Selecting prosthetic components in thick mucosa in the maxillary anterior region?
I have a new patient who presented with two dental implants in the maxillary anterior region way too deep. Patient does not want to return to the prior dentist. We were able to identify the brand of implant used. Now while considering the restorative phase, selection of the prosthetic components is quite difficult under the circumstances. How do I select a transmucosal healing abutment for this case? What kind of definitive abutment should I select? I do not want the finished product to show gum recession later which would severely compromise the aesthetics. What do you recommend?
9 Comments on Selecting prosthetic components in thick mucosa in the maxillary anterior region?
New comments are currently closed for this post.
Carlos Boudet, DDS
10/29/2013
Neither the apical placement of the implant, nor the selection of a transmucosal healing abutment is a problem.
If the implant comes with an implant mount such as the zimmer screwvent, you can use it to create a custom healing abutment to form your ideal emergence profile by adding flowable composite to it.
If there is no implant mount available, you can use a temporary or peek abutment for the same thing.
If the screw acces is in the right position, you can even make a screw-retained temporary crown and start developing the papillae and soft tissue.
If you don't push the labial tissue too much with your components or restoration, you may be able to reduce or prevent the recession.
For the final abutment I suggest a custom zirconia abutment to duplicate the tissue emergence that you created with your temporary.
Tushar
10/30/2013
Thanks Carlos,
But the Implant manufacturing Company is Hiossen.
The screw holes are in good centric-position. The company have just round bodied healing abutments so how to create a triangular emergence profile.
and the distance from the crest of the bone to the gingiva border is approximately 5 mm, so iam assuming that the height of healing abutment would be approximately 5-6mm. which would again result in future recession because the gingiva is un-supported without any bone.
Any techniques to prepare a nice emergence profile or any prosthetic manual for reference.
Please help.
CRS
10/29/2013
I would be cautious with restoring any case that a disgruntled patient presents with and you did not treatment plan. Are you going to cantilever the lateral incisor off of the implant? Anyway how about a nice set of provisionals to be sure this will work out. Charge appropriately since you are starting out in a compromised placement. If there s no plan there could be a problem and the last person to touch this will get burned. If you are not happy with the placement, remove and start over. What makes a good restoration in the esthetic area is a good foundation and treatment plan on which you are not privy to I would have the patient sign a waiver don't be a hero! I think we as dentists myself humbly included think we can do things better than our predecessors just be careful and no gaurentees!
Carlos Boudet, DDS
10/29/2013
CRS has pointed out an even more important fact than any of the tips I mentioned.
Make sure that you have a treatment plan that addresses all the issues and has a sound prosthetic endpoint in mind.
Present your plan to the patient prior to starting any work, including disclosure of pre-existing problems or complications and make sure that the patient is in agreement, or you may be the second dentist that he or she does not want to go back to.
Dr. Alex Zavyalov
10/30/2013
To my mind it’s not correct to choose prosthetic components such as healing abutment material without having a prosthetic treatment plan which comprises (at least) a quantity of included teeth. Any material is the only part of the plan Regardless of panoramic distortion (especially in frontal areas) I think the implants were installed according to the bone level, not deeply as mentioned. Theoretically I would suggest making two fixed prostheses: to join the left implant and canine; left incisor with right implant and canine
.
MPEDDS
11/5/2013
It appears that these implants were placed at the crest of the bone. So the issue is not that they are too deep, but rather, the tissue is very thick. I don't see the value in saving the one incisor, and so I think this should have been treatment planned differently. Consider a UCLA type abutment. I have cases going back 25 years that are way deep in the tissue. The tissue and bone levels look the same now as when I restored them. I agree that this patient should be in provisionals for a while.
nailesh gandhi
11/6/2013
UMA abutments can be a great help in such cases.It will be screw retained.Since last 25 years we have used and are very useful esp.in such cases.
THP
11/6/2013
I don't know if I'd use a zirconia abutment with such an unfavorable crown-implant ration as it'd be prone to fracture. I'd keep them in a temp for 4-6 months and look more towards a custom gold. But I'm also fresh out of dental school so what do I know haha
CRS
11/10/2013
You are wise. Now in my experience thick anterior tissue is a great problem to have. The implants were placed appropriately at the height is the resorbed bone, thi could only be fixed with grafting to try and get more width and a bit more height. Based on only this X-ray they implants look pretty good. I can't tell much more without a clinical photo . I would still advise to place provisional and charge appropriately for this since this is not your original case. If it doesn't look right then what you do is reversible if the case need be scrapped and the implants need to be removed. Now one very very important point make the provisional screw retained , place Teflon tape so you can get access. Have the screw hole come thru the labial and place light cure composite to cover. Then wait and see. If this works make a custom impression coping (look it up on the web)or get help from a prosthodontist you trust not a lab tech, that's how you get better not burned. Good luck.
