Clin Oral Impl Res 2000: 11 (Suppl.

): 126–145 Copyright C Munksgaard 2000

Printed in Denmark ¡ All rights reserved

ISSN 0905-7161

Chapter 8

Prosthetic management of the partially dentate

patient with fixed implant restorations
Belser UC, Mericske-Stern R, Bernard JP, Taylor TD. Prosthetic manage- Urs C. Belser1,
ment of the partially dentate patient with fixed implant restorations. Regina Mericske-Stern2,
Clin Oral Impl Res 2000: 11 (Suppl.): 126–145. C Munksgaard 2000. Jean-Pierre Bernard3
Thomas D. Taylor4
1
Department of Prosthodontics,
University of Geneva, Geneva,
2
Department of Prosthodontics,
University of Bern, Bern, and
3
Department of Stomatology and Oral
Surgery, University of Geneva, Geneva,
Switzerland; 4Department of
Prosthodontics, University of Farmington,
CT, USA

Key words: consensus conference –

dental implants – partial edentulism –
treatment planning – prosthodontics

Committee Members:
The aim of this chapter is to discuss the current prosthetic management Nikolaus Behneke, Germany, Urs C.
of the partially dentate patient by means of fixed implant restorations in Belser, Switzerland, Urs Brägger,
the scope of the ITIA Dental Implant System. For that purpose, the related Switzerland, Kurt Flury, Switzerland,
Alfred H. Geering, Switzerland, Daniel
statements defined by the participants of the prosthodontic section of
Hess, Switzerland, Frank L.
the 1997 ITI Consensus Conference in Vitznau, Switzerland, will be pre- Higginbottom, USA, Alfons Kiener,
sented, completed by explanatory comments where appropriate. Distinct Switzerland, Maurice Leize, France,
conceptual differences will be made between the esthetic zone (areas of Jean Paul Martinet, Uruguay, Regina
the dental arches where esthetic considerations are of primary concern) and Mericske-Stern, Switzerland, Herman S.
the non-esthetic zone (regions of the jaws where esthetic aspects do not Oosterbeek, The Netherlands, John R.
represent a priority), and between single tooth replacement and multiple Richardson, Great Britain, Alwin J.
unit implant restorations. Furthermore, it is underlined that current clin- Schönenberger, Switzerland, Gary S.
ical concepts should be based on both predictable treatment outcome and Solnit, USA, Takayuki Takeda, Japan,
Thomas D. Taylor, USA, Adrian C.
cost-effectiveness. In this context, a straightforward surgical and pros-
Watkinson, Great Britain, Daniel
thetic protocol is generally preferred in posterior locations of the oral cav- Wismeyer, The Netherlands
ity, using a nonsubmerged implant placement comprising an easily access-
ible implant shoulder location, and subsequently cemented implant restora- Urs C. Belser, Department of
Prosthodontics, School of Dental
tions, basically according to a traditional prosthodontic approach. In
Medicine, University of Geneva,
esthetically demanding indications, where normally a distinctly submu- 19, rue Barthélemy-Menn,
cosal implant shoulder location is advocated, screw-retained restorations CH-1211 Geneva 4, Switzerland
are preferred, based on prefabricated prosthetic components (e.g. ma- Tel.: π41 22 382 91 29
chined cast-on copings) to assure optimum surface properties and con- Fax : π41 22 372 94 97
tour, and to achieve adequate marginal adaptation. e-mail: Urs.Belser/medecine.unige.ch

126
 Fixed implant restorations in partially dentate patients
In the past 12 years, the range of implant indi-
cations has been significantly widened, and par-
tially dentate patients clearly represent the ma-
jority of patients seeking treatment with dental im-
plants today. Patients presenting with missing teeth
generally do not directly ask for implants. They
would like to have their teeth replaced in the most
elegant and long-lasting way possible. This in-
cludes criteria such as maximum preservation of
sound tooth structure, avoidance of removable
prostheses, minimal surgical risk, as well as cost-
effectiveness and a low-maintenance design. With
recent developments, such as the wide body im-
plant (WBI) and the narrow neck implant (NNI),
the ITIA Dental Implant System has become a
complete implant system allowing the clinician to
treat all potential implant indications in esthetic
and non-esthetic sites (Figs. 8.1 & 8.2). The actual
Fig. 8.1. The ITI Dental Implant System comprises a variety of
different implant configurations and dimensions, such as the
Narrow Neck Implant (NNI), the Diameter-Reduced Solid
Screw Implant and the Standard Solid Screw Implant (from left
to right), permitting the replacement of missing incisors and
canines.
Fig. 8.3. Maxillary anterior region of a young patient three
months after placement of two implants in the region of the
lateral incisors.
clinical concepts are based on both predictable
treatment outcome and cost-effectiveness. Thus, a
straightforward surgical and prosthetic protocol is
generally preferred in posterior sites, with a non-
submerged implant placement comprising an eas-
ily accessible implant shoulder location, and subse-
quently cemented implant restorations, basically in
accordance with a traditional prosthodontic ap-
proach. In esthetic sites, a submerged implant
placement is mostly utilized to satisfy the specific
esthetic demands, i.e. no visible metal margin and
an emergence profile that is in harmony with the
adjacent natural dentition. In this context, screw-
retained implant restorations are preferred, based
on prefabricated prosthetic components such as
machined cast-on copings, to guarantee optimum
surface properties and contour, as well as adequate
marginal suprastructure fidelity.
Fig. 8.2. The Standard Solid Screw Implant (left), the Wide
Body Implant (WBI, center), and the Wide Neck Implant
(WNI, right) have been designed for the replacement of missing
canines, premolars and molars.
Fig. 8.4. Seven-year follow-up after the replacement of both
congenitally missing lateral incisors by two implants, restored
with screw-retained ceramometal suprastructures.
127
Belser et al.
The present paper will focus on the prosthetic
management of partially dentate patients within
the scope of the utilization of ITI dental implants.
More specifically, the related consensus statements
defined by the participants of the prosthodontic
section of the 1997 ITI Consensus Conference in
Vitznau, Switzerland, will be presented, completed
by explanatory comments where appropriate.
Single tooth replacement in the appearance zone
Single tooth replacement with dental implants has
recently become an increasingly used treatment op-
tion in the anterior maxilla (Belser et al. 1996a),
and the retrospective and prospective studies avail-
able to date have reported favorable results (And-
erson et al. 1995; Avivi-Arbor & Zarb 1996;
Bernard et al. 1996; Eckert & Wollan 1998; Henry
et al. 1996; Higuchi et al. 1995; Kemppainen et al.
1997; Laney et al. 1994; Lekholm et al. 1994;
Lindh et al. 1998; Norton 1998; Palmer et al. 1997;
Scheller et al. 1998; Schmitt & Zarb 1993; Wyatt &
Zarb 1998; Zarb & Schmitt 1993a; Zarb & Schmitt
1993b).
In the case of congenitally missing lateral in-
cisors, after tooth loss following traumatic injury,
and after local endodontic or periodontal failures,
an implant-supported fixed prosthesis is currently
considered first due to its non-invasive nature as
far as the intact adjacent tooth structure is con-
cerned. Beyond any doubt, the implant solution
represents the most adequate approach in the pres-
ence of perfectly intact neighboring teeth or in the
case of anterior diastemata (Belser et al. 1998).
These specific situations not infrequently con-
cern rather young patients, for whom a traditional
fixed prosthodontic approach, involving partial or
complete coverage of neighboring teeth, can in
most instances be used. As conventional prostheses
normally provide excellent long-term functional
and esthetic results (Leempoel et al. 1995), all im-
plant-supported restorations performed under
these well-defined conditions will eventually be
compared to this ‘‘gold standard’’. Consequently,
there is often little leeway for esthetic compromises
if the implant solution is selected, especially in the
Table 8.1. Anatomical and surgical aspects to optimize esthetic treatment outcomes
O Optimal three-dimensional implant position
– correct vertical position of implant shoulder (sink depth), approximately 1–2 mm more apical than the CEJ of adjacent teeth at the labial aspect
– correct orofacial position of the future point of emergence of the envisioned suprastructure (in alignment with the adjacent roots)
– implant axis compatible with prosthetic treatment options
O Esthetic and stable soft tissue contours
– harmonious and scalloped course of the mucosa
– sufficient thickness of buccal mucosa
– intact papillae
128
presence of a high lip line (Belser et al. 1998; Jen-
sen et al. 1999) and respective high expectations
from the patient’s side. In other terms, the clinician
has to assure an optimal and long-lasting esthetic
treatment outcome, integrating the restoration
completely and harmoniously in the existing an-
terior dentition, so that the artificial looks natural
and cannot be detected as such, even when the pa-
tient is smiling (Figs. 8.3 & 8.4). The well-known
statement ‘‘it’s not bad ... for an implant’’ can serve
less and less as an excuse in situations where a con-
ventional fixed partial denture (FPD) would pre-
dictably lead to an esthetically pleasing long-term
result (Garber 1995).
Diagnosis and treatment planning
Ideally, the implant position should be determined
primarily by the planned future prosthesis and not
by the local bone anatomy alone. As the implant
should ultimately represent the apical extension of
an optimal prosthetic suprastructure and not the
opposite, one speaks of ‘‘restoration-driven’’ rather
than of ‘‘bone-driven’’ implant placement (Garber
1995; Garber & Belser 1995). This approach implies
precise, three-dimensional implant positioning
(Table 8.1), permitting an identical emergence of the
prosthetic suprastructure from the mucosa when
compared to adjacent and/or contralateral teeth.
In the specific context of single tooth ITIA im-
plant restorations located in the appearance zone,
a number of consensus statements have been ar-
ticulated which will be presented and discussed in
the remainder of this section.
‘‘Functional and esthetic treatment success depends
on adequate diagnostics, indication and treatment
planning.’’
The presurgical examination comprises a three-di-
mensional analysis of the site, emphasizing in par-
ticular the dimension and configuration of the
edentulous alveolar bone crest, soft tissue con-
figuration, neighboring teeth, interarch relation-
ship and specific esthetic parameters (Table 8.2).
In this context, the presence of a harmoniously
scalloped vestibular aspect of the mucosa is of pri-
 Fixed implant restorations in partially dentate patients
Table 8.2. Preprosthetic evaluation of anterior edentulous sites

O Mesio-distal dimension of the edentulous gap, including its comparison with existing contralateral control teeth
O Three-dimensional analysis of the edentulous gap in relation to soft tissue configuration and underlying alveolar bone crest
O Neighboring teeth
– volume and three-dimensional position and orientation of the clinical crowns
– structural integrity and condition
– surrounding gingival tissues (course of the gingival line)
– periodontal and endodontic status
– crown-to-tooth ratio
– root length and their inclination in the frontal plane
– presence of diastemata
O Interarch relationship
– vertical dimension of occlusion
– anterior guidance
– interocclusal space
O Esthetic parameters
– height of the smile line (’’high lip’’ versus ‘’low lip’’)
– course of the gingiva-mucosa line
– orientation of the occlusal plane
– dental versus facial symmetry
– lip support

mary importance. Once the preference for an im-
plant-supported restoration over a conventional
tooth-borne prosthesis has been confirmed, a sys-
tematic therapeutic protocol allowing attainment
of the objective with the highest possible degree
of predictability should be applied. In a standard
situation, where by definition all the relevant ele-
ments or assumptions for a successful implant res-
toration are already integrated, an appropriate
practical protocol must only assure that the
inherent potential of the site is not put into jeop-
ardy.
‘‘A successful esthetic result can best be achieved
through the use of diagnostic casts, diagnostic wax-
ing and fabrication of surgical guides (stents, tem-
plates).’’
Most panelists indicated that they are not routine-
ly using surgical stents for the placement of an an-
terior single tooth implant since the adjacent den-
tition offers sufficient landmarks for an adequate
implant insertion. It should be noted, however,
that surgical guides are primarily utilized in par-
ticularly complex clinical situations, such as ex-
tremely limited mesio-distal space, converging
roots of neighboring teeth, and/or a protruding al-
veolar bone crest.
‘‘Alveolar ridge mapping or three-dimensional im-
aging can provide additional valuable diagnostic in-
formation.’’
Sophisticated three-dimensional imaging, which
entails substantial irradiation and cost, should be
limited, however, to clinical situations that really
require this precise additional information. Fur-
thermore, one can observe a general trend that the
purely legal value of such documents is widely
questionable.
‘‘A mesio-distal distance of at least 7 mm at the soft
tissue level and at least 6 mm at the bone level is
necessary for the use of a standard ITI implant.’’
‘‘A minimum of 5 mm at the bone level and 4 mm at
the proximal contact level is necessary for the use of
narrow-neck implants (NNI).’’
‘‘Situations of inadequate alveolar contour must be
corrected prior to or in conjunction with implant
placement.’’
If an optimum, stable, esthetic and functional re-
sult is to be achieved, lateral bone augmentation
procedures as well as soft tissue grafting are often
required (Bahat et al. 1993; Bahat & Daftary 1995;
Buser et al. 1993; Buser et al. 1994; Buser et al.
1995a; Buser et al. 1995b; Buser et al. 1996; Hürz-
eler et al. 1994; Hürzeler & Strub 1995; Salama &
Salama 1993; Salama et al. 1995).
‘‘In sites of esthetic concern, it is suggested that the
submucosal implant shoulder location does not ex-
ceed 2 mm at the labial aspect.’’
‘‘Optimized soft tissue contours are achieved using
the Esthetic Plus components (healing and protec-
tive caps) and/or custom provisional restorations.’’
Prosthetically, the utilization of the Octa Abut-
ment System with the associated Esthetic Plus
components (Figs. 8.5 to 8.8) and, more recently,
the SynOcta System in conjunction with standard
ITI implants or diameter-reduced (3.3 mm) im-
plants is highly recommended, as it comprises a

129
Belser et al.
Fig. 8.5. Labial view of the dentition of a 35-year-old patient,
presenting an edentulous single tooth site in the anterior max-
illa, nine months after bone augmentation and three months
after insertion of a solid screw titanium implant. Complete soft
tissue healing at the surgical site can be noticed. In particular,
almost symmetrical conditions with respect to root eminence
have been achieved when comparing the regions of the two cen-
tral incisors.
Fig. 8.7. The occlusal view documents a well-centered screw
access channel in the area of the cingulum, thus not interfering
with the incisal edge of the restoration.
precise transfer system and a variety of prefabri-
cated suprastructure components (Sutter et al.
1993). This is essential to assure both optimum
marginal fidelity and quality of surface, as well as
retrievability. These measures are considered to be
relevant in the context of a clearly submucosally
located implant shoulder (difficult excess cement
removal and not within reach of the patient’s oral
hygiene), in particular at the interproximal aspect,
to avoid potential adverse reactions with respect to
peri-implant tissue health. Screw retention is pro-
vided either by using a transocclusal or a trans-
verse screw path (Figs. 8.9 to 8.24).
When it comes to the use of Narrow Neck Im-
plants (NNI), where the equivalent of an octagonal
130
Fig. 8.6. The completed ceramometal implant-borne single
tooth restoration integrates harmoniously in the pre-existing
dentition.
Fig. 8.8. The 3-year postoperative radiograph confirms favor-
able conditions at the bone-to-implant interface.
abutment is already integrated into the implant it-
self, the recommended prosthetic protocol men-
tioned above remains basically unchanged.
‘‘Under normal circumstances, anterior implants
should not be placed prior to the end of growth (in
females prior to age 16 and in males prior to age
18).’’
With respect to potential clinical complications, the
following has been agreed upon:
‘‘Modification of the implant shoulder should only
be performed as an exception–i.e., in cases of un-
avoidable visible metal display–as it precludes the
subsequent use of prefabricated impression copings.’’
 Fixed implant restorations in partially dentate patients

Fig. 8.9. Preoperative view of a 35-year-old patient presenting Fig. 8.10. Four weeks after extraction of the deciduous tooth
with a persisting deciduous tooth in the position of the upper and initial soft tissue healing, the resulting single-tooth gap is
left canine. Note the irregular course of the gingiva in this re- ready for the placement of an implant.
gion.

Fig. 8.11. Clinical view 3 months following placement of a solid Fig. 8.12. Once the titanium healing cap is removed, the internal
screw implant. An excess of keratinized tissue has been main- octagon, which allows indexing of the implant position, be-
tained on the labial aspect. comes visible.

Fig. 8.13. For esthetic reasons, a distinct submucosal implant Fig. 8.14. The implant shoulder and the position of the internal
shoulder position has been chosen. octagon are picked up by a screw-retained retentive impression
coping to guarantee a precise and reproducible transfer from
the mouth to the master cast.

131
Belser et al.
Fig. 8.15. After loosening of the positioning screw, the im-
pression is removed from the mouth. The impression coping
remains embedded in the polymerized impression material.
Note the distinct submucosal implant shoulder location, par-
ticularly on the palatal and interproximal aspects.
Fig. 8.17. The finalized master cast resembles the patient’s oral
situation.
Fig. 8.19. A transverse screw retention has been chosen to com-
pensate for a slightly vestibular inclination of the implant.
132
Fig. 8.16. Prior to the master cast fabrication, an identically
color-coded implant analogue is fixed to the impression coping
by means of a positioning screw.
Fig. 8.18. A SynOcta TS abutment has been selected, as the
implant axis requires transverse screw-retention of the supras-
tructure.
Fig. 8.20. Labial view of the completed ceramometal implant
restoration on the master cast.
 Fixed implant restorations in partially dentate patients
Fig. 8.21. The clinical aspect immediately after insertion of the
ceramometal suprastrucure documents stable and esthetic peri-
implant soft tissue contours.
Fig. 8.23. The preoperative labial view documents an irregular
gingival course due to the persisting deciduous tooth in the
upper left canine position.
‘‘Transverse screw retention is indicated for correc-
tion of axis discrepancies.’’
As Narrow Neck Implants (NNI) do not presently
include components permitting transverse screw
retention, the fabrication of a mesiostructure as a
base for a cemented crown may be necessary to
overcome major axis discrepancies (Figs. 8.25 to
8.34). It should be noted, however, that the more
coronally located second margin should follow the
scalloped course of the peri-implant mucosa in a
distance that assures ease of excess cement removal
and permits efficient use of oral hygiene measures
such as superfloss.
Fig. 8.22. The six-month follow-up radiograph confirms the
stability of the osseointegrated 10 mm solid screw implant.
Fig. 8.24. The respective postoperative situation shows a more
esthetic mucosal course and a quite harmonious integration of
the implant-borne prosthesis.
Multiple unit restorations in the appearance zone
The loss of two or more adjacent teeth in the an-
terior maxilla leads normally to a characteristic re-
sorption pattern of the alveolar bone crest and its
associated overlying mucosa. Essentially, one can
observe a flattening of the ridge, which loses both
its original scalloped configuration in the frontal
plane and its root eminences or ‘‘jugae alveolaria’’
in the horizontal plane (Van der Zypen 1996).
A conventional, tooth-borne fixed partial den-
ture can often efficiently reestablish appealing es-
thetics, as the respective pontics – featuring a
133
Belser et al.

Fig. 8.25. Clinical view three months following placement of Fig. 8.26. After removal of the titanium healing caps and inser-
two narrow neck implants (NNI) in a 21-year-old female pa- tion of the screw-retained retentive impression copings, the oc-
tient suffering from congenitally missing lateral maxillary in- clusal view documents a vestibularly inclined implant axis, in-
cisors. terfering with the incisal edge of the future restorations.

Fig. 8.27. On the corresponding master cast, comprising the Fig. 8.28. In order to compensate for the axis problem, a cus-
respective implant analogues, both the clearly submucosal im- tomized mesiostructure based on a prefabricated cast-on coping
plant shoulder location and the labial inclination of the implant has been produced.
axis can be noted.

Fig. 8.29. The mesiostructure includes a shoulder finish line for Fig. 8.30. A suprastructure framework has been cast which sub-
the suprastructure which follows the scalloped course of the sequently will be cemented to the screw-retained mesiostrucure
peri-implant mucosa. after porcelain veneering.

134
 Fixed implant restorations in partially dentate patients
Fig. 8.31. Labial view of the completed ceramometal restora-
tions on the master cast.
Fig. 8.33. The corresponding 2-year radiograph documents the
stability of the osseointegrated 10 mm NNI.
modified ridge lap-design – are labially adapted to
the edentulous ridge and thus create the illusion of
a scalloped gingival course with distinctly formed
interproximal papillae (Magne et al. 1994). In case
of a more severe ridge atrophy, the application of
one of the various soft tissue and/or bone augmen-
tation techniques (Abrams 1980; Garber & Rosen-
berg 1983; Seibert 1983) will normally suffice to
achieve an excellent esthetic result.
When it comes to the use of implants to support
a traditionally designed fixed partial denture, how-
ever, the reestablishment of naturally appealing es-
thetics is frequently much more complex (Figs.
Fig. 8.32. After cementation of the two ceramometal crowns
both the presence of a healthy, esthetic mucosal course and a
harmonious integration of the implant-borne prostheses can be
noticed.
Fig. 8.34. Note that the transition between the mesiostructure
and the cemented margin of the suprastructure is hardly visible
on the radiograph.
8.35 to 8.42). As far as inter-implant papillary
tissue configuration is concerned, this remains a
parameter that is difficult to control, as current im-
plants are fabricated according to a flat, rotation-
symmetrical design without a scalloped cemento-
enamel junction-like configuration, which does not
provide interproximal soft tissue support nor does
it permit the insertion of collagen connective tissue
fibers (Buser et al. 1992a; Listgarten et al. 1992).
Due to this implant-specific problem, the treat-
ment approach to be chosen depends primarily on
the location of the smile line in a given patient. In
situations with a rather low lip line, a prosthetic
135
Belser et al.
Fig. 8.35. Frontal view of a 32-year-old female patient. The two
central maxillary incisors have been lost due to a traumatic
injury and subsequently replaced by two 12 mm solid screw
titanium implants.
Fig. 8.37. The configuration of the peri-implant mucosa has
been enhanced by means of two individualized plastic protec-
tion caps with a respective optimal emergence profile.
Fig. 8.39. Facial view of the two implant-supported ceramomet-
al restorations, replacing the missing maxillary central incisors.
136
Fig. 8.36. Clinical close-up view three months following place-
ment of the two implants, using a one-stage transmucosal surgi-
cal protocol. Beveled Esthetic Plus titanium healing caps have
been utilized.
Fig. 8.38. Ideally, a flat emergence profile of the suprastructures
is recommended from both an esthetic and an oral hygiene
point of view.
Fig. 8.40. The corresponding close-up view documents the use
of a long vertical contact line, the presence of pronounced me-
sial ridges, and a more saturated color in the cervical area.
These prosthetic measures help to compensate for a flat and
more apically located labial mucosa line.
 Fixed implant restorations in partially dentate patients
Fig. 8.41. Six years postoperatively a slight fill-in of inter-im-
plant mucosa and an overall stable soft tissue situation can be
noticed.
reconstruction of lost papillary tissue, either by
means of a removable soft tissue epithesis or by
means of a mucosa-colored integral part of the
prosthesis itself, can be a viable treatment alterna-
tive.
With regard to implant-supported fixed multiple
unit restorations in the appearance zone, the fol-
lowing general consensus statements have been
made:
‘‘Multiple-unit restorations in sites of esthetic con-
cern should be supported by a minimum of two im-
plants.’’
‘‘The placement of an implant for each missing tooth
is not necessary.’’
‘‘Angled abutments and transverse screw-retention
are indicated for correction of axis discrepancies.’’
Single tooth replacement in the non-appearance
zone
In the regions of the jaws where esthetic consider-
ations are not essential, the primary treatment ob-
jective is the reestablishment of function, and es-
thetic aspects may become less important. Further
objectives include the achievement of a long-term
result with the least demanding surgical and pros-
thetic procedure, in order to reduce the chairside
time and the related costs for both patient and cli-
nician. Surgically, a one-step nonsubmerged ap-
proach is generally preferred, allowing the avoid-
ance of a second surgical procedure. If necessary,
special soft tissue techniques are utilized to main-
tain or create a keratinized peri-implant mucosa at
the time of implant placement. Consequently, the
shoulder of the integrated implant is normally
located at the soft tissue level, allowing easy access
Fig. 8.42. The respective x-ray, taken six years after placement
of the two 12 mm solid screw implants, reveals a favorable oss-
eous integration and adequate marginal adaptation.
for the subsequent prosthetic procedures. In most
cases, the implants are restored with cemented res-
torations utilizing the conical solid abutments. The
implant-abutment connection is based on the
morse taper principle with an 8æ inner cone (Sutter
et al. 1988a; Sutter et al. 1988b; Sutter et al. 1993).
This interface provides an optimal friction fit,
thereby transmitting functional loading forces
from the abutment directly to the implant body
and from there into the surrounding bone struc-
ture without exerting undesirable bending mo-
ments to the abutment screw. This is clearly su-
perior from a biomechanical point of view when
compared with a flat hextop connection (Sutter et
al. 1993; Merz et al. 2000). The insertion torque is
set at 35 Ncm, utilizing a calibrated torque wrench.
The related transfer system comprises disposable,
inexpensive injection mold ‘‘self-centering snap-
on’’ transfer copings and respective analogues.
This approach is straightforward, similar to con-
ventional crown- and bridgework, and allows mi-
nor corrections of the conical abutments. Further-
more, the absence of an occlusal screw path simpli-
fies the design of the ceramometal restoration, and
hence does not jeopardize its mechanical resistance
(Hebel & Gajjar 1997).
Since the introduction of the Wide Neck Im-
plant (WNI), which features a shoulder diameter
of 6.5 mm, significant progress has been made in
the context of replacing single missing molars. In
fact, it is now frequently possible to avoid excessive
mesio-distal overcontouring of implant suprastruc-
137
Belser et al.
Fig. 8.43. In case of multiple adjacent implants located in the
posterior areas of the mouth, minimal inter-implant distances
should be respected to facilitate prosthetic procedures and ac-
cess for oral hygiene measures.
tures or extremely open interproximal embrasures
which may lead to food impaction and/or oral
parafunctional habits.
From a prosthodontic point of view, the panel
has agreed on the following general statements:
‘‘In sites outside the appearance zone a submucosal
implant shoulder placement is not necessary.’’
‘‘A single-tooth implant should be centered mesio-
distally.’’
‘‘In spaces of 14 mm or greater at the proximal con-
tact level, two implants are indicated.’’
Multiple unit restorations in the non-appearance
zone
In most cases, implant-borne restorations are not
extended beyond the first molar area for func-
Fig. 8.44. If three missing premolar units are to be replaced in
a distally shortened arch, under normal conditions a mesial
and a distal implant support a cemented three-unit fixed partial
denture with a central pontic.
138
tional, practical and economic reasons. This is in
accordance with well-documented long-term
studies evaluating the number of occlusal units
necessary for sufficient masticatory function
(Käyser 1989). If an existing upper second molar
requires an occlusal stop to avoid overeruption, the
implant-borne restoration in the mandible can be
extended to the mesial area of the second molar.
In these cases, the mandibular first molar is re-
placed by two implants to be restored with two
premolar-sized units of approximately 8 mm me-
sio-distal diameter.
The recommendation to utilize premolar-sized
units for implant-borne fixed partial dentures
(FPDs) has proven its validity in more than 10
years of clinical experience (Buser et al. 1997;
Belser et al. 1996b; Bernard et al. 1996; Buser et
al. 1992b; Buser et al. 1988). In fact, a crown of 7–
8 mm mesio-distal diameter is ideal to allow for a
harmonious axial profile, gradually emerging from
the implant shoulder (Ø 4.8 mm) to the maximum
circumference. In addition, the occlusal table is re-
duced, thereby diminishing the risk for unfavor-
able bending moments to the implants and their
components.
The replacement of each premolar unit by one
implant is reserved for clinical situations, where
either diameter-reduced or short implants of 6 or
8 mm lengths have to be used (Figs. 8.43 to 8.45).
If a mesial implant cannot be inserted due to ana-
tomical restrictions, a 3-unit FPD with a mesial
cantilever has proven to be a viable alternative. A
distal cantilever unit or connection to natural teeth
should only be used in exceptional situations. The
panel has agreed upon the following statements:
‘‘The replacement of each missing premolar unit by
one implant is reserved for clinical situations where
Fig. 8.45. The corresponding three-year postoperative radio-
graph confirms the stability of the two osseointegrated 10 mm
solid screw implants.
 Fixed implant restorations in partially dentate patients
Fig. 8.46. In case of edentulous tooth gaps in the range of 15
to 17 mm at the interproximal tissue level, the placement of two
standard implants is normally recommended.
Fig. 8.48. In case of edentulous tooth gaps in the range of 18
to 20 mm at the interproximal tissue level, a combination of a
standard and a wide neck implant may be undertaken.
either diameter-reduced or short implants have to be
used.’’
‘‘The position, diameter and number of implants is
determined by prosthetic parameters as well as the
local anatomy.’’
‘‘In case of three missing occlusal units and suf-
ficient bone anatomy, the standard solution consists
of the placement of two implants to support a 3-unit
FPD with a central pontic.’’
‘‘If a mesial implant cannot be inserted due to ana-
tomical restrictions, a 3-unit FPD with a mesial
cantilever has proven to be a viable alternative.’’
‘‘A distal cantilever unit or the connection to natural
teeth should only be used in exceptional situations.’’
Recently, it has been proposed to insert at least
three implants in a distal extension situation and
Fig. 8.47. In case of edentulous tooth gaps in the range of 12
to 15 mm at the interproximal tissue level, a combination of a
standard and a narrow neck implant may represent an adequate
solution.
to place the fixtures in a tripod (the central implant
offset buccally) rather than in a straight line
(Rangert et al. 1997) to diminish bending moments
and potential biomechanical complications (screw
and abutment loosening, fractures of components
of the implant-abutment complex).
This theoretical recommendation, however, ap-
pears impractical from a clinical point of view be-
cause of space limitations in either mesio-distal or
orofacial dimensions, and increases the related
treatment costs significantly. Regarding ITI im-
plants, this concept does not apply due to: (a) a
significantly stronger bone anchorage of ITI im-
plants with a rough (TPS/SLA) surface when com-
pared to machined titanium surfaces (Buser et al.
1998), (b) a much stronger implant-abutment com-
plex based on the morse taper principle (Sutter et
al. 1988a; Sutter et al. 1988b), and (c) the prefer-
ence for cemented restorations in posterior areas
(Belser et al. 1996b; Buser et al. 1988).
Consequently, the following additional consen-
sus has been pronounced in relation to multiple
unit implant-supported fixed restorations in the
non-appearance zone:
‘‘Tripodization (offset, staggered placement) is not
necessary for successful implant restorations in pos-
terior segments.’’
‘‘Under normal occlusal loading conditions, one im-
plant replaces one natural tooth as an abutment.’’
(Figs. 8.46 to 8.48)
‘‘Edentulous spaces of five or more premolar units
are generally an indication for the placement of ad-
ditional implants.’’
139
Belser et al.

Fig. 8.49. Occlusal view of the right mandibular quadrant dis- Fig. 8.50. In the perspective of a 4-unit cemented fixed partial
playing three solid screw implants in the locations of 44 and denture, the appropriate solid abutments have been selected,
46, three months after insertion using a one-step transmucosal inserted and then tightened to 35 Ncm.
surgical protocol. Note the completely healed peri-implant soft
tissue, as well as the easily accessible implant shoulders, signifi-
cantly facilitating the subsequent prosthetic procedures.

Fig. 8.51. In order to transfer the in-mouth situation to the Fig. 8.52. The procedure is completed by the insertion of a cen-
dental laboratory, self-centering injection-moulded plastic tral positioning cylinder for the pick-up of the spatial orien-
transfer copings have been attached to the implant shoulders. tation of the antirotational feature of the abutments.

Fig. 8.53. The impression can be taken with a stock tray. Both Fig. 8.54. Once the color-coded analogues are secured in the
the retentive transfer copings and the associated positioning impression, the master cast can be fabricated.
cylinders remain embedded in the polymerized impression,
allowing the subsequent repositioning of the laboratory ana-
logues.

140
 Fixed implant restorations in partially dentate patients

Fig. 8.55. The completed master cast, displaying the aluminum Fig. 8.56. Plastic burn-out patterns with an inherent optimal
analogues, is ready to be mounted in an articulator. marginal adaptation are selected and repositioned onto the
analogues, serving as a base for an abbreviated waxing pro-
cedure.

Fig. 8.57. Cervical view of the assembled burn-out patterns Fig. 8.58. After casting, the marginal area is recalibrated using
prior to sprueing and embedding. a self-centering reaming device.

Fig. 8.59. During the clinical framework try-in, the marginal Fig. 8.60. The respective cervical view confirms adequate mar-
adaptation and the overall fit are verified with a silicone-based ginal fidelity of the metal framework.
material (Fit-checker, GC, Japan).

141
Belser et al.
Fig. 8.61. Final ceramometal fixed partial denture ready for
clinical try-in. Note the flat emergence profile of the suprastruc-
ture.
Fig. 8.63. One-year follow-up radiograph confirming the sta-
bility of the osseointegrated 10 mm solid screw implants.
Fig. 8.65. Color-coded, screw-retained retentive impression
copings of the SynOcta System have been used to transfer the
precise position of the implants to the master model.
142
Fig. 8.62. Occlusal view of the cemented implant-borne ceramo-
metal prosthesis.
Fig. 8.64. Clinical view of the upper left posterior region of a
45-year-old female patient, three months after placement of
three implants. Note the distinct submucosal location of the
most distal implant. This implies a screw-retained suprastruc-
ture.
Fig. 8.66. The SynOcta System comprises angled abutments
(right) as well as abutments for either transocclusal screw reten-
tion (left) or transverse screw retention (center).
 Fixed implant restorations in partially dentate patients
Fig. 8.67. The appropriate abutments are selected in the dental
laboratory and will subsequently be sent to the clinician to-
gether with the completed respective suprastructure.
Fig. 8.68. The updated ITI Dental Implant System includes sev-
eral abutments that permit the fabrication of a cementable sup-
rastrucure: the standard solid abutments (left), the SynOcta
abutment in combination with a milling cylinder (center), and
the angled abutments (right).
Fig. 8.69. The updated ITI Dental Implant System includes sev-
eral abutments that permit the fabrication of a screw-retained
suprastructure: The SynOcta abutment for transocclusal screw
rention (left), the SynOcta TS abutment for transverse screw
retention (center), and the SynOcta angled abutment (right).
(Figs. 8.49 to 8.63)
(Figs. 8.64 to 8.67)
(Figs. 8.68 & 8.69)
Combining implant and natural tooth support
A recently published literature review (Gross &
Laufer 1997) has addressed the still controversial
question of whether it is recommendable to splint
osseointegrated implants and natural teeth to sup-
port a fixed partial denture. Clinical studies re-
porting prospectively documented long-term data
did not show adverse effects of splinting teeth to
implants (Olsson et al. 1995). The issue of con-
necting implants and teeth by means of rigid or
non-rigid connectors remains unresolved to date.
Root intrusion has been reported as a potential
clinical hazard of non-rigid connection (Sheets &
Earthman 1993).
In appreciation of the currently available scien-
tific evidence, the panel agreed on the following
statement:
‘‘A combination of implant and tooth support for
fixed partial dentures is acceptable.’’
Acknowledgements
The authors wish to express their gratitude to the clinicians Dr.
Daniel Buser (University of Bern), Dr. Viviana Coto-Hunziker,
Dr. Stephan Dieth, Dr. Deborah Herzfeld and Dr. Jean Paul
Martinet (all University of Geneva) for their significant contri-
bution during the treatment of the patients presented in this
article. Furthermore, the authors’ gratitude is extended to the
dental technicians/ceramists Michel Bertossa (University of Ge-
neva), Michel Magne (Montreux), Etienne Martini (Geneva)
and Alwin Schönenberger (Glattbrugg), involved in the fabri-
cation of the associated ceramometal implant suprastructures.
References
Abrams, L. (1980) Augmentation of the deformed residual
edentulous ridge for fixed prosthesis. Compendium of Con-
tinuing Education in Dentistry 1: 205–214.
Anderson, B., Oedman, P., Lindvall, A.M. & Lithner, B. (1995)
Single-tooth restorations supported by osseointegrated im-
plants: results and experiences from a prospective study after
2 to 3 years. International Journal of Oral and Maxillofacial
Implants 10: 702–711.
Avivi-Arbor, L. & Zarb, G.A. (1996) Clinical effectiveness of
implant-supported single-tooth replacement: the Toronto
study. International Journal of Oral and Maxillofacial Im-
plants 11: 311–321.
Bahat, O., Fontanesi, R.V. & Preston, J. (1993) Reconstruction
of the hard and soft tissues for optimal placement of osseo-
integrated implants. International Journal of Periodontics
and Restorative Dentistry 13: 255–275.
Bahat, O. & Daftary, F. (1995) Surgical reconstruction–a pre-
requisite for long-term implant success: a philosophic ap-
143
Belser et al.
proach. Practical Periodontics and Aesthetic Dentistry 7: 21–
31.
Belser, U.C., Bernard, J.P. & Buser, D. (1996a) Implant-sup-
ported restorations in the anterior region: prosthetic con-
siderations. Practical Periodontics and Aesthetic Dentistry 8:
875–883.
Belser, U., Mericske, R., Buser, D., Bernard, J.P., Hess, D. &
Martinet, J.P. (1996b) Preoperative diagnosis and treatment
planning. In: Schroeder, A., Sutter, F., Buser, D. & Krekeler,
G., eds. Oral Implantology. Basics, ITI Dental Implant Sys-
tem, 2nd edition. New York: Thieme Medical Publishers
Inc., pp. 231–255.
Belser, U.C., Buser, D., Hess, D., Schmid, B., Bernard, J.P. &
Lang, N.P. (1998) Aesthetic implant restorations in partially
edentulous patients–a critical appraisal. Periodontology
2000 17: 132–150.
Bernard, J.P., Belser, U.C., Marchand, D. & Gebran, G. (1996)
Implants et édentements partiels: aspects chirurgicaux et
prothétiques. Les Cahiers de Prothèse 96: 254–259.
Buser, D., Schroeder, A., Sutter, F. & Lang, N.P. (1988) The
new concept of ITI hollow-cylinder and hollow-screw im-
plants: Part 2. Clinical aspects, indications, and early clinical
results. International Journal of Oral and Maxillofacial Im-
plants 3: 173–181.
Buser, D., Weber, H.P., Donath, K., Fiorellini, J.P., Paquette,
D.W. & Williams, R.C. (1992a) Soft tissue reactions to non-
submerged unloaded titanium implants in beagle dogs.
Journal of Periodontology 63: 225–235.
Buser, D., Sutter, F., Weber, H.P., Belser, U. & Schroeder, A.
(1992b) The ITI Dental Implant System. Basics, clinical in-
dications and procedures, results. Clark’s Clinical Dentistry
1: 1–23.
Buser, D., Dula, K., Belser, U.C., Hirt, H.P. & Berthold, H.
(1993) Localized ridge augmentation using guided bone re-
generation. I. Surgical procedure in the maxilla. Interna-
tional Journal of Periodontics and Restorative Dentistry 13:
29–45.
Buser, D., Dahlin, C. & Schenk, R.K., eds. (1994) Guided bone
regeneration in implant dentistry. Chicago: Quintessence
Publishing Co., Inc.
Buser, D., Dula, K., Belser, U.C., Hirt, H.P. & Berthold, H.
(1995a) Localized ridge augmentation using guided bone re-
generation. II. Surgical procedure in the mandible. Interna-
tional Journal of Periodontics and Restorative Dentistry 15:
13–29.
Buser, D., Ruskin, J., Higginbottom, F., Hardwick, W.R., Dah-
lin, C. & Schenk, R.K. (1995b) Osseointegration of titanium
implants in bone regenerated in membrane-protected de-
fects: a histologic study in the canine mandible. International
Journal of Oral and Maxillofacial Implants 10: 666–681.
Buser, D., Dula, K., Hirt, H.P. & Schenk, R.K. (1996) Lateral
ridge augmentation using autografts and barrier mem-
branes: a clinical study with 40 partially edentulous patients.
Journal of Oral and Maxillofacial Surgery 54: 420–432.
Buser, D., Mericske-Stern, R., Bernard, J.P., Behneke, A.,
Behneke, N., Hirt, H.P., Belser, U.C. & Lang, N.P. (1997)
Long-term evaluation of non-submerged ITI implants. Part
I: 8-year life table analysis of a prospective multi-center
study with 2359 implants. Clinical Oral Implants Research
8: 161–172.
Buser, D., Nydegger, T., Oxland, T., Schenk, R.K., Hirt, H.P.,
Cochran, D.L., Snétivy, D. & Nolte, L.P. (1998) Influence of
surface characteristics on the interface shear strength be-
tween titanium implants and bone. A biomechanical study
in the maxilla of miniature pigs. Journal of Biomedical Ma-
terials Research 45: 75–83.
Eckert, S.E. & Wollan, P.C. (1998) Retrospective review of 1170
endosseous implants placed in partially edentulous jaws.
Journal of Prosthetic Dentistry 79: 415–421.
144
Garber, D.A. & Rosenberg, E. (1983) The edentulous ridges in
fixed prosthodontics. Compendium of Continuing Education
in Dentistry 2: 212–224.
Garber, D.A. (1995) The esthetic implant: letting restoration be
the guide. Journal of the American Dental Association 126:
319–325.
Garber, D.A. & Belser, U.C. (1995) Restoration-driven implant
placement with restoration-generated site development.
Compendium of Continuing Education in Dentistry 16: 796–
804.
Gross, M. & Laufer, B.Z. (1997) Splinting osseointegrated im-
plants and natural teeth in rehabilitation of partially edentu-
lous patients. Part I: Laboratory and clinical studies.
Journal of Oral Rehabilitation 24: 863–870.
Hebel, K.S. & Gajjar, R.C. (1997) Cement-retained versus
screw-retained implant restorations: achieving optimal oc-
clusion and esthetics in implant dentistry. Journal of Pros-
thetic Dentistry 77: 28–35.
Henry, P.J., Laney, W.R., Jemt, T., Harris, D., Krogh, P.H.J.,
Polizzi, G., Zarb, G.A. & Herrmann, I. (1996) Osseointe-
grated implants for single-tooth replacement: a prospective
5-year multicenter study. International Journal of Oral and
Maxillofacial Implants 11: 450–455.
Higuchi, K.W., Folmer, T. & Kultje, C. (1995) Implant survival
rates in partially edentulous patients: a 3-year prospective
multi-center study. Journal of Oral and Maxillofacial
Surgery 53: 264–268.
Hürzeler, M.B., Quinones, C.R. & Strub, J.R. (1994) Advanced
surgical and prosthetic management of the anterior single
tooth osseointegrated implant: a case presentation. Practical
Periodontics and Aesthetic Dentistry 6: 13–21.
Hürzeler, M.B. & Strub, J.R. (1995) Guided bone regeneration
around exposed implants: a new bioresorbable device and
bioresorbable membrane pins. Practical Periodontics and
Aesthetic Dentistry 7: 37–47.
Jensen, J., Joss, A. & Lang, N.P. (1999) The smile line of differ-
ent ethnic groups depending on age and gender. Acta
Medicinae Dentium Helvetica 4: 38–46.
Käyser, A.F. (1989) The shortened dental arch: a therapeutic
concept in reduced dentitions and certain high risk patients.
International Journal of Periodontics and Restorative Den-
tistry 9: 427–449.
Kemppainen, P., Eskola, S. & Ylipaavalniemi, P. (1997) A com-
parative prospective clinical study of two single-tooth im-
plants: a preliminary report of 102 implants. Journal of
Prosthetic Dentistry 77: 382–387.
Laney, W.R., Torsten, J., Harris, D., Henri, P.J., Krogh, P.H.J.,
Polizzi, G., Zarb, G.A. & Herrmann, I. (1994) Osseointe-
grated implants for single-tooth replacement: progress report
from a multicenter prospective study after 3 years. Interna-
tional Journal of Oral and Maxillofacial Implants 9: 49–54.
Leempoel, P.J.B., Käyser, A.F., Van Rossum, G.M.J. & De
Haan, A.F.J. (1995) The survival rate of bridges. A study of
1674 bridges in 40 Dutch general practices. Journal of Oral
Rehabilitation 22: 327–330.
Lekholm, U., van Steenberghe, D., Herrmann, I., Bolender, C.,
Folmer, T., Gunne, J., Henry, P., Higuchi, K., Laney W.R. &
Lindén, U. (1994) Osseointegrated implants in the treatment
of partially edentulous jaws: a prospective 5-year multicenter
study. International Journal of Oral and Maxillofacial Im-
plants 9: 627–635.
Lindh, T., Gunne, J., Tillberg, A. & Molin, M. (1998) A meta-
analysis of implants in partial edentulism. Clinical Oral Im-
plants Research 9: 80–90.
Listgarten, M.A., Buser, D., Steinemann, S.G., Donath, K.,
Lang, N.P. & Weber, H.P. (1992) Light and transmission
electron microscopy of the intact interfaces between non-
submerged titanium-coated epoxy resin implants and bone
or gingiva. Journal of Dental Research 71: 364–371.
 Fixed implant restorations in partially dentate patients
Magne, P., Magne, M. & Belser, U.C. (1994) Natural and re-
storative oral esthetics. Part III. Fixed partial dentures.
Journal of Esthetic Dentistry 6: 15–22.
Merz, B.R., Hunenbart, S. & Belser, U.C. (2000) Mechanics of
the connection between implant and abutment – an 8æ morse
taper compared to a butt joint connection. International
Journal of Oral and Maxillofacial Implants 15 (accepted for
publication).
Norton, M.R. (1998) Marginal bone levels at single tooth im-
plants with a conical fixture design. The influence of surface
macro- and microstructure. Clinical Oral Implants Research
9: 91–99.
Olsson, M., Gunne, J., Astrand, P. & Borg, K. (1995) Bridges
supported by free standing implants vs. bridges supported
by tooth and implants. A five-year prospective study. Clin-
ical Oral Implants Research 6: 114–121.
Palmer, R.M., Smith, B.J., Palmer, P.J. & Floyd, P.D. (1997) A
prospective study of Astra single tooth implants. Clinical
Oral Implants Research 8: 173–179.
Rangert, B., Sullivan, R.M. & Jemt, T.M. (1997) Load factor
control for implants in the posterior partially edentulous
segment. International Journal of Oral and Maxillofacial Im-
plants 12: 360–370.
Salama, H. & Salama, M. (1993) The role of orthodontic ex-
trusive modeling in the enhancement of soft and hard tissue
profiles prior to implant placement: a systematic approach
to the management of extraction site defects. International
Journal of Periodontics and Restorative Dentistry 13: 312–
334.
Salama, H., Salama, M. & Garber, D.A. (1995) Techniques for
developing optimal peri-implant papillae within the esthetic
zone. Part I, guided soft tissue augmentation: the three-stage
approach. Journal of Esthetic Dentistry 7: 3–9.
Scheller, H., Urgell, J.P., Kultje, C., Klineberg, I., Goldberg,
P.V., Stevenson-Moore, P., Alonso, J.M., Schaller, M., Cor-
ria, R.M., Engquist, B., Toreskog, S., Kastenbaum, F. &
Smith, C.R. (1998) A 5-year multicenter study on implant-
supported single crown restorations. International Journal of
Oral and Maxillofacial Implants 13: 212–218.
Schmitt, A. & Zarb, G.A. (1993) The longitudinal clinical effec-
tiveness of osseointegrated implants for single-tooth replace-
ment. International Journal of Prosthodontics 6: 197–202.
Seibert, J. (1983) Reconstruction of deformed, partially edentu-
lous ridges, using full-thickness onlay grafts. Part I. Com-
pendium of Continuing Education in Dentistry 4: 437–454.
Sheets, C.G. & Earthman, J.C. (1993) Natural tooth intrusion
and reversal in implant-assisted prosthesis: evidence of and
a hypothesis for the occurrence. Journal of Prosthetic Den-
tistry 70: 513–522.
Sutter, F., Schroeder, A. & Buser, D. (1988a) The new concept
of ITI hollow-cylinder and hollow-screw implants. Part 1.
Engineering and design. International Journal of Oral and
Maxillofacial Implants 3: 161–172.
Sutter, F., Schroeder, A. & Buser, D. (1988b) Das neue ITI-
Implantatkonzept – Technische Aspekte und Methodik.
Quintessenz 39: (Teil I) 1875–1890, (Teil II) 2057–2061.
Sutter, F., Weber, H.P., Sorensen, J. & Belser, U.C. (1993) The
new restorative concept of the ITI Dental Implant System:
design and engineering. International Journal of Periodontics
and Restorative Dentistry 13: 409–431.
Van der Zypen, E. (1996) Anatomic basis of implantology. In:
Schroeder, A., Sutter, F., Buser, D., Krekeler, G., eds. Oral
Implantology, 2nd edition. pp. 11–34. New York: Thieme
Medical Publishers Inc.
Wyatt, C.L. & Zarb, G.A. (1998) Treatment outcomes of pa-
tients with implant-supported fixed partial prostheses. Inter-
national Journal of Oral and Maxillofacial Implants 13: 204–
211.
Zarb, G.A. & Schmitt, A. (1993a) The longitudinal clinical ef-
fectiveness of osseointegrated dental implants in anterior
partially edentulous patients. International Journal of Pros-
thodontics 6: 180–188.
Zarb, G.A. & Schmitt, A. (1993b) The longitudinal clinical ef-
fectiveness of osseointegrated dental implants in posterior
partially edentulous jaws. International Journal of Prostho-
dontics 6: 189–196.
145