Tissue Impingment?

[ParkwayDental]

Hey everyone, we have been doing a lot of custom abutments these days and although we have been to numerous classes and certifications I just had a question hit me today.

When I design my custom abutment I design it at 1mm sub gingival on the buccal, .5mm sub gingival on the mesial and distal, and right at crest on the lingual so the GP can get the excess cement out with out having any issues.

Well my question is how far can I impinge the tissue? Sadly to say most of our docs do not do any tissue management of forming the tissue when doing their temps, so most of the time the tissue is the same diameter as the implant. Well I know every patient is different but how far can I push that tissue without causing problems? Is there any research and articles on this?

-John Wilson I know your a big Nobel guy and we have been threw some of their courses and we do a monthly meeting with all of our GPs and OFS in town sponsored by Nobel covering a numerous amount of things, and even had Dr. Sam Strong come do a presentation, but this is the first time this has hit me? Does Nobel have and standars on this?

 

[2thm8kr]

Unlike traditional crown and bridge, where you don't really want any impingment of soft tissues.
Make the tissue conform to the implant abutment, it will after a little blanching, and after a few minutes
blood flow returns and the tissue looks normal again. There are techniques for incising the tissue to relieve
it for really large posterior abutments, but I wouldn't do that for any of my clinicians except for the most
apt that I deal with. Plus it I don't see the patient enjoying that procedure and/or refering their friends/family
for implant treatment.

 

[Labwa]

If i need to change the emergence for aesthetic cases i adjust the tissue on the model(within reason). i would rather have the patient deal with a little pain at insert and have a better formed implant crown. If the dentist doesn't appreciate that maybe they need to spend time in a aesthetic implant class. i had a dentist send me a case he wanted no pressure on the tissues. He said 10 seconds of blanching was too long and wouldn't insert any crown that blanches. Needless to say i dont work for him anymore.

 

[Jo Chen]

As you have discovered, there is no hard and fast rule how much tissue can be displaced. Three options present themselves; no blanching, slight blanching and disregard soft tissue. Each practitioner has their own preferences. It is up to you to find out what the dentist likes if he does not indicate his preference on the Rx. Atlantis has perfected preference options on their Rx, not only tissue displacement but also the sub gingival emergence profile.
With that said there are some conditions to consider in general in regards to the emergence profile design.
1. Tissue thickness
Thin biotype tissue most often encountered in the maxillary anterior region (labial) will not tolerate displacement well.
2. Tissue consistency
This can range from tough leather like (inflexible) to the consistency of Jell-O (very flexible).
3. Tissue depth
Lots of tissue above the implant will allow you to more freely design the emergence profile as opposed to limited tissue height above the implant.

 

[Affinity]

I think tissue management has to start at placement.. If the Dr doesnt guide the tissue, an abutment will almost always impinge. I have a case Im working on #7, custom zr abut. and its a nobel bone level.. this thing is like 7-8 mm sub g. and it is so narrow its almost impossible to fit the interface and abutment in there with the minimum space required for the zr interface.. Sometimes it its just going to impinge.. I agree the Dr should note what type of tissue the pt. has.. this can affect the outcome of the entire implant... Correct me if Im wrong but I was taught severe tissue impingement KILLS soft tissue, obviously because there is not blood flowing.. So you must be careful in these situations..