IMPLANT DENTISTRY / VOLUME 28, NUMBER 6 2019 523
Book Review
Nicolas Elian, DDS
Zero Bone of this book, a selective approach was bone-level implants without platform
Loss Con- taken. First, implant design factors switching should have a machined collar
include the presence or absence of a approximately 1 mm and must be placed
cepts polished implant neck and the implant supracrestally to compensate for the loca-
Tomas Linke- soft-tissue thickness and attached gingiva. tion of the microgap and potential bacterial
vicius. ISBN: leakage. Tissue-level implants must keep
9780867157- Chapter 2 the polished collar above the bone crest
994 (hard- There are multiple implant designs and must take into considerations the
cover), Quin- available on the market. It is the clini- soft-tissue thickness to avoid restorative
tessence cian’s responsibility to have an in depth complications.
Publishing Co, knowledge of the particular features and
design concepts of the selected system for Chapter 4
Inc, Batavia, each treatment. In regards to crestal bone The author and his team embarked on
IL: 286 pages. $198.00. stability, 2 primary components are dis- several clinical trials that will be high-
cussed in details: the implant polished lighted in the following chapters. As
From the onset of his journey to collar and the microgap. It is very well promised in the beginning of the book,
write this book, the author and contrib- documented that a polished implant “It is this marriage of science and prac-
utors were committed to provide an collar/neck does not integrate and tice” that is the foundation of every study
evidence-based publication for all levels presents a potential liability for further that they have conducted. The primary
of clinical expertise. The primary focus is bone loss if it is positioned below the focus of this chapter is the vertical soft-
to understand the “Zero Bone Loss Con- crestal bone level. On the other hand, tissue thickness and how it is measured. A
cepts” in regards to crestal bone stability. the microgap is even more complex. thorough literature review of the biologic
The interplay between biology, biome- Three major factors in a microgap design width, its importance in understanding the
chanics, surgical, and prosthetic factors must be managed: (1) bacterial contami- volumetric soft-tissue requirements
is very well documented. Furthermore, nation, (2) location of the microgap, and around implants, and that the bone loss
he highlights the distinction between clin- (3) micromovements. All 3 are detrimen- occurs as a protective biologic mechanism
ical practice and scientific research and tal to bone loss. However, the conical against bacteria serves as a guideline for
how these disciplines can be integrated. connection and platform switching can the clinical studies. Many clinicians
The hierarchy of evidence serves as the reduce or prevent this loss by controlling believe that the conical connection and
backbone for the manuscript that consists bacterial leakage and enhancing the platform switching are absolute remedies
of 2 major parts: surgical and prosthetic. implant–abutment stability. in preventing bone loss. However, it has
SECTION I: SURGICAL CONCEPTS been demonstrated in this chapter that in
Chapter 3 the presence of thin vertical soft tissue,
Chapter 1 The implant placement depth is a bone loss will still take place. It is well
A fundamental understanding of critical variable in the zero bone loss defined now that vertical soft tissue is a
bone biology is emphasized in this chap- concepts. Therefore, a clinician’ selection new biologic factor that must be taken into
ter to allow clinicians to distinguish of an implant for a particular therapy must considerations and must be measured
between zero bone loss, stable remodel- depend on the understanding of the before implant placement. Based on the
ing, progressive bone loss, bone implant design and its impact on the crestal studies presented in this chapter, at least
demineralization/mineralization, cortical- bone. There are 2 primary philosophies in 3 mm of vertical soft-tissue thickness
ization, and bone growth. Building on this regards to implant design: (1) tissue-level must be present to avoid crestal bone loss
knowledge, it is accepted that crestal bone implants and (2) bone-level implants with during the formation of the biologic width
loss is multifactorial. The challenge is and without platform switching. The around implants.
separating and balancing the impact of bone-level implants with platform switch-
various factors to achieve desired out- ing can be placed at or below the bone Chapters 5, 6, and 7
comes. Because the crestal bone loss level depending on the stability of the These chapters are combined for the
variables are vast and exceed the scope implant–abutment connection. However, purpose of the book review to deliver a
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524 BOOK REVIEW
more complete assessment of the issues soft-tissue thickness and attached gingi- author is very methodical in his
affecting crestal bone stability. Several val tissues around dental implants. One approach. He defines the problem
protocols and clinical techniques are cannot substitute for the other. They are through clinical evidence, designs a
presented in regards to crestal and sub- both necessary determining variables for series of clinical studies, and presents
crestal implant placement based on achieving crestal bone stability. It has the results as a guideline or a decision
clinical trials conducted by the author been defined that a minimum of 2 mm on tree for clinicians. Cemented restora-
and his team. As discussed earlier, the the buccal and lingual aspect of implants tions with standard abutments can be
clinician must follow the manufacturer’s is a requirement. Similar to the vertical very challenging for cement removal
recommendations to determine the soft-tissue augmentation, allografts and regardless of the technique. Clinicians
implant placement depth and take into xenografts seem to gain great popularity. must adhere to a strict protocol, using
consideration the available bone These substitutes eliminate the need for a custom abutments with supragingival
between the crest and anatomical struc- secondary surgical site to harvest autolo- margins to ensure removal of cement
tures. The subcrestal implant placement gous grafts and provide an unlimited remnants. All other methods do not
is a widely accepted method to compen- supply. guarantee complete cement removal
sate for the lack of vertical soft-tissue and predispose patients to potential
thickness. However, the clinician must Chapter 10 peri-implantitis.
select an implant system with a conical The previous chapters served to
connection and a platform switching. define the problems associated with Chapter 13
Another method to aid in increasing crestal bone stability as well as Because the concept of cement res-
the vertical soft-tissue volume is flatten- presenting a sequence of studies to offer toration can be beneficial in achieving
ing of the alveolar ridge. This is defi- potential solutions based on accurate passive fit and creating an interface
nitely helpful in situations with a short diagnoses. This chapter is a practical between implant–abutment restoration, a
clinical crown. However, if the 2 previ- guide for various clinical situations modification is required to minimize
ous methods are contraindicated, the previously presented with excellent complications. The hybrid cement/screw
tent-pole technique can represent a step-by-step illustrations, side by side retention with titanium-base abutment is
potential alternative. This approach is with clinical cases. This is an outstand- an excellent alternative. There are various
more technical and requires much higher ing summary. clinical and laboratory steps that are nec-
surgical skills because the soft-tissue essary to fabricate such a prosthesis. It is
mandatory not to treat the titanium
release is the most important and diffi- SECTION II: base with airborne particles to maintain
cult variable to control.
PROSTHETIC CONCEPTS maximum retention and to use resin
Chapter 8 cement for chemical bonding. The hybrid
Chapter 11
The primary and crucial requirement cement/screw restoration and traditional
Section I focused on the vertical
for zero bone loss has been defined, by the cement restoration have a similar clinical
soft-tissue thickness as a singular vari-
author, as a vertical soft-tissue thickness behavior.
able. It became very evident that there
or volume. One must remember it is not are multiple other factors that must be Chapter 14
the only variable that must be controlled taken into consideration from a surgical The previous chapters featured
to achieve success or the defined concept perspective. Now, that we have defined the different modalities in treating a
at hand. The deficient soft tissue can be that the crestal bone stability is multi- single-tooth restoration. The fixed
corrected by vertical soft-tissue augmen- factorial, the multiple prosthetic options partial denture represents a higher
tation using a variety of graft sources, a will come into play and further influence level of complexity. The selection of
technique that is widely around natural how zero bone loss can be achieved. impression coping and abutment is
teeth and implants. A series of studies Rather than a top–down approach, the different. The clinician must be com-
reflecting real clinical situations are pre- author selected the reverse. Regardless fortable with the open-tray impression
sented. Allografts and xenografts can be of this change in the sequence, the pros- techniques. It is possible to combine
used as connective tissue substitutes or thetic variables must be examined thor- hexed and nonhexed components for
alternatives. The most widely used is oughly. Cement- or screw-retained the final restoration. This treatment
porcine-derived. A minimum of 2 mm restorations, abutment selection, emer- modality requires segmentation of the
gain in vertical augmentation can be gence profile and biomaterial selection case and therefore will require addi-
achieved. However, in the event that the will influence our clinical decision- tional implants. There are several
gain is greater, we should consider that making and judgment. clinical cases presented in the chapter
beyond 5 mm can be problematic. The to demonstrate all the necessary steps
selection of a single- or two-stage Chapter 12 to manage this type of advanced
approach is clinician-dependent. The available data in the literature therapy.
can be confusing and conflicting
Chapter 9 regarding the “best” type of therapy Chapter 15
The clinician must distinguish when it comes to the selection of the The abutment selection criteria
between adequate and acceptable vertical type of restoration. Once again, the seem to focus on materials and design.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IMPLANT DENTISTRY / VOLUME 28, NUMBER 6 2019 525
However, many other variables must be be stable in the long term. The labora- gingival portion is polished. It cannot
considered such as anterior or posterior, tory does not have radiographic data; it be glazed or veneered with ceramics.
cement or screw retained, and soft- is the responsibility of the clinicians, for The supragingival zirconia is glazed
tissue thickness, etc. The cement- implants in the subcrestal position, to and colored. At times, when consider-
retained restoration for the posterior select the appropriate titanium base gin- ing combining zirconia with other
implants, zirconia custom abutments gival height. materials, clinicians and laboratory
with supragingival margin location are technicians need to weigh the func-
the recommendations of the author and Chapters 17 and 18 tional and aesthetic for long-term suc-
what is widely accepted in today’s clin- These chapters are combined for cess. Clinicians can combine zirconia
ical practice. The anterior implants the purpose of the book review; they are with lithium disilicate for strength and
require different steps from a design both addressing the concerns related to zirconia with feldspathic veneering for
perspective. A margin verification abut- prosthetic materials and selection. Den- great aesthetics.
ment replica is used to accurately and tal implants can be restored with a Zero Bone Loss Concepts are
intraoraly determine the desired margin variety of materials. The clinician and presented with excellent details
location. The screw-retained restora- the laboratory technician must work from a clinical point of view. Tomas
tions can be used anteriorly depending very closely to select and more impor- was focused and delivered a very
on the 3 dimensional implant place- tantly to distinguish the differences in comprehensive book addressing the
ments. For all anterior treatments, the subgingival and supragingival material complex world of crestal hard- and
clinician must be adept at impression requirements. The impact on cellular soft-tissue stability. I understood the
techniques that allow duplication of adhesion and plaque control takes cen- author’s goal from his introduction.
exact soft-tissue topography after ter stage for the subgingival material of The references are expansive, current,
provisionalization. choice. At the present time, zirconia is and support the clinical narrative. Very
the most biocompatible, followed by high-quality clinical documentations
Chapter 16 titanium and polished lithium disilicate. showcase the team’s skills and com-
The emergence profile and restora- The least compatible is veneering ce- mitment. My only concern is that the
tion contour impact the crestal bone ramics. Clinicians should follow a radiographic data were not standard-
response and stability. As previously cleaning protocol for abutments and ized and its interpretation could be
seen, the author supports his study prostheses. challenged. Regardless, this text is
design by clinical manifestation of a clinically relevant and a must have in
problem. He attempted to continue on Chapter 19 and 20 every implantologist’s library.
this path in this chapter and selected Clinically, subgingival and supra-
cases to support the narrative. It should gingival materials must respond to
be noted that some of the cases selected, different needs. However, it is impos- Nicolas Elian, DDS
based on radiographic evidence, are not sible to analyze these components Prosthodontic and
clinically acceptable, and therefore, the separately because they will have to Implant Certification,
bone loss was expected. It is evident be integrated together, to deliver a final New York University
that if the angle of the restoration restoration. To maximize the biocom- School of Dentistry,
exceeds 25°, the crestal bone will not patibility benefits of zirconia, the sub- New York, NY
All Book Reviews are the sole wording and opinions of the reviewer; and are not those of the Editorial Staff, the Editor-
In-Chief, the International Congress of Oral Implantologists, or of the publisher, Lippincott, Williams and Wilkins.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
