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Continuing Education

Biologically Contoured Esthetic Implant
Restorations
Course Author(s): Swati Ahuja, BDS, MDS
CE Credits: 1 hours
Intended Audience: Dentists, Dental Hygienists, Dental
Assistants, Dental Students, Dental Hygiene Students, Dental
Assisting Students, Office Managers, Dental Educators
Date Course Online: 07/15/2024
Last Revision Date: NA
Course Expiration Date: 07/14/2027
Cost: Free
Method: Self-instructional
AGD Subject Code(s): 690
Online Course: www.dentalcare.com/en-us/ce-courses/ce684
Disclaimers:• P&G is providing these resource materials to dental professionals. We do not own this content nor are we responsible for any material herein.
• Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice.
Only sound evidence-based dentistry should be used in patient therapy.

Conflict of Interest Disclosure Statement• Dr. Ahuja reports no conflicts of interest associated with this course. She has no relevant
financial relationships to disclose.
Short Description
Dental professionals are often times fixated on the idea that toothpaste abrasiveness is the
key factor in tooth wear. This course will review the history of RDA and modern erosive toothwear; which will demonstrate that acid-mediated tooth wear, so-called erosive tooth wear, is thedominant process for tooth loss. The course will also focus on prevention strategies to reduce therisk of erosive tooth wear.

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Course Contents
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Introduction
Dental Trauma PrevalenceSports Dentistry
Oral and Dental Injuries
Prevention Levels
Mouthguards
Face Shields
ToothSOS app
Save Your Tooth Poster
Save a Tooth Kit
IADT Guidelines for Treatment of Traumatic
Dental Injuries
Dental Trauma Guide (DTG)
Conclusion
References / Additional Resources••

Use the cervical contouring concept, readymade molds, or CAD-CAM technology for
optimally conditioning the soft tissues.
Describe the techniques for capturing tissue
architecture in the definitive restoration.
Develop the clinical workflow for fabricating
implant restorations (emphasizing
the creation of biologically contoured
restorations).

Introduction

An implant-supported restoration is consideredsuccessful when it provides comparable
esthetics and function as the natural tooth it isreplacing.1,2 Esthetics of an implant restoration
is not only associated with the visible portionof the prosthesis but also the surrounding
peri-implant soft tissue architecture.3-6 Bycomparison, implants have a narrower diameter
platform and circular diameter as opposedto the wider and broader cervical anatomy
observed in most natural teeth to be replaced.1,4Proper transition from the small,rounded
implant platform to the ideal restorative cervicalcontour is critical for developing an optimal soft
tissue architecture.1,4,7 The desired transition
involving the peri-implant mucosa is predicatedon the development of an appropriate
restorative emergence profile.1,4,7

Overview

One of the most significant challenges in
implant therapy involves optimally managing
the transition of the restoration from theimplant body through the soft tissues. This
course will detail the importance of various
factors affecting the diagnosis and treatment
planning of biologically contoured implant
restorations including the assessmentof hard and soft tissues, peri-implantmucosal phenotype, restorative space,crown morphology, three dimensional (3D)and restoratively driven implant planning,developing consensus for ideal surgical implant
position and placement of well-contoured
provisional restorations or custom healing
abutments. This course will also describe
various techniques for fabricating customized
healing abutments and the techniques for
capturing tissue architecture in the definitive
restoration.

Emergence Profile

Emergence profile is defined as the contourof a restoration as it relates to its emergencefrom the circumscribed soft tissues.8,9 It
specifically represents the restoration region
located between the implant platform andthe soft tissue cervical margin (Figure 1).4,7
The emergence profile allows a transition
from the narrow diameter cylindrical implant
platform to the visibly wider cervical portionof the restoration.1 Ideally, the transition fromthe implant platform to the cervical marginof the restoration should be smooth andgradual. However, correct three-dimensional
surgical implant positioning and sufficienttissue volume are required to achieve optimal
emergence profile.4,6,7 The emergence profile
has implications in esthetics as well as inmaintaining the peri-implant soft tissue
health.7,10 A restoration with an optimal,
biologically contoured emergence profile
provides support to the perimucosal tissues
around the implant restoration, hence, it

Learning Objectives

Upon completion of this course, the dental
professional should be able to:• Define emergence profile and list
considerations for creating an optimum
emergence profile.
• Identify the factors affecting the diagnosis
and treatment planning of biologicallycontoured implant restorations.
• List the importance of the fabrication ofprovisional restoration.
• Describe the importance and theprocedures for fabricating a customized
healing abutment.
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is rarely associated with the formation ofproximal and/or buccal/lingual food traps.11
Developing a restorative contour of optimal
emergence profile, is one of the mostsignificant challenges in implant therapy.12

transitional phase to maintain/recreate thesoft tissue form.1,3,7 The critical and subcriticalcontours may be concave, flat, or convex.4 The
facial critical contour affects the zenith, theposition of the labial mucosal margin, and theapparent length of the clinical crown whereas
the interproximal critical contour affects theapparent shape of the clinical crown (triangularor square).7 A convex facial critical contour isplanned (to support the marginal tissues) when
the implant is positioned lingually or when
there is a need to transpose the peri-implantmucosal margin apically.4 Conversely, a flat orconcave facial critical contour is designed for
implants that are positioned labially or when
there is a need to transpose the peri-implantmucosal margin coronally.4

Based on the response of the peri-implantmucosal tissues to abutment/crown contour
modifications the emergence profile is further
divided into two regions: the superficial/criticalcontour and the deep/subcritical contour(Figure 2).7 The critical contour is associatedwith the cervical margin of the restoration.7 It
dictates the mucosal margin level, architecture,and shape of the tooth in the cervical region.7
The subcritical contour is located immediately
coronal to the implant platform and extends
coronally to the critical contour.7 It helps
volumetrically support the drape of the periimplant mucosa and harbors the supracrestal
tissue attachments.7 The deep/subcriticalcontour should help facilitate a gradual andharmonious transition from the implant
platform to the critical contour.7 However,this can only be appropriately facilitatedwhen the implant is positioned at an optimal
apical-coronal depth at the time of surgicalplacement.7
The critical and subcritical contours can help
alter the soft tissue architecture.1,7 These
contours can be customized and thoughtfully
modified as needed during the healing/

The subcritical facial contour is usually concave
or flat in shape and helps support the tissues
in their existing position.4,6 However, a convex
subcritical contour may be designed on
the facial aspect, when the soft tissue form
appears deficient facially.4,6 Subcritical contourin the interproximal region is usually concave
or straight in esthetic areas and straight inposterior sites; it is planned to be convex
only when tissue support is necessary or
when there is a slight deficiency.4,6 A concave
subcritical contour in the midfacial andinterproximal areas helps facilitate soft-tissue
ingrowth.6

Figure 2. Critical and Subcritical Contours of a
Restoration

Figure 1. Emergence Profile

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Diagnosing and Treatment Planning
Biologically Contoured Implant
Restorations

When the bone volume is adequate but
there is a buccal plate deficiency, implant
placement may be more palatal comparedto the optimal position thereby resulting in aridge lap restoration which may be difficult
to clean and maintain.17 Also, interproximalbone loss is associated with the loss of papillathereby resulting in compromised esthetics
and cleansibility of the restoration.13 When thepatient has hard and/or soft tissue deficiencies
they need to be informed regarding thechallenges and augmentation procedures thatare necessitated to help improve the overalloutcome.13

A restoration that provides optimal support tothe peri-implant mucosal tissues and prevents
them from injury is termed a biologicallycontoured restoration. The various factorsthat should be taken into consideration while
treatment planning biologically contoured
implant restorations include the following:
1. Assessment of the hard and soft tissues
2. Determination of peri-implant mucosal
phenotype
3. Assessment of the form of adjacent teeth
4. Assessment of the restorative space
5. 3D and restoratively driven implant planning
6. Establishing the implant surgical positioningthat is prosthetically and biologically
optimal. Interdisciplinary communication
between restorative, surgical, and laboratory
teams is critical to a well-planned implant
position especially when implant placement
and restoration are not going to be
performed by the same practitioner.

Figure 3. Deficient Hard and Soft Tissues

7. Placement of a well-contoured provisional
restoration or custom healing abutment

Determination of Peri-implant Mucosal
Phenotype
The term periodontal biotype was introduced
by Seibert and Lindhe.18 As per theirclassification, the gingiva may be categorized
into “thick-flat” or “thin-scalloped” biotypes
and is currently referred to as “periodontal/
peri-implant phenotype”.18 When the periimplant mucosal thickness is 2mm or more,
it is classified as a thick peri-implant mucosal
phenotype whereas a mucosal thicknessof 1.5mm or less is characterized as a thinphenotype.18 The thick peri-implant mucosal
phenotype is characterized by the presenceof a wide band of keratinized tissue, flat bonyarchitecture, thick marginal bone, broad
contact areas, and square-shaped anatomic
crowns.13,18 The thin peri-implant mucosal
phenotype is characterized by a narrow zone

Assessment of the Hard and Soft Tissues
Prior to the placement of an implant, it isimportant to evaluate the existing hard andsoft tissues associated with the proposed
implant site (Figure 3).13 It is reported that atleast 2mm of keratinized tissue should bepresent to maintain the long-term health of
the implant.14 Likenvicius et al., have reported
that the peri-implant crestal mucosal thicknessof 2.0 mm or less may predispose to crestal
bone loss regardless of supracrestal positionof the implant-abutment interface or platform
switching.15,16 In addition to the thicknessof peri-implant mucosal tissues, history of
periodontal disease which affects the presence/
absence of a buccal plate and the interproximalbone should also be reviewed.14

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of keratinized tissue, pronounced scallopingof the tissue, thin marginal bone, narrowproximal contact areas, triangular crownmorphology, and reduced quantity and qualityof keratinized tissues.18 A site with a thin periimplant mucosal phenotype has an increased
risk of marginal and papillary recession andbony dehiscence and fenestration. Therefore,such tissues must be handled carefully during
surgery, making of impressions, and restorative
procedures.13 Surgical implant placement inthin phenotype patients should be performed
more palatally, and slightly deeper to mask
the visibility of titanium and facilitate thedevelopment of a proper emergence profile.13
Further, phenotype modification proceduresmust be considered to enhance implant soft
tissue stability and esthetics.19

in teeth with a triangular-shaped crownmorphology, the black triangle embrasurespace created due to the loss of papilla isdistinctly visible.21 This is associated withnarrow interproximal contact areas thatare located close to the incisal aspect of the
tooth crown.21 Teeth with a triangular crownmorphology are also associated with a thinperi-implant mucosal phenotype.21
Assessment of the Restorative Space
Restorative space is the 3-dimensional oral
space available to receive the proposed
prosthodontic restoration.22 It may bemeasured conventionally using mounted casts
on an articulator (Figure 6) or digitally during
implant planning (Figure 7).22 Misch suggeststhat at least 7-8mm of vertical restorative space(dimension between the implant platform andthe occlusal plane) should be available forrestoring a single implant crown estheticallyand functionally.23 Inadequate restorative
space leads to the development of restorations
with suboptimal contours (ball on a stickappearance).22 However, excessive verticalrestorative space results in an increased
vertical cantilever and ultimately a magnified,
off-axis load on the implant.24 In the mesiodistal
dimension, at least 7mm of restorative spaceis necessary for optimal restoration of a single
implant.25 Restoring implants with excess
space in the mesiodistal dimension also results
in a horizontal cantilever and consequently
magnified, off-axis forces that can overload
the implant-restoration system.26 It has also
been noted that an emergence angle of > 30
degrees is associated with an increased risk forperi-implantitis and limited restorative space
may also result in increasingly high emergenceangle.27

Assessment of the Form of Adjacent Teeth
It is important to match the shape of theimplant restoration with the shape of theadjacent teeth, as it affects its appearance
and final esthetic outcome.13 The dental crownmorphology may be classified as square or
triangular (Figures 4 & 5).20 In teeth with asquare-shaped crown morphology, the “black
triangle” open embrasure created due to theloss of papilla is relatively inconspicuous.20,21
This is associated with broad interproximal
contact areas that are located close to thecervical aspect of the tooth crown.21 However,

3-D (3-dimensional) and Restoratively
Driven Implant Planning

Figure 4. Square-shaped Crown Morphology

A prosthetic wax-up is critical in the implant
treatment planning process to help assess
tissue deficiencies and the final restorative
position.13 Cone-beam computerized
tomography (CBCT) scans in conjunction withintraoral scans are routinely used for implant
planning in partially edentulous patients.28,29
The data obtained from the CBCT scans,

Figure 5. Triangular Crown Morphology

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Establishing Proper Communication with
the Implant Surgeon and Determining Ideal
Implant Position
During implant planning, communication among
all members of the implant treatment teamis required to ensure ideal implant surgicalposition. Once the implant is placed, its position
cannot be altered! The restorative dentist andthe implant surgeon can collaboratively decideon the ideal implant angulation and bodily
position based on the prosthetic position andthe type of the implant restoration desired.31
In addition, the surgeon should be specificallyinformed regarding the desired cervico-enamel
junction (CEJ) level and the timing of provisional
restoration placement. A 3D surgical guide thatis based upon careful implant planning and isstable intersurgically should be provided to thesurgeon for the implant placement procedure.31

Figure 6. Restorative space assessed on an articulator
using a clinically approved wax-up.

Ideal implant body position
The correct three-dimensional implant position(interproximal, bucco-lingual, inciso-apical, andaxial inclination) is a fundamental factor inproviding a natural-looking final restoration.4,7
Mesio-distally, the implant should be centeredin the missing tooth space with at least 1.5mm
space between the implant platform andadjacent tooth CEJ to provide optimal tissue
contours and appropriately distribute theforces.32 It has been reported that maintaining
the minimum 1.5mm distance ensures thatthe potential vertical defect associated with
the implant (smooth collared implants) will notaffect the bone of the adjacent natural toothand thus help in maintaining the interdental
papilla.33 Faciopalatally, the implant should bepositioned 2mm from the buccal plate at the
crest and 1.5mm or more from the palatalbone.34,35 Implants planned in the anterior
region of the jaw should have a cingulum/
incisal sagittal angulation. Posterior implants
should be positioned such that their long axes
are perpendicular to the occlusal plane.36,37
Incisoapically, implants planned in the anterior
and the posterior regions of the jaw shouldbe placed 3-4mm and 2-3mm respectively
below the ideal prospective zenith of theplanned restoration.4 Implant placement thatis too apical may predispose the implant toperi-implantitis and adversely affect the bone

Figure 7. Restorative space measured digitally during
implant planning.

intraoral scans, and the prosthetic wax-up is
combined and used for 3D implant planningin dedicated software.29 3D implant planning
helps assess the 3 dimensional bone volume ofthe edentulous site and the health of adjacent
teeth.30 It also aids in determining the optimal
restorative implant position with respect tothe bony architecture.29 It is also critical todecide the type and design of the restoration(screw or cement retention) at this point in theplanning process to ensure a restoration withhygienically cleansable contours.

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levels around the implant. Shallow implant
placement (with a standard-diameter implant)
leads to insufficient crown-height restorative
space, and consequesntly the development of an
abrupt flare in the emergence of the restoration(Figure 8).4,38 Osteoplasty may be performed insuch situations to permit implant placement at
the ideal restorative depth. This will allow thedevelopment of a gradual flare in the emergenceof the restoration.

of the edentulous area.45 In such situations,a provisional restoration may be utilized tocondition the mucosal tissues around the implantso that an ideal emergence profile can beachieved in the final restoration.46 Conditioning,or shaping, of the soft tissues is a gradual andtime-consuming process necessitating multiple
appointments. At these visits the transmucosal
contour of the provisional restoration is modified
using flowable composite resin or acrylic resin toreshape the peri-implant tissues and sculpt thedesired morphology (Figures 9, 10 & 11).46-48

Figure 8. Suboptimal emergence profile associatedwith shallow and off-centered implant placement
and/or improper implant diameter.

Figure 9. Provisional restoration placed for
conditioning tissues.

Placement of a Well-contoured Provisional
Restoration/Custom Healing Abutment
Traditionally, stock healing abutments areattached to the implant at the time of implant
placement or second-stage surgery to promotehealing of the peri-implant soft tissues.39
However, their rounded configuration createsa circular soft-tissue contour that typically does
not replicate the original soft tissue architectureof the tooth being replaced. This consequently
results in the fabrication of an unesthetic final
restoration with contours that are difficult for thepatient to maintain hygienically.39,40

Figure 10. Improvement in soft tissue contours(occlusal view) observed after removal of theprovisional restoration.

Provisional restorations are widely used in theanterior esthetic zone (after implant placement
or the second stage surgery ) for immediate
restoration of esthetics and function.41 In theanterior regions of the mouth, the extracted
tooth/crown may be modified and used as aprovisional restoration to maintain the soft tissue
architecture.42
Immediately placed implants in conjunction
with immediate provisional restorations help
maintain and preserve the soft tissue height andgingival profile established by natural teeth.36,43,44
However, when implant placement is delayed,ridge resorption leads to the loss of osseous
structures, overlying mucosal tissues, and contour

Figure 11. Improvement in soft tissue contours(Facial view) observed after removal of theprovisional restoration.

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The contour of the provisional restoration
crown also helps determine the contactpoint position with the adjacent teeth. The
proper positioning of the contact area iscritical to positively affect the development ormaintenance of the interproximal papilla.49 To
maintain the interproximal papilla/facilitate its
growth, the distance from the interproximalbone crest (of the adjacent tooth) to the apicalextent of the contact point (established by theprovisional restoration) should be less than orequal to 5 mm.49,50

They are also avoided in patients exhibitinga deep anterior bite, signs of bruxism, and/or malocclusion.50 In such situations, acustomized healing abutment may be utilized
for soft tissue conditioning.50 The submucosal
portion of the customized healing abutment
is essentially the same as a provisional
restoration, however, it lacks occlusal contact(Figures 12 & 13).5050

A customized healing abutment may beplaced at the time of implant placement or
the second-stage surgery.53 When placed at
the time of implant surgery, it conditions thesoft tissues,47 contains bone graft materials,53
covers the surgical site (without the need for
an invasive procedure),54 maintains the alveolarbone contour,53 prevents food lodgment,53 andeliminates the need for a second-stage surgery
and placement of a provisional restoration.52,53
The custom healing abutment aims to
reproduce the natural cervical contours of theextracted tooth thereby maintaining the soft
tissue architecture during osseointegration
and/or healing of the peri-implant mucosa(Figure 14).55 Its contours may be gradually
modified until the desired soft tissue form
is achieved. However, its fabrication is timeconsuming and requires multiple steps both
chairside and in the dental laboratory.56 Also,
if the resin is incompletely polymerized it may
cause soft tissue irritation in some patients.56

A well-contoured provisional restoration
not only helps the mucosal tissue grow anddevelop optimally but it also serves as atemplate for the final restoration.51 In addition,
the provisional restoration helps in assessment
and understanding the patient’s expectations
which are also critical to the success andacceptance of the final clinical outcome.51 The
disadvantages of provisional restorations
include the need for extra time, materials,
components, technical skill, and added financial
liability.41 Further, minimal implant stability
at the time of surgical implant placement isrequired to ensure stability for immediateprovisionlization.
The placement of an overcontoured provisional
restoration may result in excessive pressure
on the mucosa thereby leading to transientischemia, tissue inflammation, and/or
necrosis.46 This may be clinically visible asblanching of the peri-implant tissues during
seating of the provisional restoration.48 If the
blanching persists for more than 10 minutes,
the provisional restoration crown should
be removed and its critical and subcriticalcontours should be evaluated and adjusted/
reduced as necessary.
Placement of a Customized Healing
Abutment
Immediate provisional restorations may becontraindicated in the posterior quadrantsof the oral cavity (as increased masticatory
forces adversely affect osseointegration of
the implant during the healing phase) and in
implants with suboptimal primary stability.41,47,

Figure 12. Custom healing abutment attached to theimplant (occlusal view).

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help maintain and preserve the soft
tissue height and profile from the time ofextraction.36, 43 The custom healing abutment
is attached to the implant (immediately
following its placement) and left in place until
osseointegration and tissue maturation areachieved. After the completion of the healing
phase, the preserved soft tissue contour
is replicated in the definitive restoration.41
Customized healing abutments may befabricated using the direct or indirect method.
Figure 13. Custom healing abutment attached to theimplant (buccal view).

Direct Method
The direct method involves selecting andpreparing a temporary abutment extraorally byadding a light polymerized flowable composite
resin.50 The abutment is placed intraorally,
and additional composite resin is added to fill
the space between the temporary abutment
and the soft tissue margin (established by thenatural tooth that was extracted).50 The additionof composite resin should be performed
incrementally and with caution to prevent theresin material from flowing over the implantsurface.50 The abutment is then taken out of
the mouth and attached to an implant analog.
Composite resin is added to the assembly tofill in voids and develop a proper emergenceprofile.50 The custom-healing abutment is triedin intraorally to ensure the achievement of
optimal soft tissue support.50 Once contour
is finalized, it is finished, and polished. The
supramucosal extension of the temporary
abutment is cut at the coronal aspect to thelevel of the composite resin. This technique
should be implemented prior to the placementof bone graft material. Next, graft material
may be placed (if necessary) and the custom
healing abutment is attached to the implant. A
radiograph is taken to ensure intimate seating
and appropriate orientation.

Figure 14. Maintenance of soft tissue formed by thecustom healing abutment.

Techniques for Fabricating Custom
Healing Abutments

The concept of customizing the standard
healing abutment was first described by Pow
and McMillan.57 This was accomplished byaltering the size and transmucosal shape of astock healing abutment.57 Customized healing
abutments can be fabricated using different
materials and various techniques depending on
the timing of implant placement.

Indirect Method
The indirect method involves making a
conventional implant-level impression ordigitally recording the implant position
immediately after tooth extraction and implant
placement and fabricating the custom healing
abutment on the cast or with computer-aided
design-computed aided manufacturing (CADCAM) techniques. In addition, digital and CADCAM technology may be utilized to prefabricate
a customized healing abutment prior to theimplant placement procedure.47

Immediate Implant Placement with
Immediate Custom Healing Abutment
Placement
Immediate implants and immediate custom
healing abutments (or provisional restorations)9

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Delayed Implant Placement with Immediate/
Delayed Custom Healing Abutment Placement
When implant placement is delayed, ridge
resorption leads to the loss of osseous
structures, overlying mucosal tissues, andcontour of the edentulous area.45 Conditioningof the peri-implant mucosal tissues is required
so that an ideal emergence profile can beachieved in the final restoration.43,58 This may be
accomplished using a custom healing abutment.
In these cases, the custom healing abutment
may be fabricated:

The procedural steps for fabricating a custom
healing abutment using the cervical contouringconcept are shown in the following Table 2: 60
CAD-CAM Fabrication of Custom Healing
Abutments
Currently, CAD-CAM technology is being
commonly used for the fabrication of custom
healing abutments.61,62 The data obtained
from intraoral and cone beam computerized
tomography scans is imported into the
CAD software and used for designing thecustom healing abutment. The individual
emergence profile of the custom healing may
be designed by mirror flipping the emergenceprofile of the contralateral tooth or by using
the CBCT measurements of human teeth
crosssections.40,61,63 The custom healing abutment
is then milled using CAM technology.

Chairside Fabrication of Custom Healing
Abutments
Various cervical formers (templates) (Figure15) are available to help with the chair-side
fabrication of custom healing abutments.
Some manufacturers also sell pre-fabricatedformers, similar to prefabricated polycarbonate
provisional crown shells, that may be used forease of creation of custom healing abutments.
The procedural steps are shown in the following
Table 1:

Clinical Workflow for Fabricating
Biologically Contoured Restorations

The soft tissue form established by theprovisional restoration/custom healing
abutment should be recorded while transitioning
from provisional restoration to definitive
restoration.10,41,64,65 It may be recorded digitallyusing an intraoral scanner or conventionallyby making an implant-level impression witha custom impression coping to avoid tissue
collapse.10,64,66
Custom Impression Coping
A custom-made impression coping should mimic
the exact submucosal emergence profile of theprovisional restoration or the custom healing
abutment (Figure 27).

Figure 14. Maintenance of soft tissue formed by thecustom healing abutment.

Conventional Laboratory Fabrication ofCustom Healing Abutments
Bichacho introduced the cervical contouringconcept for developing soft tissue architecturewith a main focus on the marginal soft tissuelevel and the facial zenith position.59,60 The
cervical contouring concept involves modifying
the implant level cast (through conventional
sculpting of the sub-mucosal contour) and thenusing it for the fabrication of custom healing
abutment.60

Figure 27. Custom Impression Coping(Picture provided by Dr. Russell Wicks)

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Table 1 Cont.

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Table 1 Cont.

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Table 2 Cont.

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The procedural steps for the fabrication of a custom impression coping are shown in the following
Table 3:

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Table 3 Cont.

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Next, the interocclusal record, the opposing
arch, and the shade are recorded. The
restoration is fabricated and placed using
standard prosthodontic procedures.

abutment. Depending on the thickness ofthe soft tissues, implant position, and timingof placement, the transmucosal region of
the provisional restoration/custom healing
abutment may require different shapes.
Provisionalisation/placement of a custom
healing abutment is a crtical step to help
achieve optimal implant esthetics and soft
tissue contours in a final restoration. Carefulattention to the key steps in the fabricationand development of provisionals and/or
custom healing abutments can optimize
implant success and patient satisfaction.

Summary

Thorough diagnosis and treatment planning
are necessary to develop the optimaltransmucosal contours of an implant
restoration. The contour of the soft tissues
may be either preserved at the time of tooth
extraction or subsequently reconstructedusing a provisional restoration/custom healing

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Course Test Preview

To receive Continuing Education credit for this course, you must complete the online test. Please
go to: www.dentalcare.com/en-us/ce-courses/ce684/test
1. Which two factors play a critical role in developing an optimal emergence profile?
A. Implant position and bone volume
B. Implant position and tissue volume
C. Restoration position and bone volume
D. Restoration position and tissue volume
2. The emergence profile of a restoration will affect the ___________.
A. esthetics and occlusion.
B. esthetics and the periodontal health of the surrounding soft tissues.
C. occlusion and periodontal health of the surrounding soft tissues.
D. orthodontic stability.
3. Consider the following two statements:
The subcritical contour is associated with the cervical margin of the restoration.
The critical contour is located immediately coronal to the implant platform.
A. Both the statements are false.
B. Both the statements are true.
C. The first statement is true the second is false.
D. The first statement is false, the second is true.
4. The interproximal critical contour affects the _____________ .
A. apparent shape of the crown.
B. position of the facial gingival margin.
C. shape of the crown and the zenith of the facial margin.
D. zenith of the facial mucosal margin.
5. Which form/shape is most commonly used while designing the subcritical facial contour?
A. Concave
B. Convex
C. Convexo-concave
D. Straight
6. What is the minimum amount of keratinized tissue thickness that should be present tomaintain the long-term health of the implant?
A. 1mm
B. 2mm
C. 3mm
D. 4mm
7. A thick peri-implant mucosal phenotype has a mucosal thickness of __________.
A. equal to or more than 0.3mm.
B. equal to or more than 0.5mm.
C. equal to or more than 1.3mm.
D. equal to or more than 1.6mm.
E. equal to or more than 2mm.

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8. Which of the following is a characteristic of thin peri-implant mucosal phenotype?
A. broad contact areas.
B. large amount of keratinized tissue.
C. flat bony architecture.
D. thick marginal bone.
E. triangular anatomic crowns.
9. Consider the following two statements:
Mesio-distally, the implant should be centered in the missing tooth space with at least
2.5mm space between the implant and the adjacent tooth CEJ to provide optimal tissue
contours and appropriately distribute the forces.
Maintaining the minimum distance ensures that the vertical defect associated with theimplant will not affect the bone of the adjacent natural tooth.
A. Both the statements are false.
B. Both the statements are true.
C. The first statement is true the second is false.
D. The first statement is false, the second is true.
10. Which of the following would be indicated to maintain/condition the soft tissues when theimplant has suboptimal primary stability?
A. Custom healing abutment
B. Customized impression coping
C. Provisional restoration
D. Stock healing abutment

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References

1. González-Martín O, Lee E, Weisgold A, Veltri M, Su H. Contour management of implant
restorations for optimal emergence profiles: Guidelines for immediate and delayed provisional
restorations. Int J Periodontics Restorative Dent. 2020;40(1):61-70.
2. Rojas-Vizcaya F. Biological aspects as a rule for single implant placement. The 3A-2B rule: aclinical report. J Prosthodont. 2013;22(7):575-80.
3. Beretta M, Poli PP, Pieriboni S, Tansella S, Manfredini M, Cicciù M, Maiorana C. Peri-implant soft
tissue conditioning by means of customized healing abutment: A randomized controlled clinical
trial. Materials. 2019;12(18):3041.
4. Esquivel J, Meda RG, Blatz MB. The impact of 3d implant position on emergence profile design.
Int J Periodontics Restorative Dent. 2021;41(1):79-86.
5. Liu X, Tan Y, Liu J, Tan J. A digital technique for fabricating implant-supported interim
restorations in the esthetic zone. J Prosthet Dent. 2018;119(4):540-4.
6. Chu SJ, Kan JY, Lee EA, Lin GH, Jahangiri L, Nevins M, Wang HL. Restorative emergence profilefor single-tooth implants in healthy periodontal patients: Clinical guidelines and decisionmaking strategies. Int J Periodontics Restorative Dent. 2019;40(1):19-29.
7. Su H, Gonzalez-Martin O, Weisgold A, Lee E. Considerations of implant abutment andcrown contour: critical contour and subcritical contour. Int J Periodontics Restorative Dent.
2010;30(4):335-43.
8. The Glossary of prosthodontic terms 2023: Tenth edition. J Prosthet Dent. 2023;130(4 Suppl1):e1-e3.
9. Minoru S, Sato D, Baba K. Optimization of emergence profile of implant prosthesis: a literature
review. Scientific Dental Journal. 2018;2(1):31. Accessed June 6, 2024
10. Son MK, Jang HS. Gingival recontouring by provisional implant restoration for optimal
emergence profile: report of two cases. J Periodontal Implant Sci. 2011;41(6):302-8.
11. Bishara M, Kurtzman GM, Krause ES. Implant restorations: Establishing a proper emergence
Profile. Compend Contin Educ Dent. 2020 Sep;41(8):e16-e20.
12. Alshiddi IF, Dent DC. Accurate registration of peri-implant soft tissues to create an optimal
emergence profile. Contemp Clin Dent. 2015;6(Suppl 1):S122-5.
13. Jivraj S, Chee W. Treatment planning of implants in the aesthetic zone. Br Dent J.
2006;201(2):77-89.
14. Ramanauskaite A, Schwarz F, Sader R. Influence of width of keratinized tissue on the prevalenceof peri-implant diseases: A systematic review and meta-analysis. Clin Oral Implants Res.
2022;33 Suppl 23:8-31.
15. Linkevicius T, Puisys A, Steigmann M, Vindasiute E, Linkeviciene L. Influence of Vertical Soft
Tissue Thickness on Crestal Bone Changes Around Implants with Platform Switching: A
Comparative Clinical Study. Clin Implant Dent Relat Res. 2015 Dec;17(6):1228-36.
16. Linkevicius T, Apse P, Grybauskas S, Puisys A. The influence of soft tissue thickness on crestal
bone changes around implants: a 1-year prospective controlled clinical trial. Int J Oral Maxillofac
Implants. 2009 Jul-Aug;24(4):712-9
17. Cavallaro J, Greenstein, G. Prosthodontic complications related to non-optimal dental implant
placement. Dental Implant Complications: Etiology, Prevention, and Treatment. 2010:156-71.
Accessed June 6, 2024
18. Seibert JL, Lindhe J. Esthetics and periodontal therapy. In: Lindhe J, editor. Textbook of Clinical
Periodontology. 2nd ed. Copenhangen, Denmark: Munksgaard; 1989. pp. 477–514. Accessed
June 6, 2024
19. Lin GH, Curtis DA, Kapila Y, Velasquez D, Kan JYK, Tahir P, Avila-Ortiz G, Kao RT. The significanceof surgically modifying soft tissue phenotype around fixed dental prostheses: An American
Academy of Periodontology best evidence review. J Periodontol. 2020 Mar;91(3):339-351.
20. Song JW, Leesungbok R, Park SJ, Chang SH, Ahn SJ, Lee SW. Analysis of crown size andmorphology, and gingival shape in the maxillary anterior dentition in Korean young adults. J
Adv Prosthodont. 2017;9(4):315-20.

21
Crest® + Oral-B® at dentalcare.com

21. Singh VP, Uppoor AS, Nayak DG, Shah D. Black triangle dilemma and its management in esthetic
dentistry. Dent Res J (Isfahan) 2013;10(3):296-301.
22. Ahuja S, Cagna DR. Defining available restorative space for implant overdentures. J Prosthet
Dent. 2010;104(2):133-6.
23. Misch C. Dental Implant Prosthetics, Second Edition, Elsevier Health Sciences, St. Louis, MO,
2015.
24. Nissan J, Ghelfan O, Gross O, Priel I, Gross M, Chaushu G. The effect of crown/implant ratio andcrown height space on stress distribution in unsplinted implant supporting restorations. J Oral
Maxillofac Surg. 2011;69(7):1934-9.
25. Shenoy, Vidya Kamalaksh. Single tooth implants: Pretreatment considerations and pretreatment
evaluation. J Interdiscip Dent. 2012;2(3):149-57.
26. Monteiro DR, Silva EV, Pellizzer EP, Filho OM, Goiato MC. Posterior partially edentulous jaws,
planning a rehabilitation with dental implants. World J Clin Cases. 2015;3(1):65-76.
27. Katafuchi M, Weinstein BF, Leroux BG, Chen YW, Daubert DM. Restoration contour is a risk
indicator for peri-implantitis: A cross-sectional radiographic analysis. J Clin Periodontol. 2018
Feb;45(2):225-232.
28. van Hooft J, Kielenstijn G, Liebregts J, Baan F, Meijer G, D’haese J, Bronkhorst E, Verhamme L.
Intraoral scanning as an alternative to evaluate the accuracy of dental implant placements inpartially edentate situations: A prospective clinical case series. J Clin. Med. 2022;11(19):5876.
29. Flügge T, Kramer J, Nelson K, Nahles S, Kernen F. Digital implantology-a review of virtualplanning software for guided implant surgery. Part II: Prosthetic set-up and virtual implant
planning. BMC Oral Health. 2022;22(1):23.
30. Bianchi J, Mendonca G, Gillot M, Oh H, Park J, Turkestani NA, Gurgel M, Cevidanes L. Threedimensional digital applications for implant space planning in orthodontics: A narrative review. J
World Fed Orthod. 2022;11(6):207-15.
31. Luthra KK. Implant success!!!.....simplified. J Indian Soc Periodontol. 2009;13(1):27-9.
32. Liu W, Zhu F, Samal A, Wang HL. Suggested mesiodistal distance for multiple implant placement
based on the natural tooth crown dimension with digital design. Clin Implant Dent Relat Res.
2022;24(6):801-8.
33. Su, CY, Fu JH, Wang HL. The role of implant position on long-term success. Clin Adv Periodontics
2014;4:187-93.
34. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant relationship on esthetics.
Int J Periodon Restor Dent. 2005;25:113-9.
35. Ebenezer S, Kumar VV, Thor A. Basics of dental implantology for the oral surgeon. In:
Bonanthaya, K., Panneerselvam, E., Manuel, S., Kumar, V.V., Rai, A. (eds) Oral and Maxillofacial
Surgery for the Clinician. Springer, Singapore 2021. Accessed June 6, 2024
36. Meng HW, Chien EY, Chien HH. Immediate implant placement and provisionalization in theesthetic zone: A 6.5-year follow-up and literature review. Case Rep Dent. 2021;2021:4290193.
37. Verma, Mahesh; Nanda, Aditi; Sood, Abhinav. Principles of occlusion in implant dentistry. J Int
Clin Dent Res Org. 2015;7(Suppl 1):p S27-S33.
38. Hamilton A, Putra A, Nakapaksin P, Kamolroongwarakul P, Gallucci G.O. Implant prosthodontic
design as a predisposing or precipitating factor for peri-implant disease: A review. Clin Implant
Dent Relat Res 2023;25(4):710-22.
39. Chokaree P, Poovarodom P, Chaijareenont P, Yavirach A, Rungsiyakull P. Biomaterials andclinical applications of customized healing abutment-A narrative review. J Funct Biomater.
2022;13(4):291.
40. Teślak M, Ziemlewski A, Foltyn I, Ordyniec-Kwaśnica I, Drogoszewska B. Development of custom
anatomic healing abutment based on cone-beam computer tomography measurement on
human teeth cross-section. Materials. 2021;14:4570.
41. Santosa RE. Provisional restoration options in implant dentistry. Aust Dent J. 2007;52(3):234-42;
quiz 254.

22
Crest® + Oral-B® at dentalcare.com

42. Ladino LG, Rosselli D. Use of extracted anterior teeth as provisional restorations and surgical
guide for immediate multiple implant placement: A clinical case report. J Esthet Restor Dent.
2019;31(3):209-12.
43. Khzam N, Arora H, Kim P, Fisher A, Mattheos N, Ivanovski S. Systematic review of soft tissue
alterations and esthetic outcomes following immediate implant placement and restoration of
single implants in the anterior maxilla. J Periodontol. 2015;86(12):1321-30.
44. Kan JY, Rungcharassaeng K, Lozada J. Immediate placement and provisionalization of maxillaryanterior single implants: 1-year prospective study. Int J Oral Maxillofac Implants 2003;18(1):319.
45. Pagni G, Pellegrini G, Giannobile WV, Rasperini G. Postextraction alveolar ridge preservation:
biological basis and treatments. Int J Dent. 2012;2012:151030.
46. Wittneben JG, Buser D, Belser UC, Bragger U. Peri-implant soft tissue conditioning with
provisional restorations in the esthetic zone: The dynamic compression technique. Int J
Periodontics Restorative Dent. 2013; 33(4):447-55.
47. Beretta M, Poli PP, Pieriboni S, Tansella S, Manfredini M, Cicciù M, Maiorana C. Peri-implant
soft tissue conditioning by means of customized healing abutment: A randomized controlled
clinical trial. Materials. 2019;12(18):3041.
48. Bichacho N, Landsberg CJ. Single implant restorations: Prosthetically induced soft tissue
topography. Pract Periodontics Aesthet Dent. 1997;9(7):745-52.
49. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to thecrest of bone on the presence or absence of the interproximal dental papilla. J Periodontol.
1992 Dec;63(12):995-6.
50. Janakievski J. Case report: Maintenance of gingival form following immediate implant
placement - The custom-healing abutment. Advanced Esthetics & Interdisciplinary Dentistry.
2007;3:24-8.
51. Sutariya PV, Mehta SP, Upadhyay HH, Pathan MR, Patel SR, Bhatia YA. The soft tissue esthetic
outcome with and without immediate provisionalization in immediate implants: A systematic
review and meta-analysis. J Indian Prosthodont Soc. 2022;22(1):2-12.
52. Ruales-Carrera E, Pauletto P, Apaza-Bedoya K, Volpato CAM, Özcan M, Benfatti CAM. Periimplant tissue management after immediate implant placement using a customized healing
abutment. J Esthet Restor Dent. 2019;31(6):533-41.
53. Akin R, Chapple AG. Clinical advantages of immediate posterior implants with custom healing
abutments: Up to 8-year follow-up of 115 cases. J Oral Maxillofac Surg. 2022 ;80(12):1952-65.
54. Menchini-Fabris GB, Cosola S, Toti P, Hwan Hwang M, Crespi R, Covani U. Immediate implantand customized healing abutment for a periodontally compromised socket: 1-year follow-up
retrospective evaluation. J Clin Med. 2023;12(8):2783.
55. Douglas M. Custom healing abutment fabrication using extracted teeth. Replicating the natural
emergence profile supports the dentogingival complex, facilitates hygiene
Inside Dental Technology 2023;14(1).
56. Vág J, Freedman G, Szabó E, Románszky L, Berkei G. Cervical tooth anatomy considerations for
prefabricated anatomic healing abutment design: A mathematical formulation. J Prosthet Dent.
2022;127(6):852-9.
57. Pow EHN, McMillan AS. A modified implant healing abutment to optimize soft tissue contours:
A case report. Implant Dent. 2004;13:297–300.
58. Almadani TM, Abozaid HM, Elsayed IS, Amer AM. Clinical and radiographic evaluation of periimplant tissue changes associated with use of standard versus customized healing abutments.
Al-Azhar Journal of Dental Science 2023;26:229-39. Accessed June 6, 2024
59. Bichacho N. Cervical contouring concepts: enhancing the dentogingival complex. Pract
Periodontics Aesthet Dent. 1996;8(3):241-54; quiz 256. PMID: 9028279.
60. Bichacho N, Landsberg CJ. A modified surgical/prosthetic approach for an optimal single
implant-supported crown. Part II. The cervical contouring concept. Pract Periodontics Aesthet
Dent. 1994;6(4):35-41; quiz 41. PMID: 8054640.

23
Crest® + Oral-B® at dentalcare.com

61. Zeng H, Zhou M, Ge Y, Yao Y, Cai X. Digital workflow in the design of individualized emergenceprofiles of implant restorations based on the contralateral tooth. J Prosthodont Res. 2024 Jan 3.
62. Alshhrani WM, Al Amri MD. Customized CAD-CAM healing abutment for delayed loaded
implants. J Prosthet Dent. 2016;116(2):176-9.
63. El-Danasory MB, Khamis MM, Abdel Hakim AA, Fahmy RA. CAD-CAM custom healing abutments:
A dental technique. J Prosthet Dent. 2022 Nov 8:S0022-3913(22)00638-2.
64. Chee WW, Cho GC, Ha S. Replicating soft tissue contours on working casts for implant
restorations. J Prosthodont 1997;6:218-20.
65. Buskin R, Salinas TJ. Transferring emergence profile created from the provisional to thedefinitive restoration. Pract Periodontics Aesthet Dent. 1998;10:1171-9.
66. Patras M, Martin W. Simplified custom impression post for implant-supported restorations. J
Prosthet Dent. 2016;115(5):556-9.
Additional Resources•

No Additional Resources Available

About the Author
Swati Ahuja, BDS, MDS
Dr. Ahuja graduated with a BDS from Nair Hospital Dental College in 2002 and an MDS certificate
in Prosthodontics from the University of Tennessee Health Science Center,
Memphis, TN. She then joined the same University as an Assistant Professor
in the Department of Prosthodontics where she worked for 3 and half years.
She served as the editor for the Department of Prosthodontics at Universityof Tennessee Health Science Center, Memphis, TN for the next 6 years. She
has lectured nationally and internationally on various prosthodontic topics atvarious dental conferences. She has more than 60 publications in peer reviewed
national and international journals. Dr. Ahuja is also the co-author of the
textbook titled, “Applications of the Neutral Zone in Prosthodontics.” Currently,
she has a private practice in Mumbai.
Updated: Nov 2022
Email: swatiahuja@gmail.com

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