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.
Recent research has looked at the response from both soft tissue and bone when we place an immediate provisional. The findings show that the presence of resin, gold or traditional porcelain against the junctional epithelium can have a dramatic impact on tissue and bone response. This tissue response can lead to alterations of the free gingival position by 1mm or more. This change can have a dramatic esthetic impact. With this new information the conversation of moving away from immediate provisionals on implants has reopened. The movement back to placing a healing cap and using a resin bonded bridge or removable prosthesis as a provisional is increasing in our attempt to maximize the pink esthetics around anterior implants.
In cases where the pre-op conditions are set up for predictable tissue response and esthetic outcomes immediate temporization is still a viable technique. In the cases where the presenting condition is higher risk for an optimal esthetic outcome, being more cautious and using an alternative to immediate provisionalization may be the better path. We will look at evaluating high versus low risk presentation for immediate placement and load in tomorrow’s post.
Once the bone healing occurs, a fixture level impression is taken and a titanium or zirconia custom abutment is placed. Both of these materials have been shown to be tissue friendly against the junctional epithelium. At this point a final or temporary crown can be placed. One thing to consider is having a fixture level impression taken at the time or surgical placement when fixture stability is present. This impression with bone sounding and planning can allow a custom abutment and provisional to be made and placed quickly.
Another key is to limit the number of times we move implant parts on and off to minimize the tissue trauma. Additionally the parts should be cleaned prior to being placed back on the fixture. Contamination of healing caps and abutments can contribute to negative tissue response.