A noview of impiant Aiiutmonts - Abutmont Ciassification
to Aid Prostiiotic Soioction
Sanjay Karunagaran, B.D.S., D.D.S., M.S.D., Gregory J. Paprocki, D.D.S.,
Russell Wicks, D.D.S., M.S., Soriy Markose, B.D.S., D.D.S., M.S.D.
Introdnction
The dental implant is rapidly
becoming a cornerstone in the
current practice of dentistry. The
predictability of dental implants as a
treatment modality has sustained a
considerable amount of research and
investment in producing more durable
restorations. The development of
implant surfaces, surgical protocols
and prosthetic components have
helped to provide the dentist with
the required armamentarium to aid in
planning, placing and restoring missing
dentition.'
An abutment is a component that is
intermediate between the implant and the
restoration and is retained to the implant
by a screw or locking taper. Abutments
can usually be separated from the implant,
but in some cases they may form part of
the implant itself Additionally, not all
implant restorations require abutments. In
these cases, the crown is fabricated to be
attached directly to the implant platform.
Abutments effectively help form the
restorative part of the implant prosthesis.
The abutment provides the retention,
support, stability and optimal position for
the final restoration.
The integration of the final restoration
to the implant platform can either be
planned as a three-tier or two-tier system,
as outlined in Figure 1. A three-tier
I»
system incorporates three separate
component, the implant, the abutment
and the crown. A two-tier system
incorporates two separate components,
the abutment and the crown form a
single unit and the implant is a separate
component or conversely, the implant
and the abutment form a single unit and
the crown is separate.
impiant Tier Systom
Most abutments are retained
into the implant platform by a screw
(Screw-retained) and the final crown
can be screw-retained directly onto the
18
- D O^
I JOURNAL ~
o •:>
EXAM #50
ABSTRACT
With an increase in the availability of implant restorative components, the
selection of an appropriate implant abutment for a given clinical situation has
become more challenging. This article describes a classification system that will
help the practitioner understand the different implant abutments available and
therefore be able to understand the selection of abutments for single and multiple
unit fixed implant prosthesis.
abutment (Three-Tier system) or directly protocol to help with the process of
onto the implant platform (Two-Tier implant crown fabrication.
system). Alternatively, the crown can be 1. Diagnostic wax up or Trial tooth set
cemented as in a conventional crown and up
bridge protocol (Cement-retained) onto 2. Fabrication of Radiographic and
the abutment which is retained to the Surgical template
implant by a screw (Three-Tier system). 3. Surgical Phase and placement
There are also current implant systems 4. Provisional Phase and soft tissue
that enable the abutment to be locked contouring
or friction fit into the implant, without a 5. Impression making
screw or cement method of retention. 6. Jaw Relation record
The availability of a vast number of 7. Prosthetic Abutment selection and
prosthetic components has left many Crown Design
dentists confused at the selection process 8. Prosthesis delivery
of these components and in particular
the indications for the use of such Types Of Abutment
components. This article will outline a Implant abutments are generally
method to classify appropriate abutments either custom made in a dental
for implant restorations. This will laboratory or prefabricated from implant
hopefully serve to enhance understanding manufacturers.- Custom abutments
of the best available options for the require the dentist to make an implant or
treatment of our patients. fixture level impression of the implant
When considering restorative options, platform with the aid of an impression
the clinician should consider the following coping. A prefabricated abutment is
igure 1 - implant Tier System
JOURNAL OF THE TENNESSEE DENTAL ASSOCIATION . 93-2
machine made by the manufacturer, and connect to the implants with an implant to establish tooth and gingival contours.
it may be selected directly by an implant platform that is either internally or Many of these abutments are modified
or fixture level impression or it may be externally connected. The type of to establish tissue contours especially in
directly adapted to an existing platform connection seems to have an influence the esthetic region. These abutments help
and impressed as a conventional crown. on the incidence of prosthetic failures, create the emergence profile, esthetic,
Custom abutments ean be eostly as and internal connections are used more phonetic boundaries, the position and
they are commonly used in situations commonly.'' the shade of the desired final restoration.
when prosthetic It can be used
corrections with
the standard
i Figure 2 - Customized Lingual Set Screw Abutment
to help establish
the final form
prefabricated of the definitive
implant parts are not restoration.
possible. Insufficient time
Prefabricated spent on this stage
abutments are less can often lead
expensive and to an inadequate
easy to use, but restoration and
they do have some unsatisfied patients.
limitations and there
Impression
are instances where
Abutments
such abutments are
contraindicated.^ Open tray
Situations that may impression
require custom abutments are
abutments may often called
include: (1) if there pick-up or direct
is insufficient copings. Closed
interocclusal tray impression
restorative space, (2) abutments are often
if there is an angle called Transfer or
correction problem indirect copings.
greater than 15°, (3) Figure 3 - Temporary Abutment Classification Table 1 illustrates
if the collar height the differences
needed is more between the two
than 1 mm greater as well as the
than the largest indications for their
collar height offered uses. Figure 4
by the implant shows an open tray
manufacturer, (4) pick-up coping.
if there is a need to TEMPORARY HEALING ABUTMENTS
Healing Abutments
replicate the original ABUTMENTS AND COVER SCREWS
cross-sectional The abutments
profile of the tooth illustrated in Figure
in order to obtain 5 are used to cover
an ideal emergence METAL AND PLASTIC the implant platform
profile, and finally PROVISIONAL ABUT following surgical
(5) if there is a need placement of the
to splint three or implant and to
more implants. In prevent tissue and
bone growth into
these situations customizing the implant Temporary Abutments the implant body. It also helps establish
abutment may be more beneficial as
Temporary abutments are usually epithelization of the tissue and prevents
the standard stock abutments might not
be able to accommodate the corrected produeed in a stock prefabricated fashion, influx of fluids from the oral cavity into
in that they are maehine premade. They the implant body. They can be used as a
changes needed. Figure 2 illustrates
include impression abutments, healing one-stage or two-stage protocol. A one-
a customized abutment to help correct
incorrect implant angulations. abutments and metal or plastic provisional stage surgical protocol allows the healing
abutments, as illustrated in Figure 3. The abutment to traverse the soft tissue in
Abutments can be divided into
clinician has the option to use them as a transmucosal fashion and is exposed
two forms: temporary abutments and
is or to try to customize them as needed during the healing phase. This allows
definitive abutments. These abutments
the dentist access directly to the implant

93-2 . A REVIEW OF IMPLANT ABUTMENTS-ABUTMENT CLASSIEICATION TO AID PROSTHETIC SELECTION

 platform without involving a second stage either a standard prefabricated, custom
manufactured stock abutments to try
of surgery. A two-stage protocol involves castable or computer generated abutment,
to cut down the preparation time by the
covering the entire implant platform, dentist. This has included abutments
as illustrated in Figure 6. The choice
sealed with a cover screw, under the soft which are shaped more to the natural
is dictated by the individual clinical
tissue and requires a second surgery to contours ofthe crown and are termed
situation, clinical experience level and
expose the implant. patient preference. esthetic abutments. In addition these
abutments also come in a variety of
Metal or Plastic
angulations to
Abutments
deal with implant
These abutments Figure 4 - Impression Abutments Nobel Biocare™ positional problems.
are used following Standard stock
exposure of the abutments vary
implant platform according to the
and prior to the manufacturer
final restoration. and they come
They are used in as fixed and
the provisional removable abutment
phase and help restorations each
to customize the having their own
form, shade, soft indications. Fixed
tissue profile and abutments include
the occlusion prior Snappy abutments.
to the definitive Multi-unit
restoration. abutments. Esthetic
They can be abutments. Procera
metal titanium, abutments. Gold
ceramic zirconia adapt abutments
or acrylic PEEK and single tooth
(polyetheretherketone). abutments.
The abutments can Removable
also be engaging abutments are
or non-engaging at Table 1 - Differences between Closed Tray and Open Tray Locator, GPS
their interfaces to Impression Copings abutments, ERA,
the implant surface, Mini ERA, Ball
which can provide attachments, ZAG
the dentist with
Factors Transfer Coping Pick np coping
etc.
the option of using Less space needed for More space required to
them in single or Interarch Space impression, Suitable for accommodate the larger Custom Castable
multi-unit situations. Abutments
posterior areas copings
Abutments are
Customized
also fabricated in a Must be perforated to
Tray Preparation No preparation necessary abutments,
standard stock round, accommodate the coping illustrated in
stock anatomical
Figure 7, are
profile which follows Splinting more commonly
the patient's natural Multiple Not possible Possible
in used in situations
gingival profile. Copings where stock
These abutments can
Less distortion because abutments cannot
also be customized Possible distortion because
the coping remains in the be used to correct
by the technician Precision of the copings liave to
impression. Splinting the extreme angulation
(indirect lab impression be reinserted into the problems or to deal
fabrication) or by copings have no value on
es
impression with corrective
accuracy
w the dentist (direct abutment designs to
intraoral fabrication). accommodate proper
Definitive Abutments
coping and crown
Standard Stock Abutments
designs. In addition to the previously
Permanent abutments are used for Stock abutments are pre-machined mentioned criteria. Table 2 also illustrates
the final restoration and will remain abutments that can be modified by the some ofthe situations that may require the
in place definitively. The dentist has a dentist or the laboratory technologist. selection of custom castable abutments.
choice during the final fabrication to use Implant companies have recently These abutments are waxed by the

JOURNAL OF THE TENNESSEE DENTAL ASSOCIATION . 93-2

technician to the required contours and 1) NobelProcera® (Nobel Biocare 2) Bella Tek® Endocde® (BIOMED
custom fit into the restorative space. They USA, LLC, Yorba Linda, CA) 3i, Palm Beach Gardens, FL)
tend to be quite labor intensive and costly. provides abutments in titanium, is a robotic analog design. This
They utilize UCLA, gold adapt, or cast to zirconia or alumina. Fixture system uses an impression of
abutments for the casting process. level impressions are made and a the healing abutment to design
Computer Generated Abutments master cast is produced. This cast and fabricate the final abutment.
can then produce the abutment These healing abutments come in
CAD/CAM a two-piece system
technology was which has notches
incorporated into Figure 5 - Healing Abutments on its occlusal
the production of surface which act
implant abutments as codes that the
and frameworks in computer can scan
the 1980s.' These and translate into
abutments are implant abutment
fundamentally designs.' The
changing present scanner can extract
restorative protocols. information about
Traditional the position of the
techniques relied hex, the diameter
on the accuracy of the implant
ofthe processes platform, the collar
of impression height and then
materials, gypsum exact 3D placement
products, waxing of the implant.
crowns, investing This then allows
and casting with CAD and CAM
alloys at high fabrication.
temperatures. These 3) Straumann®
produce avenues CARES«
for inaccuracies r Figure 6 - Definitive Abutment Classification
(Straumann, USA,
to develop. CAD/ Andover, MA)
CAM has introduced makes two-types
STANDARD STO
methods of Tl, ZR of abutments:
fabricating the final (CEMENT) zirconium dioxide
impression with and titanium. In this
digital methods of system an implant
impression making level impression
M CASTABLE (CCA)
and scanning and PERMANENT ABUTMENTS Ti,Zr is made and then
then milling out (CEMENT OR SCREW) duplicate model
prefabricated metal of the master cast
alloys to produce is fabricated. This
a restoration that COMPUTER GENERATED is called the scan
is more precise (VAD/CADD)
model and is made
Tl, AL, ZR
than the traditional of a type of plaster
(CEMENT OR SCREW)
casting methods. that is scanable.*" A
When considering scan body is also
CAD/CAM implant attached to the implant analog
abutments there are several systems in two modes.'' The cast can be
scanned and the abutment can be prior to the scan to delineate
available on the market currently, but implant position. The custom
they all seem to stem from the following designed in an entirely 3D fashion
by computer software. Another abutment is then designed CAD
protocol:'' on screen to the contours needed
method would allow a preprepared n
a. Scannable Abutments (Scan bodies) base cylinder to be placed on the and transmitted to the Straumann
b. Prepable Scanned Abutments cast and then waxed. This wax-up center. Etkon is another system that
c. Virtual Assisted Design is then transferred to the scanner. uses the same principles of waxing
d. Robotic Analog Design This information for both systems up onto a plastic cylinder which is
Implant manufacturers have developed is then sent to the Nobel Biocare then removed and scanned.
unique proprietary systems. Some of the facility for CAM and sent back as Atlantis"', (DENTPSLY,
4)
common systems are outlined below: either a metal or ceramic coping. International, York, PA) abutments

93-2 . A REVIEW OE IMPLANT ABUTMENTS-ABUTMENT CLASSIFICATION TO AID PROSTHETIC SELECTION 21

 can be fabricated Conclusion
in titanium or gold Figure 7 - Customized Abutments Understanding
shaded titanium abutment
or zirconium. classification is
The gold-shaded just one step in the
abutments aid in process of creating
covering up the the ideal restorative
silver color ofthe prosthesis. This
titanium and provide article presents
a more esthetic a classification
value to the patient. system to outline a
Thissystem can be method for abutment
used with any ofthe selection. The
available implant treatment, however
systems and begins remains the same
with a fixture level and will invariably
impression and involve correct
then the diagnostic treatment planning,
cast and the master decision making
cast are scanned. and sequencing of
The abutment is treatment that will
then designed on ensure a successful
software termed end result.
virtual assisted
design (VAD) and
Disclosure:
milled. Guidelines
The authors did
for the design are
not report any
incorporated into
disclosures.
the prescription,
including:
Table 2 - Factors Requiring Custemized Abutments References:
a. Implant
1. Giglio, G.D., Abutment
information: selection in implant-
Tooth number, Criteria (or impiication for abutment selection
supported fixed
prosthodontics. Int J
implant brand Customization Periodontics Restorative
Dent, 1999. 19(3): p. 233-41.
and platform
2. Miseh, C.E., Screw-retained
diameter Abutment margins should be supragingival in versus cement-retained
implant-supported
b. Abutment Tissue Collar Height nonesthetic zones and slightly subgingival in the prostheses. Pract
material: esthetic zone Periodontics Aesthet Dent,
1995. 7(9): p. 15-8.
Titanium,
3. Philip G Kotick, B.B.,
gold shaded Abutment height must not exceed the space Abutment selection for
Crown Height Implant Restorations. Inside
titanium, available for the crown materials Dentistry, July 2011. 7(7).
zirconia and 4. Gracis, S., et al.. Internal
Gemini Abutment width must be sufficient to support vs. external connections for
abutments/reconstructions: a
c. Margin design: Interproximal Distance the crown but interproximal access to hygiene systematic review. Clin Oral
I» Implants Res, 2012. 23 Suppl
Chamfer, instruments must be sufficient 6: p. 202-16.
Shoulder 5. Priest, G., Virtual-designed
d. Retentive and computer-milled implant
Implant Angulation Abutment must counter an implant angulation abutments. JOral Maxillofac
Surface: Yes Surg, 2005. 63(9 Suppl 2):
p. 22-32.
orno
e. Healing Margin should be subgingival in the esthetic 6. Kapos, T., et al.. Computer-
aided design and computer-
CO Abutment zone, and the emergence profile must support assisted manufacturing in

w Esthetics prosthetic implant dentistry,

diameter the gingival tissues. A porcelain abutment may Int J Oral Maxillofac
Implants, 2009. 24 Suppl:
f Margin improve the esthetics p. 110-7.
Position: 7. Drago, C.J., Two new
Free gingival clinical/laboratory protocols
for CAD/CAM implant
margin (FGM) Emergence profile options: Full restorations. J Am Dent
Assoc, 2006. 137(6): p.
to abutment or implant platform to anatomic. Contour soft tissue. 794-800.
abutment Support tissue or no tissue
displacement

22 JOURNAL OF THE TENNESSEE DENTAL ASSOCIATION > 93-2

 Sanjay Karunagaran, B.D.S., D.D.S.,
M.S.D., Assistant Professor, Department
ofProsthodontics, University of Tennessee
Health Science Center College of Dentistry,
Memphis, Tennessee. Contact Dr.
Karunagaran at skaruaga@uthsc.edu or 901-
448-6380.
Gregory! Paprocki, D.D.S., Assistant
Professor and Director, Maxillofacial
Prosthodontics, Assistant Director, Advanced
Prosthodontic Program Co-Director, Head
and Neck Cancer Clinic University of
Tennessee Health Science Center College of
Dentistry, Memphis, Tennessee.
Russell Wicks, D.D.S., M.S., Chairman
and Professor, Department ofProsthodontics,
University of Tennessee Health Science Center
College of Dentistry, Memphis, Tennessee.
Sony Markose, B.D.S., D.D.S., M.S.D.,
Private Practice, Carrolton, TX

Questions for Continuing Education Article - CE Exanri #50

Publication date: Fall/Winter 2013. Expiration date: Fall/Winter 2016.

This exam is also available online. If you take the exam online, you can pay with a credit card and print out your
certificate in a matter of minutes. Visit the TDA's website at www.tenndental.org

1. When considering custom abutments, which of the Which of the following is NOT a temporary abutment:
following is TRUE: a. Impression abutments
a. They require an impression of the implant platform b. Healing abutments
b. They require an impression of the abutment c. Standard Stock abutments
c. They are used in situations where the prosthetic d. Metal or plastic provisional abutments
corrections cannot be made by prefabricated
abutments
When considering transfer copings, which of the
d. Both a and c are true following are FALSE:
a. Less space is needed for the impression and it is
2. Custom abutments can correct which of the following: suitable for posterior areas
a. Insufficient interocclusal restorative space b. No preparation of the tray is necessary
b. Angle correction problems greater than 15° c. Splinting of the copings is possible
c. Need to replicate the original cross sectional profile d. Possible distortion, as the coping have to be
of the tooth reinserted into the impression
d. To obtain the correct emergence profile as it exits the
implant platform
When considering 3i CAD/CAM BellaTek® Encode®
e. All statements are true abutments which of the following designs does it
incorporate:
a. Scan Bodies
b. Prepable, Scanned abutments
c. Virtually assisted design
d. Robotic Analog design

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93-2 . A REVIEW OE IMPLANT ABUTMENTS-ABUTMENT CLASSIFICATION TO AID PROSTHETIC SELECTION - EXAM 23

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A Review of implant Abutments-Abutment Classification to Aid Prosthetic Selection
Publication date: Fall/Winter 2013. Expiration date: Fall/Winter 2016.
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