CONNECTION (DO WE NEED ONE?) BETWEEN DENTAL IMPLANTS AND ABUTMENTS!!!

Hopefully, all of us, dentists would have heard about different types of connections between dental implants and abutments in our graduate days. I'm quite sure it was confusing and I'm also quite sure that it will still be confusing for many of the students and younger dentists!

I'm a graduate from the first decade of the 21st  century and for us, implants were always two-piece, the idea of single piece implants was never there in our minds. 

For quite a long time I used to hear only about Nobel Biocare implants and the trilobe connection (frankly, I think it's not even close to pass by the OK standard in today's implant world). Until I graduated and started practicing, I was thinking Nobel Biocare is the only implant available! That's how strong was the monopoly achieved by Nobel Biocare! Sure, they have come up with lots of changes, but it must be accepted that they are no more the only company or the only boss! 

While I was training to be a prosthodontist between 2013-2016, during my postgraduate days, I had developed a keen interest in analyzing each and every implant system that I heard about!! And somehow, due to time constraints, we stuck to the popular implantology textbook "contemporary implant prosthetics" by Dr. Carl Misch. Carl Misch had a great way of explaining things. His text, honestly, is one of the most evidence-based text of all time! Though it was a standard textbook for beginners, it did not contain any detailed explanations on the radical protocols of single-stage implantology, which many refuse to accept as a treatment protocol. 

There are quite a lot of companies that manufacture dental implants and the exact count would be quite not possible. Many of them for the sake of avoiding lawsuits for patent infringement, create designs that vary slightly or abruptly. This, along with marketing strategies of implant companies, that claim that the connection of their system is superior to others, causes so much of confusion. 

Let's try and understand why a contemporary dental implant in the recent past were most of the times a two-piece structure requiring a connection with abutment and why not a single piece, like a natural tooth.

"Afterall a dental implant is nothing but a substitute for a lost natural tooth"

To start with, even as Dr. Branemark's (basically an orthopedic surgeon) experiments in the rabbit tibia were leading to the discovery of osseointegration of titanium inserts, there were quite a few notable signs of progress that were happening in the world of dental implantology and those were from people who were actually dentists - Dr. Leonard Linkow, Dr. Tramonte, Dr. Raphael Chercheve and the likes. These dentists were actually trying to find solutions with different dental implant designs rather than different materials. Their implants were mainly based on Vitalium and Tantalum alloys and most of them were protocols that suggested immediate loading of implants, the abutment being an integral part of the implant itself - essentially a monobloc design- taking shapes like blades, plates, helices etc.

On the contrary, Dr Branemark's titanium implants were not monobloc in design and were like threaded screws used in tool making and engineering. Dr Branemark's experiments, that had titanium tubes placed in rabbit tibia, originally had them submerged within the bone. Hence,and maybe, the original surgical protocol was adopted to have the implants submerged within the bone and covered completely inside the mucosa. 

The abutments were connected to the implants at a later date, usually in about 4-6 months' time, after a brief period involving the use of healing collar to allow tissues to heal. This happens after the second stage surgery that was required to uncover the submerged implants. This was in contrast to the other types of implant protocols available at that time, most of them being single stage protocols with loading as soon as possible.

The eventual success of Dr Branemark's titanium implants, boosted by the patents and funding from Nobel pharma company, created a monopoly in the industry. Eventually, the entire dental field obsessed and mesmerized by the titanium miracle started believing and following the Branemark protocol, eventually leading to an insurgence of designs that were essentially two pieced. This made the other protocols and designs that were progressing alongside less popular.

Now, it must be logical to understand and accept how Dr Branemark's popular protocol allowed two-stage implants take over dental implantology from the other pioneering researchers who were working differently, using implants without any connections and made of different alloys and not titanium. 

However, the monobloc designs did not disappear altogether, because their design and principles are more sound and were based on orthopedic traumatology principles. Today the monobloc immediate loading protocol is edging close to the popularity because of tremendous developments that had happened over the years. These implants are popularly now called basal cortical implants and the basic principle is to have a primary anchorage in cortical and dense mineralized bony regions in the maxillofacial region. They can be indicated in severe resorption cases. Also, now they are available in titanium and it's alloys which are much stronger than the commercially pure titanium which was originally used in Branemark implants.

However, when you let these two philosophies go head on head in a match, they will end up in a checkmate. Obviously, no single philosophy is flawless in both surgical protocols and prosthetic protocols. Thus, considering this deadlock, one cannot rely just on monobloc designs to face all situations. This necessitates knowledge about the two-stage implants and all types of implant connections that are available.

Now, we have the answer to the question!

Do we need a connection between implant and abutment??

Of course, we need one, as long as the two-stage protocol exists. I'm sure it will not become extinct and also I'm sure that as a beginner, or a post-graduate resident, you are most likely to follow a two-stage implant protocol, which can be safer in an ideal situation. 

NExT uP: External connection and evolution of the modern internal connections!