Maintenance of Gingival Form Following Implant Placement

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Immediate dental implants placed in a

transmucosal technique have proven tobe a predictable treatment modality.1,2

This one-stage protocol negates the needfor complete socket closure, thus improv-ing soft tissue esthetics by maintainingthe position of the mucogingival junc-tion and amount of keratinized tissue.3

Although this helps to maintain the softtissue appearance on the facial of the ridge,we are still faced with a flattening of thesoft tissue scallop. A review of previousstudies examining the dento-gingival rela-

tionship will help in understanding whythese changes occur and how a strategyaimed at preservation of the existing gin-gival anatomy may be beneficial.

The presence of a papilla and its rela-tionship to embrasure space has beenevaluated. In a study examining the softtissue dimensions between teeth, re-searchers found that in sites where thelinear measurement was 5 mm betweenthe contact point and the level of the in-terproximal bone, the papillae filled theembrasure almost 100% of the time.4Asimilar value was measured in an evalua-tion of the total dento-gingival complexon maxillary incisors.5 The interproximalaverage values were up to 4.5 mm andthe facial measurements were 3 mm. Al-though biologic width (connective tissueand junctional epithelium) on differentsurfaces of the tooth may vary slightly, itmay not be enough to explain the dif-ference in tissue heights between the

facial and interproximal surfaces.6 Sulcusdepth seems to be responsible for these

differences and may vary depending on

periodontal biotype, tooth form, and em-brasure volume. Sites with greater sulcusdepth are prone to greater recession afterthe extraction of a tooth. The absence ofinterproximal support allows for a flat-tening of the papillae to the same levelabove bone that exists on the facial. Con-sidering these sequelae, the clinician maybe challenged to restore the missing toothwith the desired gingival profile.7

When replacing a tooth with an im-plant-supported restoration, several pro-

tocols have evolved to achieve a reasonableoutcome. The traditional approach of atwo-stage delayed implant placement fol-lowed by a period of osseo-integration hasproven successful.8 The re-creation of softtissue form may occur by re-establishmentof a gingival embrasure with the final re-storation. Researchers have determinedthat the level of bone and periodontal at-tachment on the adjacent teeth appear todetermine the height of the papillae.9,10

Although the interproximal tissue levelmay be restored close to the presurgicallevel, it appears to be dependent on theperi-implant tissue biotype. In addition,there may be a period of time after inser-tion of the restoration that is needed toachieve fill of the embrasure.11,12

Immediate implant placement fol-lowed by immediate provisional restora-tion of single sites is another protocolused to replace a failing tooth.13Alongwith the advantages of a fixed esthetic

restoration, the soft tissue profile can bemaintained from the time of extraction.

This technique may benefit patients with

a thin periodontal biotype. Another ben-efit is the simplification of the final restor-ative procedure. Pre-fabricated healingabutments are circular in shape. Attemptsat molding the tissue from a small open-ing above the implant to a contour simi-lar to the missing tooth can take time.

The preserved tissue profile can be eas-ily duplicated in the impression processand allow for an accurate fabrication of arestoration in harmony with ideal tissuearchitecture at the day of insertion. This

form of maintenance of the supportinggingival tissue has been demonstrated tobe beneficial using immediate pontics fortooth replacement.14 Preservation ofform, rather than re-creation, is achievedwith the extension of the pontic into thesubgingival zone with a contour replicat-ing that of the extracted tooth. Conceptsfrom immediate pontics have beenapplied to immediate dental implantswith a similar goal. This is achieved witheither a custom healing abutment or acomplete provisional crown. The subgin-gival portion is essentially the same. Theclinician can select either option depend-ent on the risk with respect to the patientsocclusion. The use of a custom-healingabutment is recommended in patientswho have a deep anterior bite, who pres-ent with signs of bruxism, or who have amalocclusion that is not conducive to theprotection of an immediate restoration.This article will illustrate the use of a cus-

tom-healing abutment after immediatepost-extraction implant placement.

Jim Janakievski, DDS, MSD

Affiliate Assistant ProfessorUniversity of Washington,

School of DentistrySeattle Washington

Private PracticeTacoma, Washington

Case Report: Maintenance of GingivalForm Following Immediate ImplantPlacementThe Custom-Healing Abutment

Abstract:The anatomical changes that occur with the alveolar ridge after the loss of a singleanterior tooth can be a challenge to redevelop during the restorative process. Thepreservation of the soft tissue level from the time of extraction may optimize thefinal prosthetic outcome. One technique that can be used to achieve ideal tissueform is immediate dental implant placement with a custom-healing abutment.

24 ADVANCED ESTHETICS & INTERDISCIPLINARY DENTISTRY DECEMBER 2007VOLUME 3, NUMBER 4


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CASE REPORTA 36-year-old patient presented with

a structurally compromised tooth No.8. This tooth had a failing compositeresin restoration and lacked sufficientferrule for adequate retention of a re-storation (Figure 1A and Figure 1B). Re-

pair had been attempted several timesand the patient was informed aboutthe poor restorative prognosis. Radio-graphic analysis noted the presence ofan angled post placement, a narrow ta-pering root form and short endodonticfill (Figure 1C). The soft tissue formaround this tooth was ideal, with thefacial gingival margin slightly coronal tothat on tooth No. 9. Periodontal prob-ing indicated normal attachment levelson tooth No. 8 as well as the adjacentteeth. After a complete review of the ex-amination findings, a treatment planwas proposed to replace this tooth withan implant-supported restoration. In aneffort to maximize the esthetic result,the surgical procedure was planned as animmediate post-extraction implant place-ment with a custom-healing abutment.

Surgical TechniqueExtraction of tooth No. 8 (Figure 2A)

was accomplished without flap elevationusing a periotome to sever the periodontal

ligament fibers, and forceps to gentlyrotate the tooth out of the socket. A bonecurette was used to remove any soft tissueand examine the integrity of the labialbone plate. No dehiscence was noted andthe facial bone crest was measured to be4 mm below the gingival margin.

Osteotomy preparation in immediateimplant sites is usually started on thepalatal wall. This helps to avoid perfo-

ration to the facial and positions theimplant with good bone contact on themesial, distal, palatal, and apical area. Theimplant (3i Osseotite, BIOMET 3i, PalmBeach Gardens, FL) was placed with theplatform positioned at the level of thelabial bone crest, 4 mm from the facialgingival margin (Figure 2B). Some result-ant recession would be acceptable giventhe favorable coronal position of the gin-gival margin as compared to tooth No.9.

Custom-Healing AbutmentPrefabricated healing abutments are

circular in shape and fail to provide sup-port for the supracrestal soft tissue inimmediate implant sites. Dental implantcompanies have attempted to fabricatehealing abutments with the cross-sectionof natural teeth or ones that can be cus-tomized. The problem with these ver-sions is the difficulty in adding andsubtracting material to customize theshape. The author has found it easier touse temporary abutments with the ad-dition of composite resin. The supra-gingival extension of the metal cylinderallows for easy handling during the fab-rication process. Composite resin is usedwith controlled application to customizethe emergence profile specific to the site.

A temporary abutment (BIOMET3i) is prepared extraorally with a lightaddition of flowable composite resinbefore it is inserted onto the dental

implant. Additional composite resin isadded to the abutment to fill the space

between it and the soft tissue margin.Incremental addition and curing is rec-ommended and should be executed withgreat care to prevent resin from flowingonto the implant surface. The abutmentis then taken out of the mouth and con-nected to an implant analog. Compositeresin is added to fill in and create the

proper emergence profile from the top ofthe implant to the level of the free gingi-val margin (Figure 3A and Figure 3B). Itis important to note that the soft tissuemargin will begin to collapse immediate-ly after tooth extraction. The clinicianwill need to compensate for this byadding to the perimeter of the healingabutment during the final shaping andcontouring. The custom-healing abut-ment is tried in several times to check the

profile. Radiographs are helpful to exam-ine the angle of emergence from the topof the implant. After a final polish withdiscs, the supragingival extension of thetemporary abutment cylinder is cut tothe level of the gingival margin (Figure3C and Figure 3D). The custom-healingabutment is then inserted and torquedonto the implant. Tooth replacement isaccomplished with a removable prosthe-sis (Figure4A through Figure 4C). Eitheran Essix appliance or an interim remov-

able partial denture can be adjusted to fitover the healing abutment. Adjustmentof the appliance is necessary to avoidcontact with the healing abutment andpressure on the implant.

ImpressionAfter the osseointegration phase is

complete, a polyvinylsiloxane impres-sion can be taken to register the positionof the implant and contour of the soft tis-sues. The custom-healing abutment hasmaintained support of the gingival archi-tecture and this should now be trans-ferred to the working laboratory model.The best technique that has been devel-oped is the use of a custom-impressioncoping (Figure 5A through Figure 5C).14

The custom-healing abutment is re-moved from the mouth and connectedto an implant analog. Silicone im-pression material is injected around theanalog and abutment to capture the

subgingival profile. The custom-healingabutment is returned to the implant to

Figure 1A through Figure 1CAt init ial pre-

sentation, this patient had a large composite re-storation for tooth No. 8, gingival inflammation,

and incisal attrition (A and B). A tapering root

form, angled post-placement, and short endo-

dontic fill was noted on the radiograph (C).

A B

C


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continue to support the gingival tissueswhile the impression coping is beingfabricated. An implant pick-up impres-sion coping is then attached to the im-plant replica and composite resin isflowed around it to fill in the void with-in the impression material and light-cured. The custom impression coping

can then be transferred to the mouthand secured to the implant. A standardimpression is then made with this cus-tom coping supporting the soft tissueprofile. The impression is prepared inthe standard manner using a soft tissuereplacement material around the customimpression coping before it is pouredwith die stone.

Restoration

The full-contoured wax-up was usedas a guide for the fabrication of the finalrestoration. A custom abutment was thencast and modified to allow for ceramicapplication to the subgingival surface(Figure 6A through Figure 6C). For thecrown restoration, dentin and enamelporcelain powders were applied on a me-tal coping with a 360 porcelain margin(Figure 7A and Figure 7B). The abut-ment was tried in the mouth and the fitwas verified with a radiograph (Figure 8).

It was torqued to 35 Ncm and the crown

DECEMBER 2007VOLUME 3, NUMBER 4 ADVANCED ESTHETICS & INTERDISCIPLINARY DENTISTRY 27

Figure 2A and Figure 2B Tooth No. 8 was extracted with a periotome and forceps (A). The dental

implant was placed with the platform 4 mm below the facial gingival margin (B).

A B

Figure 3A through Figure 3D The custom-healing abutment was fabricated using a temporary

provisional abutment and composite resin (A and B). After the desired contour was achieved, the

abutment was polished and the supragingival portion of the temporary cylinder was cut to the level

of the composite (C and D).

C D

A B

Figure 4A through Figure 4C The custom healing abutment after insertion provides immediate support of the gingival tissue (A and B). An interim

RPD is adjusted to avoid contact with the custom-healing abutment (C).

A B C

Figure 5A through Figure 5C 6 months after implant placement, 1 mm of gingival recession is noted on the facial (A). The soft tissue form has been

maintained during the healing phase. This will simplify the restorative procedure and provide ideal soft tissue esthetics upon insertion of the finalrestoration (B). A custom impression coping is used to transfer the tissue form to the master cast (C).

A B C


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was cemented with temporary cement(Temp-Bond, Kerr Corporation, Orange,CA).The final results can be seen in Fig-ure 9A through Figure 9B.

CONCLUSIONThis article described a technique for

the maintenance of gingival form fol-

lowing immediate implant placement us-ing a custom-healing abutment. Precise

contouring of the subgingival emergenceprofile allows for the preservation of theoriginal soft tissue levels. The cliniciancan accurately transfer this informationto the dental technician to increase thepredictability of the final restorative out-come. Therefore, careful patient selectionand execution of this treatment modali-

ty provides an effective method to opti-mize implant esthetics.

ACKNOWLEDGMENTThe author would like to thank Harald

Heindl, MDT, and Daniela Heindl forthe fabrication of the restoration pre-sented in this article.

REFERENCES1. Schwartz-Arad D, Chaushu G. Immediate

implant placement: a procedure withoutincisions.J Periodontol. 1998;69(7):743-750.

2. Lang NP, Bragger U, Hammerle CH, Sutter F.

Immediate transmucosal implants using the prin-ciple of guided tissue regeneration. I. Rationale,clinical procedures and 30-month results. ClinOral Implants Res. 1994;5(3):154-163.

3. Rosenquist B. A comparison of various meth-ods of soft tissue management following theimmediate placement of implants into extrac-tion sockets. Int J Oral Maxillofac Implants.1997;12(1):43-51.

4. Tarnow DP, Magner AW, Fletcher P. Theeffect of the distance from the contact pointto the crest of bone on the presence orabsence of the interproximal dental papilla.

J Periodontol. 1992; 63(12):995-996.5. Kois JC. Altering gingival levels: The restora-

tive connection, Part I: Biologic variables. JEsthet Dent. 1994;6:3-9.

6. Vacek JS, Gher ME, Assad DA, et al. The

dimensions of the human dentogingivaljunction. Int J Periodontics Restorative Dent.1994;14(2):154-165.

7. Weisgold AS, Arnoux JP, Lu J. Single-toothanterior implant: a world of caution. Part I.JEsthet Dent. 1997;9(5):225-233.

8. Avivi-Arber L, Zarb GA. Clinical effectiveness ofimplant-supported single-tooth replacement:the Toronto Study. Int J Oral Maxillofac Implants.1996;11(3):311-321.

9. Kan JY, Rungcharassaeng K, Umezu K, KoisJC. Dimensions of peri-implant mucosa: anevaluation of maxillary anterior single implantsin humans.J Periodontol.2003;74(4):557-562.

10. Choquet V, Hermans M, Adriaenssens P, etal. Clinical and radiographic evaluation of thepapilla level adjacent to single-tooth dentalimplants. A retrospective study in the max-

illary anterior region.J Periodonto l. 2001;72(10):1364-1371.

11. Priest G. Predictability of soft tissue form aroundsingle-tooth implant restorations. Int J Perio-dontics Restorative Dent. 2003;23(1):19-27.

12. Phillips K, Kois JC. Aesthetic peri-implant sitedevelopment. The restorative connection.Dent Clin North Am. 1998;42(1):57-70.

13. Kan JY, Rungcharassaeng K, Lozada J. Im-mediate placement and provisionalization ofmaxillary anterior single implants: 1-year pro-spective study. Int J Oral Maxillofac Implants.2003;18(1):31-39.

14. Spear FM. Maintenance of the interdentalpapilla following anterior tooth removal. PractPeriodontics Aesthet Dent. 1999;11(1):21-28.

15. Hinds KF. Custom impression coping for anexact registration of the healed tissue in theesthetic implant restoration. Int J PeriodonticsRestorative Dent. 1997;17(6):584-591.


Figure 6A through Figure 6CA full-contoured wax-up is used as a guide to fabricate the restoration (A). The custom abutment is modified to allowthe addition of porcelain in the subgingival portion (B and C).

A B C

Figure 7A and Figure 7B The final restoration was fabricated with a full porcelain margin. A

scalloped finish line aids in cement removal and maintains soft tissue health.

Figure 9BAt the 2-year post-insertion follow-up,the soft tissue is healthy and the form mimics

that of the adjacent teeth.

A B

Figure 8 Radiograph of the custom-healing

abutment at initial insertion.

Figure 9A Radiograph at 6 months post-place-

ment of the implant. Normal bone remodeling tothe level of the first thread has occurred.

Figure 9C Radiograph at 2 years post-insertionof the final restoration. The bone level has re-

mained stable.

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Maintenance of Gingival Form Following Implant Placement