So a patient comes into my office complaining about her implant restoration # 19. No, the implant isn’t failing, the gingiva are basically healthy, and the crown looks decent. The problem is that she traps food around it CONSTANTLY. It annoys the crap out of her. Here’s the radiograph:
The implant was placed slightly to the distal of the edentulous space, which is not uncommon in immediate placement molar cases. If the implant is placed at the same time as the tooth extraction then there is a tendancy to place it into the socket of the distal root. Unfortunately this leaves an uneven area of gingiva underneath your new implant restoration. It’s not quite as bad as this situation I wrote about, but it’s a similar problem.
The three types of implant restoration complications are functional, esthetic, and hygienic.
Function: Keep occlusal contact off the mesial marginal ridge here. In this situation the mesial marginal ridge is the location of a long horizontal cantilever. If there are occlusal forces there then you’ll find more abutment screw loosening, decementation, bone loss, etc. Fortunately there are no dots on the mesial margial ridge after checking with bite paper.
Esthetics: Not a factor here, the crown looks normal clinically.
Hygiene: Yup, that’s our problem. Even with a closed mesial contact, we have an undercontoured restoration that allows the patient to store food like a chipmunk.
What the restoring dentist could have done was develop the emergence profile with a temporary abutment and crown. Over the course of a month or so the gingiva could have been slowly sculpted to accept an implant restoration with fuller contours. I’ve discussed techniques here and here.
So what do we do for this patient? We’re going to remove this restoration, develop better soft tissue contours on the mesial, and then fabricate a new restoration. I attempted to pry off the cemented crown but unfortunately it looks like the prior dentist used permanent cement. So now I have to carefully drill through the crown and try to not nick the abutment screw.
Whew! I broke a sweat on that one.
Okay, success. I unscrew the restoration so we can get a good look at it:
To save the patient some dough I decided to use this restoration as the temporary. Believe it or not you can bond flowable composite to the metal. The secret is to carefully place cyanoacrylate (Crazy Glue) in the area of interest, allow to dry, then cover that same area with bonding agent and cure. Now we can add flowable composite to develop the emergence profile.
Voila! Note the more developed contour on the mesial.
We try this in to make sure we haven’t pushed the gingiva too far too quickly. If there’s still blanching in ten minutes we’ll trim it down. If the blanching goes away less than ten minutes then we should be groovy. Warn the patient as you screw this down that they’ll feel pinching. That means it’s working. Polish it up as much as possible so that it won’t be a playground for bacteria and insert.
After a month or so of playing with this we’ll be ready for the final. We’ll make a custom impression coping to faithfully transfer our new emergence profile to the lab.
So what’s the lesson? I recommend every single patient have a temporary implant restoration before going to final. I need to test the esthetics, hygiene, and function with my temporary, otherwise my final restoration will be just an educated guess. If a patient refuses to have an implant provisional then I have them sign a form that states they understand that they may experience complications including but not limited to food traps, uneven gingiva, and so on.