A single tooth or multiple implants in the anterior maxilla require special attention to emergence profile and aesthetics. The placement of cylindrical healing abutments at second stage surgery often does not provide optimal tissue contour, therefore compromising overall aesthetics. The following principles and techniques may be used to maximize tissue healing and contour in maxillary anterior single tooth implants.
- Evaluate for hard tissue or soft tissue defects, requiring possible bone or gingival augmentation.
- Ensure placement of the implant to allow 4mm of gingival transition for proper emergence profile.
- Conservative surgical techniques minimize insult to the dental papilla and gingival margins.
- Complete indexing at stage I surgery if possible.
- Place a provisional crown at second stage surgery instead of cylindrical healing abutments.
Sequence of treatment
Visit #1 – Consultation with restorative doctor
- Obtain lower and upper study models.
- Evaluate occlusion.
- Evaluate existing hard and soft tissue.
- Establish prosthetic design, e.g. single crowns or bridge.
- Discuss with patient the prosthetic design and role of dental implants in establishing that goal.
- Refer to oral & maxillofacial surgeon for consultation.
Visit #2 – Consultation with oral surgeon
- Perform complete examination.
- Take appropriate X-rays.
- Based on the prosthetic design and patient desires, establish a surgical plan.
- Discuss various grafting or augmentation techniques and implant procedure steps.
- Obtain appropriate consents; give patient prescriptions and pre-operative instructions.
- If further evaluation is necessary, schedule another consultation.
- Discuss the details of the treatment plan with the restorative doctor.
Fabrication of the surgical guide should be completed by the restorative doctor, dictating implant position based on the study casts and occlusion. The stent should be made of acrylic and should be solid, with positive seating on adjacent teeth. A 2mm-guide drill may be used to place the precise angle and emergence of the implant in the stent. The stent can be given to the patient to bring to surgery or mailed to the surgeon in advance.
Visit #3 – Implant placement
- Place the implants using the surgical stents provided by the restorative dentist.
- Index the implants.
- Send the index impression to the restorative doctor for abutment design and provisional fabrication. If Atlantis Abutment System is used, Dr. Kazemi will send all the necessary material directly to them.
- Schedule the patient for appropriate follow-ups.
- Allow 3-4 months of healing for mandibular implants, and 6 months of healing for maxillary implants.
Visit #4 – Exposure of implants
- Implants are exposed.
- The prepared abutment is placed and screwed to the fixture.
- The provisional restoration is placed with temporary cement.
- Flaps are closed and the patient is scheduled for suture removal.
- Allow 6 weeks of gingival healing prior to next visit with the restorative doctor.
Visit #5 – Final impression
- Take the provisional out and examine tissues and abutment for proper architecture and health.
- Make any modification or preparations necessary.
- Once completely satisfied with the provisional and tissue shape and health, take final impression and send for final crown.
- Re-cement provisional prior to discharge.
Visit #6 – Placement of final crown
When using the Atlantis Abutment System, you will receive the patient with prepared abutment and provisional in place already. All you will need to do is evaluate the tissues and margins of the abutment, make any necessary preparations, and take a final impression for the final crown/bridge.
- After treatment planning, a surgical template should be constructed to assist the surgeon in proper positioning of the implant. The stent may be used for indexing.
- Following placement of the implant, an impression coping is attached to the implant.
- Soft tissue is reflected away from the coping.
- A heavy-bodied polyvinylsiloxane impression is injected around the coping and the adjacent teeth.
- Once the impression is set, remove the screw from the coping and remove the tray.
- Obtain an inter-occlusal registration.
- The impression is then disinfected.
- The following materials are sent to the lab for model fabrication:
- Upper and lower models
- Bite registration
- Index impression
- Shade for provisional
An abutment and provisional restoration can be fabricated to optimum dimensions to “guide” the gingival tissue to heal with correct anatomic contour. This provisional is placed on the implant at the second stage surgery.
After an appropriate healing period and maturation of the gingival cuff (usually six weeks), the original customized abutment can be modified with regard to margin placement and a final restoration constructed on a new master cast following standard crown-and-bridge techniques.