Development of implant soft tissue emergence profile:

A technique
David Neale, DDS, MSEd,a and Winston W. L. Chee, BDSb
University of Alberta, Faculty of Dentistry, Edmonton, Alta., Canada, and University of Southern
California, School of Dentistry, Los Angeles, Calif.

Despite successful osseointegration of dental implants, patients can be dissatisfied

with the definitive restoration because of a poor esthetic result. An esthetic implant
restoration depends on correct implant placement and a well-designed and
fabricated prosthesis that includes the prosthetic teeth and the surrounding matrix,
whether it is acrylic resin or soft tissue. This article describes a technique to help
predict, develop, and evaluate implant prostheses and their soft tissue contours at
the provisional restoration stage. This technique records the planned and subse-
quently proven contours, which are then used to guide fabrication of the final
prosthesis and produce a predictable esthetic result. (J PROSTHET DENT
1994;71:364-8.)

I mproperly contoured tooth-supported restorations tured by other companies, have also been used to facilitate
are associated with compromised access for oral hygiene placement of the porcelain margin subgingivally, thereby
procedures and inflamed soft tissues that can result in decreasing the display of the metal abutment compared
compromised esthetics. Dental implants differ from teeth with astandard abutment. The DIA abutment (Impla Med,
not only by the nature of attachment to bone and soft tis- Sunrise, Fla.) is used to create a semicustomized emergence
sue but also in their size and shape. Whatever the specific profile with a wide selection of manufactured titanium
size of a particular manufacturer’s implant, it is unlikely to healing abutments. After soft tissue healing, a titanium
correspond accurately to the size or shape of a natural tooth abutment, with an emergence profile that corresponds to
at the gingival level. Without the appropriate shape, size, the healing abutment, is selected and modified to allow a
and location of the implant restoration as it emerges from semicustomized emergence profile and the ability to have
the soft tissue, the final esthetic result will be compro- porcelain margins that may be only slightly subgingiva12
mised. Even a large selection of abutments may not provide In the esthetic zone, the emergence profile of dental im-
the contour required for an esthetically demanding situa- plant restorations should mimic natural teeth. To achieve
tion. this, some degree of soft tissue modification is often
Various prosthetic components have been used to im- required. There are several different approaches. The first
prove the esthetics of implant restorations by decreasing approach is to expand the tissues surgically, and this is
metal display and allowing more natural contours at the done when healing abutments, which are preselected to
gingival level of the restoration. The nonsegmented (UCLA) correspond to the size of tooth to be placed in this location,
restoration facilitates placement of porcelain and develop- are placed on implants at the second stage. Selecting an
ment of esthetic contours close to the head of the implant. abutment from a wide assortment of various tapers and
A transition from the 4 mm diameter of the implant to the heights will achieve an emergence profile necessary to ap-
shape and size of the natural tooth replaced is possible, proximate the size of a natural tooth at the gingival mar-
provided the implant is placed appropriately and sufficient gin. Full-thickness flaps are raised, contoured, and then
soft tissue is present.’ The EstheticCone (Noblepharma adapted around the chosen healing abutments. The second
USA Inc., Chicago, Ill.), or similar abutments manufac- approach is to remove excess soft tissue by gingivoplasty.
In either case, if the soft tissue surgical procedure is done
at the time of definitive restoration placement, or if the
prosthesis does not closely mimic the contour of the heal-
Presented before the Pacific Coast Society of Prosthodontists,
Newport Beach, Calif., June 1993. ing abutment, the final soft tissue contours will not be pre-
YXnical Instructor, Department of Fixed Prosthodontics, Uni- dictable and uncertain esthetic results can occur.
versity of Alberta, Faculty of Dentistry, and Private Practice, The proposed technique uses a combination of both soft
Edmonton. tissue techniques (expansion and gingivoplasty) and a cus-
bAssistant Professor, Director of Implant Dentistry, University of
tomized provisional restoration, which is used as a healing
Southern California, School of Dentistry.
Copyright @ 1994 by The Editorial Council of 'I&R JOURNAL OF matrix for the soft tissues in much the same manner as used
PROSTHETICDENTISTRY. with the ovate pontic technique.3v 4Thus, the tissues obtain
0022~$918/94/$1.00+.10. 10/1162431 stability before fabrication of the definitive prosthesis, and

364 VOLUME71 NUMBER4

NEALE AND CHEE THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 1. Initial soft tissue cast with adjusted temporary abutments.

Fig. 2. Provisional restoration A, before and B, after addition of acrylic resin painted on
to create idealized emergence profile.
Fig. 3. A, Putty matrix and B, modified provisional restoration ready for fabrication of
new soft tissue cast.

a matrix is used to ensure a close duplication of provisional tic wax-up, which is then clinically verified with either
contours in the definitive restoration. The technique also a wax try-in or placement of a provisional restoration.
provides the laboratory technician with a soft tissue cast A radiographic stent with radiopaque prosthetic teeth
that is almost identical to the soft tissue contours that will will relate available bone to the proposed prosthetic
be formed by the provisional restoration. teeth, thus defining optimal implant placement. The
surgical placement can be guided by conversion of the
radiographic stent to the surgical stent.
TECHNIQUE 2. A full-arch impression is made with implant impres-
1. Implants must be placed accurately with respect to sion analogs, which record the relationship between
lateral location, angulation, and depth. This is best any remaining teeth, the implant, and the existing soft
determined presurgically through the use of a diagnos- tissue profile.

APRIL 1994 365

TEE JOURNAL OF PROSTHETIC DENTISTBY NEALE AND CHEE

Fig. 4. New soft tissue cast.

Fig. 5. Prepared soft tissues ready for insertion of provisional restoration.
Fig. 6. Sutured soft tissues against provisional restoration.
Fig. 7. Stable contours of soft tissues formed by provisional restoration.
Fig. 8. Definitive prosthesis.

3. After implant analogs are attached to the impression of the intended provisional restorative contour (Fig. 1).
copings, soft tissue cast material is placed around the A clear plastic matrix made from the diagnostic wax-up
neck of the implant analogs, followed by casting of the can be used as a guide.5
remaining impression in improved dental stone (Die 5. Provisional restorations are fabricated on the soft tis-
Keen, Miles Inc., South Bend, Ind.). sue cast with the adjusted temporary implant abut-
4. After the cast is separated and trimmed, temporary ments. The same clear plastic matrix or a more detailed
implant abutments (Implant Innovations Inc., #ITC putty matrix can be used to create the same contours
31) are attached and trimmed to fit within the confines as the original wax-up. The use of warm water and 20

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NEALE AND CHEE THE JOURNAL OF PROSTHETIC DENTISTRY

lb pressure in a pneumatic pressure pot will result in made to closely resemble the provisional restoration
a dense acrylic resin with added strength and reduced with predictable contours (Figs. 7 and 8).
porosity.6
6. After the cured provisional restoration is removed from ADVANTAGES
the cast, the flash is trimmed. At this time, a definite The use of this technique allows control of the soft tis-
discontinuity exists between the contour of the provi- sues around a customized provisional restoration with
sional restoration at the gingival aspect of the crown contours that mimic natural teeth. This can optimize the
and the width of the temporary abutment. With the esthetic result. The patient and dentist can evaluate the
“paint on” technique, acrylic resin is added to create a
esthetic potential before fabrication of the definitive pros-
smooth emergence profile. The provisional restoration
thesis. Evaluation of the patient’s ability to perform oral
is polymerized with heat and pressure (Fig. 2). The
restorations are finished, polished, and characterized hygiene with the anticipated contours is also possible. A
as required. Provisional restorations for two or more laboratory-made provisional restoration eliminates most
splinted implant restorations may require sectioning of the chair time associated with this phase of treatment,
and reconnecting to compensate for polymerization and use of the indirect technique ensures a restoration
shrinkage. with high surface quality that facilitates oral hygiene.
7. The soft tissue insert is removed from the original soft This technique allows accurate determination of the
tissue cast, and the completed provisional restoration gingival crest location if provisional restorations are main-
is attached to the implant analogs. Additional stone is tained 12 to 20 weeks.7 The location of subgingival
removed as needed to ensure a space between the pro- porcelain placement can subsequently be determined, re-
visional restoration and the stone cast (Fig. 3).
ducing the risk of metal display. The use of a provisional
8. The matrix used in step 5 is modified by a hole placed
restoration also allows evaluation of function by the
at each end of each soft tissue area. Then it is carefully
placed against the cast over the attached provisional patient. This will often be a patient’s first experience with
restoration. Soft tissue material can be injected through implant-supported teeth. With this approach, a minimum
a hole made in one end of the matrix and vented out of implant components is required, which reduces the
the hole made in the other end. The two holes cost of a large inventory of healing caps and eliminates
should be considered sprues and vents for a casting the potential delays of ordering components. The range
(Fig. 3). of size and shape of prosthetic contours is limited only
9. The components are dissembled, flash is removed, and by physiologic limitations of existing soft tissue or soft
the anticipated soft tissue contours are evaluated (Fig. tissue augmentation procedures. The dental laboratory
4). At any time in the future, if modification of the will also have a cast of the soft tissue profile that is
provisional restoration becomes necessary, a new soft identical to the patient’s. This ensures that the definitive
tissue insert should be made by repeating steps 5
restoration will match the provisional restoration when
through 8. This soft tissue insert, the cast, and the cor-
responding matrices are used by the laboratory to de- completed.
termine the contours of the definitive restoration. DISADVANTAGES
10. If the anticipated soft tissue contours appear to be
within physiologic limits, the provisional restoration is An increase in total treatment time is to be expected
inserted. A full-thickness flap is reflected and used to whenever procedures to alter soft tissue contour are used.
create a root eminence facially when it is placed over The development of restorative emergence profile with this
the provisional restoration. Soft tissue is surgically re- technique is initiated below the level of the gingival crest
moved by gingivoplasty to create smooth contours on and therefore direct observation to verify seating of the
the lingual or palatal surfaces. An implant cover screw prosthesis is not possible. When the provisional or defin-
placed on the implant should be used to protect the itive restoration is removed, the soft tissue tends to collapse
fragile head of the implant during surgical procedures after a short period if left unsupported.
(Fig. 5). Interrupted vertical mattress sutures are
placed interproximally to help stabilize the full-thick-
ness flaps (Fig. 6). SUMMARY
11. Accurate adaptation of the provisional restoration, and A technique has been described that will allow custom-
indirectly the master cast, must be verified either ized development of the soft tissue profile at the provisional
through direct visualization or radiographically at the stage of a dental implant restoration. This customized soft
time of flap reflection.
tissue profile can be evaluated and modified before fabri-
12. The provisional restoration should be maintained un-
til the soft tissue has stabilized, at which time the es- cation of the definitive prosthesis. A soft tissue cast that
thetic result can be evaluated. The patient may accept closely resembles the soft tissue contours intraorally can be
the result, or further modifications can be instituted. provided to the laboratory. This allows fabrication of a de-
13. The definitive prostheses can then be made on the new finitive restoration that will duplicate the esthetics of the
soft tissue cast and, with the use of matrices, can be provisional restoration.

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resin polymerized by four different techniques. J PROSTHET DENT

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