There are two general surgical approaches for the placement and restoration of missing teeth using endosseous dental implants. One approach places the top of the implant at the alveolar crest and the mucosa is sutured over the implant, which results in a submerged surgical approach. An alternative approach places the coronal aspect of the implant coronal to the alveolar crest and the mucosa is sutured around the transmucosal aspect of the implant. This results in a non-submerged surgical approach. Different implant designs are generally used for submerged and non-submerged approaches and these designs have biological implications. When a submerged implant design is used, secondary implant components are added that extend through the mucosa to place the implant restoration. The connection of these components requires a second surgical procedure for the patient and results in interfaces in close proximity to the alveolar crest. These connections typically are flat connections maintained by screws within the secondary components. Data demonstrate that such connections become contaminated with bacteria and that the host reacts by creating an inflammatory immune reaction. This host response results in bone loss and soft tissue changes including an enlarged biologic width dimension and recession. With non-submerged implant designs, only one surgical procedure is required and no interfaces are created at the alveolar crest. Consequently, the host inflammatory immune response is negated and the hard and soft tissue changes are minimized. The restoration of both implant designs can be achieved with either cemented restorations or restorations retained by screws. Screw-retained restorations offer the advantage of retrievability. However, in single teeth and short-span implant restorations, removal is not usually indicated. In these situations, cemented restorations offer simplicity, similarity to conventional crown and bridge techniques, and low maintenance. Regardless of implant design, surgical technique, or final restoration retention, endosseous dental implants have revolutionized restorative dentistry and made a significant impact on improved patient care.
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