What is the best way to achieve emergence profile in dental implant restoration?

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    What is the best way to achieve emergence profile in dental implant restoration?


    Many would argue that the time to do this is not after osseointegration has been achieved but would be preferred as a technique that should be provided at the time of implant insertion. So this would be immediate implant insertion ( at the time of tooth extraction) with insertion of a provisional restoration on that same day. That provisional restoration should exhibit the contours that you would want for the final restoration with a few caveats. The idea is that if the provisional restoration has the contours that you want that the soft and hard tissue will heal to those contours. To ensure that this occurs or to at least increase the likelihood that it occurs you could move the gingival emergence further towards the incisal edge on the provisional restoration. Assuming that the soft tissue heels to the contour that you’ve established this then means that when you make your final restoration you would have an excess soft tissue (and hard tissue ) to compress on the soft tissue slightly (with the final restoration) which would put the soft tissue where it would be most desirable from an esthetic and phonetic standpoint.
    Years ago, when we were not talking about immediate implant placement, when all implant placement was performed with healing abutments and removable non-loaded provisional restorations, there were these discussions of “training” or conditioning the soft tissue after osseointegration had been achieved to make it cosmetically acceptable. The idea works great if you have excessive soft and hard tissue but if you have deficient soft and hard tissue making that deficient tissue “grow” is and always has been unpredictable.
    You can do things like secondary soft tissue grafting after the implant has achieved osseointegration with the surrounding bone to compensate for deficient soft tissue and you can do bone augmentation to compensate for inadequate bone dimension but you are unlikely to achieve predictable re-integration of an implant surface that has been in contact with soft tissue and/or the oral environment. Although there certainly are people who show radiographic images taken at some point after they created regenerative procedures this does not mean that it happens every time. We all have images like those but to suggest that they are absolutely predictable would be a pretty big stretch. I would probably put it a different way and suggest that we don’t truly understand why this works sometimes and why it fails to work other times. To suggest that such grafts are unpredictably predictable might be more realistic. Yes I understand the oxymoron in that sentence.
    Getting back to the original description of an integrated implant and then using progressively modified provisional restorations to train the tissue to a position that you wanted it to be seems like a nice, artistic way to do this. If it’s predictable, why not just make the provisional restoration or even the permanent restoration at the contours and dimensions that you so desire, once again assuming that there is excessive soft and/or hard tissue? After all, the provisional restoration is probably fabricated from a porous, at the least relatively porous, polymer surface whereas the definitive restoration is much more likely to be a less porous, sometimes almost nonporous, ceramic material. That definitive restoration made with the ceramic material should be much kinder to the surrounding soft tissue. Why a porous polymer is the recommended approach to “train” soft tissue is a question that I’ve never seen anyone answer in a compelling and convincing way. If you can train the tissue to a certain position why can’t you just make it happen in one step with a more favorable restorative material?
    Please indulge me in a tangential discussion.
    Think about it, If you violate the Biologic width on a natural tooth, what happens? Certainly sometimes the response will be tissue recession away from the Biologic violation. I mean the body has to respond to this Biologic violation by remodeling itself in some instances.
    We know that patients can have gingival recession occur that may be somewhat self-limiting. Have you ever seen an orthodontic patient where the teeth were moved outside of the labial plate of bone creating a soft tissue recession that mimics the underlying bone. I guess we could say that soft tissue recession should have an etiologic factor or factors but we certainly have clinical situations where it is really perplexing to describe the etiology of every instance of soft tissue recession.
    Classic description of a biologic width violation is that you will see inflamed hyperplastic or hypertrophic tissue in response to a Biologic width violation. Why doesn’t the tissue just recede in response to that violation ( and the associated inflammatory response) thereby forming a new equilibrium?
    Let’s think about the situation above While considering what happens with natural teeth we have reactive gingivitis do we always have responsive periodontitis? The answer is no, You absolutely can have gingivitis and not see that gingivitis progress into periodontitis. If one disease was 100% associated with the other then we don’t need two distinct diagnoses, instead what you would have phases of one disease entity. Iif bone always responded to gingivitis, there is one diagnosis that needs to be described at different phases of the same disease process. (which is not the case, gingivitis is not always a consistent progression towards periodontitis with associated periodontitis)
    To me this is what always makes Biologic Width violation a difficult concept to embrace without any hesitation. We should all recognize biologic width when it is occurring but how many violations have occurred with the apparent soft tissue response but without a hard tissue response? What do we do when we see a violation of the biologic width? Well what we hear about is resective and/or re-contouring procedures of the soft and hard tissue.
    Remember this is all occurring on natural teeth that have a periodontal ligament with bundle bone and complex gingival fiber orientations. Take out the tooth and you remove the Periodontal ligament then you place an implant and the bundle bone loses vascularity. If the bundle bone was thin you likely lose bone height and bone width. How many times have we seen descriptions of how bone resorb’s after a tooth is removed. They all basically say the same thing. So how do you combat it? One way to combat it is to remove the tooth preserves the socket and place an implant secondarily with a much thicker facial plate of bone on the facial aspect of the implant which is usually the aspect where the bone is thinner (if nothing is done to preserve it). Another way to combat the problem is to graft the defect between Implant and surrounding bone assuming that the surrounding bone was maintained at the time of tooth extraction. If that graft is osteoconductive (Osteoconductive graft Autografts, treated al- lografts, and bone substitutes that provide a scaffold for osteoid formation.) the chance of healing is pretty good. Another option is to prevent epithelial down growth with the implant placement in the extraction socket that has preserved the labial plate allowing bone to heal in the clot that forms between the implant in the existing bone. The trick of that is to have a sufficient gap dimension that will heal more rapidly in the form of osseous tissue than it does in the form of soft tissue going into the defect area.
    Why did I bring up Biologic width? I would suggest to you that this topic was brought up because we look at implant placement and soft and hard tissue contours as if they were in entirely foreign concept relative to the concept of Biologic width on natural teeth. If we have to make a transmucosal abutment and a crown the D connects to that trans mucosal abutment and both of those occur above the level of the Implant Restorative platform and we measure the distance between that restorative platform and where the restoration begins what we are going to find is that if this were analogous to a natural tooth setting it would be at very high risk of a Biologic width violation wouldn’t it? So is it a different biologic situation that we are looking at with the avascular implant placed within a bony housing in situations sometimes where there is very little bone to the facial or to the palatal or lingual of the implant thereby compromising the vascular supply. Does this lead to a situation where we more frequently should consider soft tissue grafting particularly with connective tissue and epithelium or perhaps just with connective tissue to create a better vascularity to the tissue on the facial aspect of the implant

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