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Soft Tissue Management around Implant in the Esthetic Zone: A Case Report

Rawan Al-Rethia*, Abdulaziz Al-Dayel

Department of Prosthodontics, Dental College at ArRass, Qassim University, Qassim, KSA

Abstract: One of the challenges in restoring anterior space with implant restoration is maintaining the natural looking of peri-implant area. A 48 years old Saudi female came to the prosthodontic clinic complaining from unaesthetic appearance of her upper anterior teeth. After clinical examination, the patient was diagnosed with advanced periodontitis in teeth #12,11,21,22. After discussion with the periodontist, the decision was to extract these teeth and immediately place implants in the sockets of teeth #11 and #22 followed by immediate loading. Implant surgery was performed but primary stability was not gained. The treatment changed to fabricating custom healing abutments to preserve the soft tissue and the use of transitional denture as a temporary restoration. After 3 months, the soft tissue management using provisional restoration with dynamic compression technique and gingivoplasty was done. Then, the use of an indirect-direct technique for transferring and replicating the cervical contours of provisional restorations to a modified impression coping, which is then used to make an impression of both soft tissue contours and implant positions in the dental arch to fabricate the final prosthesis. This method helps to control gingival contour around implant prosthesis to create an emergence profile. It is relatively easy, precise and predictable method for accurate duplication of soft tissue profile. The technique presented differs from other techniques in that it reduces gingival trauma by eliminating the intra-oral use of resin monomer that avoid chemical or thermal insult to the tissues. It also minimizes surgical procedure by remodeling the soft tissue during the healing process to create the proper contour needed. In addition to that, the important advantage is avoiding the possibility of soft tissue collapsing that may occur during the impression procedure, which gives accurate of the peri-implant soft tissue contours. This case report describes the dynamic compression technique with provisional restorations in the esthetic zone and an alternative impression procedure that accurately captures the emergence profile and soft tissue contours around implants after a provisional restoration has been placed.

Keywords: esthetic zone, Implant, Soft tissue management

Received November 19, 2020; Revised December 23, 2020; Accepted January 06, 2021

Citation: Rawan Al-Rethia, Abdulaziz Al-Dayel, Soft Tissue Management around Implant in the Esthetic Zone: A Case Report. International Journal of Dental Sciences and Research, 9 (1). 6-10. January 2021. doi:10.12691/ijdsr-9-1-2

1. Introduction

Achieving an optimal esthetic outcome with implant-supported crowns in the esthetic zone remains one of the greatest challenges in implant dentistry. The creation of an appealing implant restoration in the esthetic zone is based on detailed treatment planning and consideration of possible risk factors [1]. Even after a successful and meticulous surgical protocol, the prosthodontics finalization remains challenging. The esthetic outcome depends on surgical and prosthetic aspects. Prosthetic aspects include the quality of the restoration itself and the creation of surrounding peri-implant soft tissues that harmonize with the adjacent dentition [2].

2. Case Presentation

A 48 years old Saudi female came to the prosthodontic clinic complaining from unaesthetic appearance of her upper anterior teeth (Figure 1).

Figure 1.

After clinical examination, the patient was diagnosed with advanced periodontitis in teeth #12,11,21,22 (Figure 2).

Figure 2.

After discussion with the periodontist, the decision was to extract these teeth and immediately place implants in the sockets of teeth #11 and #22 followed by immediate loading (Figure 3, Figure 4).

Figure 3.

Figure 4.

3. Treatment Details

Implant surgery was performed but primary stability was not gained. The treatment changed to fabricating custom healing abutments (Figure 5, Figure 6) to preserve the soft tissue and the use of transitional denture as a temporary restoration (Figure 7, Figure 8).

Figure 5.

Figure 6.

Figure 7.

Figure 8.

After 3 months, soft tissue management with simplified method was performed. The healing abutment was removed and an impression of the resultant tissue contour was made.

On the resultant stone cast, the inner gingival sulcus was reshaped by a rotary instrument to approach the final desired crowns contour. Then, fabrication of an interim crowns was done (Figure 9).

Figure 9.

During temporary crowns insertion, we used high speed handpiece with an oval shaped bur to remove circum-implant soft tissue (Figure 10).

Figure 10.

During that time, selective pressure was applied by adding volume using flowable composite resin onto the inter proximal and external gingival contours (Figure 11- Figure 13). This process will naturally stretch the gingival tissues, and it was done in increments over a period of time.

Figure 11.

Figure 12.

Figure 13.

After achieving good soft tissue profile (Figure 14), the following technique have been used to transfer the created soft tissue profile to the final master cast: by using an individualized impression coping that has the same tissue profile as the clinically approved provisional (Figure 15 -Figure 18).

Figure 14.

Figure 15.

Figure 16.

Figure 17.

Figure 18.

The definitive restorations were fabricated and inserted (Figure 19 - Figure 22).

Figure 19.

Figure 20.

Figure 21.

Figure 22.

4. Discussion

This case report describes a clinical method that helps to control gingival contour around implant crown to create an emergence profile for the crown. Provisional restoration for implant-supported restoration can help in predicting and achieving the esthetic result. One of the important advantages of provisional restorations is modeling of soft tissue during the healing process [3]. Several techniques have been proposed to restore gingival contour and create emergence profile for an esthetic restoration during provisional restoration. Neale and Chee, Chee and Donovan advised performing gingivoplasty procedures to recontour the tissues before making provisional [4,5]. Hinds [6] described the fabrication of a custom impression coping for the replication of the healed tissue around the implant. Bain and Weisgold [7] and Ormianer et al [8] recorded the soft tissue contour by inserting autopolymerizing acrylic resin directly into the sulcus during impression making. However, use of acrylic resin monomer intraorally may cause thermal and chemical irritation of the soft tissue. Attard and Barzilay [9] presented a technique using a provisional restoration-level impression to register the soft tissue configuration and shape, as well as the implant position.

In this case, we used a relatively easy, precise and predictable method for accurate duplication of soft tissue profile. The technique presented differs from other techniques in that it reduces gingival trauma by eliminating the intra-oral use of resin monomer that avoid chemical or thermal insult to the tissues. It also minimizes surgical procedure by remodeling the soft tissue during the healing process to create the proper contour needed. In addition to that, the important advantage is avoiding the possibility of soft tissue collapsing that may occur during the impression procedure, which gives accurate of the peri-implant soft tissue contours.

5. Conclusion

This case report describes the dynamic compression technique with provisional restorations in the esthetic zone and an alternative impression procedure that accurately captures the emergence profile and soft tissue contours around implants after a provisional restoration has been placed. The definitive restoration is shaped exactly like the provisional, and excellent esthetics results can be achieved.

Acknowledgement

We would like to express our special thanks to our training center King Saud Bin Abdulaziz University for health science (KSAU) as well as our program director Dr. Nadia Alangari who gave us the golden opportunity to do this wonderful case during our residency. Secondly, we would also like to thank our Periodontist Dr. Sa’ad Alazmi who did the main surgery of our case and helped us a lot with the final result.

Lastly, we wish to show our appreciation to our skillful dental lab technicians Mr. Ahmed Alrayes and Mr. Majed ben Jahlan for their great work.

References

[1]   | Chen ST, Buser D. Clinical and esthetic outcomes of implants placed in postex- traction sites. Int J Oral Maxillofac Im- plants 2009; 24(suppl): 186-217.
[2]   | Wittneben JG, Buser D, Belser UC, Brägger U. Peri-implant soft tissue conditioning with provisional restorations in the esthetic zone: the dynamic compression technique. Int J Periodontics Restorative Dent. 2013 Jul-Aug; 33(4): 447-55.
[3]   | Ganddini MR, Tallents RH, Ercoli C, Ganddini R. Technique for fabricating a cement-retained single-unit implant-supported provisional restoration in the esthetic zone. J Prosthet Dent. 2005; 94: 296-8.
[4]   | Neale D, Chee WW. Development of implant soft tissue emergence profile: A technique. J Prosthet Dent. 1994; 71: 364-8.
[5]   | Chee WW, Donovan T. Use of provisional restorations to enhance soft-tissue contours for implant restorations. Compend Contin Educ Dent. 1998; 19: 481-6. 8.
[6]   | Hinds KF. Custom impression coping for an exact registration of the healed tissue in the esthetic implant restoration. Int J Periodontics Restorative Dent. 1997; 17: 584-91.
[7]   | Bain CA, Weisgold AS. Customized emergence profile in the implant crown - a new technique. Compend Contin Educ Dent. 1997; 18: 41-5.
[8]   | Ormianer Z, Laufer BZ, Nissan J, Gross M. An investigation of heat transfer to the implant-bone interface related to exothermic heat generation during setting of autopolymerizing acrylic resins applied directly to an implant abutment. Int J Oral Maxillofac Implants. 2000; 15: 837-42.
[9]   | Attard N, Barzilay I. A modified impression technique for accurate registration of peri-implant soft tissues. J Can Dent Assoc. 2003; 69: 80-3.