Soft tissue conditioning with the Straumann ® Bone level implant ...

The ITI (International Team for Implantology) is academic partner of Institut Straumann AGin the areas of research and education.

Communication is key in the dental implant treatment flowInterdisciplinary treatment planning includes the collaboration of differentparties such as:ppPatientppGeneral practitionerppSurgeonppProsthodontistppDental laboratoryIn order to reach a successful treatment outcome, communication betweenall involved is essential. The parties should be aware of the steps and interfacesand exchange their positions in order to be able to make the correctdecisions.A general overview of the treatment flow is depicted below, broken downinto various treatment steps. Before each decision step (lime green in the picturebelow) communication can be helpful.Surgical intervention(transmucosal healing)Case analysis andtreatment planningSurgical intervention(submucosal healing)Flap openingTreatment type1 st flap openingImplant placementImplant placementClose flapFlap re-openingHealing abutment choiceHealing abutment placementTemporizationTemporary placementin order to perform softtissue conditioningFinal restorationProcedure stepDecision/communication step1

Treatment FlowhighEsthetic complexitylowlowTreatment time & costshighI. Case analysis and treatment planningSoft tissue management starts when planning the casebecause the soft tissue shape has to be analyzed andsoft tissue conditioning is influenced by the implant placement.Each case is different; therefore accurate analysisand planning from the very beginning is helpful to reachthe desired esthetic outcome. Various factors (e.g. indication,patient expectations, soft tissue shape, bone quality,site position) have an effect on the treatment outcome.The degree of complexity and risk involved in individualprocedures can be assessed, for example, with the ITISAC Assessment Tool 1 . As a general principle the level ofcomplexity rises with an increase in the number of stepsinvolved and the esthetic outcome that must be achievedto attain a satisfactory result.Increasing esthetic complexity leads in general to longertreatment time and higher costs. Informing and educatingthe patient at the beginning of the treatment might increasehis or her willingness to collaborate.II. Surgical treatment and healing phaseBased on the case and his or her preferences, the clinicianwill choose a submucosal or a transmucosal approach.With the submucosal approach, a closure screw is placedafter the implant placement and the flap is closed. In a secondsurgery after a first healing phase, the healing abutmentis placed and soft tissue conditioning is started.The healing abutment initiates the first phase of soft tissuecontouring. Bone Level healing abutments were designedin order to correlate with the size of the abutments for thefinal restoration. This concept is called ‘Consistent EmergenceProfiles’.2Schematic depiction of the submucosal procedure,which requires two surgical interventions

The transmucosal approach allows a straightforward procedure,avoiding a second surgery.Schematic depiction of the transmucosal procedureThe decision, as to which abutment to use for the finalrestoration needs to be made at beginning of the treatmentso that the healing abutment can be chosen accordingly.Therefore, backward planning and good communicationbetween the treating clinicians and the dental lab areneeded. The tables on the following pages support thechoice of the healing abutment by showing the best fitbetween conical healing abutment and the final restoration.There are further alternatives in the healing abutmentportfolio (e.g. customizable abutments, bottle-shaped healingabutments) which are not displayed in the tables. Thesealternatives are meant to meet additional needs for individualcases and to be used based on user preferences.More details about these solutions can be found in thebrochure “Basic information on the surgical procedures”(pages 60 – 65).III. Temporization (shaping of the soft tissue)After the first healing phase, the soft tissue can be shapedwith the help of temporary abutments. This additional softtissue conditioning with the temporary abutment mayachieve an even more esthetic outcome and widen thesoft tissue when needed (see cases on page 10–14). Thepapilla can be additionally shaped and adapted to the finalrestoration. For these steps, the patient has to be madeaware about the additional effort which is needed to increasethe esthetic outcome. Again, good communicationwith the dental lab and the treating clinicians supports thefinal outcome.IV. Treatment closure and follow-upOnce the prosthesis is placed, adapted and the treatmentis finished, regular follow-up visits and good oral hygienehelp to prevent any undesired effects and to keep patientsatisfaction high.3

The healing and temporary abutment portfolioIn case of submucosal healing, closure screws are availablein different heights for the different platforms (NarrowCrossFit ® [NC] and Regular CrossFit ® [RC]). These allow asimple submerged healing due to their reduced height anddiameter (adapted to implant diameter).Closure screws available for both platforms in 2 differentheights.In case of transmucosal healing or after re-opening in asubmerged case, Straumann offers various healing abutmenttypes. These abutments allow the soft tissue to beshaped.Conical abutments are the straightforward solution for soft tissuemanagement. They are available for both platforms in differentdiameters and heights.In specific cases, e.g. thin mucosa type, a bottle shape abutmentmight be beneficial. Bottle-shaped abutments are availablefor both platforms in different heights.For specific patient cases or if a cementable abutment with adiameter of 6.5 mm is used, the customizable abutment hasshown to be the ideal solution. These abutments are availablefor both connection platforms.4

In general a temporary restoration is recommended toreach a good esthetic outcome. When a temporization isrequired two types of abutments are available: PEEK temporaryand titanium temporary. These support additionalsoft tissue conditioning. One example is shown in the attachedcase.PEEK temporary abutments are available for additive andsubtractive procedures.The PEEK temporary abutment allows a subtractive and additiveprocedure to create a temporary restoration.The titanium healing abutments are designed to build upa temporary restoration by adding material on the post.Titanium temporary abutments are available for additiveprocedures (3D view needed).5

The consistent emergence profiles conceptThe healing abutments, temporary abutments and finalabutments of the Straumann ® Bone Level implant systemwere designed to have an emergence profile which is thesame at all treatment steps when combining specific products.For each final standard abutment (excluding Meso,Straumann ® CARES ® and gold abutments) there is a correspondinghealing abutment. Accordingly, the final abutmentwill possess the same emergence profile that waspreviously created by the respective healing abutment. Thepictures show examples of matching healing abutmentsand final abutments.=In the Straumann ® portfolio there is a best fit combinationbetween one final abutment and one conical healing abutment.The examples are depicted showing a final abutmentwith the specific conical healing abutment which fits thebest. Tables on the following pages can be consulted inorder to find the healing abutment which is the best fitfor a specific final abutment. Key properties of the finalabutment are type (e.g. Multi-base abutment), abutmentdiameter (Ø) and gingival height (GH). Abutment height(AH), angle and material do not affect the choice of thehealing abutment. Once these parameters are known acorresponding healing abutment can be chosen.The tables on page 7–9 include only the best fit betweenthe conical healing abutment and the final abutment. Detailedinformation about the possible combinations of allStraumann ® healing abutments with the final abutments canbe found in the brochure “Basic information on the surgicalprocedures” (pages 60–65).6

Cement-retained solutionsPlatformNCTypeAnatomic abutmentCementable abutmentMaterialAngleØ (mm)GH (mm)Ti Ti IPS e.max ® IPS e.max ® Ti Ti0° 15° 0° 15° 0° 0°4.0 4.0 4.0 4.0 3.5 5.02.0 3.5 2.0 3.5 2.0 3.5 2.0 3.5 1.0 2.0 3.0 1.0 2.0 3.0GH (mm)Ø (mm)3.5 5.0 3.5 5.0 3.5 5.0 3.5 5.0 3.5 3.5 5.0 2.0 3.5 5.04.8 4.8 4.8 3.6 4.8TypeConical healing abutmentPlatformRCTypeAnatomic abutmentCementable abutmentMaterialAngleØ (mm)GH (mm)Ti Ti IPS e.max ® IPS e.max ® Ti Ti0° 15° 0° 15° 0° 0°6.5 6.5 6.5 6.5 5.0 6.52.0 3.5 2.0 3.5 2.0 3.5 2.0 3.5 1.0 2.0 3.0 1.0 2.0 3.0GH (mm)Ø (mm)4.0 6.0 4.0 6.0 4.0 6.0 4.0 6.0 2.0 4.0 6.0 2.0 4.0 6.06.0 6.0 6.0 6.0TypeConical healing abutment7

Screw-retained solutionsPlatformNCTypeAnatomic abutmentMulti-base abutmentMaterialAngleØ (mm)GH (mm)IPS e.max ® IPS e.max ® Ti Ti Ti0° 15° 0° 0° 25°4.0 4.0 3.5 4.5 4.02.0 3.5 2.0 3.5 1.0 2.5 4.0 1.0 2.5 4.0 2.5GH (mm)Ø (mm)3.5 5.0 3.5 5.0 2.0 3.5 5.0 2.0 3.5 5.0 3.54.8 3.6 4.8 4.8TypeConical healing abutmentPlatformRCTypeAnatomic abutmentMulti-base abutmentMaterialAngleØ (mm)GH (mm)IPS e.max ® IPS e.max ® Ti Ti Ti0° 15° 0° 0° 25°6.5 6.5 4.5 6.5 4.02.0 3.5 2.0 3.5 1.0 2.5 4.0 1.0 2.5 4.0 2.5GH (mm)Ø (mm)4.0 6.0 4.0 6.0 2.0 4.0 6.0 2.0 4.0 6.0 4.06.0 4.5 6.0 6.0TypeConical healing abutment8

HYBRID solutionsPlatformNCTypeMulti-base abutment Locator ®MaterialAngleØ (mm)GH (mm)Ti Ti Ti Ti alloy0° 0° 25° 0°3.5 4.5 4.0 3.81.0 2.5 4.0 2.0 2.0 3.5 2.5 2.0 3.0 4.0 5.0 6.0GH (mm)Ø (mm)2.0 3.5 5.0 2.0 3.5 5.0 3.5 2.0 3.5 5.03.6 4.8 4.8 3.6TypeConical healing abutmentPlatformRCTypeMulti-base abutment Locator ®MaterialAngleØ (mm)GH (mm)Ti Ti Ti Ti alloy0° 0° 25° 0°4.5 6.5 4.0 3.81.0 2.5 4.0 1.0 2.5 4.0 2.5 1.0 2.0 3.0 4.0 5.0 6.0GH (mm)Ø (mm)2.0 4.0 6.0 2.0 4.0 6.0 4.0 2.0 4.0 6.04.5 6.0 6.0 4.5TypeConical healing abutment9

Case example for soft tissue conditioningEvery patient is an individual case and may need tobe treated in a different way. Accordingly, the followingcase shows one treatment strategy and procedure andillustrates how soft tissue conditioning can be handledto reach an esthetic result. The process in the cases correspondsto the previously explained treatment flow (page1–2) and is always the result of the collaboration of differentparties.Prof. Dr. D. Buser, Dr. J. Wittneben, CDT T. Furter (f.l.t.r.)Case: Soft tissue conditioning with the dynamiccompression technique 2(Courtesy of Dr. Wittneben)The following treatment was performed at the Universityof Berne in Switzerland. Various parties were involvedin this patient’s case. The surgery was performed byProf. Dr. D. Buser, soft tissue conditioning and the prosthodontictreatment was accomplished by Dr. J. Wittnebenand the dental laboratory work was done by CDT T.Furter from ArtDent in Berne. Extensive com municationand continuous information exchange between thetreating parties were essential for the treatment. Thepatient was also involved and well-educated during thetreatment.tooth 117.62 mmCase analysis and treatment planningA 21-year-old, non-smoking female patient was referredto the Oral Surgery Department from a private practicebecause tooth 11 presented an acute fistula includingan external root resorption following trauma. The patientwas referred from the Oral Surgery Departmentto the Department of Fixed Prosthodontics, University ofBerne, to perform a combined surgical-prosthodontic treatmentapproach.Figure 1: Initial situation presenting external root resorptionin position 11; thin buccal plate is visible in cone beamCT diagnosticAt the initial examination, the patient’s chief complaint wasbad odor and pus emerging from the fistula – she wantedto have a final treatment of her anterior tooth. The extraoralexamination showed no pathological findings. The intraoralexamination revealed that her teeth were all naturaland non-restored except for tooth 11, which presented witha composite restoration with discoloration and wear. Inthe radiographic analysis the diagnosis of a well-definedlateral root resorption could be confirmed presenting in theCT as well as in the periapical radiograph.10

Therefore, tooth 11 was considered hopeless and implanttherapy was recommended as the neighboring teeth werenon-restored.Due to her young age and no previous experiences withdental treatments other than in area 11, the patient hadhigh esthetic expectations. At full smile, the patient presenteda high lip line, exposing all anterior maxillary teethand surrounding ginigiva.The gingival biotype was thin and highly scalloped withtriangular-shaped anterior teeth. These findings led to thefollowing SAC profile 1 : complex, because of the estheticrisk factors involved.Figure 2: The young patient has a high lip line, thin gingivabiotype, a highly scalloped gingiva and triangular-shapedanterior teethThe oral surgeon and prosthodontist discussed the casewith and without the patient. It was important to evaluatethe patient’s expectation before starting the treatment. Thepatient was also informed about the length of the treatmentand its implications. She agreed and was willing tocollaborate.The dental technician was also introduced to the patientand the final position of the implant was discussed withall clinicians on the basis of a wax-up. During the planningphase, the decision was made to resolve this casewith a screw-retained ceramic abutment. This decisionwas based on the anatomical situation (frontal tooth, highlip line) and the patient’s expectations regarding the estheticoutcome.11

Surgical treatment and healing phaseThe tooth extraction was performed carefully without theelevation of a flap in the Oral Surgery Department by Prof.Dr. Buser. Exactly 6 weeks later (early placement concept)a Straumann ® Bone Level SLActive Implant with a diameterof 4.1 mm (RC platform) was inserted by the same clinician,including Guided Bone Regeneration (GBR). The implantwas placed in a correct three-dimensional position and,when primary stability was achieved, GBR technique wasadded. The flap was closed for submucosal healing dueto simultaneous GBR procedure.Figure 3: X-ray showing idealimplant placement and the firstconical healing abutment(RC Ø 4.5 mm) placed for thehealing phase 1The patient received a simple flipper as an interim provisionaldenture during the time of healing. After 10 daysthe denture tooth had to be modified by adding material.After the reopening procedure, a conical healing abutment(Ø 4.5 mm) for the RC platform was inserted. Soft tissueconditioning starts with the first insertion of the healingabutment. After taking the impression for the provisional, alarger diameter (6 mm) was chosen to prepare the site forinsertion of the temporary abutment with the provisional.To improve the mucosa architecture surrounding the futureimplant crown, soft tissue conditioning with the “dynamiccompression technique” was performed.Figure 4: The narrow healing abutment has been replaced by awider healing abutment to widen the soft tissue12

Soft tissue conditioning with the “dynamic compressiontechnique”Using the early loading concept, a screw-retained implantsupportedprovisional (PEEK Temporary abutment) was insertedafter 6 weeks post placement. The shape of theprovisional crown was slightly overcontoured in order tocreate pressure, to form the mucosa, the emergence profileand to have an approximal contact present. As an temporarilyeffect, there was an ischemic reaction (white softtissue) for about 10 to 15 minutes, after this time, the softtissue returned to its pink color.Figure 5: A slightly overcontoured provisional crown has beenplaced. An ischemic reaction can be observed, which disappeared10 to 15 minutes after crown placementDuring the following 2 weeks, selective pressure was applied(pressure phase) to the provisional crown by addingextraorally light-cured acrylic material. After 2 weeks, theshape of the provisional was modified by removing acrylicmaterial in the interproximal/cervical area in order to createspace for the papillae (release phase). This approachis performed in several steps and can be done intraorallywith a fine diamond bur and then polished with an arkansasstone – without removing the provisional.Figure 6: After two weeks of pressure phase the release phaseis initiated by removing acrylic material intraorally13

Soft tissue conditioning is recommended for 3–5 monthsfor single edentulous gaps and for 6–8 months for adjacentimplants in the esthetic zone. In the present case,soft tissue conditioning was performed for 5 months. Thepatient is visiting the prosthodontist at a regular basis forthe removal of material.Figure 7: Period after provisional crown placement: 20 daysThe created final soft tissue architecture and emergenceprofile were transferred to the final master cast by the fabricationof an individualized impression coping.Figure 8: Period after provisional crown placement: 2.5 monthsFigure 9: Period after provisional crown placement: 5 months;finalized soft tissue architecture and end of provisional phaseTreatment closure and follow-upFor the final reconstructive design, a screw-retained singleimplant crown was chosen and an individualized zirconiumdioxide Straumann ® CARES ® customized abutmentwas fabricated.14Figure 10: Final restoration

The planned abutment was waxed up and scanned viathe Straumann ® CARES ® Visual software and a zirconiumdioxide abutment was delivered. Feldspathic ceramic washand-layered on top of the abutment. The final restorationwas inserted with 35 Ncm. The occlusion was adjusted.Figure 11: Radiograph of thefinal restorationThe follow-up after 1 year showed no changes in soft tissuearchitecture or in implant crown. This was also confirmedby a prospective clinical study on Bone Level implants withearly placement, contour augmentation and early loadingconcept in single edentulous space in the esthetic zone –there were no changes in the overall esthetics (pink andwhite esthetic parameters) over a follow-up time of 3 years. 2Figure 12: One year after insertion of the final restoration,a follow-up visit revealed stable soft tissue and crestal boneFigure 13: One year follow-up pictureWe are thankful to Dr. Julia-Gabriela Wittneben (Universityof Berne) for providing this case and all accompanyingfigures.15

References1 Dawson A, Chen S, Buser D, Cordaro L, Martin W, Belser U. The SAC Classificationin Implant Dentistry: Straightforward – Advanced – Complex.In Dawson A. and Chen S (eds):2009:Quintessence Publishing Group.2 Buser D, Wittneben J, Bornstein MM, Grütter L, Chappuis V, Belser UC. Stabilityof contour augmentation and esthetic outcomes of implant-supported singlecrowns in the esthetic zone: 3-year results of a prospective study with earlyimplant placement postextraction. J. Periodontol. 2011;82(3):342–9.16

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