Preserving and perfecting the gingival emergence profile

Editor’s intro: Dr. Todd Liston discusses the Gingival Cuff  Link™, a core abutment made of titanium and specifically designed to fit with the implant manufactures’ implant design to maintain tissue form and function and esthetics.

Dr. Todd Liston discusses an implant method that maintained soft tissue form and function and esthetics

Introduction

Dental implants have changed the face of dentistry as much as any other technology in the last century. Since the discovery of osseointegration and the development of the modern-day dental implant, millions of lives have been enhanced with the ability to chew food and to function in a way that was not previously available. Significant research and development have been undertaken to allow bone to integrate more quickly and effectively with the dental implant. Despite achieving this very high level of success, the predictability of maintaining and establishing ideal soft tissue emergence profile has been far from successful, resulting in less-than-acceptable esthetic outcomes.

Background

Traditional implant soft tissue management has been with round healing cuffs/abutments, but there are ironically no round teeth. The importance of gingival tissue manipulation to establish an ideal emergence profile has been discussed for years, and many techniques have been proposed or developed, which have fallen short to predictably preserve and perfect gingival tissue. This has been due to their inability to provide the dentist with three key elements: adaptability, durability, and dependability. The Gingival Cuff Links System™ was developed to meet all three elements.

Materials and methods

Each Gingival Cuff Link™ core abutment is made of titanium specifically designed to fit with the implant manufactures’ implant design. The Gingival Cuff Link™ body is made of bisacrylic resin — the same material from which many temporary dental restorations are fabricated — can be easily sculpted by reduction using dental rotary instrumentation or addition using flowable composite or bisacrylic. The body is molded to 11 different emergence profiles to assist in establishing and maintaining a natural soft tissue emergence for every tooth. The Gingival Cuff Links System™ was used in hundreds of cases, in all areas of the mouth, and at all stages of the implant process (immediate and delayed). In all cases, the Cuff Link was either customized as a healing cuff and/or a provisional crown.

Case 1 (Figures 1-10)

Advanced resorption of the root of tooth No. 8 with resultant significant mobility and discoloration. Removal of the tooth is done and the site addressed with immediate implant placement and provisionalization using the Cuff Links System.

• Preoperative photos and X-rays of the tooth No. 8
• Removal of tooth and implant placement
• Chairside fabrication of a provisional restoration using a Cuff Links healing cuff
• Bone grafting the surgical site
• Placement of a subepithelial connective tissue graft
• Shade correction of the provisional 3 weeks after implant placement using a flowable composite veneer.

Figure 1: Resorption of tooth No. 8 root requiring removal

Figure 2: Pink hue of tooth No. 8. Notice the high smile line

Figure 3: Implant placed into the area of tooth No. 8

Figure 4: Seated Cuff Links healing cuff

Figure 5: Cuff Links healing cuff seated with the buccal “T” handle and palatal guide handle removed

Figure 6: Fabrication of the provisional crown using the Cuff Links system

Figure 7: Healing at 4 months
< Figure 8: Soft tissue at 4 months. Notice the preservation and enhancement of the gingival form
Figure 9: Soft tissue healing at 4 months. Notice the enhanced buccal soft tissue thickness

Figure 10: Two-year follow-up. Veneers were placed on all anterior teeth
Case 2 (Figures 11-18)

Decay under the crown of tooth No. 19 and fractured root of tooth No. 20 rendered them non-restorable. Removal of the teeth was done; immediate implant placement was accomplished; and soft tissue was managed with custom gingival healing cuffs using the Gingival Cuff Links System.

Results

Immediately placed implant soft tissue emergence profile was able to be maintained or enhanced in nearly all cases using the Gingival Cuff Links System™ either as a gingival healing cuff or a provisional crown. In delayed or second-stage surgery, gingival recontouring using flap procedures was necessary, resulting in longer healing time and not always as predictable results as with the immediate implant protocol. When multiple implants were placed adjacent to one other, the ability to maintain the interproximal papilla was predictable with immediate implant and provisional crown or custom-healing cuff placement. In all situations, the results were substantially better for each member of the implant team (Surgeon, Restorative Dentist, Laboratory Technician, Patient) than using the traditional method of a round healing abutment.

Conclusion

Management of the implant soft tissue is possible and predictable if anatomic support is provided. The Gingival Cuff Links System™ is fully sculptable to provide not only soft tissue form and function, but also esthetics when indicated. Ultimately the following benefits are realized by the implant team:

• Surgeon: the ability to preserve and perfect the soft tissue emergence form and function
• Restorative Dentist: the precise soft tissue profile for the optimal esthetic restoration
• Laboratory Technician: the ability to fabricate the ideal esthetic and functional restoration
• Patient: the implant treatment desired and deserved

Figure 14: Gingival Cuff Links aligned with opposing dentition

Figure 11: Radiograph of the carious tooth No. 19 and fractured tooth No. 20

Figure 12: Implant placement into sockets of teeth Nos. 19 and 20 with recontouring of the peripheral bone margins of implant site 19.

Figure 13: Gingival Cuff Links seated on the implants. Note that the “T” handle is aligned parallel with the buccal surface of the adjacent teeth, verifying the correct rotational implant placement for this internal hex system

Figures 15 and 16: 15. Sculpting of implant No. 20 Gingival Cuff Links being done with a 703 surgical bur using a surgical handpiece. Note the pink flowable composite on the lingual aspect to aid in retaining anatomic orientation. 16. Application of flowable composite to the customized gingival healing cuff to obtain a final surface<
Figures 17 and 18: Soft tissue healing and emergence profile preservation at 3 months post implant placement<

For more information on the benefits of the Gingival Cuff Link™, read this Step-by-step article.