When I left last weeks post I had just spent a significant amount of time to create and perfect the provisional crown contours that would produce the soft tissue outline form for my final implant restoration. The question now becomes how would I transfer that information to the dental ceramist?

You have two options if you are going to take a final implant impression.

1.    You can use a stock open or closed tray impression transfer.
2.    You can create a custom impression transfer.

Some of you may be thinking why would you bother spending the time to create a custom transfer? I will answer that I feel when you have spent time and effort to create a specific soft tissue form that the extra time you spend to create a custom transfer is worth the effort.

You may think that a standard transfer will capture the tissue contours well enough but I would argue that when you remove your provisional the soft tissue will not be supported and will collapse slightly. This may not be an issue with a molar but with a central incisor I think it is a huge concern.

So, for arguments sake lets assume that you want to make a custom impression transfer for anterior cases and you will use a standard transfer for molars and decide on the need with bicuspids depending on the case. Let me share with you a fairly simple way to create a custom transfer.

The first thing you need is an impression analog and for a number of years I would just hold them in a hemostat but for the past six months I have them mounted in a plaster cup and ready to use for cases.

I remove the provisional from the patient’s mouth and screw it onto the analog that is mounted in the plaster. I then inject Mach 2 Die Silicone around the cervical half of the provisional and let it set.

The next step is to remove the provisional from the analog and if you look at the result you have an exact replica of the soft tissue form created by the provisional in the Mach 2 Die Silicone.

I will then screw the appropriate impression transfer onto the analog. In this case a Straumann RC bone level implant was used with the Straumann closed tray RC impression transfer. The final step is to fill in the space between the transfer and the silicone with flowable composite resin and light cure.
When you remove the impression transfer from the analog you have a customized surface created by the flowable composite that is an exact copy of your provisional contours.

I hope this post helps to clear up how I create this transfer with a technique that is simple and easy to use in your dental practice. As always thanks for reading and feel free to add any comments or questions using the link above.

Best regards,

Dr. Stephen Phelan

Completed soft tissue outline form.

Completed soft tissue outline form.

Standard impression transfer in place with the soft tissue starting to collapse.

Provisional seated on stone mounted analog.

Injecting the Mach 2 Die Silicone.

Provisional with the die silicone setting around it.

Completed soft tissue outline form replicated in the silicone.

Completed soft tissue outline form replicated in the silicone.

Creating the custom transfer with flowable composite.

Completed custom transfer being removed from the silicone mould.

Comparison of the custom provisional and custom impression transfer.

Custom impression transfer in place.

Custom impression transfer in place.

Final Permadyne impression.

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.

Tissue levels prior to alteration.

First addition with flowable composite.

Tissue result with first addition. The level needs to be raised apically.

Second increment of flowable composite is added to the provisional.

Tissue result from this addition. The free gingival margin is better but the papilla contour needs more development.

Final addition of composite to the mesial papilla area.
Final addition of composite to the mesial papilla area.

Final addition of composite to the mesial papilla area.

Final tissue contour is better but slight tissue blanching remains.

Ten minutes later the tissue blanching is resolved.

Final Result 2 weeks later.

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I was very careful with measurements made clinically from the existing gingival margin and the new planned gingival margin as well as checking with radiographs.  Using a computer-generated guide is another option for these cases, but will still require good clinical judgement.

The implant was positioned with the platform 3 mm from the future gingival margin to accommodate a favorable emergence profile. It is important to note that the interproximal bone must be modified to create space for the future restoration; otherwise, it may be a challenge to seat the restorative abutment and there is possible risk of developing bone necrosis due to excessive interproximal pressure. (See radiographs)

Interproximal Bone Adjusted At Time Of Surgery To Provide Room For Future Restoration

Provisional And Final Restoration

The gingival recession on the adjacent central incisor #8 (FDI #11), was improved by a semi-lunar coronally advanced flap.

After the implant has osseointegrated, it is time to shape the abundant soft tissue from that of a circular healing abutment to that of a triangular tooth form.  The provisional restoration is fabricated with a sub-gingival profile that will create tissue support and an ideally positioned height of contour to move the gingival margin to the desired level.

After a couple of months, the tissue form created by the provisional restoration can be duplicated by using a custom impression coping during the impression procedures.  The final crown should follow these sub-gingival contours to maintain this soft tissue form.

The restorative phase was completed with a custom cast gold abutment and a cemented PFM crown.  The crown form was slightly flatter at the mesial line angle than the provisional restoration and we can see the change in the soft tissue form.  Overall, the treatment sequence insured a predictable outcome for this patient.

Coronally advance flap #8(FDI #11) and flapless implant placement #9 (FDI #21)

Implant Placed According To Future Gingival Margin

Provisional Restoration

Provisional Restoration

Provisional Restoration At Placement

Provisional Restoration After Tissue Shaping

Final Restoration

Unfortunately, we can not always provide this form of treatment to all patients.  When should we separate treatment into phases?

I had mentioned that we must take into consideration the shape and dimensions of the labial bone, the existing soft tissue profile and the amount of apical bone.

Immediate post-extraction implant placement requires ideal bone volume. The immediate implant is anchored into the apico-palatal bone.  If the bone is this area is compromised, then implant stability may not be achievable.  In addition, the bone on the facial supports the soft tissue profile.  Thin bone or large dehiscences are a risk for future gingival recession. A patient with inadequate facial alveolar bone should not receive an immediate implant.

This next patient I will present also had a non-restorable failing maxillary central incisor. As a teenager, this tooth was traumatized during a sports injury.  It was endodontically treated and crowned.  Ten years later, this tooth required apical endodontic surgery. The patient is now 40 years old, and presents with a fistula at the apex of the central incisor. The patient consulted with members of our team, including an endodontist.  After reviewing his options, he requested to have this tooth replaced with a dental implant.

From the clinical exam, we can determine that the soft tissue profile for this failing tooth is more coronal than the adjacent central incisor, which has slight gingival recession.
We have a very favorable soft tissue position prior to surgery, so soft tissue augmentation may not be necessary.

Further clinical evaluation we note a fistula at the apex of #9(FDI #21).  On the radiographs, we determine that there is a peri-radicular lucency that extends to the floor of the nose.  Since this is the area that I depend on for implant stability, it is unlikely that I can predictably place the implant at the time of extraction.

So how should we manage this site?  How do we extract, debride and graft the alveolar ridge?

My approach follows a sequence of steps, intended to both correct and maintain the alveolar dimensions.

After extraction, I observed that the crestal bone on the facial aspect of the socket was intact and at a favorable level.  However, the lesion had resorbed the overlying bone in the apical zone.

So to gain good access to the lesion, I made a C-shape incision around the apical fistula.  In addition, this allowed access for placement of the bone graft and membrane.  By avoiding flap reflection in the crestal half of the ridge, I was able to maintain the blood supply to the alveolar facial bone.  The ridge was grafted with allograft bone and the socket closed with an epitheliazed graft.

In the next blog, we will discuss implant placement and restoration.

Note Large Apical Lucency

Interproximal Bone Adjusted At Time Of Surgery To Provide Room For Future Restoration

Provisional And Final Restoration

Initial Presentation

Occlusal View Of Socket

Apical Lesion Debrided

Alveolar Grafting Completed

Alveolar Ridge Graft Healed

If an implant is to be placed, should we perform the procedure as an immediate extraction socket placement or should we delay the implant placement?

The implant was placed immediately at the time of the extraction for this patient.  In the next blog posting, we will look at how I managed the soft tissue form.

Full Smile View

Retracted View

Crown Fracture Resulting In Inadequate Tooth Structure For Predictable Restoration

Dental Implant Placed With Platform 3 mm Below The Free Gingival Margin

Dental Implant Placed Towards Palatal Aspect Of Socket With Bone Augmentation In Residual Socket

Radiographic Evidence Of Large Pulpal Chamber And Extent Of Fracture Line. There Is Abscence Of Any Peri-Radicular Lesion.

Now that the implant is placed, we have several options to consider for interim tooth replacement and/or soft tissue management.

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I wanted to start off by thanking all of you for the excellent ideas and comments related to my last post. Many of you had excellent thoughts about how this wear evolved over the years and how you would help this patient. Today I would like to share with you the etiology of the wear and the actual treatment plan that the patient selected.

As I stated in the last post this particular patient came into my practice with a significant amount of tooth wear but he had no TMJ or muscle symptoms and has good bone levels around his teeth.

There are a number of correct answers to the question I asked about the etiology of wear for a patient like this and if you look in the comments section of the first post you will see many great ideas from the people that participated.

Examination of the tooth wear revealed that the wear facets were present on tooth surfaces that were not in occlusal contact. Attrition requires the wear to be derived from tooth to tooth contact so this wear appears to be predominantly from erosion.

This patient was aware that he had significant wear and when questioned about the etiology he let us know that he consumed one 1.5 liter bottle of Coca-Cola per day for the last 20 years. With a pH of 2.48 Coca-Cola consumption of this magnitude and duration would certainly lead to this amount of erosion and tooth loss.

During the functional analysis large centric relation interference was discovered on the palatal cusp of 17 and the buccal cusp of 47. This interference was also located and verified with the 2 sets of the CR mounted study models that were made with the 2 CR bite records. I take 2 sets of CR bite records and make 2 mountings to verify the accuracy of the bite records and the mountings. I am looking for the 2 sets of bite records and the 2 sets of mountings to be the same.

I then verify that the point of initial contact on the mountings matches what I found in the mouth. If all of this is consistent then I feel that the CR bite records and the mountings are accurate and can be used for the diagnostic wax-up.

As you can see with the photograph of the 2 sets of mountings they match each other and the point of initial contact that I found during the functional analysis.

For this case the patient recognized that he needed significant restorative dentistry to be restored to a more healthy functional and aesthetic condition. He did ask if I could figure out a treatment plan that would fit within a reasonable budget and avoid a full mouth rehabilitation. With this in mind I treatment planned to open the vertical dimension to the point of initial contact and restore the upper arch from first molar to first molar and the first bicuspids and first molars on the lower arch. This treatment plan would lead to a 16 unit partial rehabilitation and I planned to use direct composite bonding to restore any erosion that is present in the remaining dentition.

I also planned to alter the gingival levels of 11 (8) and 21 (9) to improve the gingival symmetry as well as the retention and resistance form.

If you place the study models from this case on the Sam 3 articulator and close to the point of initial contact you can see the vertical dimension that the case will be waxed up to. This technique will open the vertical dimension in most cases more than enough for the restorative material requirements without increasing the contracted length of the elevator muscles.

For this patient with his MI position he had no room for the restorative material due to extensive erosion and tooth eruption that has led to an end-to-end anterior tooth relationship. If you tried to restore him to his MI position you would compromise the structural integrity of the upper anterior teeth.  This can be solved with either orthodontics or opening his vertical dimension.

I have completed the crown lengthening with my Waterlase MD dental laser and the case is now being waxed up with the initial preparations scheduled in 3 weeks. I hope these posts have provided you with some interesting ideas about treating this type of case. As usual you can add any questions or comments using the link above.

Anterior Teeth Before Gingival Adjustment

Anterior Teeth After Gingival Adjustment With The Waterlase MD Laser

2 Sets Of Mounted Models

Models At The Point Of Initial Contact

Models At The Point Of Initial Contact

Models At The Point Of Initial Contact

Models At The Point Of Initial Contact

Panorex