In the esthetic zone (whatever shows when the patient smiles) it is important to develop an emergence profile for your implant restoration. Is it essential? No. You can certainly insert a prepared stock abutment with a cylindrical emergence profile and cement the permanent crown on top. The patient may still be pleased with the result. But more esthetically demanding patients will greatly benefit from slowly developing a more anatomical emergence profile with a customized temporary abutment followed by a customized final abutment.
Maximum cosmetic potential is often earned and rarely the result of dumb luck. It requires patience on the part of the restoring dentist and the patient. It can easily add a couple of months to the overall treatment. It incurs additional fees for temporary abutments and chair time.
Why not just have the lab create an anatomical, customized final abutment and then insert it without going to the trouble of a customized temporary abutment? There are a few problems with that. The cross section of a tooth between the osseous crest (where the implant platform should be) and the free gingival margin (where the abutment should terminate and the crown begins) is not the shape of a cylinder. Not even close. Find your Dental Anatomy textbook. Good. Now blow the layers of dust off of it. Excellent. Look up the cross sections of teeth and you’ll find something like this:
From G.V. Black's "Dental Anatomy" 1897
Do you know any implants or a standard healing abutments that look like that? Me neither. So a customized abutment attempts to reclaim the real estate once owned by the tooth between the osseous crest and the free gingival margin. And that real estate is not a cylinder. Expanding the soft tissue back to its original shape around that real estate takes time. If you were to insert a customized abutment into a cylindrical soft tissue profile, the patient would likely be in significant discomfort. You may not even be able to get it all the way down. Even if you do, you probably have blanched the tissue so severely that necrosis may follow. And let’s say you do get the abutment fully seated and the patient is not in agony… how do you know that the soft tissue will stay put and not recede?
So to realize maximum cosmetic potential, use a temporary customized abutment in the esthetic zone. And charge the patient for your time and materials; do not give this away. Help them understand that this process will take additional time but it will be worth it in the end.
Let’s get down to materials. Traditionally the temporary abutment is titanium-based. Some companies are now making temporary abutments out of PEEK (Poly-ether-ethyl-ketone), which I love. I find that acrylic, bis-acrylic, and composite hold very well to PEEK.
Which leads me to the chairside materials. Acrylic has been the gold standard for years, but the power and liquid, salt and pepper technique is labor intensive. Also, many patients hate the smell of the monomer. I prefer to use bis-acrylic to make the bulk of the temporary and then I use flowable composite to modify and repair. Oh, and in my experience, I’ve never had success trying to use flowable composite to modify and repair regular acrylic. Stick with bis-acrylic for the bulk material.
Now comes the fun. First, get yourself pre-operative model (before the tooth was extracted) or wax in a fake tooth to the model with the tooth missing. Next, duplicate that model and make a vaccu-form stent of it. No need to trim it like a bleaching tray; we just need it for a matrix.
Vaccu-form from a pre-operative model.
Matrix to replace tooth # 8.
Now insert the temporary abutment and cut a hole in the stent so that it can completely seat intra-orally.
Access hole in matrix with temporary abutment underneath.
Place the driver in the access hole to maintain patency and squirt your bis-acrylic inside.
Filling up the matrix with bis-acrylic.
You’re almost home free. Can you feel it? Okay, now when the bis-acrylic is done setting, remove it from the stent and trim. Use flowable composite of a similar shade to repair any defects. Why flowable? Because bis-acrylic is expensive and those darn mixing tips aren’t cheap either. Flowable bonds nicely to bis-acrylic. Sweet.
Ready to be trimmed.
Now add some flowable composite to the subgingival area and develop your emergence profile. Cure it and seat it intraorally. Add and subtract material. Let your inner Michelangelo run loose. Oh boy, this is looking good.
Send the patient home for a couple of weeks. It takes that long for the gingiva to expand and adapt to the contours of your emergence profile. When you bring the patient back, evaluate the soft tissue contours relative to the contralateral tooth. Continue to modify as needed. You can always call your friendly neighborhood periodontist or oral surgeon to evaluate the need for soft tissue grafting if you really hate what you see. Typically I am satisfied with the results in two or three visits.
Don’t expect your papilla to be fully developed in two months time. It can take many, many months for the papilla to drop into full maturity. I will address papilla in another post, because that’s a whole big deal. Just know for now that there are predictable values for the lengths of papilla you can expect depending upon the adjacent structures.
Sorry this post was so long, but there was a lot of ground to cover for this topic. In a future post I’ll talk about how I copy the contours of my temporary customized abutment to the final customized abutment.