisor 283

Literature Review 283

Clinical Case Presentation 286

Appointment 1: Initial Clinical Visit (3/4 Hour) 286

History of the Present Illness 286

Radiographs 286

Physical Examination 287

Diagnostic Casts 287

Surgical Guide 287

Diagnoses 288

Prognosis 288

Appointment 2: Consultation Restorative Dentist/Patient (1/2 Hour) 288

Appointment 3: Consultation Restorative Dentist/Surgeon (1/2 Hour) 288

Size and Type of Implant 288

Implant/Abutment Connection 291

Surgical Protocol 292

Interim Abutment 292

Implant Restorative Wish List 292

Appointment 4: Extraction, Implant, and Interim Abutment Placement (Surgical Office: 1 Hour) 292

Extraction and Implant Placement 292

Insertion Torque 293

Appointment 5: Restorative Appointment INOL Provisional Restoration (Same Day: 3/4 Hour) 293

Interim Abutment Placement 294

Abutment Preparation 294

Immediate Nonocclusal Loading Provisional crown (INOL-No Centric/Eccentric Contacts) 294

Dietary and Oral Hygiene Instructions 296

Appointment 6: Reevaluation Appointment – 24 Hours (1/2 Hour) 297

History 297

Clinical Examination 297

Appointment 7: Reevaluation Appointment – 2 Weeks (1/2 Hour) 297

History 297

Clinical Examination 297

Appointment 8: Reevaluation Appointment – 10 Weeks (1/2 Hour) 297

History 297

Clinical Examination 297

Appointment 9: CADCAM Healing Abutment Impression (16 Weeks: 1 Hour) 298

History 298

Clinical Examination 298

Abutment Selection 298

Remove INOL Provisional Restoration/ Interim Abutment and Place CADCAM Healing Abutment 299

BellaTek Encode Healing Abutment Intra Oral Scan 300

Appointment 10: CADCAM Abutment and Crown Insertion (3/4 Hour) 303

Interim Abutment and Provisional Crown Removal 303

Definitive Abutment Placement 303

Radiographic Verification 304

Torque 304

Crown Try-In 304

Cementation 305

Postoperative Instructions 306

Appointment 11: 2-Week Follow-Up Appointment (1/4 Hour) 306

11 Computed Tomography (CT)-Guided Surgery/Immediate Occlusal Loading with a Full-Arch Prosthesis in the Edentulous Mandible 309

Literature Review 309

Immediate Occlusal Loading 309

Tilted Implants 310

Diagnostic Imaging 310

Computed Tomography (CT) 313

Interactive Computed Tomography (ICT) 314

Interactive Computer Software 314

Computer-Guided Surgery 315

Overview of Ct-Guided Surgical and Prosthetic Protocols 316

Surgical Guides 316

Master Tubes 317

Prosthetic Laboratory Kit: Implant Analog Mounts 317

Surgical Kit Components 317

Fabrication of Master Cast for Immediate, Fixed Provisional Prosthesis 319

Abutment Selection for Fixed, Screw-Retained Provisional Prostheses 320

Fabrication of a Screw-Retained Provisional Prosthesis 321

Appointment 1: Clinical Patient Presentation 323

Preoperative Radiographs 324

Diagnosis 325

Assessment 325

Treatment Plan 326

Construction of Wax Dentures 326

Appointment 2: Clinical Try-In of the Wax Dentures 329

Fabrication of CT Scanning Appliance 330

Appointment 3: Intraoral Ct Scan and Treatment Plan 332

Fabrication of Master Cast with Implant Analogs 332

Laboratory Abutment Selection and Placement 335

Fabrication of Metal Framework for the Provisional Prosthesis 336

Fabrication of the Provisional Prosthesis 339

Appointment 4: Surgical and Prosthetic Treatment 342

Surgical Implant Placement 342

Clinical Abutment Placement 343

Insertion of Provisional Prosthesis 344

Appointment 5: Postoperative Visit 346

12 Review of Concepts for Designing and Fabricating Metal Implant Frameworks for Hybrid Implant Prostheses 349

Introduction 349

Historical Perspective 349

Original Framework Designs for Fixed Hybrid Prostheses 350

Passively Fitting Implant Frameworks 352

Prosthetic Complications Associated with Fixed Implant Frameworks 352

Physical Properties of Metals Used in Fixed Implant Frameworks 353

Cast Noble Alloys 353

Cast Base Metal Alloys 353

Milled Titanium Frameworks 353

Milled Zirconium Frameworks 353

Design Considerations 356

The Rationale For Cantilever Length 357

A/P Spread and the All-on-4™ Protocol 358

Guidelines for Implant-Retained Hybrid Frameworks 358

Conclusions 359

Index 363