Ttie Intenationai Journai of Periodontics S Restorative Dentisfty

31

Anterior Single-Tooth
Implant Restorations

Steven Lewis, DMD'

The opptication af impiant dentistry to the treatment of partial edentulism

has necessitated the development afnew components and techniques.
This article reviews the various systems and techniques used to fabricate
successfui anterior single-tooth implant restorations. Placement techniques
for nonsegmented, sarew-retoined abutments: segmented, screw-retained
abutments: and segmented, cement-retained abutments ore illustrated.
(IntJ Periodont Rest Dent 1995; 15:31-41)

Private Practice, San Antonio, texos.

Reprint requests; Dr Sleven Lewis, 17 Inwood Point, San Antonio,
Texas 782d8.

The successful treatment ot

edentulism with osseointegrated prostheses hos iead to a
revolution in dentistry. With this
success ultimateiy came the
desire to appiy the same technoiogy to the partiaiiy edentulous popuiation as weli.
i-iowever, many different ciinicai
chaiienges were encountered
when this adaptation was initiaiiy attempted, ond it soon
became evident that new
components and techniques
were necessary to overcome
some of the probiems unique
to the partiaiiy edentuious
pctient, Ohe of the greatest
chaiienges was that of the
anterior singie-impiant restoration and the abiiity to achieve
a stabie and esthetic impiant
restoration. Various system
designs and restorotive techniques used to create successfui anterior singie-impiant
restorations are reviewed in this
articie.
One ciassification divides
impiant components and techniques into those restorotions

Volume 15, Number 1,1995

32

that are cement-retained and

those that are screw-retained,
Anather classificatian relates to
fhe averall design, either nonsegmented Of segmented. The
nonsegmented design consists
of a restoration that connects
direofiy fo the impiant fixture,
while the segmented design
inciudes a restoration that fits
over a fitanium abutment. The
categories of single-tooth technique described in this artioie
are (1) the nonsegmented
sorew-retained abutment,
(2) the segmented, screwretained
Fig 1 Nonsegmented single-tooth
implant restorations (UCi-A abutment)
t directly to the implant fixfure and
must engage the hexagon of the
impiant tar antiratation.

abutment,

and

(3) the segmented, cementretained abutment. Examples

of fhe nonsegmented, sorewretained, and segmented,
cement-retained types will be
of the same clinicai restoration
to allow oomparison.

Nonsegmented, screwretained restoration

The nonsegmenfed restoration
connects direotiy to the
implant fixfure. This technique,
introduced by Lewis et al,' is
populariy referred ta as the
UCLA abutment. Far single-unit
UCLA abutment implant
restorations, it is criticai to utilize
implant fixtures that cantain
hexagcns on their coronal
aspect. Because the restoration
is begun directly at the impiant
fixture, it is possible to incorporate a hexagon within the base
of the restoration to engage

The International Journol of Peiiodontics & Restorative Dentistry

the hexagon at the implant

(Fig 1 ). With this connection, the
restoration shouid exhibit the
antirotation neoessary for a sfabie single-tooth restoration.
Also, with proper implant countersinking, beginning the
restoration at this level shouid
allow adequate vertical space
to develop a natural and gradual emergenoe prafiie, providing exceilenf esfhetios and
easy aooess for aral hygiene
measures.
With the nonsegmented
technique, only screw-retained
restorations are recommended. Cementing directly to the
implant makes retrievabiiity
and access to the implant itself
quite difficuif,
To tabricate fhe nonsegmented screw-retained restoration to fit directiy to the
implant fixture, an impression
coping that fits directiy to the
implant fixture must be used. It
is important that the impression
coping contain a hexagonai
base that matches the hexagon of fhe implanf. This is crificai, because fhe tinal restoration must engage the impiant
hexagan; theretore, the rotational aiignment of the hexagon in the wori<ing oast must
match that of fhe actuai
impianf. When fhe impression
coping is seated intraoraliy to
the impiant, a radiograph is
necessary to ensure that the
hexagons are matched and
compiete seating is achieved.
After fhe impression is made, a

33

laboratory implont replica is

connected to the impression
coping and a cost is poured
(Fig 2), The laboratory replica
must also contain o hexagon
identicol to the implant fixture.
Because the implont fixture
snould ideally be positioned 3
to 4 mm beneath the gingival
margin to create an esthetic
anterior restoration with a gradual emergence profile, the finai
cast should contain a tiexible
materiai that duplicotes the sulcular tissue around the implant
(Fig 3). This soft tissue cast
allows the laboratory technician to f a b r i c a t e the tinai
restoration without accidentaily altering the soft tissue contours. Mony technicians prefer
that this materiai be separable
from the master cast. Thus, as
the restoration is being waxed
and contoured, the soft tissue
materiol may actuoily be
removed from the cast, ideai
emergence protiles can then
be aftained without being dict a t e d by the design of the
healing abutment or subgingival portion of the impression
coping.
The UCLA abutment inifioiiy
was a piastic burn-out pattern
that connected direcfiy to fhe
implanf tixture. One pattern
contained o round base for
muitiple implant restorations,
whiie the other contained a
hexagonal base for the antirotation necessary in singleimplant restorotions. Today
these plastic pafterns may still

Fig 2 An imptanf fixfure onalog is connected to the impression coping

before the cast is poured

be utilized, or machined goid

alloy cylinders may be used.
These fit to the impiant fixtures
as do the piastic patterns.
Fabrication of a restoration with
the plastic pottern invoives
securing fhe pattern to the
implant fixture replioo of the
moster oast and incorporating
it withih the substructure pottern (Fig 4). The wox and plastic
burn out otter being invested,
resulting in a tramework with o
cast base. The machined cylinder would also become part of
the wax substructure, but after
investing, it does not burn out.
After the wox burn out, o fromework is made by casting to the
machined oyiinder. Thus, the
bose of the metal substructure
contains o mochined cylinder
with a machined hexogonal
paftern. The advantage of this is
thot the quality of the fit of the
restoration to the impiont fixture

Fig 3 The master oasf contains fhe

implanf tixfure replica wifft the fofationol alignment of the hexagon identical
to thot of fhe acfuai implant. The soft
tissue maferial wiil preserve the soft fissue contours during fobricafion of fhe
tinai restoration.

Fig d The UCLA abutment burn-ouf

pattern ts direcfly to the implanf fixture and has a hexagonai paftern at
the base that fs over fiie implant
hexagon. Once secured fo fhe tixture
anaiog, the burn ouf potfern will
become parf of the substructure wax
pottern.

Volume 15. Number 1,1995

34

Fig S Tile compiete porcelain-fused-to-metal restoration

fits directly to fhe top of fhe implont xfure, matcfiing the hex
of the fixture, and is refaihed wifh a titanium alloy screw
fighfened fo 20 Ncm

is always predetermined with

the machined cylinder. In contrast, the quality of the fit with
the castable plastic pattern is
more technique sensitive and
differs from restoration to
restoration. In any case, no matter which technique is utilized, it
is always best to check the fit of
the restoration to an actuai
implant tixture microscopically.
Discrepancies may be overcome with a milling instrument
when necessary.
Use of alioys with at least
50% gold hos been recommended with the UCLA abutment technique,' This should
minimize the potential for gaivanism or corrosion at the
implant-restorotion junction.
However, the long-term ramifications of placing two dissimilar
metals at this level are still
unknown.

Fig 6 The nonsegmenfed impiant resforotion replaces the

maxiiiary left central incisor with a natural appearance.

Porceloin is applied to the

casting and the restoration is
compieted (Fig 5). This final
restoration is retained to the
implant fixture with the use ot a
titanium alloy screw tightened
to a force of 20 Ncm (Fig ).
Radiographs ore absolutely
critical to assure a d e q u a t e
seating. Unless the hexagon ot
the restoration is pertectly
oligned with the hexagon ot
the implant tixture, the restoration vi/ill not be seoted.

The Internofional Journal ot Periodontics & Restorative Dentistry

The screw-access channel

is uitimately sealed with guttapercha and either amaigam or
resin. If the restorative material
surrounding the surface ot the
screw-access opening is metal,
amalgom is preterred. It the
screw-access opening is surrounded by porcelain, resin is
used. In either case, the restorative materiai is easily removed
when access to the retention
sorew is desired. The gutta-percha protects the heod ot the
screw trom being damaged
when access is being gained,
because this material may be
removed with an excavator
rather than a hondpiece.

35

Fig 7 The titanium EsfhetiCane is secured to the top of the

impiant fixture with a pure titanium abutment screw The
external walls of the abutment may be used for antirotatian.

Segmented, screw-retained
restoration
Segmented restorations may
be considered those that fit
over titanium abutment cylinders rather than connect
directly tc the implant fixtures.
Thus, there are various segments to the restaration.
Advantages of having the
titanium abutment include the
tact that there is now a titanium-titanium interface at the
level of the implant fixture.
Galvanism and corrosion
should no longer be o concern. The interface at this level
is now between two machined
companents and thus the
technique sensitivity of a casting is eliminated. Also, there
now exists a titanium-soft" tissue
interface. Although some
researchers oonsider the

FigB The -mm collar EsfhetiCone abutment wiliallow the

restoration to begin 2 fo 3 mm beneath Ihe gingival margin.
The restoration has a natural ond gradual emergence profile.

potential hemidesmosomal
attachment betvyeen the titanium and soft tissue to be an
important factor for long-term
success,^'^ others feel that this
sa-called biologic seal may
minimize pocket depth but will
in no way inhibit epitheliol
downgrowth. should the
implant become mobile," Still
others mointain that o
hemidesmosomal ottachment
to sott tissue is not unique to
titonium and con octuolly
occur with ceramics or a voriety ct metal alloys.^ Thus, the
true significance of this interface is somewhat unclear
Ta achieve an acceptable
esthetic result, it is critical that
the restoration begin 2 to 3 mm
beneoth the mucosa. With the
nonsegmented technique, the
restorotion begins directly at
the implont fixture. With the

placement ot a titanium abutment, however, the restoration

must begin closer to the gingival morgin. Titanium abutments
such as the EsthetiCone
(Nobelpharma) are designed
for subgingival restorations (Fig
7), These abutments contain
either 1-, 2-, or 3-mm collars at
the base. The restoration fits
over the abutment down to
the top ot the collar. Thus, with
the 1-mm titonium collar, the
restorotion may begin 1 mm
from the implont fixture. As long
OS the implant fixture is positioned 3 to 4 mm beneath the
mucosa, the restoration has
adequate room (2 to 3 mm) to
develop o natural and gradual
emergence profile (Fig 8). With
a properly positioned implant,
the result is the appearance of
a tooth at the gingival margin.

Volume 15, Number 1,1995

36

Fig 9 The gold alioy cylinder contains an

internal hexagon that engages the iateral walls af the EsthetiCone abutment

Fig 10a The mpressian coping contains an internal hexagan ta properiy

align the laboratory repiica

Fig IQb The laboratory replica IS

similar to the EsthetiCane abutment
replica used for muitipie implant
restorations (left) except that it contains an externai hexagonal pattern
(right) that is necessary far single-tooth
restorations.

Whiie the EsthetiGone

abutment was originaiiy crea t e d for muitipie impiant
restorations oniy,"^ modifications
have been made to allow its
use as a singie-tooth impiant
restoratian. To provide stabiiity,
an antirotationai design was
necessary. The goid aiioy cyiinders that become part of the
wax pattern and then part of
the metai substructure now
contain an internai hexagon
that matches the externai
hexagon of the EsthetiCone
abutment (Fig 9). The impression copings and laboratory
replicas aiso contain hexagonai patterns matching the
hexagon of the abutment so
that the rotationai aiignment of
the abutment hexagon is transferred to the master cast (Figs
10a and 10b).

implant fixture, and a radiograph is taken to ensure that

the hexagon of the abutment
base is aiigned properiy with
the hexagon of the impiant
fixture, aliowing compiefe
seating. The titanium abutment
screw is then tightened to 20
Ncm. The impression coping fits
over the abutment cyiinder and
is retained vyith a guide pin.
Because the internai aspect of
this impression coping contains
a hexagon matching that of the
abutment, care must be taken
to ensure proper seating. A radiograph is often useful to confirm
this, and the same radiograph
that evaluates abutment seating may aiso be used to evaiuate the impression coping
seating.

gival impiant restorations, a soft

tissue cast is fabricated (Fig 12).
The goid aiioy cylinder is
secured to the iaboratory
repiica and becomes incorporated within the wax pattern.
The buccai inciination of th
impiant fixture is criticai with
this technique, because the
restoration wiii contain a screwaccess opening on the surface.
An impiant angied too far
faciaiiy wiii resuit in an unacceptabie faciai screw channel.
This is true of the nonsegmented or UGi-A abutment as
weil. The screw-ohannei opening with the segmented technique wiii be smaiiet, however,
because the retention screw is
a smaii goid aiioy screw that fits
within the titanium abutment
screw. The segmented technique utiiizes a iarger screw
that is the same size as an
abutment screw.

The technique of fabricating

a singie-impiant restoration is
fairiy simpie. i h e abutment
cyiinder is c a n n e c t e d to the

The impression coping is

retrieved with the impression,
and tfie iaboratory abutment
repiica with the hexagon is
connected (Fig 11). As with the
UCLA abutment and aii subgin-

Ttie Internotionol Journol of Periodontics & Restorotive Dentistry

37

F/g (lefr) The impresin ooping Is

retrieved with the impression and fhe
at:>utment repiica is connected.

Fig 12 (right) The master oast contains

the hexed abutment replica. The soft tissue material wiii preserve the satt tissue
contours during laboratory procedures.

Fig 13 (left) The compieted porcelaintused-to-metai restoration contains the

gold aiiay cylinder with the internal
hexagon.

Fig 14 (rigM) The tinal restoration is

secured in piace by tightening the
gold aiioy screw to 10 Nom.

A variety of alloys may be

cast to the gaid alloy cyiinder.
as iong as a nonpreciaus aiioy
is avoided. The gold aiioy cylinder would be destroyed at
temperatures high enough to
cast the nonprecious aiioys.
An infraoral fry-in is not neoessary tor the metal substructure, because the fit of this
restoration is predetermined
by fhe fit between fhe
machined gold cyiinder and
the machined titanium abutment. Porcelain is applied to
the metal substructure and fhe
restoration is readied for a clinical try-in (Fig 13). At this time,
the interpraximal contacts are
adjusted, the occlusion is evaluated, and the final esthetics are
deveioped.

The restoration is secured

in place with a gold alloy
retention screw (Fig 14). This is
the same screw used to retoin
multiple implant restorations on
the EsthetiCone abutment system. These screws are tightened to 10 Ncm. Radiographs
are useful to evaluate complete seating. As with fhe nonsegmented technique, the
screw channeis are then obturated with gutta-peroha and
either resin ar amalgam.
The advantage of this segmented teohnique is that a
sorew-retained, retrievable
impiant restoration that can be
both esthetic and funotionaiiy
sfabie is fabricated. Although
this is simiiar to the advantages of the nonsegmented

restoration, the titanium-titanium implant-abutment junction and the titanium-soft tissue

interface are biomeohanioai
considerations that are more
similar to the time-tested and
well-dooumented oylindrioal
titanium abutments used in 15year olinioai trials.' The longterm ramificafions of fhe
changes infroduoed wifh fhe
nonsegmented technique are
stiii unknown.

Volume 15. Number 1,1995

38

Segmented, cementretained restoration

The CeraOne abutment (Nobelpharma) is a pure titanium
obutmenf cyiinder that provides a cement retained singietooth restoration^ (Fig 15), The
obutment contains coiiars at
the bose just iike the
EsthetiCone abutment aithough 4- and 5-mm collars are
available as well. Thus, the titanium CeraOne obutmeht
adheres to the bioiogic and
mechanicol principles of the
EsthetiCone abutment by providing o mochined titaniumtitanium interface at the ievei
ot the implant fixture and a titanium-soft tissue interface
between the titanium coliar
and suicuiarepitheiium (Fig 16).
The finai restoration is
designed to cement over the
CeroOne abutment. Becouse
there is no need for a restorative retention screw, there is no
need for on external screw
channel. The porallel waiis of
the abutment cyiinder provide
exceilent retention. However, if
the abutment screw were to
loosen, acce5S to this screw
would be difficult and it moy
be necessary to section the
final restoration, it is for this reason that the abutment sorew
joint was designed to be tightened to a torce of 32 Ncm. The
retentive strength of this screw
joint is approximately three
times that ot the EsthetiCone
gold screw. This abutment

screw itself is also made out of

a differeht materioi than other
abutment screws manutactured by Nobelpharma. The
CeraOne abutment screw is
made ot a goid aiioy.
The abutment screw must
be tightened with an electric
torque controiier, whioh can be
programmed to 32 Ncm. A
countertorque device is olso
utiiized to prevent the possibiiity
of damaging the bone-impiant
intertace during tightening.
The segmented, cemehtretained restorations described
in the foliowing poragraphs
(both ali-ceramic ond porceiain-fused-to-metai) were fobric a f e d to repiace the same
tooth used to iiiustrate the nonsegmented, screw-retoined
technique.
The impression coping fits
over the various sized abutments and remains in piace
through trictional resistohce.
Because plastic provides better
frictionai resistance than does
metal, the impression coping
and the laboratory repiico are
made of plastic. The impression
coping is picked up in the
impression, and the laboratory
repiioa is inserted into it (Fig 17).
A soft tissue cast is then poured
(Fig 18).

The Infernafionol Journal of Periodonfics & lesforcfive Denfisfry

The CeraOne system allows

several prosthetic designs. An
ail-ceramic restoration may be
tabricoted by incorporating
the aluminous oxide c a p : a
porceiain-fused-to-metai or
even ali-metal restoration moy
be made by Inoorporoting the
gold alloy cylinder. Both the
ceromic cop and gold cylinder
are designed to fit preclseiy
over the abutment. Thus, when
either one becomes incorporated in the final restoration, the
restoration is cemented onto
fhe abutment cyiinder, seating
to the ievei ot the collar.
The ceramic cap is avaiiable in two sizes, short and toll
(Fig 19), These aiuminous oxide
caps moy be ground down as
iong as they remain at leost 0,5
mm thick. Additional core
material may be a d d e d to
increase the size of the core
and to prevent excess unsupported porcelain in the tinai
restoration. The porceloin
added to the cop to develop
the restorotion must be an aluminous oxide porcelain rather
than felspathic porcelain (Fig
20). The materiai recommended is Vitddur Alpha (Vita
Zahnfabrik), The finai ailceramic restoration is then permanently cemented into position (Fig 21). Temporary cement
is not recommended with this
restoration, because fracfure af
the oeramic material could
ocour during any attempt to
remove the crown from the
paraliel-sided abutment.

39

Fig 15 (left) The CeraOne abutment is

o pure titanium abutment held to the
impiant fixture with a gold alloy abutment screw.

Fig I (right) The CeraOne abutment

siiouid allow the testorotion to begin
approximately 2 to 3 mm beneath the
gingival margin. The finai restoration wili
be cemented over the obutment.

Fig 17 (left) The impression coping

comes out with the impression. The plastic laboratory abutment replica is then
inserted into the impresin coping.

Fig IS (right) Tiie master cast contains

the plastic laboratory obutment replica
with soft tissue material surrounding it.

Fig 19 The tall ceramic cap is placed

ah the master cast This ceramic cap
has been modified by slight grinding.

Fig 20 The Una! ati-ceramic restoration

is fabricated by adding porceiain to
the ceramic cap.

Fig 21 The ali-ceramic restoration is

permanentiy cemented aver the
CeraOne abutment.

Volume 15, Number 1,1995

40

Fig 22 (ieft) The gold alloy cylinder fts

over the laboratory replico as does th,ceramic cap. This cylinder allows the
fabrication of a porceiain-fused-tometal restoration.

Fig 23 (rigtit) Thefinalrestcraflon contains tfie gold cylinder, which provides the
fit of the restorafian onto the abutment

The gold alloy cylinder is

designed to oilow porcelointused-to-metal restorations (Fig
22), Similar to the properties
of the EsthetiCone gold cylinder, the gold alloy cylinder
becomes part of the wax
pattern and then part of the
metal substructure. Ultimately
the porcelain-fused-to-metal
restoration contoins this gold
cylinder as its core, allowing
it to fit over the abutment
(Fig 23). While a varief/ of olloys
may be used to create the
substructure, nonpreoious
alloys are not recommended,
because the gold alloy cylinder
would be destroyed under the
high-temperature conditions.
Conventional felspathic porcelains may then be applied ta
the metal substructure. The
advantages of the porcelainfused-to-metal restoration
include the possibility of
improved structural integrity as
well as the obility to utilize
temporary cement. It is less risky
to affempt to remove a porcelain-fused-to-metal restoration
than ah all-ceramic restoration.

The metal lingual surface also

provides the obility to place o
cement escope channel. This
allows the restoration to seat
more easily during the cementation process and minimizes
the amount ot excess cement
at the subgingival restorative
margih. This cemeht esoape
channel could ultimately be
restored with resin or amalgam.
Another possible advantage of the porcelain-fused-tometal technique is the ability to
create G screw-access opening in the restoration. Thus, the
CeraOne restorotion could
actually be considered screwretained and retrievable.
Without the obility to ploce the
countericrque device ever the
cemented restoration, however, the gold alloy abutment
screw should probably not be
tightened more than 20 Ncm,
This would still provide considerqbly more retentive strength
than the EsthetiCone gold
retehtive screw, which is much
smaller and tightened to only
10 Ncm, Retrieval would actually involve retrieving the crown

The Internotional Jouinoi of Periodontics & Restorative Dentistry

ond abutment os one segment, because the crowh

v^ould be c e m e n t e d to the
abutment. Even if permonent
oement were used, this cement
could burn out at opproximately 1,OOO''F if it were necessary to separate the crown
from the abutment. The screwaccess opening would also
provide a cement escape
channel during the cementation procedure, although Vi/ith
this technique the crown could
be oemented to the abutment
either intraorally or extraorally.
If size of the screw-access
opening is o concern, it should
be noted that the CeraOne
and the UCLA abutment
screws are similar and considerably larger in diameter
(approximately 35% larger)
than the EsthetiCone gald alloy
screw. With a Vi/ell-placed
implant, hov^ever. the screw
channels are en the lingual surface and once obturated with
resin or omalgam provide a
very normal lingual contour.

41

For impiants that are positioned with a siightiy buocai

inciination, the cementretained CeraOne restoration is
the technique of choice.
Screw-retained restorations in
this situation would contain a
screw channei through the
incisai edge or faciai surface,
seriousiy compromising the
restoratian. A cement-retained
restoration contains no externai
screw channei and so the
externai surface wouid not be
compromised trom the buccai
inciination.

Summary
Singie anterior implant restorations are categorized as either
nonsegmented or segmented.
Nonsegmented restorations
connect direotiy to the impiant
fixture and are screw-retained.
These restorations are fabricated with either piastic burn
out patterns resuiting in a cast
base or the use of prefabricated goid aiioy cylinders that
are cast-to, becoming part of
the metai substructure. Screwretained and cement-retained
segmented restorations are
thase that fit aver titanium
abutment cyiinders. This may
be advantageaus. because
the bioiogic considerations of
piacing titanium abutments
subgingivaiiy inciuding a titanium-titanium interface at the
levei of the impiant fixture as

well as a titanium-soft tissue

intertace, have been weii documented over extended periods of time.
Utilization of a goid alloy
cylinder with an internal hexagon allows the fabrication of
singie-impiant restorations on
the EsthetiCone abutment. The
OeraOne abutment is primariiy
designed for cemenf-retoined
singie impiant restorations.
Geromic cops aiiow the tabrication of aii-ceramic restorations and goid alioy cyiinders
aiiow the fabrication ot porcelain-fused-to-metal restorations.
Although not originally intended tor this modification,
the use of the gold cylinder
does give the opportunity for
screw retention on the
GeraOne abutment.
With these components, a
variety ot techniques exist
today for the fabrication of
esthetic singie-tooth impiant
restorations. iHowever, despite
the evoiution in components
and techniques, paramount to
the finai prosthetic success are
proper impiant placement and
soff tissue management.
Restorative components cannot overcome deficiencies in
either of these two criticoi
aspects.

References
1. Lewis S, Beurrer J, Per'i G, Homburg
W. Single-tooth implant-supported
restorations. Int J Oral Moxillotac
Implonis 1988:3:25-30.
2. Gould TRL Brunette DM, Westbury L.
The a t t a c h m e n t mechonism of
epithelial cells to fitanium in vitro. J
PeriodonI Res 1981:16:61 l-l.
3. Honsson HA, Albrektsson T Branemark
P-l. Structural aspects of the interface between tissue and titanium
implonts. J Prosthet Denf 1983
50:108-113.
4. ten Cote AR. The gingival junction. In;
Brnematk P-l, Zarb G, Albrektsson T
(eds). tissue-Integrated Proslheses:
Osseointegration in Clinical Dentistry.
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Volume 15, Number 1,1995