Healing Cap vs. Healing Abutments?

I have a general question regarding healing caps vs healing abutments since evidence and philosophies change over time. I attended an intermediate hands-on class and there were implant representatives there as well. I thought it was interesting that one of the representative said to one of the other students to always place a healing cap and bury the implant for a 2-stage surgical approach because the patient might use a healing abutment to chew on, thereby shifting the implant. Is there evidence that this happens? I have done it both ways depending on how confident I felt about the primary stability of the implant and tissue health. What is the current consensus out there? I did not get a chance to talk to that representative about his statement.

19 thoughts on: Healing Cap vs. Healing Abutments?

  1. Roadkingdoc says:

    Tough to chew one below the occlusal plain. I don’t think there is much difference between healing cap and screw as long as they are out of occlusion. I am more comfortable with a screw.

  2. WJ Starck DDS says:

    Sounds like a certain someone just wants to sell more implant parts.

    I most always go with a single stage approach. Patients hate that uncovering. I’m not fond of it either. The only time I do it nowadays is when I have exposed threads and need to graft. Also, it seems to me that the little load that they do place on them assists in osseointegration.

    Not a big fan of two stage approach unless I absolutely have to

  3. Neil I Park says:

    It’s a question of primary stability, measured by the amount of placement torque or an ISQ reading. Highly stable implants can be provisionally loaded at placement. Implants with lower stability, such as those in Type 4 bone, should be buried. Those that are somewhere in between can be placed with a healing abutment protruding through the tissue, well below the occlusal plane. As Dr Starck says, eliminating Stage ll surgery is a worthy goal.

  4. OMFSEric says:

    Personally I always do two stage. Anybody WILL chew on the fresh implant in error. A flat head cover screw won’t get extra pressure The second stage is like 3-5 minutes w local only at the exact ridge spot. I believe this is what gives me a 99.5 long term success rate. My partner does immediate healing collars and immediate implants. 92 % success and his surgery is fine, so what’s the rush?? Save a few months w immediate but perhaps less success. OR longevity? And a a simply uncovering? I use a biopsy punch. No flaps usually ( unless bone over implant, an no sutures. Also no fee after placement I vote two stage .

    • Tim Hart says:

      Also, going back to 2nd stage protocol, with a really short appointment, is another reason to engage CT-derived surgical guides, whether pilot or full. The guide makes your 2nd stage a snap and a breeze.

  5. Matt Helm DDS says:

    IMO, each situation demands its own approach, based on the various factors and variables that we are all aware of, including (but not limited to) bone type and quality, area of implant placement, restorative plan, aesthetics, and so on. There is no one-size fits all, and there shouldn’t be. There will be times when I feel I can safely place a healing cap, or preload with a temp if I have good primary stability and the aesthetic situation truly warrants it. That said, personally I do prefer the two stage approach — it’s safer and more predictable. Uncovery surgery is really merely a tiny incision, so there is no reason for a patient to dread it if the patient is primed and educated regarding the process.

    • WJ Starck DDS says:

      Other than parroting what others have said (while offering no proof), what proof do you have that it’s ‘better and safer?’

      I see too much of this in dentistry.

  6. Trung Doan says:

    I always placed healing cap when I had primary stability of the implants, until this case. I placed 2 implants at positions of #s 19 and 20. I placed healing cap on #19, but a flat cover screw on #20 due to low torque (about 15 N cm). Patient did not return for 2 years, when she finally came back, #20 was solid, ready to be restored, #19 failed with an abscess. I think what happened was that food trapped around the healing cap, causing the abscess thus the failed implant. The take away is that there is a chance that bacteria travel down the healing cap during osseous integration stage, causing that annoying little trough around the neck of the implants after healing? I don’t know, but since that day i always bury my implants. As some other doctors pointed out, it take only 5 minutes for the 2nd stage.

  7. Angela Toy

    Thank you everyone for your input. I admit when possible I like placing a tissue level healing abutment at the time of placement because I am starting to form tissue contours from the get go and switch collar sizes at integration to further contour the tissue. I certainly can see the validity of other comments above for 2 stage. It would be interesting to find papers comparing the two approaches.

  8. R Gangji says:

    Advantage of two stage surgery are all the great things listed by other clinicians here and if you are less experienced ,then please do two stage with cover screw until you are more comfortable.
    However, another very important factor is to always look at your soft tissue health in terms of how much keratinized tissue you have, especially on the facial/ buccal side of your fixture
    We know , for better successes , several years after, we need more keratinzed tissue on facial / bucal side of your fixture , so when you place a healing cap/cuff/ abutment/collar, you eliminate the chance of creating a thicker facial keratinized profile for you fixture
    Two stage allows you to expose the fixture more palatally or lingually and then you can move your flap more facial to the new taller healing cap during stage 2 recovery. Therefore you have just found a method of creating more keratinized attached tissue around your fixture on the buccal aspect. So please don’t tissue punch everything! That tissue punch saves you two minutess but feeds your suction tip, vital soft tissue that will prevent the threads of your implant from showing in 5-10 years or sooner.
    Only tissue punch on sites where you have abundant pink keratinized zone.
    I usually do one stage on slam dunk predictable sites , healthy patients ,lots of bone, and and when I have enough attached tissue w/ good primary stability …….but for onlay / veneer grafts around fixtures , vertical/ crestal or lateral sinus lifts and cases where I need primary closure ,like immediate placements w/ grafts , or to bulk gingival tissue on facial later on , or D4 and some D3 patients where if you over-prep your osteotomy and get less then optimum primary stability ,medically compromised cases, smokers ,diabetics ,I do stage two recovery with a cover screw.
    Great site , first time responder!!

    • Matt Helm DDS says:

      Great comment Gangji. I agree on just about everything, as I am also generally against the tissue punch. Experience has shown that generally, besides allowing the manipulation of tissue (as you said with a bit more lingually-placed incision), the uncovering incision generates tighter, more predictable and more keratinized tissue around the collar of the healing abutment. And of course the tighter the tissue is around the abutment, the better in the long term.

  9. WJ Starck DDS says:

    Sorry, but again, this is utterly untrue.

    In the case of an immediate implant, the keratinized tissue is what existed before the tooth was extracted, so there is no need to increase the amount.

    In the case of a healed site, incisions are always preferred over punching, as the incision can be biased to the palate if need be to regain as much keratinized tissue as necessary.

    I can accomplish everything you stated above with a single stage surgery with the exception of, as I mentioned above, the need to graft exposed buccaneers threads. So why put the patient (and yourself) through a second surgery?

  10. Leonard Smith DDS says:

    Thanks for the question. I feel most of the answers are correct for specific conditions. I first was confused by nomenclature of healing cap , healing screw. Went to AAID glossary of terms and found Both cover screw and healing screw listed as the same and healing cap but not healing abutmentment listed . Interesting to me to be sure of what the discussion is about.
    Remember that initial torque or iso readings go down in the initial 2-4 weeks as remodeling takes place, woven bone mineralization takes time and there is a case for a healing cap (abutment ) to be under load from chewing and especially tongue force. Food mass is a force factor (how much micro moment does it take to be micro movement). The tongue is well known to create orthodontic sheer stress. How much sheer stress does it take for micro or macro movement. If the case is successful then it doesn’t matter but if the implant floats out in 2 weeks then I’m looking for reasons that really won’t satisfy the patient or me. Nothing is ever always.
    Knowledge, predictability, experience

    • Angela Toy

      I realize I needed to more clear here with nomenclature. Healing cap in my mind is the flat screw head that sits flush with the implant platform and buried for a 2 stage approach. Thank you for your input.

  11. Perio D says:

    No patient would want two surgical sessions compared to a single session no matter how minor the second surgery.
    To say the second surgery is 3 to 5 minutes seems an exaggeration. It takes an assistant much more time to prepare the room for surgery and the room is tied up at least 30 minutes
    For two steps the patient has two trips to the office, parking, time off work, anesthetic, healing
    A 5 minute second stage surgery would require a tissue punch for exposure and would decrease the zone of keratinized gingiva which could be important to long term health
    Two surgeries will cost more than doing the same treatment in a single visit and whether all the cost is at the first appointment doesn’t matter in regards to the total cost.
    The success rate and complication rate are the same whether its one surgery or two

    HOWEVER, two stage implant surgery definitely has its place when doing bone grafts, or when a removable denture sits over the implant sites. Overall I will try to do one step implant surgeries anytime its appropriate for the situation.

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