Tissue Sculpting

[user name]

When I get implant cases in, the impression usually looks like the gingiva is tight against the impression coping. How do you know how much you can sculpt away with out being too much or too little? I must be just getting lucky and guessing close, but there must be a better way than guessing.

Please teach me.

 

[2thm8kr]

I don't really have a recipe, but for the most part I make the tissue conform to my restoration. There is a limit to how much you can get away with especially if the tissue is keratinized.
If you look closely at the surface of the tissue and it appears grainy. It is usually an indication that the tissue is keratinized. You will not get away with sculpting that tissue. It has no give.
The tissue blanches and the patients whinge, but the tissue conforms rapidly. Usually by the end of the appointment. Not much help, but something.

 

[CatamountRob]

If it was up to me, I'd relieve enough tissue to make it as ideal as possible. I have accounts that I can do that with and others that want no blanching at all, so I can relieve almost nothing on their cases.

 

[zero_zero]

I'd talk with the dentist about prescribing tissue training healing caps for their patients...it makes a big difference...

 

[dimtsic]

For larger cases or ones we have doubts we have prototypes tried in.This step helps us determine if our tissue mods are realistic and comfortable for patient (cleaning,pressure,aesthetics)
Our clients then can confirm and communicate by griding or adding if necessary then we replicate what was confirmed intraorally. It is an extra step but worth while since occlusion can also be verified at the same time.

 

[cipro]

All these suggestions should work to some degree but the safest way to go is to follow the emergence profile of the teeth desired.
I usually start with a full contour wax up and then mark its gingival profile on the solid or soft tissue part of the cast, al this point I removing the tissue towards the fixture following the emergence profile of the tooth, this way the amount of tissue removed is controlled and the end result should be as close as possible to the tooth required.

 

[JohnWilson]

With bone level fixtures becoming the norm your knowledge and understanding of how a fixture is placed is helpful in determining when and where to contour tissue. One of our requirement for every case now is to have a PA emailed and tagged to the case in the cloud. This has many obvious benefits and allows us to make sure our clients have taken an impression with the assembly fully seated. It also helps when clients send in a multi unit case with impression copings of different heights the are not labeled. BTW I hate that implant companies (ASTRA ESPECIALLY) have made the top portion EXACTLY the same so you can screw this up.,

Over the years I have learned how to read these to see bone contour and use this to help determine how aggressive I can be. Its truly evident on a case where the fixture is the terminal restoration in the arch and the natural tooth next to it shows the bone sloping down and to the distal. This is where a lot of problems can arise if you do not have this info or understand what can happen its best to become a resource and learn. If you think about these sorts of fixtures and how the abutment has a stand off its to protect and save bone long term but also there as a built in fudge factor if the fixture is mistakenly put sub crestal and there is a ski slope of bone above it. I have seen many over contoured abutments not seat because of this.

As for everything else I do not believe I have ever seen anything that had a step by step outline on how to do this. Like a lot of things in this trade its experience.

One of the best benefits of CAD design is the freedom to make EVERYTHING full contour and allow for the paper emergence by over/under contouring from the scan.

Now in the esthetic zone when there is no tissue sculpturing or modified flared impression coping used I often will make beta in PMMA even if its for just a single to double check my estimation.

 

[Car 54]

I just routinely take a worn high speed football diamond and go around the inside of the soft tissue mask relieving it a bit. I then use this as my emergence. If the tissue is "overlapping" (usually interproximally) the platform and tight against the abutment, I adjust it a bit more to get better emergence and leave it at that. I have yet had a Dr ask for what we can do for better emergence, so I'm just leaving it that way for now.

From my understanding, the way the tissue fibers run, you can compress the tissue interproximally (impinge) within reason without causing to much harm, and the tissue will adapt. It's the buccal and lingual manipulating of the tissue (trying to push it out further) that can cause the irritation and recession due to the force of how the tissue fibers run. I guess that is why most of the time when we see "angry" labial/buccal tissue or recession (esp. crown and bridge),it's due to violating the tissue in this way.

 

[Affinity]

There are volumes written about this.. but to me, starting with the end in mind seems to be the best bet.. When surgeons place the implant, most pay no attention to the way the emergence heals.. generally leaving a 4mm hole, obviously smaller in diameter than a tooth..
IMO the pressure needs to be on the Dr to require whoever places the implant to have an esthetic plan for healing, not leave it up to a tech with a rubber model to trim away.

 

[TheLabGuy]

The simple is answer is you can't...Dentists responsibility. Usually done before any implant is even placed i.e. tissue temps, adaptations to the healing cap, perio, immediate loading, etc...

 

[2thm8kr]

The simple is answer is you can't...Dentists responsibility. Usually done before any implant is even placed i.e. tissue temps, adaptations to the healing cap, perio, immediate loading, etc...

Totally agree. Tissue management is not the responsibility of the lab. So if they leave it up to you, charge if you have to do a remake.