I wanted to create a follow up post for the series of articles I created last spring that discussed techniques to treat a hopeless central incisor. If you recall I left the series with the dental implant placed using a flapless technique with a Surgiguide created from the Simplant treatment plan. I created an immediate implant provisional crown but I left the facial emergence profile really flat during the initial healing so I would not stretch the tissue too much post surgically.
The post surgery results were very good and the interdental papilla level was excellent but its shape and the free gingival margin were located too far incisally. This gingival asymmetry leads to a result that makes the implant provisional crown look too short compared to the adjacent natural central incisor.
There are two techniques that will correct this problem.
1. Adjust the gingival tissue surgically.
2. Adjust the provisional crown contours.
I thought about which option would work better for my patient and because the initial provisional crown was slightly under-contoured I decided the best option was number 2.
Adjusting the subgingival contours of an anterior implant provisional will have a dramatic effect on the free gingival margin. If the free gingival margin is slightly too far apically you can try to flatten the emergence profile to encourage the gingival tissue to migrate incisally. If the free gingival margin is too far incisally, such as this case, you can add to the provisional contour to encourage the gingival tissue to migrate apically.
The technique that I use in my practice is to mark the free gingival margin right on the provisional in the mouth with a pencil. I then unscrew the provisional crown and add flowable composite resin to the portion of the provisional below the pencil line. You want a screw retained provisional for a case like this because the tissue will resist seating the over-contoured provisional.
Once you are satisfied with the contour of the provisional you will screw it back into place and assess the results. If you have added enough flowable composite to change the gingival tissue levels you will see a fair amount of blanching of the tissue. I will leave this in place for about 5 to 10 minutes and then reassess the tissue colour and position.
If the free gingival margin is still too far incisal I will remove the provisional and add more flowable composite subgingivally and then try it in again.
If the free gingival margin is too far apically, I have added too much flowable composite so I will remove the provisional and remove some of the composite. I will then try the provisional into place and reassess the tissue levels.
As you can imagine all of this takes a little trial and error and time. This is the reason my fees for anterior dental implants are so much more than for molars. I feel that I need to spend this time to make sure that the tissue levels are ideal BEFORE the final custom porcelain restoration is created.
Once you are satisfied with the final gingival tissue levels you need to assess the tissue colour. If the tissue is still blanched I will continue to wait until the colour returns to normal which can take up to 30 minutes. I prefer not to dismiss the patient if the tissue is blanching because you may have stretched the tissues to far and run the risk of creating a pressure necrosis.
I would also recommend that you take a radiograph of your provisional in place and make sure that it is not too close to the bone.
In the next post I will share with you some of the techniques that I use to communicate the exact provisional and tissue contours to my ceramist. As always feel free to add any questions or comments using the link above this post.