Chapter 13 

–  Plate/Blade Form Implants

Treatment of Posterior Partial Edentulism Diagnosed for a Fixed
Prosthesis With Natural Co-Abutments BENEFITS AND DESCRIPTION
OF THE MODALITY AND SYSTEM USED IN THE TEACHING CASE

Plate/blade form implants are 65% narrower labio/buccolingually than conventional root form
implants. Because of the various configurations that accommodate the anatomy of available bone
in partially and totally edentulous ridges,[1] most cases that present for treatment are suitable
candidates for mainstream plate/blade form treatment. The Oratronics Osteo-Loc Generation-Ten
Plate/ Blade Form System used in the teaching case in this chapter offers a broad range of
implant configurations to take maximum advantage of narrow and shallow available bone. The
One-Stage Oratronics Weiss Osteo-Loc Standard Plate/Blade Form Implant System has been
granted full acceptance by the American Dental Association (ADA) for use with natural co-
abutments.[2] No other implant system of any modality has been granted acceptance for treatment
that includes taking advantage of the substantial additional support afforded by natural co-
abutments. A more detailed analysis of the use of natural co-abutments is presented in Chapter
16 .

Tissue Integration Options

For reasons best understood in terms of biomechanics and physiology, all abutments supporting
a prosthesis should have an equivalent mode of tissue integration. Because the plate/blade form
is the only modality proven to successfully function long-term in either the osteopreservation or
osteointegration mode of tissue integration, it has broad diagnostic applicability in treatment
planning.[3][4][5][6] Although plate/blade forms can be joined to natural co-abutments, an advantage
of the osteopreservation mode of tissue integration ( Fig. 13-1 ), they can also osteointegrate.
Osteointegrated plate/blade forms can help eliminate the need for cantilevering extensive root
form–supported prostheses by adding biomechanically compatible distal support in shallow bone
under sinuses and over inferior alveolar canals. Because of their basic shape and comparatively
large width (diameter), conventional root form implants generally can only be used in the minority
of healed partially edentulous ridges in the premolar and molar areas of the mandible and maxilla.
Using the osteopreservation mode of tissue integration, plate/blade form implants with natural co-
abutments can treat the majority of such cases. In non-mainstream, totally edentulous cases,
when root forms are used to support a fixed prosthesis, distal cantilevering typically is required
because of proximity to the mental foramen and insufficient depth of bone over the inferior
alveolar canal or under the sinuses for further placement of root form implants. Distal
cantilevering was performed in the seminal root form clinical trials most often cited in the
literature.[7] In many such cases, osteointegrated two-stage plate/blade forms can be placed into
healed edentulous premolar and molar ridge areas to support what would otherwise have been
cantilevered pontics ( Fig. 13-2 ).

Figure 13-1  Osteopreservation—one-stage implants with natural co-abutments.

 Figure 13-1 Osteopreservation—one-stage implants with natural co-abutments

Figure 13-2  Osteointegrated plate/blade forms serving as distal abutments in thin or shallow bone.

Figure 13-2 Osteointegrated plate/blade forms serving as distal abutments in thin

or shallow bone

Non-mainstream complete-arch cases can also be fully supported by three to four plate/blade
form implants, which the clinician can cause to heal in either the osteo-preserved or
osteointegrated mode of tissue integration ( Fig. 13-3 ).

Figure 13-3  Complete arch fixed prostheses supported by osteopreserved or osteointegrated

plate/blade forms.
 Figure 13-3 Complete arch fixed prostheses supported by osteopreserved or
osteointegrated plate/blade forms

Preparation for Treatment

Diagnosis and treatment planning are routine. Periapical radiographs, supplemented by

panoramic radiographs if desired, are all that are required. Out-of-office radiography is not
required for mainstream cases.

Technique-Permissive Implant Insertion

In mainstream cases, the implant insertion protocol is organized, simple, and predictable. Local
anesthetic is easy to administer. The incision is routine, and tissue reflection is minimal.
Osteotomy preparation is performed quickly using only one osteotomy bur, or a maximum of two.
Implant insertion is aided by a well-designed set of seating instruments that are easy to use and
adapted for every need that may arise during the procedure. Bone augmentation or spreading is
not required in mainstream cases. Experienced practitioners often complete the insertion of a
plate/blade form implant in a routine office visit of 30 to 45 minutes.

Whereas plate/blade form implant insertion is rarely difficult in mainstream cases, it can be
demanding in more complex cases, in which there may be marginal available bone, severe
undercuts, and/or sharp curvature of the arch. In addition, when several implants are used, they
require bending for abutment parallelism among them. Bone augmentation rarely is required.

Restorative Simplicity

Mainstream osteopreserved plate/blade form cases usually are restored with three-, four-, or five-
unit fixed prostheses that are conventionally fabricated and cemented into position. The
practitioner uses the same system favored when fabricating conventional fixed prostheses of
similar size over natural abutments. The same master impressions, bite registrations, shade
selection, trial seatings, occlusal adjustments, and the like are used. No special training is
required to accomplish the prosthodontic phase of treatment. No special components need be
affixed to the implant, which is supplied as a single contiguous unit with the abutment attached to
the body. At the time of insertion, the abutment portion has already been adjusted for parallelism
and inter-occlusal clearance. In addition, because most plate/blade form buccal/labial pergingival
sites are in attached gingiva, the crown over the abutment may be ridge lapped if esthetic
considerations indicate that doing so is desirable. The criteria and procedure for ridge lapping are
covered later in this chapter. This prosthodontic simplicity affords significant advantages in terms
of ease of fabrication, cleansability, reduced treatment time, and predictability.

Proven Long-Term Success/Survival Rates

The Oratronics Weiss Osteo-Loc Standard One-Stage Plate/Blade Form Implant System has
been given full acceptance by the ADA. This acceptance was granted in part as a result of
independent government-funded clinical trials conducted by the Veterans Administration at five
hospital centers,[8] and replicated at Harvard University[5] under grants from the National Institutes
of Health. These controlled, prospective, independent, longitudinal, randomized clinical trials are
recognized as being among the finest ever conducted to validate the safety and efficacy of a
dental implant system.[9] They are discussed in detail in Chapter 8 .

In addition, the plate/blade form modality has been successfully used for more than 35 years in
millions of cases worldwide. Their use conserves bone long-term in edentulous alveolar ridges,
and helps preserve remaining natural teeth that would otherwise be clasped or used for
attachment if conventional removable partial dentures were used. [8]

Unique Features

The unique features of plate/blade forms provide substantial benefits to treatment. Plate/blade
forms afford the clinician the only opportunity to use a modality that can succeed in either the
osteointegration or osteopreservation mode of tissue integration. The implants in the system used
in the teaching case are coined, affording significant metallurgic and physiologic benefits. [10]
Treatment time, costs to dentist and patient, and trauma are low. Ability to cleanse the restoration
and general esthetics are excellent. Prosthodontic procedures are conventional, requiring little or
no special training. Only one or occasionally two burs are all that are required for osteotomy
preparation. Insertion instrumentation is simple, easy to use, and inexpensive. Conventional high-
speed airotors with externally cooled burs are routinely used. [11][12]

The implant interface substantially increases surface area. It is impressed into the metal, not
applied to it, thus avoiding the dissolution, cracks, and delamination sometimes associated with
coatings. The implant body can be curved to follow the arch, and the abutments can be angled at
chairside for parallelism. The width and variety of plate/blade form configurations allows treatment
to take advantage of most healed partially or totally edentulous alveolar ridges. One plate/blade
form implant used in a mainstream case can be functionally equivalent to two or three root forms.

Nomenclature and Configurations of Plate/Blade Form Implants

The mainstream application of the Oratronics OsteoLoc Generation Ten One-Stage Plate/Blade
Form Implant System is taught in this chapter ( Fig. 13-4 ). The one-stage implant is fabricated in
one solid piece, with the abutment(s) integral with the body. No components are required.
Abutments are 7 to 8 mm high, tapered to promote ease of achieving parallelism, and faceted to
form an unequal-sided octagon to enhance cement retention. Toward the occlusal of each
abutment, four lines are spaced 1 mm apart for guidance in making adjustments for interocclusal
clearance. Beneath the abutment is the safety stop, a bevel that wedges within cortical bone at
the ridge crest to enhance stability at the time of initial seating, and acts to prevent overseating of
the implant as it is tapped into position. The osteotomy width at the abutment area after seating is
slightly more than 1 mm, whereas the bucco/labio-lingual width of the safety stop is 3 mm. The 2
additional millimeters rest securely on solid buccal and lingual cortical bone. The two-stage
configuration is the same as the one-stage, except that it has a removable universal abutment
that screws down onto a 2.5-mm J-threaded post that rises from the safety stop. Each two-stage
implant is supplied with a removable universal abutment and a removable healing collar ( Fig. 13-
5 ).

Figure 13-4  One-stage Oratronics Generation Ten plate/blade form.

Figure 13-4 One-stage Oratronics Generation Ten plate/blade form

Figure 13-5  Universal healing collar (left) and abutment (right).

Figure 13-5 Universal healing collar (left) and abutment (right).

The neck extends from the safety stop to the shoulder of the implant, which forms the crestal
border of the body. The neck ensures that the shoulder is positioned below the crest of the
alveolar ridge. During the healing process, bone grows over the shoulder to encase the implant
for improved retention. Near the mesial and distal ends of the implant, on the crestal surface of
the shoulder, are circular indentations called shoulder set-points. These are used to aid in
implant seating by engagement with a shoulder set-point seating instrument. Using the shoulder
set-points allows one to control relative mesio-distal seating to enhance parallelism with other
implants and/or natural co-abutments.
The body of the implant is bordered by the shoulder, its mesial and distal ends, and the edge of
the deepest portion, or base, of the implant. Standard implants have openings at the base, and
configurations called feet. These openings permit additional bony ingrowth from the base
crestally, as well as bucco/labio-lingually. Generation Ten implants have a closed base, with a
strip called a force distribution bar, round in cross section, running its length to biomechanically
enhance the implant’s ability to diffuse and transmit functional loads. Within the body of the
Generation Ten implant are vents, which permit bucco/labiolingual bony ingrowth to enhance
physiologic health and vascular communication between the buccal/labial and lingual plates of
bone on either side of the implant. Viewed in cross section, the implant is tapered from shoulder
to base. This taper enhances frictional fit and retention on the day of implant insertion, and
reduces shear at the interface during function. Coined into the body of the implant on the
buccal/labial and lingual surfaces are a series of wedge-shaped areas running linearly from
mesial to distal, comprising the Tru-Grip Body. This unique feature increases interface area and
enhances implant stabilization and resistance to dislodging forces. Also impressed into the
implant interface area at the time of coining is the Tissue-Tac surface texture ( Fig. 13-6 ). This
smooth, undulating surface further increases interface area by approximately 300%. It cannot
resorb, crack, or delaminate. The implant can be handled safely while making contour
adjustments at the time of trial seating during insertion. If the interface brushes against soft
tissue, cells do not abrade into its surface.

Figure 13-6  Tissue-Tac interface texture impressed into the interface

Figure 13-6 Tissue-Tac interface texture impressed into the interface.

Incorporating Plate/Blade Form Treatment into Practice

The plate/blade form is an excellent modality to study early in one’s learning curve because of its
wide range of applicability, relatively small total treatment time, reduced number of treatment
visits, conventional prosthodontics, reduced costs, ease of training, and use of the same high-
speed drill and handpiece used in conventional dentistry.

TYPICAL MAINSTREAM CASE—DIAGNOSIS, TREATMENT PLAN,

AND END RESULTS
Case as Presented
Patient’s Story.

A typical mainstream case presents with posterior partial edentulism in either the maxilla or
mandible. The patient may have a removable bilateral free-end saddle partial denture, in which
case one may hear complaints of complications associated with the natural abutments that have
either been clasped or fitted with semi-precision or precision attachments, or complaints of odor,
compromised function, esthetics, and gingival tissue complications. When no removable
prosthesis exists, or one cannot be tolerated, added concerns are a more significant inability to
function; interference with speech patterns; sunken, hollow cheeks; and loss of facial height.

Clinical Appearance.

Examination reveals a loose, unesthetic denture; poor hygiene; some loss of gingival height; and
perhaps the initial stages of bone loss around abutment tooth roots. Often, accelerated wear of
the occlusal and incisal surfaces of the remaining teeth is observed. Facial contours may be
compromised, and interocclusal clearance reduced. The edentulous portion of the alveolar ridge
is full, with adequate bucco-lingual width and a good band of attached gingiva.

Radiographic Interpretation.

The radiograph reveals adequate osseous support around potential natural co-abutments, and
sufficient length and depth of available bone to accommodate the insertion of adequate implant
abutment support to withstand anticipated functional loads long-term within physiologic limits of
health. The landmarks and osseous borders are clearly identified ( Fig. 13-7 ).

Figure 13-7  Panoramic preoperative radiograph showing bilateral posterior edentulism in mandible.

Figure 13-7 Panoramic preoperative radiograph showing bilateral posterior

edentulism in mandible

Rejected Alternative Treatment Plans

The practitioner and the patient do not feel that adjustments to an existing partial denture or the
fabrication of a new one would be satisfactory. The status quo is also unacceptable, for the
conditions about which the patient has complaints would remain and become exacerbated over
time. Therefore, implant treatment is indicated. A subperiosteal implant is not indicated in this
case. There is too much alveolar bone, which would continue to resorb after placement of a
subperiosteal, causing substantial complications in the future. Root forms are not indicated in this
case if the treatment is to remain mainstream, in part because the patient has time constraints
related to the number of visits and elapsed time in treatment. Teeth adjacent to the edentulous
area require restorative treatment unrelated to implant treatment, so avoiding reduction of these
teeth is not a consideration. In addition, the patient is reluctant to undergo the bone augmentation
that would be required to obtain sufficient bone width and depth to accommodate root form
dimensions. A basic tenet of mainstream implant dentistry is to fit the implant to the patient, not
the patient to the implant.

Accepted Treatment Plan—An Overview of Visit-By-Visit Case

Sequencing

The objectives of each of the treatment visits for the teaching case in this chapter are shown in
Box 13-1 . It is important to have a basic understanding of the entire course of treatment, so that
one can appreciate how the step-by-step procedures presented in this chapter contribute to
ultimate success.

Box 13-1
VISIT-BY-VISIT TREATMENT OBJECTIVES

   Preoperative procedures
   Visit 1: Implant insertion
   Visit 2, week 1: Suture removal
   Visit 3, week 2: Master impression and interarch occlusal registration
   Visits 4 to 5, weeks 3 to 5: Fabrication, try-in, and adjustment of final prosthesis
   Visits 6 to 7, weeks 6 to 7: Cementation of final prosthesis
Completed Case

Having the goal of treatment firmly in mind during each patient visit is important. Every step in
each procedure is directed toward successful completion of the case. For this reason, the end
result is presented here, to help the reader understand how each step of treatment contributes to
the final objective, and to convey the satisfaction and benefits of treatment for the patient and the
practitioner.

Patient’s Story.

The treatment goals have been achieved. The patient’s missing teeth have been replaced with a
nonremovable, comfortable, esthetic restoration that is efficient and easily maintained, and that
does not interfere with normal control of speech. The patient is pleased and grateful.

Clinical Appearance.

The esthetics of the completed prosthesis more closely resemble those of conventional three- or
four-unit fixed bridges than do those of other implant modalities. This is due to ridge lapping of the
crown that seats over the implant abutment, enabled by the predictable presence of attached
gingiva. In nonesthetic areas posteriorly, the crown can be bullet-shaped for greater ease of
cleansability, especially for elderly or infirm patients. However, ridge lapping of plate/blade form–
supported crowns has been successfully accomplished for more than 30 years, and should be
used to full advantage. With proper home care instruction, excellent hygiene is routinely
achieved.

Radiographic Interpretation.
Postoperative panoramic and periapical radiographs reveal a well-positioned implant. The
landmarks and borders surrounding the seated implant have not been abridged or traumatized.
The restorative prosthesis shows good marginal adaptation to the implant and natural co-
abutments. A review of several postoperative radiographs reveals harmony of the axial inclination
of the implants, the result of careful planning and execution of treatment ( Fig. 13-8 ).

Figure 13-8  Completed mainstream plate/blade form cases.

Figure 13-8 Completed mainstream plate/blade form cases.

Microscopic Interpretation at the Interface.

Following healing, light microscopy and scanning electron microscopy (SEM) reveal that the
collagenous fibers of the osteostimulatory peri-implant ligament are organized in a manner similar
to the fibers of the periodontal ligament. The fibers are bundled, run parallel to one another, often
anastomose, and are held together to act in unison by a network of reticular fibers[13] ( Fig. 13-
9 ). The collagen fibers attach to the first and often second layers of trabeculae of the cribriform
plate–like dense accumulation of trabecular bone that forms the socket close to the implant ( Fig.
13-10 ). The fibers that arise from these trabeculae pass almost vertically to the implant interface,
weave around and between vents and the borders of the implant body, and reinsert into other
trabeculae ( Fig. 13-11 ). Thus, they form a sling around the implant, the fibers of which are
stressed in function to stimulate the trabeculae into which they are inserted at each end. This is
hypothesized to produce bioelectric, cell-generated, and ground substance–generated signals
that result in bone deposition on the trabecular surface closest to the implant interface, known as
the osteostimulatory effect.[14] A detailed explanation of this hypothesis is given in Chapter 6 .

Figure 13-9  Scanning electron microscopy of peri-implant ligament fibers.

Figure 13-9 Scanning electron microscopy of peri-implant ligament fibers

Figure 13-10  Peri-implant ligament. Tetracycline labeling (A) and conventional staining (B).

Figure 13-10 Peri-implant ligament. Tetracycline labeling (A) and conventional

staining (B).

Figure 13-11  Peri-implant ligament fibers encompassing plate/ blade form implant
 Figure 13-11 Peri-implant ligament fibers encompassing plate/ blade form implant

PLANNING AND PROCEDURES BEFORE IMPLANT INSERTION

The steps that are performed before the implant insertion visit are shown in Box 13-2 .

Box 13-2
PREOPERATIVE PROCEDURES

   Quantify available bone

   Choose mode of tissue integration
   Choose single- or double-abutment option
   Select ideal implant configurations
   Prepare and temporize natural co-abutments
   Prescribe preoperative medication
Osteopreserved One-Stage and Osteointegrated Two-Stage Options

In mainstream cases supported by a combination of plate/blade form implants and natural co-
abutments, the one-stage osteopreservation mode of tissue integration is used. It is axiomatic
that the tissue integration around all of the abutment support under a prosthesis should be
biomechanically equivalent. Because the presence of the periodontal ligament makes teeth
function in a way that is biomechanically similar to an osteopreserved plate/blade form,
osteopreservation is required around the implant. The osteointegration option for plate/blade
forms, which is only used when specifically indicated but nonetheless has mainstream
applications, is discussed in the variations and alternatives section found later in this chapter. The
type of tissue integration, osteopreservation or osteointegration ( Fig. 13-12 ), is determined by
the healing protocol chosen by the practitioner, not by the configuration of the implant.

Figure 13-12  Osteopreserved (A, arrow shows peri-implant ligament) and osteointegrated (B, arrow
shows bone interface) plate/blade forms.

Figure 13-12 Osteopreserved (A, arrow shows peri-implant ligament) and

osteointegrated (B, arrow shows bone interface) plate/blade forms

Single- and Double-Abutment Options

An important prosthodontic consideration is correct placement of abutments under the crowns of

the proposed prosthesis. Note that on the plate/blade form overlay, many implant models with the
same body configuration are supplied with either one or two abutments. Abutments should pass
through the pergingival site into the oral cavity in positions that allow prosthetic teeth to
harmonize with the opposing dentition. When abutments are located as ideally as possible under
overlying crowns, and not in embrasures, the positioning of the teeth in the proposed prosthesis
is closer to ideal ( Fig. 13-13 ). Several implant models are supplied with offset abutments. In
using these implants, reverse the mesial and distal of the implant before final seating to evaluate
options in abutment positioning to enhance esthetics. In closed-bite cases, in which the height of
a single abutment compromises the interocclusal clearance, and reduction of this abutment for
adequate interocclusal clearance would make the cementing area inadequate, a double-abutment
implant doubles the cementing area to improve retention.

Figure 13-13  Choosing between single- or double-abutment options to avoid embrasures.

 Figure 13-14 Oratronics Generation Ten (left) and Standard (right) plate/blade form
overlays

Select the Ideal Implant Configuration for Placement Within the

Available Bone
Determine the Mode of Tissue Integration.

In the teaching case in this chapter, the premolars are used as mesial co-abutments. Again,
because these teeth have periodontal membranes and are not ankylosed, the plate/blade form
should function in the osteopreserved mode of tissue integration. Thus, hypofunctional healing
and controlled micromovement are required to provide a periimplant ligament as the implant
heals.

Determine Whether to Use a One-Stage or Two-Stage Implant.

The one-stage option, used in the teaching case in this chapter, is the configuration of choice in
cases that call for osteopreservation. The implant is fabricated from one piece of titanium and is
fully adjustable for parallelism, interocclusal clearance, and curvature of the arch, and for
increasing initial retention in the osteotomy on the day of insertion, if required.

Alternatively, the two-stage option may be used to achieve osteopreservation. Two-stage

implants are provided with a threaded post extension from the neck, onto which a removable
abutment or healing collar can be seated. The implant with its abutment in position is seated
according to the same insertion protocol. The abutment is then removed, and the healing collar is
attached. Following suturing, the healing collar remains semi-submerged, with its crestal surface
flush with or approximately 1 mm above the gingival crest, resulting in the transmission of less
functional load but permitting sufficient micromovement to ensure osteopreservation. Before
taking the master impression for prosthesis fabrication, the healing collar is removed, and the
abutment is cemented into position, adjusted, and never again removed to ensure accurate fit of
the final prosthesis. Thus, only 2 weeks of reduced load is gained. This is of questionable benefit,
because the load applied to a one-stage implant at this time is not excessive. During the first
several weeks of healing following implant insertion, the implant is rigid. At the time of insertion it
is tapped into position and wedged firmly between the buccal and lingual plates of bone, in a
state of direct bone contact. The completed prosthesis is cemented over the implant and natural
co-abutments. It provides rigidity for the remainder of the healing cycle and is never removed.
The one-stage, one-piece implant is generally preferred in mainstream osteopreserved cases.

Quantify the Available Bone.

Having determined to use an osteopreserved one-stage implant, the next step is to quantify the
available bone in the area targeted for implant insertion, following the principles laid out in
Chapters 3 and 9 . To review briefly, use periapical radiographs to determine the length and
depth of available bone between landmarks and borders. In cases of mandibular partial posterior
edentulism, such as the teaching case, recall that length of available bone is measured mesio-
distally from the distal of the nearest tooth root to the ascending ramus. Treatment of maxillary
partial posterior edentulism, not shown in the teaching case, is also considered mainstream. In
such cases, length is measured from the distal of the nearest tooth root or from the mesial border
of the sinus to the distal of the tuberosity.

Outline the “usable” available bone on the radiograph to visualize the length and depth of
available bone into which the implant will be inserted, according to the principles described in
Chapters 3 and 9 . Determine width while being mindful of the differences in gingival thickness
between the mandible and maxilla. In the teaching case, placing a caliper on the gingiva 1 to 2
mm from the crest and subtracting 2 mm from this measurement accurately gives the width of the
ridge in the mandible. In the maxilla, passing the caliper measuring points through anesthetized
tissue until they touch bone is the most accurate method.

Select the Ideal Implant Configuration for Placement Within the Available Bone.

A key question asked during diagnosis and treatment planning when one first evaluates the
available bone and determines the extent of the final prosthesis bears review at this juncture. The
question is, if one inserts an implant that takes full advantage of the available bone, will it
withstand the anticipated functional forces to which it will be subjected long-term within
physiologic limits of health? Will support be adequate? Will the case be properly engineered? If
the answer is no, reconceive the treatment plan. The possibility of over-engineering the case
bears as much consideration as underengineering. Often, so much available bone is present that
use of only a portion of it is more than adequate for long-term support in health, and use of all of it
would result in complications related to overengineering, potentially resulting in bone loss caused
by hypofunction. In such cases, the safety margin of 1 to 2 mm clearance from landmarks and
borders can often be extended to 4 to 5 mm.

The periapical radiograph marked to outline the extent of available bone is used in conjunction
with a plate/blade form overlay to select the most appropriate configuration.

The plate/blade form overlay displays every configuration of implant available within the system
selected—in the teaching case, the Oratronics Generation Ten system ( Fig. 13-14 ). The overlay
shows the length and depth of each implant configuration in millimeters, and model numbers for
use when ordering the one-stage or two-stage options. For ease of implant selection,
configurations are categorized into those for use in the upper arch, lower arch, and either arch. In
general, lower arch implants are inserted into the posterior mandible, over the inferior alveolar
canal. The base of each implant is curved to parallel the usual curvature of the roof of the inferior
alveolar canal. In general, upper arch implants are inserted into the posterior maxilla, under, in
front of, and/or behind the maxillary sinus. The curvature of each implant base reflects the
curvature of the floor of the sinus. Some are for use only under the sinus, others are for use
under and anterior or under and posterior to the sinus, and some are only for use in the tuberosity
( Fig. 13-15 ).

Figure 13-14  Oratronics Generation Ten (left) and Standard (right) plate/blade form overlays.

Figure 13-13 Choosing between single- or double-abutment options to avoid

embrasures

Figure 13-15  Various configurations that accommodate available bone

Figure 13-15 Various configurations that accommodate available bone

Plate/blade form overlays come in two sizes. One, for use with periapical radiographs, has life-
sized representations of each configuration. The other, for use with panoramic radiographs, has
120% representations to approximately compensate for expected enlargement of the radiograph.

In the teaching case, the target location of the implant is in the posterior mandible, and a one-
stage singleabutment Oratronics Generation Ten implant is desired. Therefore, attention is
directed to the lower arch or either arch implants on the Generation Ten blade form overlay.
Thirteen lower arch implants are available, and six of them are single-abutment models. Above
each implant on the overlay is a series of numbers. The first one, in bold type, is the mesio-distal
length of the implant in millimeters. The numbers in the parentheses represent the depth of the
implant measured in millimeters from the level of the safety stop down to the implant base. Some
implants (e.g., models 014 and 045) are deeper mesially and shallower distally. For these
implants, for example, the depth measurements are shown as (11-9-8), in which 11 mm is the
depth measurement mesially from the level of the safety stop to the base, 9 mm is the depth
measurement at the center of the implant, and 8 mm is the depth measurement at the distal. Note
that the bodies of these two models are identical, but model 014 has an offset single abutment
and model 045 has two abutments. In the case of models 033 and 034, the same choices exist,
but the body of each implant is symmetrical at 24 (7-8-7), and in the single abutment version the
abutment is centered. Model 042 has the same implant body, with the single abutment offset.

Place the plate/blade form overlay over the periapical radiograph such that an implant body is
centered over the area of usable available bone outlined earlier. Suppose one first tries model
033, but determines that the 24-mm length is too short. One would then try model 043, with a 27-
mm length and one offset abutment. When the dimensions of the body are appropriate, one must
determine where the abutment should be. Suppose that for prosthodontic purposes, the abutment
should be toward the distal. If so, the overlay is turned over to view the abutment in its distal
position. Note that in every case, once the implant body fits the available bone, it is always
positioned in the same location, and only the mesio-distal location of the abutment that most
nearly satisfies prosthodontic requirements is considered. In the teaching case, we try model 007,
and find that its length is acceptable at 18 mm, but that its 11-mm depth is excessive ( Fig. 13-
16 ). Model 024, at the same 18-mm length, may be safer at 8 mm in depth ( Fig. 13-17 ). Pass
each implant candidate over the marked radiograph, and the optimal choice becomes evident.

Figure 13-16  Implant overlay (A) placed over periapical radio-graph indicates that base of implant is
too close to canal (B).

Figure 13-16 Implant overlay (A) placed over periapical radio-graph indicates that
base of implant is too close to canal (B).
 Figure 13-17  Implant overlay (A) placed over periapical radio-graph indicates adequate clearance
around implant (B).

Figure 13-17 Implant overlay (A) placed over periapical radio-graph indicates
adequate clearance around implant (B).

Choose Backup Configurations.

Having sterilized backup implants at hand is an advantage. During implant insertion, one may
realize that a longer or shorter implant, a deeper or shallower implant, or a double-abutment or
single-abutment implant may be more appropriate for the case at hand ( Fig. 13-18 ).
 Figure 13-18  A selection of backup implants

Figure 13-18 A selection of backup implants

Order the Implants and Record the Product Number and Manufacturer’s Control
and Lot Numbers on the Patient Record.

When the final and backup configurations have been selected, order the implants. When they
arrive, record each product number in the patient record in case a reorder is indicated, along with
the lot and control numbers of each implant. These numbers comply with government regulations
for traceability and quality control of implanted devices.

Adjust Implant to Clear Anatomic Landmarks

Because of the variety of plate/blade form implant configurations available, it seldom is necessary
to adjust an implant to ensure clearance from a landmark or boundary. However, if the best
available configuration may impinge on a landmark, the implant can be modified. Such
adjustments can be made easily.

The first step is to hold the implant over the periapical radiograph marked to show the usable
available bone. Note the portion of the body of the implant that extends beyond the boundary,
and remove it ( Fig. 13-19 ). A carborundum disk, green stone, or heatless wheel is used for
trimming. A metal bur is contraindicated when adjusting the body of the implant to preclude
contamination by metal transfer. The procedure is completed by smoothing rough edges with a
sterile rubber wheel, followed by thorough cleansing and resterilization.

Figure 13-19 
 Figure 13-19 Adjusting an implant to clear a landmark

Adjust Abutment for Interocclusal Clearance

Basic abutment adjustments for interocclusal clearance are made before the insertion visit.
Experience has shown that clearance of 2 mm or more is ideal, and that 1 mm is acceptable. In
the mandible, the gingiva is most often 1 to 2 mm thick, and in the maxilla gingival thickness can
be as high as 10 mm. Implant abutments are 7 or 8 mm in height as measured from the safety
stop. To test whether adjustment is required, and if so to what extent, observe on the study
models or intraorally the distance from the gingival crest to the occlusal surface on the opposite
arch. If this distance is 7 mm or greater, no adjustment is required, because the implant safety
stop at the base of the abutment will be 2 mm apical to the gingival crest when seated. If the
distance is less than 7 mm, the abutment is reduced in height by a minimum of the number of
millimeters required to make the height equal to the measured distance from the gingival crest to
the opposite occlusal surface ( Fig. 13-20 ). In measuring, always account for gingival thickness.
Abutment height is reduced using a carborundum disk or heatless wheel, followed by smoothing
of rough edges.

Figure 13-20  Adjusting an abutment for interocclusal clearance.

Figure 13-20 Adjusting an abutment for interocclusal clearance

Implant Sterilization

Implants are supplied sealed in two pouches. The outer pouch contains product and usage
information required by Food and Drug Administration (FDA) regulations and the Good
Manufacturing Practices Act. The inner pouch contains the implant. If no adjustments to the
implant body or abutments are required, do not remove the implant from the inner pouch. If
adjustments are required, remove the implant, make necessary adjustments using only solid
titanium or titanium-tipped instruments, and repouch the implant as one would for the routine
sterilization of dental instruments. Sterilize the implant in the conventional manner. Guidelines for
gravity air displacement steam sterilization are for an exposure time of 30 minutes at 250° F (121°
C) or 15 minutes at 270° F (132° C). For prevacuum steam sterilization, an exposure time of 4
minutes is required at 270° F (132° C). The sterilized implant in its pouch is transferred to the
implant insertion surgical tray setup. The implants used in the teaching case can be cleansed and
resterilized, even if they are tried into an osteotomy and a decision is made to use a different
configuration.

Prepare and Temporize Premolar Abutment(s)

For solo practitioners who will both insert the implant and fabricate the final prosthesis,
preparing and temporizing the natural co-abutments is almost always accomplished during the
implant insertion visit, under the same local anesthetic. For the first several mainstream cases
being treated, it may be advisable to prepare ( Fig. 13-21 ) and temporize the natural co-
abutments before the implant insertion visit, at least until the insertion procedure becomes
routine. It is also advisable to prepare and temporize the natural co-abutments before referring a
patient to another practitioner for implant insertion, if the team approach is used. In such cases,
the insertion practitioner removes the provisional restoration on the natural co-abutments to
accurately assess the parallelism requirements, and for enhanced ac-cess to and visibility of the
field of operation.

Figure 13-21  Natural co-abutments prepared before implant insertion.

Figure 13-21 Natural co-abutments prepared before implant insertion

Natural co-abutment preparation and temporization is performed in the same manner as for
conventional fixed bridgework. Any one of several common methods, well executed,
accomplishes the task.

Prescribe Preoperative Medication for the Insertion Visit

Prescribe preoperative medication for the insertion visit as discussed in Chapter 9 . Recall that
preoperative administration of anti-edema medication is generally not required for mainstream
cases, unless the patient’s history suggests that edema may be greater than normal. Nor is
preoperative sedation recommended. Patients who take prophylactic aspirin daily are advised to
discontinue doing so for at least 3 weeks preoperatively, to allow for normal clotting at the
insertion visit.

VISIT 1: IMPLANT INSERTION AND PROVISIONAL

PROSTHODONTICS

The steps that are performed during the implant insertion visit are shown in Box 13-3 .

Box 13-3
VISIT 1: IMPLANT INSERTION

   Confirm use of prophylactic antibiotic

   Set up instrumentation
   Administer anesthetic
   Make incision
   Reflect tissue
   Mark location and extent of osteotomy
   Prepare osteotomy
   Evaluate osteotomy suitability
Adjust implant to conform to crestal curvature, clear anatomic landmarks, accommodate
  
interocclusal clearance, and achieve prosthodontic parallelism as required
   Perform final seating of implant
   Perform soft-tissue treatment
   Suture
   Check temporization of premolar co-abutments
   Select shade
   Provide home care instruction
   Schedule follow-up visit
Confirm That Preoperative Medication Has Been Taken

As discussed in Chapter 9 , it is not necessary to postpone the case if the patient has not taken
the preoperative prophylactic antibiotic medication. The practitioner should have antibiotics on
hand for preoperative administration in such cases. If a patient on an aspirin regimen has not
discontinued its use, insertion may nonetheless be performed, with delayed clotting expected.

Instrumentation Setup— The Armamentarium

Two sterile tray setups are recommended. The first, which holds all instruments that do not come
in direct contact with the implant during the insertion procedure, is described in Chapter 9 . The
second surgical tray holds all instruments involved with implant insertion, as well as the implants
themselves and implant components if a two-stage implant is being used. The trays are placed
side by side.

The second tray includes a semi-lunar tissue punch, channel curette and depth gauge, implant
carrier, single-abutment seating instrument, double-abutment seating instrument, shoulder set-
point seating instrument, set of two bending pliers, implant remover (reverse mallet), and tissue
marker. These instruments are either solid titanium or titanium tipped, and are anodized blue for
ease of identification and segregation ( Fig. 13-22 ).

Figure 13-22  Selection of specialized instruments for implant insertion.

Figure 13-22 Selection of specialized instruments for implant insertion

Sterilization is performed as with all dental treatment instrumentation.

Presurgical Treatment

Prepare the surgical field, administer local anesthetic containing vasoconstrictor to promote
comfort and control bleeding, and prepare the oral cavity and targeted tissues according to the
principles and procedures described in Chapter 9 .

Make Incision

Evaluate the attached gingiva, plan the incision line, incise, and ensure hemostasis according to
the principles and procedures described in Chapter 9 . Healed one-stage plate/ blade form
implant abutments have the highest percentage of attached gingiva at every aspect of the
pergingival site because they are sutured within attached gingiva. The practitioner controls this.
When planning the incision line, reconfirm the correct choice of implant and visualize its planned
mesio-distal location by holding it above the ridge crest at its planned position. Mark the points of
the mesial and distal extent of the implant on the ridge crest. Place additional marks 3 to 5 mm
distal to the distal mark and 3 to 5 mm mesial to the mesial mark. Connect the most distal to the
most mesial mark, on or slightly buccal to the ridge crest, with the tissue marker. If the mesial
extent of the marked incision line is within 5 mm of the gingival cuff of a natural tooth, draw the
line through the cuff.

Reflect and Prepare Tissue Before Insertion

Reflect the tissue using the periosteal elevator, trim the tissue flap edges to ensure healing by
primary intention, and cleanse and alter the exposed alveolar ridge as required according to the
procedures and principles described in Chapter 9 .

Mark Location and Extent of the Implant Osteotomy

Place the implant firmly in an implant carrier, with the manufacturer’s logo or other identifying
mark on the implant oriented toward the buccal or lingual aspect of the ridge ( Fig. 13-23 ).

Figure 13-23  Exposed ridge (A), and use of implant carrier to confirm required osteotomy length (B).
 Figure 13-23 Exposed ridge (A), and use of implant carrier to confirm required
osteotomy length (B).

   Remember and repeat this orientation to ensure ease of implant insertion at

the time of trial seatings and adjustments.

Retract the flaps and hold the implant directly over the area of the ridge crest planned for the
osteotomy. Using an XL channeling bur, mark the mesial and distal extents of the implant on the
ridge.

   The marked extent of the planned osteotomy delineates its mesio-distal

positioning. This should correspond to the position of the implant when its life-sized
replica on the plate/blade form overlay was held against the periapical radiograph of
this area during implant selection.

With the XL channeling bur, create a 1-mm penetration 1 to 2 mm distal to the distal mark, and
another penetration 1 to 2 mm mesial to the mesial mark ( Fig. 13-24 ).
 Figure 13-24  Exposed ridge (A), and bur penetrations marking mesial and distal extent of planned
osteotomy (B).

Figure 13-24 Exposed ridge (A), and bur penetrations marking mesial and distal
extent of planned osteotomy (B).

   Osteotomies are prepared 1 to 2 mm longer at each end than the space to be

occupied by the implant. This affords ease of implant insertion and the ability to more
precisely adjust for correct mesio-distal location of the abutments.
Prepare Implant Osteotomy
Primary Penetration Through Cortical Bone.

Insert the XL channeling bur into a high-speed contra angle. Orient the long axis of the bur to
bisect the buccal and lingual cortical plates of bone ( Fig. 13-25 ).

Figure 13-25  Osteotomy bone bur at correct axial inclination.

Figure 13-25 Osteotomy bone bur at correct axial inclination

   This bucco-lingual long-axis orientation is maintained throughout osteotomy

preparation, ensuring that the maximum bone possible exists on each side of the
seated implant. Parallelism with other natural or implant co-abutments is not a
consideration when preparing the osteotomy. In most cases, the abutments initially
are parallel with other abutments. If necessary, they are adjusted for parallelism in a
 subsequent step.

Using copious coolant, maintain the bur orientation, and start from the distal to prepare a series of
initial penetrations 3 to 5 mm apart along the crest of the ridge ( Fig. 13-26 ). Penetrate just
through the cortical bone into the cancellous bone, to mark the path of the osteotomy. Stay on the
ridge crest, whether it is straight or curved mesio-distally.

Figure 13-26  Primary ridge crest penetrations.

Figure 13-26 Primary ridge crest penetrations

   The XL channeling bur prepares an osteotomy that is slightly narrower than

the bucco-lingual width of the implant. This ensures frictional fit and implant
immobilization following final seating and during the early healing period. The ability
to follow the mesio-distal curve of the arch is an advantage of the plate/blade form
modality. The practitioner always is able to take advantage of favorable bone. No
other considerations interfere, and no trade-offs occur that may compromise the use
of the best available bone for prosthodontic requirements. In plate/blade form
treatment, prosthodontic requirements always can be satisfied.
Secondary Penetration to 50% Depth.

Maintaining the bur orientation, perform the secondary penetration with adequate coolant.
Starting from the distal, reenter each primary penetration and carry it to a depth equal to 50% of
the depth of the implant.

   Implant depth is measured from the safety stop under the abutment to the
base of the implant. Glancing from the tip of the bur up the shank, note the spot that
corresponds to 50% of the implant depth. With each secondary penetration, the bur
is removed when that spot reaches the crest of the ridge, thus affording depth control
by the practitioner. The XL channeling bur passes into cancellous bone with ease.
The contra angle may be fitted to supply saline. Superior efficiency of cutting at high
speed, together with the application of controlled intermittent pressure and copious
external coolant, maintains a cool, cleansed field of operation. Note that the XL and
XXL channeling burs are tapered to create an osteotomy that corresponds to the
taper of the plate/blade form implant to be inserted.
Maintaining the bur orientation, starting from the distal, reenter the most distal penetration and
carry it mesially, connecting one penetration point at a time. Repeat until the entire length of the
planned osteotomy has been prepared to 50% of its final depth ( Fig. 13-27 ).

Figure 13-27  Preliminary osteotomy at 50% of planned depth.

Figure 13-27 Preliminary osteotomy at 50% of planned depth

   This partial-depth intermediate osteotomy preparation is recommended for

implants that are 10 mm in depth or deeper. It affords continuing control and an
opportunity to change to the XXL channeling bur to complete the procedure. For
implants shallower than 10 mm, the secondary penetration can be made to final
depth and the osteotomy completed in one pass.
Check Location Accuracy/Bone Harvesting.

The intermediate osteotomy now is cleansed and checked for dimensional accuracy with the solid
titanium channel curette and depth gauge. Gently insert this instrument distally to the base of the
preliminary osteotomy, and carry it mesially as it curettes out and harvests a paste of bone chips
and blood. If desired, this may be preserved in a sterile dappen dish on the tray setup. Several
passes may be needed to clear the channel. Check the depth and evenness of the base of the
preliminary osteotomy, and make any necessary corrections to ensure conformity. Place the
implant in its preliminary osteotomy to confirm that the mesio-distal length of the osteotomy can
accommodate the length of the implant, with an extra 1 to 2 mm of clearance at each end.

   The solid titanium channel curette and depth gauge is narrower bucco-
lingually than the preliminary osteotomy, to prevent injury to its lateral walls during
curettage. The instrument has the same horizontal Tru-Grip markings, 2 mm apart,
that are on the surface of the implant. As the instrument is passed along the base of
the preliminary osteotomy, direct depth readings can be made at every point mesio-
distally along the site. Corrections are made if and as required to bring the
intermediate osteotomy to its proper depth at every point.
Preparation to Final Depth.

Insert the XXL channeling bur into the contra angle. Hold the tip of the bur opposite, but not
against, the safety stop under the abutment. Note the point on the shank of the bur that
corresponds to the base of the implant. Add 1 mm, and mark that point on the shank by spinning
it against a disk. Some bone burs are premarked for depth.
    This step marks the point on the bur’s shank that must be brought flush with
the crest of bone to ensure the proper depth of final osteotomy preparation. This will
safely and predictably avoid landmarks. In rare cases in which an implant was
recontoured to avoid a landmark, or if the selected implant model is asymmetrical,
mark the bone bur to reflect the deepest and shallowest planned osteotomy depths.

Prepare the osteotomy to its final depth. Maintaining the bur orientation, make a series of 1-mm
vertical penetrations 3 to 5 mm apart into the floor of the intermediate osteotomy, starting from
the distal and proceeding to the mesial end. Reenter and complete each penetration to the final
osteotomy depth as marked on the shank of the XXL bur. Reinsert the bur distally and connect
each penetration until the entire length of the osteotomy has been prepared to its final depth, or to
graduated depths along the length of the osteotomy in the case of asymmetrical implants.

   Essentially, this technique repeats the process of creating the preliminary

and intermediate osteotomies. The cutting edges of the XXL bur are 5 mm deep. At
this point, they are within cancellous bone at all times, well below the cortical plate at
the ridge crest. This protects the integrity of the osteotomy borders along the ridge
crest as the deeper portions of the osteotomy are prepared.
Confirm Osteotomy Correctness.

Confirm the proper depth of the osteotomy at every point. Hold the channel curette and depth
gauge opposite the implant such that the tip of the depth gauge is at the base of the implant. Note
the point on the depth gauge that corresponds to the level of the safety stop, and add 1 mm ( Fig.
13-28 ). Insert the instrument and pass it along the base of the osteotomy from distal to mesial,
and observe the relationship of the noted point to the ridge crest at all times. Harvest bone chips
in the dappen dish, if desired. If the depth gauge reveals that a portion of the osteotomy is too
shallow or uneven, deepen or even it. Remeasure to confirm the correction. Osteotomy
preparation now is complete ( Fig. 13-29 ).

Figure 13-28  Depth gauge (A) used to measure depth of osteotomy (B).
Figure 13-28 Depth gauge (A) used to measure depth of osteotomy (B).

Figure 13-29  Completed osteotomies.

 Figure 13-29 Completed osteotomies

   In the mandible it is important to avoid the roof of the inferior alveolar canal
and the mental foramen. The implant should be placed at least 1 to 2 mm distal to
the foramen and superior to the roof of the canal. In the maxilla, the implant should
be placed not closer than 1 mm to the floor of the maxillary sinus. Proper selection of
the configuration using the plate/blade form overlay on a peri-apical radiograph helps
ensure that these requirements can be met.
Adjust Implant Body to Conform to Mesio-Distal Ridge Crest
Curvature

It may be necessary to curve the implant mesio-distally to follow the contour of the bone. To place
the osteotomy within ideal bone, the mesio-distal curvature of the bone is followed during
osteotomy preparation. All bending adjustments are performed with the titanium-tipped bending
pliers. Using the manufacturer’s logo or other identifying mark on the implant as a positioning
guide, note which side is buccal and which lingual for orientation during bending. One of the pliers
is held parallel to the implant shoulder from the distal, and the other from the mesial. View the
implant base from below, and bend the implant such that it matches the curve of the arch as
closely as possible. Hold the implant above the crestal opening of the osteotomy, observing the
logo or other identifying mark to orient it properly bucco-lingually, and check both the shoulder
and inferior borders of the implant to determine whether the adjustments are adequate. Correct if
necessary ( Fig. 13-30 ).

Figure 13-30  Curving of implant to conform to ridge crest.

 Figure 13-30 Curving of implant to conform to ridge crest

   Because the dental arches are curved, osteotomies often are curved.
Previous periodontal conditions and prior surgical interventions may cause uneven
ridge healing. These result in osteotomies that reflect this varying anatomy as the
buccal and lingual cortical plates are bisected during osteotomy preparation. Note
that adjusting the implant to conform to the patient’s anatomy is only possible using
plate/blade form implants. This unique adaptability is one of their more important
attributes. It enables the use of optimum areas of available bone.
Adjust Implant to Clear Anatomic Landmarks

Preliminary adjustments to the body to clear anatomic landmarks were made before the insertion
visit as previously described, if required. Again, hold the implant opposite the periapical
radiograph, and reconfirm that any adjustments that have been made are adequate. If not, further
alter the implant contours as required.

   Checking adjustments ensures the precision of the implant placement

procedure. Safety is the most important consideration at each step.
Partial Implant Seating to Test Need for Further Adjustments
Test Mesio-Distal Curvature.

Place the implant to a depth of 2 to 3 mm within the osteotomy. If the implant body adjustments to
conform to mesio-distal crest curvature need to be perfected, remove the implant and do so now.

   Recall that the osteotomy, viewed bucco-lingually, is tapered to correspond

 to the implant taper. Providing that the implant curvature has been adjusted to
approximate the osteotomy curvature, the implant can easily seat to the 2- to 3-mm
depth, or slightly deeper. The implant seating instruments may be used.
Test Abutment Location for Prosthodontic Ease.

Consider the mesio-distal position of the abutment(s) for prosthodontic ease. Recall that the
osteotomy was prepared a few millimeters longer than necessary at each end. The implant may
now be repositioned more mesially or distally if advisable for ideal abutment positioning.

   Although it is helpful to position the abutments under the crowns of the

planned prosthesis, it is not essential to do so. This is one of the benefits of the
prosthodontic versatility of the plate/blade form implant.
Technique Options for Partial Seating/the Pro-gress Radiograph.

Place a seating instrument over the abutment(s) of the implant. In the mandible, use hand
support under the inferior border. In the maxilla, place the patient’s head securely against the
headrest. With the tapping mallet, gently tap the seating instrument until the safety stop under
each abutments is 2 mm from the ridge crest ( Figs. 13-31 and 13-32 ).

Figure 13-31  Positioning of seating instrument for malleting.

Figure 13-31 Positioning of seating instrument for malleting

Figure 13-32  Partially seated implants with safety stops 2 mm above ridge crest.

Figure 13-32 Partially seated implants with safety stops 2 mm above ridge crest

   Hold the long axis of the seating instrument parallel to the long axis of the
osteotomy, and thus parallel to the long axis of the body of the implant, as it is gently
 tapped into position. A tapping mallet is required to overcome friction between the
implant interface and bone as it seats deeper into the osteotomy, which was
prepared narrower bucco-lingually than the width of the implant. All seating
instruments are offset to promote easy access, lip clearance, and visibility.

In the mandible, single- or double-abutment and shoulder set-point seating instruments usually
are used. Tap the mesial and then the distal, working the implant to its desired depth with the
safety stop 2 mm from the ridge crest. For a single-abutment implant, use the shoulder set-point
seating instrument to engage first the mesial and then the distal shoulder set-point in the implant
shoulder. For a double-abutment implant, the single-abutment seating instrument can be used
over the mesial and then distal abutment alternately to accomplish the same result, and the
shoulder-set points can also be used. When the implant is partially seated, take a periapical
progress radiograph.

   Preliminary seating now is completed. The periapical progress radiograph is

examined to reconfirm appropriate configuration selection. Check that sufficient
available bone is present such that after final seating of the implant an additional 2
mm into the osteotomy, at least 1 mm of clearance from the nearest landmarks
remains. Also confirm that recontouring to avoid landmarks, if performed, is
adequate. If not, correct this adjustment now. If the radiograph reveals much unused
available bone, the implant originally selected may be replaced with a larger model.
However, if the implant is adequate to withstand anticipated function despite the
presence of more available bone, no change is required. If the progress radiograph
reveals that too little available bone remains and body recontouring cannot solve the
problem, a smaller backup configuration should be used.
Adjust Implant Abutment for Prosthodontic Parallelism
Check for Parallelism.

With the implant preliminarily seated, check whether the implant abutment is parallel to the long
axis of the crowns of the prepared natural co-abutments. If not, adjustments for parallelism are
required.

   Plate/blade form implants are unique in that they can predictably, routinely,
and quickly be adjusted at the time of insertion to achieve parallelism for support of a
fixed restorative prosthesis.

Examine intraorally to determine the angle of bend, if any, required to achieve parallelism with the
other abutments. Remove the implant by engaging a titanium-tipped implant remover (reverse
mallet) under the base of the safety stop, and tap the implant out of the osteotomy in the long axis
of the implant body ( Fig. 13-33 ).

Figure 13-33  Use of reverse mallet implant remover.

 Figure 13-33 Use of reverse mallet implant remover

   Do not luxate bucco-lingually and thereby widen the osteotomy. Cleanse the
implant, and orient it into its proper position by observing the manufacturer’s logo or
other identifying mark. A pair of titanium-tipped bending pliers are used for paralleling
adjustments.
Correct Bucco-Lingual Parallelism.

Position one of the bending pliers over the implant abutment with the beak even with and parallel
to the safety stop. Position the second bending pliers over the implant body with the beak even
with and parallel to the implant shoulder under the safety stop. Grasp the implant firmly ( Fig. 13-
34 ).

Figure 13-34  Position of beaks of adjusting pliers to bend across implant neck.

Figure 13-34 Position of beaks of adjusting pliers to bend across implant neck

   The exposed portion of the implant, the neck, is an area of special

metallurgic grain structure across which the bending adjustments are made.
Observe the logo or other identifying mark to reconfirm the bucco-lingual orientation of the
implant. View the implant in mesial profile as it is bent. Bend the abutment to the estimated angle
to achieve parallelism. Reseat the implant within the osteotomy to its preliminary position, with the
safety stop 2 mm from the ridge crest. Recheck for parallelism, and repeat the procedure if
necessary until the result is acceptable ( Fig. 13-35 ).

Figure 13-35  Bending for parallelism.

Figure 13-35 Bending for parallelism

   Viewing the implant’s mesial profile during bending for parallelism affords the
greatest control. The abutment may also be rotated slightly for better positioning. By
grasping the implant to expose the neck, it may also be bent mesio-distally to
improve parallelism in that plane, as shown in Fig. 13-35. The taper of the abutment
in all planes promotes parallelism, and maximizes cementation retentiveness. In the
maxilla, achieving parallelism is more of a challenge because of significant resorption
of the buccal plate at the ridge crest. Because of this resorption, the long axis of the
residual ridge is at a more acute angle to the required long axis of the implant
abutment for parallelism. As a result, maxillary abutments protrude toward the buccal
at a greater angle, and require lingual bending of 15 to 20 degrees, and sometimes
up to 45 degrees. Although it is possible to adjust further for parallelism by selective
grinding of the abutment under coolant following suturing, it is better to establish
parallelism carefully via abutment bending before final implant seating.
Adjust Implant Abutment for Interocclusal Clearance

With the implant preliminarily seated, the abutment(s) parallel, and the safety stop 2 mm from the
ridge crest, have the patient close into centric occlusion if opposing teeth are present. Reconfirm
the adequacy of preliminary adjustments, if any, for interocclusal clearance. Make further
adjustments, if required.

   If the patient can close into centric occlusion at this time without touching the
abutment, ultimately at least 2 mm of interocclusal clearance will be available
following final seating, when the safety stop rests on the ridge crest. If the abutment
interferes with closure before final seating, remove the implant and reduce the
abutment to ensure adequate clearance. Sterile heatless wheels, green stones, and
polishing wheels accomplish this task. Cleanse the implant.
Final Seating of the Implant
Technique.

Final seating of the implant is performed using a titanium-tipped shoulder set-point or single- or
double-abutment seating instrument, depending on the implant configuration and degree of prior
abutment bending for parallelism ( Figs. 13-36 , 13–37 , 13–38 ).

Figure 13-36  Placement of shoulder set-point seating instrument tip into shoulder set-point on shoulder of
implant

Figure 13-36 Placement of shoulder set-point seating instrument tip into shoulder set-
point on shoulder of implant

Figure 13-37  Use of shoulder set-point instrument.

 Figure 13-37 Use of shoulder set-point instrument

Figure 13-38  Use of single-abutment seating instrument.

Figure 13-38 Use of single-abutment seating instrument.

   If the abutment is bent more than 15 degrees, making the long axes of the
abutment and implant body substantially different, only a shoulder set-point seating
instrument is used. All seating forces must be directed in the long axis of the implant
body every time the tapping mallet strikes the seating instrument.

With gentle tapping and full vision, seat the implant until the safety stop at the base of the
abutment engages the crest of the ridge ( Fig. 13-39 ). The safety stop prevents overseating and
acts as a point of implant stabilization.

Figure 13-39  A, Correctly seated implants with safety stops against ridge crest. B, Radiographs of
correctly seated implants.
 Figure 13-39 A, Correctly seated implants with safety stops against ridge crest. B,
Radiographs of correctly seated implants

   The body of a correctly seated implant must fit tightly and securely against
the cancellous bone of the narrower osteotomy. No movement is permissible. This
tight frictional fit keeps the implant immobile during the early stages of healing.

When the abutment has been bent to a significant angle for parallelism, as is often the case in the
maxilla, the base of the safety stop may engage the lingual but not the buccal crest of the bone.
Using an XL osteotomy channeling bur, reduce the lingual crest under the safety stop. Tap the
implant apically with a seating instrument until the safety stop engages both plates of bone.
    If there is a firm lingual crest, as is almost always the case, and a more
friable buccal crest, the implant may remain seated engaging only the lingual crest.
Tap the abutment with the reverse end of a seating instrument to hear the solid
ringing sound that indicates the implant is securely and properly seated.
Increasing Primary Retention, If Required.

Occasionally an osteotomy is prepared too wide, or is inadvertently widened during repeated

preliminary insertions to make adjustments. To ensure retentive stability, the implant can be bent
into a mesio-distal curve more acute than the curvature of the arch. This creates a condition for
final seating with tight three-point contact, with the mesial and distal implant ends snug against
the lingual bone of the osteotomy and the mid-body portion under the abutment snug against the
buccal bone of the osteotomy ( Fig. 13-40 ).

Figure 13-40  Curvature adjustments to increase primary retention in osteotomy.

Figure 13-40 Curvature adjustments to increase primary retention in osteotomy

   That plate/blade form implants are bendable is another unique advantage of

this modality. Note that coatings are not recommended for plate/blade implants
because they preclude bending adjustments. Coatings may crack, peel, delaminate,
promote pit and fissure corrosion, and expose what may no longer be a
biocompatible interface. Moreover, in consideration of the success of uncoated
plate/blade form implants, coatings cannot be said to offer sufficiently significant
advantages for plate/blade form implants.
Postinsertion Soft-Tissue Procedures

If required because of the presence of flabby tissue over the incision site preoperatively, or in the
case of excessively thick maxillary gingiva, remove any excess tissue that will interfere with
coapting the flaps, decrease flap thickness if required, and reduce flabby tissue according to the
procedures and principles described in Chapter 9 .

Whether or not these plastic surgery procedures are required, in the case of one-stage implants,
tissue punch to remove any tissue that bunches around the collar upon coapting, again according
to the procedures described in Chapter 9 . When the soft tissue is ready for suturing, take a
periapical radiograph for the patient record.

Final Closure—Suturing

Suture according to the principles and procedures described in Chapter 9 . For a single-abutment
implant, place the first suture just mesial to the abutment. Penetrate first on the buccal flap even
with the mesial border of the abutment, pass the needle through the lingual flap at the mid-point
of the lingual extent of the abutment, and tie with a surgeon’s knot. Penetrate next on the buccal
flap even with the distal border of the abutment, pass the needle through the lingual flap at the
mid-point of the lingual extent of the abutment, and tie.

   This technique snugly wraps the gingival flaps around the abutment. Avoid
wound separation during healing by securing a deep bite at each penetration of the
needle, into as much of the tougher area of attached gingiva as possible.

In the case of a double-abutment implant, the first suture is placed at the mesial of the mesial
abutment, the second at the distal of the distal abutment, the third at the distal of the mesial
abutment, and the fourth at the mesial of the distal abutment.

   When angled as described for a double-abutment implant, tissue is wrapped

snugly around both abutments.
Check Temporization of Premolar Co-Abutments

If the premolar provisional crowns were removed, reseat them and recheck margins, embrasures,
and occlusion. Again check for adequate interocclusal clearance of the implant abutment(s).
Adjust if required.

   The provisional crowns over the natural coabutments are removed before
implant insertion, enhancing visibility and access to the field of operation. In checking
the marginal fit, attention is paid to the distal of the nearest natural co-abutment
where it was incised. Check the suture in that area, and the marginal fit of the
provisional crown.
Select Shade

As discussed in Chapter 9 , the practitioner now selects the shade to be used in the restoration.
In the teaching case, the shade is used both for a provisional removable prosthesis and for the
final fixed bridgework.
Provisional Removable Prostheses

Whenever possible, it is desirable not to use a removable provisional prosthesis over the implant.
Avoiding provisional restoration reduces the likelihood of complications. A removable provisional
prosthesis may not be needed when treatment is performed in a reasonably nonesthetic area,
such as in many posterior cases, and when the patient’s temperament can accommodate the
absence of replacements during healing. When a provisional prosthesis is required because the
implants have been inserted in an esthetic area, or because of patient insistence even when the
implants are in a nonesthetic area, the provisional prosthesis must be fitted carefully ( Fig. 13-
41 ).

Figure 13-41  Seating of provisional crowns.

Figure 13-41 Seating of provisional crowns

   The natural co-abutments help immobilize the provisional prosthesis. The

portion of the prosthesis over the implant and the pontic is adjusted to be out of
occlusion, and dietary constraints are emphasized. Even the most carefully made
provisional prosthesis can be weak, break, or have delicate margins. Any one of
these may interfere with healing. Diligent home care is important.

The provisional prosthesis is placed using sedative cement that is applied only to the natural co-
abutment crowns. No cement is placed within the provisional crown over an implant abutment.
Light frictional fit is adequate.

   Applying the sedative cement only to the natural co-abutments protects the
implant from being disturbed during healing when a provisional prosthesis is
removed to facilitate suture removal.
Postinsertion Home Care Instruction

As discussed in Chapter 9 , advise the patient about the effects that can result from the trauma of
the surgery, and prescribe prophylactic antibiotic and analgesic medications. Instruct the patient
in proper postoperative cleanliness, and advise the maintenance of a soft diet to ensure that
excessive function of the implant will not interfere with tissue integration.

Visit 2: Postinsertion Follow-Up Visit

As described in Chapter 9 , a postinsertion follow-up visit is scheduled for 7 to 10 days after

insertion ( Box 13-4 ). At this time, conduct a general evaluation, remove the sutures, evaluate
soft-tissue healing, and check and adjust the fit of the provisional prosthesis.

Box 13-4
VISIT 2, WEEK 1: SUTURE REMOVAL AND INTERIM EVALUATION

   Conduct general evaluation

   Remove sutures
   Evaluate soft-tissue healing
   Check and adjust co-abutment temporization as required
Postinsertion General Considerations

In cases of normal healing, to follow required case sequencing, the next appointment is made 7
to 10 days following suture removal.

   This time span allows for further healing of the soft tissues overlying the implant
and around the incised gingival cuff of the natural co-abutment before the initial
appointment for fabrication of the final prosthesis. Almost always, the site is ready for final
impressioning 7 to 10 days following suture removal.

VISIT 3: MASTER IMPRESSION AND INTERARCH OCCLUSAL

REGISTRATION FOR PROSTHODONTIC RESTORATION

The steps that are performed during the master impression and interarch occlusal registration
visit are shown in Box 13-5 .

Box 13-5
VISIT 3, WEEK 2: MASTER IMPRESSION AND INTERARCH OCCLUSAL REGISTRATION

   Expose natural co-abutments

   Take master impression
   Take interarch occlusal registration
   Reconfirm shade
General Considerations

The prosthodontic restoration of mainstream cases using plate/blade form implants as middle or
end co-abutments represents an area of significant advantage over other implant modalities.
Unlike the prosthodontic restoration of root form cases, plate/blade form restorative dentistry is
essentially identical to that of conventional nonimplant cases. One can fabricate the required
three- to five-unit fixed prosthesis as if it were intended to be entirely supported by natural
abutments. No special courses must be taken, no special laboratories must be used, and no
specialized components must be incorporated into the prosthesis. Conventional skills are all that
are required.

Although the restorative regimen is conventional, its time sequencing is critical. Awareness of the
day-by-day events that occur in the healing cycle following plate/blade form implant insertion
helps one clearly understand what is required for successful case completion and optimal
prognosis. Plan for complete fabrication of the prosthesis within 2 to 4 weeks.

Master Impressioning/Master Model

Master impressioning and pouring the master model is best accomplished using the techniques
one prefers for tooth-supported fixed bridges. Gingival cord usually is used to control bleeding
and create space for the elastic impression material of choice. Following impression removal (
Fig. 13-42 ), carefully inspect for and cleanse away any residual material.

Figure 13-42  M

Figure 13-42 Master impression for prosthesis fabricationaster impression for prosthesis
fabrication.

Recording Jaw Relationships

It is recommended that one use the same technique to record jaw relationships that one regularly
uses in the fabrication of conventional prostheses

VISITS 4 AND 5: TRY-IN AND ADJUSTMENT OF FINAL PROSTHESIS

The steps that are performed during the visits for tryin and adjustment of the final prosthesis are
shown in Box 13-6 .

Box 13-6
VISITS 4 TO 5, WEEKS 3 TO 5: TRY-IN AND ADJUSTMENT OF FINAL PROSTHESIS

   Try in bisque-baked bridge directly, or try in copings and/or assembled framework before
 bisque-bake try-in
   Check occlusion, tooth contours, embrasures, and margins, and reconfirm shade
Step-By-Step Prosthesis Fabrication and Time Sequencing

Use conventional techniques to fabricate the prosthesis. Remember that the elapsed time until
completion should be 2 to 4 weeks. Some practitioners write their laboratory prescription for a
return of an assembled bisque-baked prosthesis try-in ( Figs. 13-43 , 13–44 , 13–45 ). Many try a
one-piece frame casting first, and then bisque bake. Still others try in individual copings,
assemble them, and then bisque bake and go to completion. The number of required visits
therefore varies, but the process should be completed within 2 to 4 weeks no matter what
protocol is followed.

Figure 13-43  Three separate bridges for bisque-bake try-in. Arrows indicate junctures between
bridges.

Figure 13-43 Three separate bridges for bisque-bake try-in. Arrows

indicate junctures between bridges

Figure 13-44  Bisque-bake try-in.

Figure 13-44 Bisque-bake try-in.

 Figure 13-45  Perfecting occlusion at bisque-bake try-in.

Figure 13-45 Perfecting occlusion at bisque-bake try-in

Implant-Related Prosthodontic Considerations

Central Fossae/Ridge Crest Relationships.

When teeth are removed, resorption occurs at the expense of the buccal and labial plates of
bone. Ridges resorb medially, toward the lingual, as they lose height. After healing, the ridge
crest is lingual to its original position when the teeth were in position. The implant abutment
protrudes through the ridge crest, lingual to the position of the central fossae of the teeth when
they were present.

In positioning replacement teeth, the central fossae generally should replicate those of the
original teeth to help ensure ideal occlusion, esthetics, and the dimensional and functional
integrity of the vestibule. Therefore, properly contoured replacement teeth will be partially labial or
buccal to the healed ridge crest, and implant abutments will project under the lingual portion of
the overlying crown ( Fig. 13-46 ). In some resorbed posterior maxillary cases, it may be
necessary to establish an edge-to-edge occlusion, or even a crossbite. In more resorbed
mandibular cases, occlusion may be established primarily between the tip and buccal incline of
the maxillary lingual cusp and the central fossa and lingual incline of an extremely narrow
mandibular buccal cusp. Because of resorption patterns, it may be desirable for esthetics, and
often for function, to ridge lap the labial or buccal gingival margin of the implant abutment crown,
especially in esthetic areas.

Figure 13-46  Effect of resorption on relationship between ridge crest and central fossae of the occlusal
surface.
 Figure 13-46 Effect of resorption on relationship between ridge crest and central
fossae of the occlusal surface

Ridge Lapping Implant Abutments.

For the esthetic configuration of anterior pontics of conventional fixed bridges, the ridge lap is
important. To provide an esthetic lineup of pontics in the area of the gingival margin, a passively
placed ridge lap is formed labial or buccal to the ridge crest. These pontics are fabricated to
provide esthetic gingival curvature, and appear to be growing out of the gum. In conventional
fixed prostheses, only pontics are ridge lapped. Ridge lapping cannot be predictably or
successfully accomplished with crowns over teeth. The gingival sulcus of the tooth becomes
periodontally involved, no matter how well home care is performed.

This is not true of the abutments in mainstream plate/blade form cases. Although a peri-implant
gingival sulcus with hemidesmosomes exists, direct fiber insertion into the implant does not
occur, as it does into tooth cementum. Nonetheless, in mainstream cases, the implant margin
usually is in attached gingiva, and it is thought that this is why ridge lapping in these cases
succeeds. Plate/blade form implant prostheses have functioned successfully with ridge-lapped
implant abutments for about 30 years.[6][15][16] This is a boon to the esthetic result and ease of
cleansability compared with deep-pocketed emergent profile prostheses. In cases in which the
labial or buccal margins of root forms are in attached gingiva, ridge lapping can be performed for
this modality as well.
In forming a ridge lap, note that all proximal and lingual implant abutment crown casting margins
are created as they would be against teeth. Only the buccal/labial areas are extended ( Fig. 13-47
). This is best accomplished in the laboratory by esthetically setting replacement teeth as though
they were pontics, and permitting the implant abutments to fit whatever location they occupy
under the lingual of the replacement crowns, modified by esthetic contouring dictates. As a result,
in plate/blade form implantology, although it is desirable to have implant abutments rise through
the gingiva at a central point under the overlying crown, it is not hygienically or esthetically
essential that they do so. In the area of the ridge lap, place the metal casting margin at or slightly
above the gingiva, and extend metal 2 mm shy of the expected edge of the final resin or porcelain
ridge lap to allow ample room at try-in visits to adjust for esthetic recontouring without exposing
metal.

Figure 13-47  Positioning of ridge lap and crown finishing line over implant abutment.

Figure 13-47 Positioning of ridge lap and crown finishing line over implant
abutment

In nonesthetic areas, ridge lapping is optimal. Bullet-shaped crowns with wide embrasures also
are often used, depending on practitioner preference and patient acceptance ( Fig. 13-48 ).

Figure 13-48  Ridge laps and bullet-shaped crowns.

 Figure 13-48 Ridge laps and bullet-shaped crowns

Finishing Lines Against Abutments/Embrasures.

In the area of the ridge lap, the finishing line of the crown is placed at or up to 1 mm above the
gingival margin, to allow for proper flossing and flow of fluids during lavage. All margins are
placed above, at, or below the free gingival crest, in accordance with the same policy used for
crowned natural abutments.

Embrasures are also created in accordance with one’s preferred fixed bridgework policies. In
mainstream plate/ blade form implantology, with a few simple options, the overlying prosthesis is
conventionally fabricated. Well-made prostheses, as always, are essential to success.

Occlusion.

Occlusion is also established in accordance with the techniques and principles one prefers for
conventional fixed prostheses. No single technique is best. Narrow bucco-lingual dimensions,
anatomic or semi-anatomic noninterfering cusp relations, group function, cuspid protection, long
centric, gnathologic principles, and others are successfully used with plate/blade form implants.

Materials.

Most materials can be used. Many porcelain-to-metal prostheses have been successfully used,
as have gold occlusals with acrylic veneers, and gold superstructures with acrylic teeth. Gold and
acrylic occlusal surfaces transmit less functional force than porcelain. These alternative materials
are not required in mainstream cases but may be of benefit in cases offering a more marginal
prognosis.

VISITS 6 AND 7: CEMENTATION OF FINAL PROSTHESIS

The steps that are performed at the visits for cementation of the final prosthesis are shown in Box
13-7 .

Box 13-7
VISITS 6 TO 7, WEEKS 6 TO 7: CEMENTATION OF FINAL PROSTHESIS

   Remove provisional restoration

   Try in completed prosthesis
   Check previous adjustments and shade
   Perform provisional cementation
   Evaluate patient comfort and gingival adaptation to pontic and crowns
   Perform final cementation
Provisional Placement

The final restoration may be placed provisionally for up to 1 week. No provisional cement is
placed over the implant abutment. Conventional placement of provisional cement protects the
natural co-abutments.

Final Placement

Check the provisionally cemented restoration. Evaluate the gingiva and adjust the pontic and
crowns. If the condition of the soft tissue is acceptable, the final restoration ( Fig. 13-49 ) is
seated with one’s preferred crown and bridge cement. Zinc oxyphosphate, polycarbonate, and
acrylic cements are all successfully used.

Figure 13-49  Internal surface (A) and intraoral view (B) of the three completed prostheses.

Figure 13-49 Internal surface (A) and intraoral view (B) of the three completed
prostheses.

Postoperative Radiographic Record

A postoperative radiographic record is obtained. A simple panoramic radiograph, or a series of

periapical radio-graphs, is sufficient for this purpose ( Fig. 13-50 ).
 Figure 13-50  Postoperative panoramic radiograph of completed case.

Figure 13-50 Postoperative panoramic radiograph of completed

AFTERCARE AND MAINTENANCE

Regimen for Slowly Increasing Function

In osteopreserved cases, the regimen for slowly increasing function of the inserted prosthesis is
important. Although the soft tissues are all but fully healed at the time of final restoration, the
underlying bone growing through the implant vents and forming the cribriform plate is still
maturing, and will reorient its cancellous and cortical components in function in accordance with
the direction, magnitude, duration, and character of applied functional forces. In the earliest
stages of healing, frictional fit directly against the bone keeps the implant immobile. Seating the
final restoration, which splints the implant abutment(s) to natural co-abutments, further ensures
immobility during the remainder of the healing period. The final restoration acts as a cast does on
a fracture, to ensure an environment that promotes healing. In this case, the “cast” is never
removed—the final prosthesis remains in position. The patient remains on the same soft diet
advised before insertion of the final prosthesis. Over the next 4 to 6 weeks, the patient should
slowly increase the consistency of his or her diet, until regular eating habits are fully resumed.
Chapter 6 discusses the healing around osteopreserved implants, and demonstrates that correct
case sequencing must be coordinated with the physiologic healing process to ensure long-term
health.

As discussed in Chapter 9 , professional and home maintenance must be performed regularly

and diligently to avoid complications.

COMPLICATING AND ATYPICAL CONDITIONS

Common Complicating and Atypical Conditions

The complicating and atypical conditions that are common to the mainstream treatment
procedures using any of the abutment-providing implant modalities, as discussed in Chapter 9 ,
are all applicable here. These include questionable adequacy of ridge width, minimal width of
attached gingiva, frayed or torn flaps, excessive bleeding, retained root tip, presence of a cyst or
granulomatous tissue, unusual variation in ridge height and/or contours, labial or lingual osseous
perforation during osteotomy preparation, fracture of the labial or lingual osteotomy wall, friable
tissue at suturing, excessive postoperative edema, and retained impression material. Each of
these conditions is rare. Treating these complications properly is discussed in Chapter 9 .
Extreme Angle Between Long Axis of Osteotomy and Requirements
for Abutment Parallelism

Because of the strength and resistance to fatigue stress afforded by coining during the fabrication
of the system used in the teaching case, bending up to 60 degrees across the neck of the implant
can be performed safely, without fear of fracture. The prime consideration is biomechanical. In
such cases, bone width in excess of 1 mm on either side of the implant is an advantage. When
bending for parallelism exceeds 45 degrees, consider additional co-abutment support for the
prosthesis. Also, adjust the occlusion to reduce applied forces, and limit contact in lateral
excursions.

Minimal Interocclusal Clearance

Further reducing the implant abutment before taking the master impression may alter its
cementing surface area to the point at which retention is compromised. If so, a metal stop in the
occlusal surface may be a better choice. In such cases, a double-abutment implant may be
chosen to increase cementation surface area.

Inadequate Frictional Fit of Implant on Final Placement

Inadequate frictional fit of the implant on final placement is not a problem when using plate/blade
form implants. If during preliminary or final implant seating there is any question regarding
primary retention, the implant is removed and the body of the implant is slightly curved to
increase frictional fit as previously described. There is no reason for inadequate frictional fit of an
implant at the time of final seating

VARIATIONS AND ALTERNATIVES

Semi-Submerged Protected Healing

In nonesthetic areas, such as in most mainstream posterior cases, provisional prostheses that
include the inserted implant are not required. For patients with tongue-thrusting habits, or who
cannot be trusted to carefully maintain a soft-diet regimen during healing, semi-submerged
protected healing with a two-stage implant may be used. On a two-stage implant, the abutment is
separable from the body, and is replaced with a healing collar after implant insertion ( Fig. 13-
51 ). When the healing collar is removed and the abutment is replaced, the restoration is treated
as though the implant were a one-piece, one-stage implant. The healing collar is positioned flush
with or up to approximately 1 mm above the gingival crest ( Fig. 13-52 ). Thus, during the earliest
healing stages, the chance of excessive force being applied is diminished. Two weeks
postinsertion, approximately 1 week following suture removal, the healing collar is removed
before the start of prosthodontic restoration. The abutment, already adjusted for parallelism and
interocclusal clearance during the course of implant insertion, is test seated and then cemented
into position, never again to be removed ( Fig. 13-53 ). This is important, for if after taking the
master impression the implant abutment is removed and the healing collar replaced for further
protection until the next visit, it becomes extremely difficult to replace the abutment in the precise
position that it occupied before taking the master impression. In such cases, the prosthodontic
superstructure casting may not fully seat.

Figure 13-51  Preoperative (A) and healed (B) two-stage plate/blade form case.
 Figure 13-51 Preoperative (A) and healed (B) two-stage plate/blade form case

Figure 13-52  Healing collar in position.

Figure 13-52 Healing collar in position.

Figure 13-53  Two-stage plate/blade form universal abutment in position.

 Figure 13-53 Two-stage plate/blade form universal abutment in position

Restorative Procedure Options

Several techniques are commonly used for the conventional fabrication of a three- or four-unit
fixed prosthesis. Some practitioners have the laboratory return individual copings on the master
model. After each is tried in and adjusted, assembly indices are taken, and at the next visit the
assembled framework, or even a partially assembled framework, is tried in and adjusted. Once
the entire framework is tested, a bisque-bake try-in is used, and finally the completed restoration
is seated and cemented. Extra visits are required, but this is not problematic as long as the total
elapsed treatment time does not extend beyond 6 weeks, or if unavoidable, 8 weeks. Remember
that the finally seated, completed prosthesis becomes the “cast” that holds the implant immobile
during the weeks in which the patient is slowly increasing function as healing is completed.

Precision and Semi-Precision Attachments

Precision and semi-precision attachments are not required for restorations over one-stage
plate/blade forms with natural co-abutments. The tissue integration around the implant and the
natural co-abutments is biomechanically compatible.

Stress-Breaking

The use of stress-breaking components in mainstream plate/blade form prostheses may be

counterproductive. One objective of the final prosthesis is to provide rigidity, especially during the
healing and bone reorientation phase, and shared loading in function. Posteriorly, functional load
is up to four times greater than anteriorly. In posterior mainstream cases, the implant is almost
always posterior to the natural co-abutments. Use of a stress-breaker protects the natural co-
abutments more than the implants, which are subjected to added load. A rigid prosthesis offers
the best prognosis.

Screw Retention
The main benefits of screw retention are reentry if complications arise, and dependable
prosthesis fixation when minimal occlusal clearance does not provide for adequate cementation
area because of shortened abutments. Given the excellent survival rates of plate/blade form
implants, and the option of using a double-abutment configuration in cases with inadequate
cementation, some practitioners believe that the use of screws for retention is not worthwhile.
Loose or fractured screws are complications that should be avoided.

Implant Insertion in New or Partially Healed Extraction Sites

A plate/blade form can be inserted into an immediate extraction site if the shoulder of the implant
passes across the socket, and the safety stop under each abutment head rests securely on
healed crestal bone. However, considering the wide range of available plate/blade form
configurations, it is not detrimental to allow the extraction site to heal before implantation, even if
slight resorption is expected. If necessary, a slightly shallower configuration can be used to
accommodate the new dimensions of available bone.

Plate/Blade Form Total Support

Unilateral posterior cases cannot be supported solely by plate/blade form implants. One must at
least turn the arch in cases in which natural co-abutments are not used. Complete arch fixed
restorations totally supported by one-stage plate/blade form implants have been successfully
performed for more than 30 years ( Fig. 13-54 ).

Figure 13-54  Examples of complete arch restorations totally supported by plate/blade form
implants.

Figure 13-54 Examples of complete arch restorations totally supported by

plate/blade form implants

Plate/Blade Form—Root Form Co-Abutments

Some practitioners have achieved acceptable results using a combination of plate/blade forms
and root forms under a prosthesis. In almost all of these cases, the edentulous area
encompasses everything distal to the cuspid. In the mandible, a root form is inserted in the first
premolar area, and a two-stage osteointegrated plate/blade form is inserted over the inferior
alveolar canal, as shown in Fig. 13-2. The practitioner sequences the case for osteointegration of
the plate/blade form. Such cases are not considered mainstream.

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