Oral Surgery / Prosthodontics
Single-tooth rehabilitation using osseointegration.
A modified surgical and prosthodontic approach
Lars-Olof hrnell. DDS* / Jan M. Hirsch. DDS. PhD* / Ingvar Ericsson. DDS. PhD** /
Per-Ingvar Brnemark, MD, PhD*
Introduction
Loss of teeth may cause severe disturbances of a pa-
tient's masticatory function and comfort as well as
disturbances of a psychological nature. For esthetic
and functional reasons, most people want to replace
even a single lost tooth. Until recently the methods of
choice for rehabilitation involved conventional fixed
prostheses, removable partial dentures and. in some
patients, orthodontic treatment.' Some of these meth-
ods are. however, associated with disadvantages such
as loss of tooth substance and a potential loss of tooth
vitality, especially in young individuals. In some pa-
tients there are severe retention problems for a fixed
bridge and/or a removable partial denture. In addi-
tion, the prognosis for the reconstruction can be com-
plicated by carious lesions, progression of periodontal
disease, and/or technical failures, such as loss of re-
tention and fracture of bridge components or abut-
ment teeth.'"^
In edentulous patients successful and predictable
long-term results have been demonstrated with os-
seointegrated titanium fixtures, placed according to
the Brnemark technique, serving as abutments for
fixed bridges.^^ Because this method was developed
primarily for edentulous patients, very few reports
have been published on the outcome of the use of
implants in partially dentate jaws.^"^' Replacement of
a single missing tooth where the osseointegrated fix-
ture serves as an abutment for an individual crown
Institute for Applied Biotechnology, Box 33053, S-400 33,
Gothenburg, Sweden.
** Deparlment of Periodontology. Faculty of Odontology. Univer-
sity of Golhenburg, Box 33070, S-400 33. Gothenburg. Sweden.
Quintessence International Volume 19, Number 12/1988
has hitherto only been used in a limited number of
cases. The reasons for this have mainly been technical
and esthetic problems.'"'
After removal of a fractured or any other faulty
tooth, ie. any tooth unsuitable for convenlional ther-
apy, a healing period of three Lo six months is required
before installation of a titanium fixture. Following this
surgical procedure, an additional healing period of
four to eight months is prescribed before the abutment
can be attached to the osseointegrated fixture and con-
nected to an artificial crown.-''^
In order to improve the esthetic possibilities, shorten
the treatment period, and simplify the procedure for
replacing a single lost tooth using osseointegration. a
modified surgical and prosthetic procedure is imple-
mented.
Techniques
Surgical procedure
Mucoperiosteal flaps are raised and the tooth to be
replaced is gently removed without any osteoplasty.
The alveolus is then carefully curetted, with any gran-
ulation and fibrous connective tissue being removed.
Direction and position of the fixture is meticulously
analyzed in order to achieve optimal esthetic and bio-
mechanical results (Fig 1), The fixture site is then pre-
pared in the alveolus using a graded series of burs.'^
Self-tapping fixtures are used in the maxilla and in
the mandible when possible. The apical part of the
fixture is placed, if possible, in cortical bone to ensure
immediate stability of the fixture. Further, the fixture
is placed in the alveolus with optimal surface area, in
direct contact with the bone. Clinically this often
means that the fixture is placed below the marginal
alveolar bone level (Fig 2). After insertion of the fix-
ture, the marginal part of the alveolus may be wider
871
Oral Surgery / Prosthodontics
Fjg 1 Pholograpli illuslrating position analysis of the fix-
ture to be installed.
Fig 3 Radiograph illustrating the fixture and its supporting
alveolar bone prior to abutment connection.
than ihc corona! part of the implant (Fig 2), In this
space spongy-bone grafts arc packed to achieve Inti-
mate contact between the bone tissue and the titaniutii
surface. The bone grafts are preferably taken from
adjacent areas of the alveolar process and handled
with titanium instruments.
Following placement of the cover screws, wonnd de-
bridement is performed and includes proper removal
of pocket epithelium and subjacent inflammiitory con-
nective tissue. Finally., the mucoperiosteal flaps arc
carefully mobili?:cd. repositioned. and adapted by
means of interrupted, itraumatic, everted mattress su-
tures (nonresorb!ble) (Fig 2).
Antibiotics are prescribed postoperatively, 2 g of
phenoxymethyl-penicillin, twice a day for five to seven
872
Fig 2 Scfiematic illustration of the fixture-instailation pro-
cedure. Note that the fixture is plaoed beiow the marginal
alveolar bone level (lower left).
1
Fig 4 Schematic illustration of abutment connection pro-
cedure. Note the contra-acting device used to control the
forces applied to the center serew (lower left) and the an-
gulated manner of cutting the abutment (lower right).
days. and. if needed, analgesic. Postoperative control,
including a temporary replacement of the missing
tooth and removal of the sutures are performed after
seven to ten days.
The abutment connection procedure is performed
afler five to six months of healing." Prior to the sec^
ond-stage operation, ie, the abutment connection, in-
traoral radiographs are used to evaluate the botie qual-
ity surrounding the fixture and to decide which abut-
ment size to use (Fig 3). Further, these radiographs
later will serve as a reference when evaluating Ihe long-
term results of treatment.
Minor mucoperiosteal flaps are raised and the cover
screw is exposed and removed (Fig 4) before the newly
designed abutment is mounted onto the fixture. Dur-
Quintp&ence International Volume 19, Rfamber 12/19BB

Figo Schematic drawing of the cemented temporary
crown.
mg this procedure a contra-actmg device is used to
control the forces applied to the center screw, thus
preventing rotation of the fixture (Fig 4), The naps
are then trimmed and well adapted to the abutment
using interrupted sutures. The top of the abutment is
cut off in an angulated manner using a steel bur in a
water-eooled high-speed drill lu order to provide
enough space for the crown material (Fig 4). A pro-
visional crown is then inserted and cemented to the
abutment (Fig 5), Postoperative control is performed
seven to ten days later when all sutures also are re-
moved. After another four to seven days the prosthetic
procedure is initiated.
Titanium components
The fixtures installed have been redesigned for single-
tooth replacement. The fixture is self-tapping, the co-
ronal part is conical shaped with a smooth surface,
and the hexagonal part is extended from 0.7 mm in
the eonventional one to 1,2 mm. These fixtures are
available in different lengths (10 to 18 mm) and with
varying diameters of their conical parts (3,0 to
5.0mm) (Figo),
The abutments are of a new design (Fig 7), The part
of the abutment to fit the fixture is conically shaped
and has a smooth surface. The length of this conical
part of the abutment varies between 5 and 9 mm. The
marginal part is shaped as a hexagonal tube and, fur-
ther, the center screw has a zone between the first
thread and the serewhead which is shghtly thinner. The
loiernaional Volume 19, NunWr 12/1988
Oral Surgery / ProsthodontC
Fig 6 Photograph iliustrating the standard fixture (ieft) and
the redesigned one in two different diameters of the conical
part (right). Note the extended hexagonal part.
space inside the hexagonal shaft of the abutment is
eomplctely filled up with a sprint. This sprint fits the
top of the eenter serew hke a screw driver and is cul
off at the same level as the abutment (Fig 8),
Prosthetic procedure
About 10 to 14 days following the abutment connec-
tion, the gingiva usually is elinically healed, and the
permanent prosthetic therapy is carried out. After re-
moval of the provisional crown the center screw is
tightened. The hexagonal part of the abutment is ad-
justed by grinding, eg, sharp edges are rounded off,
and an impression is taken of the abutment and the
surrounding teeth. Occasionally, subgingivally placed
retraction threads have to be used. Sometimes a pre-
fabricated coping is placed onto the abutment (Fig 9),
is removed in the impression, and then serves as a base
for the artificial crown. With the use of conventional
techniques, the crown is manufactured and carefully
checked for perfect fit, shape, color, and occlusion.
Prior to the cementation of the crown to the titanium
abutment, the center screw has to be tightened once
again (Figs 8, 10 to 12), Follow-up controls are per-
formed after one to two weeks and then every six
months.
Discussion
The present paper describes a modified procedure for
the immediate replacement ofa single tooth. The part-
873
Oral Surgery / Prosthodontics

Fig 7 Photograpfi illusfrafing tfie redesigned abutment Fig 8 Scfiematic drawing illusfrating tfie single-footfi com-
{5 and 9 mm, respecfively). Most commonly used are fhe pone rtfs.
5 and 7 mm (not pictured).

Fig 9 Pfiotograpfi iliusfrafing tfie prefabricated coping and Fig 10 Schematic drawing illustrating single-tooth com-
the abutment separately (leff) and fhe two components put ponents in sifu.
together (right).

874 QuinfesseRCe international Voiume 19, lihimber 12/1988


Fig 11 Photograph illustrating the clinical appearance one
week following cementation of the crown (labial view).
Iy new design of the titanium components has been
used in order to improve esthetics and mimimizc the
risk of mechanicai failures.
In principal, two modifications of the fixture are
introduced: first, the hexagonal part is extended (0.7
to 1.2 mm), simphfying the abutment connection; sec-
ond, the conical part varies in diameter (3.0 to 5.0 mm;
Fig 6). The conical shape of the superior part of the
fixture will optimize the contact area between the bone
tissue and the fixture. Despite this conical shape gaps
may occur between the bone tissue and the titanium
surface. In such situations, however, spongy bone is
grafted from adjacent areas and properly packed into
this space, ensuring intimate contact between the bone
and the titanium surface and thus eventually enhanc-
ing the possibilities for osseointegration. Furthermore,
functional loads applied to such a conically shaped
ftxture will be favorably distributed to the supporting
alveolar bone.'^
The part of the abutment fitting the fixture is in-
versely conical in relation to the fixture and varies in
length between 5 and 9 mm (Fig 7), which makes it
possible to place the conical part of the abutment
subgingivally. Supragingivally the hexagonal part of
the abutment is exposed and serves as a post for the
artificial crown to be installed. The subgingival part
is conically shaped in order to facilitate a favorable
adaptation of the gingival tissues to the abutment as
well as to obtain a perfect fitting of the subgingival
part of the crown (Fig 10). The use of a cemented
crown facilitates adjustments and corrections such as
Quintesseoaerrtmational Volutne 19, NurWjer 12/1988
Oral Surgery / Prostl'
Fig 12 Photograph illustrating the clinical appearance one
week following cementation ol the crown (incisai view).
those created by color changes or wear, without dis-
turbing the dynamic equilibrium of the mueoperios-
teal interfaee.
Because the subgingivally located conical part ofthe
abutment varies between 5 and 9 mm in length, the
probing ("pocket") depth also may vary between 5 and
9 mm. Traditionally, a periodontal pocket depth
amounting to 5 to 9 mm most often is diagnosed as
pathologically deepened when bleeding oeeurs upon
probing." In addition, a microbiological analysis of
the subgingival plaque present using the dark-field
technique will reveal a large number of spiroehetes,
fusiforms, and motile rods," " An analysis using the
culturing technique will disclose a Hora dominated by
Gram-negative anaerobic bacteria.'"-'--^ However,
clinical studies analyzing the composition of the
plaque present in pockets .surrounding titanium abut-
ments have clearly demonstrated a fiora representing
a healthy periodontal situation-'"-^ even when the
pocket depth has been somewhat deepened.'^ Provid-
ing that the patient exhibits a high standard of oral
hygiene, the risk for loss of supporting alveolar bone
around sttch titanium abutments is low even when the
pocket depth is increased.
When a single missing tooth is replaced using stand-
ard fixtures and abutments, a very common problem
is loosening of the center screw, which leads to a loose
abutment and rotation of the crown. Such complica-
tions can be avoided by using the modified titanium
components presented in this report (Fig 8). Further,
the artificial crown is cemented on the abutment,
875
Oral Surgery / Prosthodontics
which increases the possibility of good esthetics iind
further decreases the risk that the crown will becotue
loose.
Summary
This paper describes ( A tnodifted surgical proce-
dure which is performed immedtiitcly following ex-
traction of a tooth and (2) a simplified prosthetic
procedtire for replacing a single missing tooth accord-
ing to tbe Brihicniark techtiiqne. These procedures will
redttce the length of the treatment period and improve
esthetics.
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Quintessence International Volume 19, Number 12/198B