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The Critical Nature of Tissue Contouring from a Periodontist’s Perspective by Robert A. Horowitz, DDS ■ The Importance of Peri-Implant Health Most people who need dental implants have lost their teeth due to restorative or endodontic complications, or to the ravages of periodontal disease. These conditions result either from failure of the patient to properly cleanse, or from iatrogenic dentistry that has left uncleansable margins. Once patients lose their teeth, there is often bone loss as well as a loss of keratinized tissue. This can lead to black triangle disease, the loss of gingival papillae between teeth that may result in esthetically compromised restorations or significant interdental food impaction. As there is a different attachment apparatus from the gingiva to implants compared to that of natural teeth, there is more susceptibility to peri-implant disease from proximal inflammation. Published periodontal literature has shown that when periodontal measurements are taken around implants with inflamed soft tissues, the endodontic probe tip reaches the alveolar bone. Due to inflammation, bone loss around implants can be quicker and more catastrophic than around natural teeth. An ideal implant-supported restoration, then, should have the same gingival contours and proximal contacts it would have were it a natural tooth. It is the goal of the surgeon to maximize bone and soft tissue preservation at the time of extraction. If a tooth is not extracted properly, or if the alveolar bone and keratinized tissue are not preserved at the time of extraction, multiple surgical procedures may be required to regenerate or rebuild the alveolar housing, further lengthening and complicating treatment. Using properly designed temporary and final restorative components enables an ideal emergence profile to be engineered from the shoulder of the implant through the keratinized tissues to the contact point. When all these pieces of the restorative puzzle come together properly, the patient will have an ideal environment for keeping the area free of inflammation. Minimizing inflammation increases the longevity of the alveolar bone, keratinized tissue, and the dental implant. An ideal implant-supported restoration should have the same gingival contours and proximal contacts it would have were it a natural tooth. ■ Soft Tissue Contouring and Successful Implant Restorations Natural teeth and crowns have certain self-cleansing contours. Contact points are located at different heights from the alveolar ridge, depending on the location of the tooth in the arch. Buccal and lingual contour heights also vary depending on the tooth. Proper sculpting of the soft tissues around an implant-supported crown will help keep the gingiva at a similar height to that of a natural toothsupported crown. In this manner, the natural actions of the lips and tongue help move food and plaque away from the gingival margin, rather than packing it into large spaces between the contact point and the gingival margin, or allowing it to build up on the facial or lingual surfaces in a more receded environment. 50 – www.inclusivemagazine.com –
After most extractions, a loss of facial bone occurs in the vertical and horizontal dimensions. This bone loss can be regained surgically or prosthetically; however, adding facial bone around an implant requires the use of grafts, barriers, and techniques that are often more advanced than the average practitioner is prepared for. Therefore, preserving the facial and lingual surfaces with bone at the time of extraction is a more predictable procedure. If the surgeon is not familiar with these techniques, however, and their value is not communicated to the patient, the patient will likely experience a site collapse (Figs. 1a–1c). The most ideal time to augment the soft tissue profile is at the time of conventional implant placement. Figure 1c: This can give the final crown the appearance of being “stuck” on the gingiva. ■ Understanding the Limitations of Stock Components Stock or standard abutments are designed in the shape of a perfect circle at the shoulder, or prosthetic base, of the abutment. The problem with this standard design is that no naturally occurring tooth is perfectly round at the alveolar crest or the cementoenamel junction (CEJ). While flared healing abutments are available, these stock components still provide only a generic solution, forming gingival contours that may be less than ideal for a specific patient. Figure 1a: After extraction, there is often site collapse necessitating implant placement further palatally to ensure 2 mm of bone on the facial aspect of the implant. To sculpt the soft tissues around an implant, the surgeon or restorative dentist should mimic the shape of the soft tissue around the natural tooth in that same area. There are numerous ways to do this. Many dentists take an implantlevel impression, insert a round healing abutment, and let the laboratory do the rest (Fig. 2). But if the laboratory makes an overly bulky crown or abutment that squeezes, pushes or compresses the gingival tissues, there is no way to account for the potential recession that can result. If the dentist places a stock final abutment on the implant and Figure 1b: In such cases, to ensure proper occlusion and esthetics, the restoration requires a facial cantilever of porcelain. Figure 2: Implant placed properly in center of ridge. Note there is no tissue sculpting with this conventional, non-contoured healing abutment. – The Critical Nature of Tissue Contouring from a Periodontist’s Perspective – 51
Page 1 and 2: Inclusive Restorative Driven Implan
Page 3 and 4: Contents 13 Intraoral Scanning and
Page 6 and 7: Publisher Jim Glidewell, CDT Editor
Page 8 and 9: Contributors ■ Bradley C. Bockhor
Page 10 and 11: Trends in Implant Dentistry Custom
Page 13: my first implant with Gordon J. Chr
Page 16 and 17: Figure 4: Following a six-month oss
Page 18 and 19: 18a 18b 18c Figures 18a-18c: The co
Page 21 and 22: Guided Implant Surgery for Single-T
Page 23 and 24: Figure 2: Tongue depressors used to
Page 25: 10a Summary Digital treatment plann
Page 29 and 30: Type D1 Type D2 Endodontic probe be
Page 31: 1Prosthetic guide in situ Because t
Page 34 and 35: 1400 Average Flexural Strength Dist
Page 37 and 38: The Do’s and Don’ts of Immediat
Page 39: cases, the caveats noted previously
Page 42 and 43: Step-by-Step 1Seat the temporary ab
Page 44 and 45: Implant& Q A: Go online for in-dept
Page 46 and 47: We have been working with dedicated
Page 48 and 49: had another way to put the occlusal
Page 50 and 51: PRODUCTION WORKFLOW The following o
Page 54 and 55: attempts to shape the tissues with
Page 56: As implant dentistry is a restorati
Page 59 and 60: Adjusting the Inclusive Custom Temp
Page 61 and 62: Delivering the Provisional Restorat

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