Soft tissue contour management of implant-supported restorations

Edwin Ruales-Carrera
Dental soft tissue management

Table of Contents

Introduction

Implant-supported restorations have been the standard of care for the past 30 years. In the beginning, the success criteria were mainly related to the survival of restorations over time (Albrektsson et al. 1986). This definition, however, has evolved in such a way that health, function, and esthetics are also crucial to reach the desired result in implant dentistry (Fürhauser et al. 2005; Papaspyridakos et al. 2012).

After tooth extraction, a reduction in soft and hard tissue volume is expected (Araújo & Lindhe 2005). Therefore, different surgical approaches have been proposed to counteract the effect of this process and provide an appropriate clinical scenario to receive implant-supported restorations (Chappuis et al. 2017). Furthermore, the correct implant position is decisive in providing a final restoration capable of integrating naturally with the adjacent teeth (Buser et al. 2004). It is important to note that the diameter and the cylindrical shape of an implant or a prefabricated healing abutment will not coincide with the natural cervical contours of teeth (González-Martín et al. 2020). Therefore, management of the transgingival region is important to deliver a natural-looking final restoration (Su et al. 2010). When adequate soft tissue volume and the correct three-dimensional implant position have been achieved, contour management of this region using provisional restorations can be considered. Otherwise, additional surgeries may be necessary before applying this strategy.

When it comes to soft tissue management using provisional restorations, different approaches have been suggested to obtain adequate contours capable of integrating white and pink esthetics (Fig. 1). This review aims to highlight some relevant concepts and techniques related to this topic.

Dental soft tissue management: FIgs. 1A, 1B, 1C
Fig. 1a: A) Contour deficiency of the implant-supported restoration in the canine region. B) projection of the desired marginal contour. C) Satisfactory marginal contours after using the provisional restoration for soft tissue conditioning
Fig. 1b: Favorable integration of the implant-supported restoration with the adjacent teeth
Fig. 1b: Favorable integration of the implant-supported restoration with the adjacent teeth

The emergence profile

Located between the implant platform and the soft tissue cervical margin, the emergence profile is responsible for the transition from the cylindrical shape of the implant to the final contour of the crown (González-Martín et al. 2020). This region should respect the anatomical characteristics of the soft tissues as well as allowing the maintenance of hygiene. In this sense, and in order to help clinicians work within this transgingival region, the critical and subcritical contours have been proposed (Su et al. 2010). The critical contour, related to the cervical margin of the restoration, is responsible for the final shape of the tooth. While the subcritical contour, apically positioned, is responsible for the support of the soft tissues (Fig. 2). 

Fig. 2: Schematic representation of critical and subcritical contour regions
Fig. 2: Schematic representation of critical and subcritical contour regions

An adequate emergence profile should allow a smooth transition from the implant platform to the cervical margin. To achieve this goal, a correct three-dimensional implant position is essential, as well as sufficient tissue volume (Buser et al. 2004). For example, a too-shallow position of the implant would impair the possibility of working on the emergence profile, which could result in an over-contoured restoration (Fig. 3). On the other hand, a too-deep position of the implant would result in a large supracrestal tissue height (STH) (Avila‐Ortiz et al. 2020), which has been reported to exhibit a less favorable pattern of resolution of peri-implant mucositis (Chan et al. 2019).

Fig. 3: Improper three-dimensional implant positioning can result in over-contoured restorations, which can lead to difficult hygiene maintenance
Fig. 3: Improper three-dimensional implant positioning can result in over-contoured restorations, which can lead to difficult hygiene maintenance

Provisional restorations design

Two clinical situations must be differentiated when considering the design of provisional restorations. In the case of immediate implants, the goal is to maintain the gingival architecture. In the case of delayed implants, the challenge is to recreate the tooth contours that were lost (González-Martín et al. 2020).

In our experience, the following strategies may allow for adequate soft tissue contour conformation:

Immediate implants

In this clinical situation, it is interesting to support the soft tissue architecture at the critical contour level (Wang et al. 2020). For this, the marginal region of the provisional restoration should accompany the gingival soft tissue contours. On the other hand, a concave subcritical contour in the buccal region will provide space for a stable blood clot that will ultimately result in thicker soft tissues after healing. 
In addition to achieving this goal with a provisional restoration, the use of customized healing abutments has also been described as a favorable alternative for this purpose (Ruales‐Carrera et al. 2019).

Delayed implants

After osseointegration and soft tissue maturation, site development to recreate the desired tooth contours can be achieved through the use of customized healing abutments or provisional restorations. In this scenario, a concave or flat subcritical contour may be adequate, while the critical contour might be positioned at the zenith level of the desired tooth.

Fig. 4a:  The use of flowable composite resin represents a practical approach to achieving volume increases in provisional restorations
Fig. 4a:  The use of flowable composite resin represents a practical approach to achieving volume increases in provisional restorations
Fig. 4b: Strategic volume increases at the critical and subcritical contour areas will allow soft tissue displacement to recreate the desired emergence profile
Fig. 4b: Strategic volume increases at the critical and subcritical contour areas will allow soft tissue displacement to recreate the desired emergence profile

Soft tissue conditioning 

If the contours are not as expected after soft tissue healing, it is still possible to condition them to achieve the desired result (Wittneben et al. 2013). For this purpose, strategic modifications can be made to the volume of the provisional restorations with the help of flowable composite resin or acrylic resin (Fig.4). Consequently, after insertion of the provisional restoration, mucosal pressure and transient ischemia (up to 10 minutes) are to be expected. It is essential to control this reaction, as excessive pressure on the mucosa can lead to a lack of vascularization and thus to the induction of necrosis and tissue inflammation (Wittneben et al. 2013). Pauses of at least one week between each increment should be considered to maintain mucosal health. These gradual modifications can be performed until the desired contours and final emergence profile are obtained (Fig. 5).

Transfer of the emergence profile

Once the desired contours have been obtained, special care must be taken to transfer all these features to the master model. Conventional or digital impressions can be used for this purpose. However, the contours of the provisional restoration should be copied using individualized transfer abutments or digital scanning to avoid the influence of the collapse of the emergence profile achieved (Hinds 1997). This will allow the delivery of a final restoration with the same contours that were achieved with the provisional restoration and, therefore, stable esthetic results can be obtained.

Fig. 5: Before and after contour soft tissue management using a provisional restoration
Fig. 5: Before and after contour soft tissue management using a provisional restoration

Contour soft tissue management through the use of provisional restorations represents an appropriate approach to achieve natural contours and improve the esthetic outcome of implant-supported restorations. Healthy tissues with adequate volume and the correct three-dimensional implant position are essential to take advantage of the benefits of this strategy. In the absence of favorable conditions, further surgical procedures may be necessary prior to the application of these techniques. Attention to detail at each stage will provide greater control and predictability.

For further references, check out the following content pieces on the ITI Academy:

Authors

Edwin Ruales-Carrera
Edwin Ruales-Carrera
Edwin Ruales-Carrera, MSc, graduated from the Central University of Ecuador in 2013. In 2017, he completed an MSc program in implant dentistry at the Center for Education and Research on Dental Implants (CEPID), Federal University of Santa Catarina, Brazil, where he is currently a PhD student. In 2019 he was a visiting researcher at the University of Minho and the University of Porto, Portugal. He is currently an ITI Scholar at the Clinic for Reconstructive Dentistry of the University of Zurich, Switzerland.

Albrektsson T, Zarb G, Worthington P, Eriksson AR (1986). The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants 1(1): 11–25.

Araújo MG, & Lindhe J (2005). Dimensional ridge alterations following tooth extraction. An experimental study in the dog. Journal of Clinical Periodontology 32(2): 212–218.

Avila‐Ortiz G, Gonzalez‐Martin O, Couso‐Queiruga E, Wang H (2020). The peri‐implant phenotype. Journal of Periodontology.

Buser D, Martin W, Belser UC (2004). Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. International Journal of Oral & Maxillofacial Implants 19(7).

Chan D, Pelekos G, Ho D, Cortellini P, Tonetti MS (2019). The depth of the implant mucosal tunnel modifies the development and resolution of experimental peri‐implant mucositis: A case–control study. Journal of Clinical Periodontology 46(2): 248–255.

Chappuis V, Araújo MG, Buser D (2017). Clinical relevance of dimensional bone and soft tissue alterations post-extraction in esthetic sites. Periodontology 2000 73(1): 73–83. https://doi.org/10.1111/prd.12167

Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G (2005). Evaluation of soft tissue around single‐tooth implant crowns: the pink esthetic score. Clinical Oral Implants Research 16(6): 639–644.

González-Martín O, Lee E, Weisgold A, Veltri M, Su H (2020). Contour Management of Implant Restorations for Optimal Emergence Profiles: Guidelines for Immediate and Delayed Provisional Restorations. International Journal of Periodontics & Restorative Dentistry 40(1).

Hinds KF (1997). Custom impression coping for an exact registration of the healed tissue in the esthetic implant restoration. International Journal of Periodontics & Restorative Dentistry 17(6).

Papaspyridakos P, Chen CJ, Singh M, Weber HP, Gallucci GO (2012). Success criteria in implant dentistry: A systematic review. Journal of Dental Research 91(3): 242–248. https://doi.org/10.1177/0022034511431252

Ruales‐Carrera E, Pauletto P, Apaza‐Bedoya K, Volpato CAM, Özcan M, Benfatti CAM (2019). Peri‐implant tissue management after immediate implant placement using a customized healing abutment. Journal of Esthetic and Restorative Dentistry 31(6): 533–541.

Su H, González-Martín O, Weisgold A, Lee E (2010). Considerations of implant abutment and crown contour: critical contour and subcritical contour. International Journal of Periodontics & Restorative Dentistry 30(4).

Wang I, Chan H, Kinney J, Wang H (2020). Volumetric facial contour changes of immediately placed implants with and without immediate provisionalization. Journal of Periodontology 91(7): 906–916.

Wittneben JG, Buser D, Belser UC, Brägger U (2013). Peri-implant soft tissue conditioning with provisional restorations in the esthetic zone: the dynamic compression technique. Int J Periodontics Restorative Dent 33(4): 447–455.

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