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26 implantology section DENTAL TECHNOLOGY, JANUARY-MARCH 2025

SUCCESS FACTOR OF IMPLANT RESTORATION:

THE CONCEPT OF CUSTOMIZED TISSUE SUPPORT

OTTO PRANDTNER, DANIEL EDELHOFF, MICHAEL C. BERTHOLD, REZA SAEIDI POUR

From the patient's perspective, the success of an implant restoration is eval-
uated based on the appearance of the crown and, especially, the harmonious
development of peri-implant soft tissues and the natural transition of color
from the white to the red zone [1] . A natural clinical aspect of an implant
restoration in the anterior region can be achieved predictably through digi-
tal pre-planning during the procedure, using the concept of customized tis-
sue support.
The use of an immediate provisional prosthesis that reflects the submu-
cosal contours of the extracted tooth at the time of implant placement is the
basis for promoting healing of peri-implant soft tissues. An individual
anatomically shaped gingival retractor or provisional implant crown serves
as a soft tissue wound closure during immediate implant placement. Both
FIG 1: Arian, a 26-year-old student, presented at the clinic with pain in the central inci-
forms stabilize the blood clot and thus contribute to tissue preservation dur-
sor and a persistent fistula. After a trauma to the anterior tooth in childhood, multiple
ing immediate implant placement.
root canal treatments, two apicoectomies, and restoration with a metal-ceramic
The concept of customized tissue support focuses on the "transition
crown followed.
zone," i.e., the area of transition from the implant's circular shoulder to the
emergence profile of the restoration from the gingiva. Root and gingival
contour information, transferable from CBCT (cone beam computed tomog-
raphy) to an STL dataset, is essential for designing the individual gingival
support.
Based on 3D radiographic diagnosis and digital recording of the oral clin-
ical situation, virtual implant placement is performed, and a guided implant
surgery template is commissioned.
Considering the biological criterias, individual PEEK gingival retractors
are designed on this basis and produced by DEDICAM. Open or closed
impression abutments are produced from the same dataset to precisely
transfer anatomical soft tissues onto the master model. The fact that the
transfer abutment is made from the same dataset is crucial for controlled
FIG 2: Due to the apicoectomy, the root of tooth 21 was shortened. A further revision
preservation of gingival geometry. Gingival geometry and the wavy course
attempt had a long-term unfavorable prognosis. Since the tooth had to be extracted,
of healed gingiva are thus optimally communicated between the dentist and
the interdisciplinary team discussed an immediate restoration protocol. The CBCT
the dental technician.
image in cross-section showed sufficient bone volume in the apical region of the tooth
An essential part of the concept is that the implant abutment is manufac- for immediate implant placement. The fistula did not constitute a contraindication.
tured with the same submucosal contour to avoid uncontrolled gingival
changes due to excessive or insufficient contouring. Excessive contouring of
the transition zone generally leads to uncontrolled apical positioning of the
gingival margin and thus to an optically elongated crown. Sub contouring
creates a crevice where the gingiva collapses, resulting in apical displace-
ment of the gingival margin. When designed according to biological crite-
ria, a zone is created where connective tissue can attach to the superstruc-
ture, the connective tissue zone. The concave shape of the superstructure
from the implant shoulder toward the epithelial attachment is decisive for
this, as it creates sufficient space for the formation of a stable mucosal cuff.
In the area of the epithelial attachment (about 1 mm) of the so-called "crit-
ical contour" [2] , the exact replica of root geometry is essential. This pro-
motes primary wound closure and stabilization of the blood clot.
The groove influences the level of the gingival margin, gingival color, and FIG 3: Pre-surgical planning includes cone beam computed tomography (CBCT), a face
scan, and digital wax-up. With the help of overlaid data, the exact location, position,
facial emergence profile architecture and papilla height and is controlled by
and length of the tooth can be defined. This forms the basis for optimal implant
the prosthetic structure. During the healing phase, manipulations in the
placement, slightly oriented towards the palate to ensure palatal screw retention of
groove area could negatively affect the wavy course of the gingiva. In
the restoration and sufficient space for peri-implant augmentation.
nature, the gingiva lies at the border between enamel and cementum.
Design of this boundary zone should only be done during definitive restora-
tion to define groove shape.
Highly aesthetic implant solutions have been produced for years with mally invasive approach appreciated by patients due to fewer
custom gingival retractors created in the laboratory. Modeled profiles are treatment sessions and reduced surgical interventions.
then transferred to the transfer abutment, which in turn serves for exact Another advantage of immediate restoration concepts is the
transfer to the master model. preservation of peri-implant hard and soft tissue contours, also
With the aim of optimizing surgical procedures and predictable implant thanks to individually fabricated temporary components pre-sur-
restorations from an aesthetic and functional point of view, patient- specific gically with controlled healing collaboration with DEDICAM
gingival retractors and transfer abutments, as well as provisional restora- based on digital planning, on the basis of backward planning, and
tions with the same emergence profile, can now be produced in and can be taking into account biological criteria for soft tissue support.
successfully implemented if certain criteria are considered. This is a mini- The following patient case describes an immediate implant