Esthetic Compromises in the anterior around implants are unfortunately more common than we would all like. Many of these issues can be avoided with proper treatment planning and the incorporation of ancillary procedures that set the anatomy up for a more favorable outcome. When this doesn’t happen and you get an unintended negative consequence, trying to correct the situation is often more difficult than the original treatment plan. This is the exact situation I was presented with recently.
As I complete the series on soft tissue esthetics around anterior implants we have worked our way back to assessing the existing architecture and planning for success. John Kois has simplified the risk assessment process when a natural tooth will be extracted prior to implant placement using five diagnostic keys, and I find the thought process invaluable when I plan.
- Tooth Position/Existing Free Gingival Margin: Low risk patients have am existing free gingival margin that is more coronal than the final position, and lingually placed teeth. High risk patients have an existing free gingival margin that is apical to where we are proposing for
One of the most challenging pieces of anterior implant esthetics is anticipating and controlling the tissue response. In the early days of implant dentistry we were cautious of loading implants due to osseous healing and response. Our plan was to place the fixture with a healing cap and wait for 3 or more months for healing prior to placing a temporary or final abutment and restoration. As our understanding of the process improved over time we began to feel more and more comfortable placing an abutment and temporary restoration the same day the fixture was placed. The decision to immediately load is most often based on bone quantity and quality, present condition around existing teeth ( or not), and our desire to give the patient an immediate esthetic outcome they are pleased with.
Another piece of learning for me out of this week’s symposium was about the design of implant abutments in the esthetic zone. A common challenge with implant restorations is that the interface between the abutment and the crown is placed further apically then it should be. Our thinking behind this is to utilize the emergence profile of the crown to help develop and hold tissue form. The final pink esthetics are founded on the surgical outcome and developed and maintained by the abutment design. The tooth esthetics is controlled by the crown.
After all of the time and effort that goes into developing the gingival tissues around an implant provisional, the challenge is how to capture that information for the laboratory technician. In an instant once the provisional has been unscrewed, and the pressure on the tissue relieved the tissue begins to deform. I have tried multiple techniques to capture an accurate soft tissue impression, and despite working quickly the technician always has to alter the gingival mask due to distortion. The only accurate way to capture the soft tissue contours is to duplicate the shape and dimension of the provisional where it was in contact with the gingiva.
I sometimes feel like I am playing that old game “Beat The Clock” when I am taking off anterior implant provisionals. This rushed sensation comes from an understanding of the role the provisional plays in creating and maintaining the shape of the soft tissue. I should take a step back, and explain that in the anterior I use the shape of the provisional over a period of weeks to months to sculpt the final position of the gingival margin on the facial and the interproximal papilla, within the limits created by the position of the fixture, bone and tissue.This process. much like that of creating an ovate pontic site, is delicate. Once the tissue is mature I want to be able to transfer the soft tissue position accurately to the laboratory so they can fabricate an exquisite restoration.