Whats up with the Gums???

[AKDental]

I was wondering how other people handle the patient gingiva in implant crowns. I'm referring to the top of the gums...I guess it would be the occlusal area of the gumswhere the crowns sit on top of...., and also the gingiva that goes down to the implant in the patients jawbone. So 1. How much contact do you put on both of those areas I described?
2. How much "can" the gums be moved or pushed at the maximum?
3. Can you begin the emergence profile making it flare out,( which I think you can),and where is a good starting point for that? I know it depends on many factors but assume it's a normal uncomplicated well placed implant.
4. Lastly I really don't know if this is a dumb question bc I have had many different answers to this but are you supposed to follow the impression exactly as far as the g u ms are concerned? And I f not then how can you know when you should and when youshouldn't? I m talking about emergence profiles BTW.
I've had some implant crowns where the Dr said they couldn't even push the Implant crown down all theway...
Oh I probably should have a said this in the beginning but I am talking about screw retained implant crowns that are on a tibase. And many times I am using the lowest gum height on them.

Just something extra cuz I didn't wantt to start a new post for thus but if anyone has an exocad perpetual that they have for a sale then can you let me know. I am interested in buying. Thanks.

 

[AKDental]

Sorry question #3 should be can you start the emergence profile flaring out earlier than the top of the gums? Also should you?

 

[doug]

You need to have a conversation with each doc to find to what their objective is. We have, in the same office, docs who want us to impinge as much as possible on the tissue as they will make a little incision on the lingual to release the tissue to allow it to form around the crown. In that same office there are docs who want the crown to just slightly push on the tissue. One office the doc uses tissue form contouring healing caps to create a very nice gingival cuff that makes the crown look as if it is coming out of the tissue just like a natural crown. Every case is different, this is where your communication skills are going to be a benefit.

 

[Brett Hansen CDT]

As doug stated, every doctor will handle these cases differently. Some are comfortable sculpting the tissue at delivery if the patient is experiencing too much discomfort. When I design an abutment, I design it to give a natural emergence profile for the crown it will be supporting. I also always make the abutment concave below the abutment margins to help with the insertion. You can push on the tissue more as you get closer to the gingival crest. For 90% of my cases and doctors, this works great and I have received many compliments from periodontists about the tissue response to my implant crowns. Sometimes, you will get a case where the implant placement is not centered very well. In those cases, you will have to use some judgement as to how much tissue displacement you can do in your abutment design. I communicate with many of my doctors using short videos or pictures through text. This is a great way to ensure you both are on the same page and the doctor can take responsibility for how the implant restoration is being handled.

My journey with implant restorations began about 16 years ago when I read the relevant parts of Misch's implantology text book for dental techs(probably overkill but I wanted to know more about what the doctors knew so I could be a better resource). At that time, I also began using Atlantis for my custom abutments. This emergence profile chart really helps to visualize the different ways you can handle the gingiva:

https://www.dentsplysirona.com/content/dam/dentsply/web/Implants/Franchise%20Content/32670166-USX-1406-ATLANTIS-abutments-Emergence-width-options-LR-8bwo2fv-en-1408.pdf

I do around 40-50 Atlantis abutments a month now and then I design another 20-30 myself that I have milled with Imagine, Vulcan, or Straumann.

 

[lcmlabforum]

As doug stated, every doctor will handle these cases differently. Some are comfortable sculpting the tissue at delivery if the patient is experiencing too much discomfort. When I design an abutment, I design it to give a natural emergence profile for the crown it will be supporting. I also always make the abutment concave below the abutment margins to help with the insertion. You can push on the tissue more as you get closer to the gingival crest. For 90% of my cases and doctors, this works great and I have received many compliments from periodontists about the tissue response to my implant crowns. Sometimes, you will get a case where the implant placement is not centered very well. In those cases, you will have to use some judgement as to how much tissue displacement you can do in your abutment design. I communicate with many of my doctors using short videos or pictures through text. This is a great way to ensure you both are on the same page and the doctor can take responsibility for how the implant restoration is being handled.

My journey with implant restorations began about 16 years ago when I read the relevant parts of Misch's implantology text book for dental techs(probably overkill but I wanted to know more about what the doctors knew so I could be a better resource). At that time, I also began using Atlantis for my custom abutments. This emergence profile chart really helps to visualize the different ways you can handle the gingiva:

https://www.dentsplysirona.com/content/dam/dentsply/web/Implants/Franchise%20Content/32670166-USX-1406-ATLANTIS-abutments-Emergence-width-options-LR-8bwo2fv-en-1408.pdf

I do around 40-50 Atlantis abutments a month now and then I design another 20-30 myself that I have milled with Imagine, Vulcan, or Straumann.

Thanks, I used to look at the chart when they only had 4 options.
They had a chart about height of finish line placement also then.
Appreciate the sharing.
LCM

 

[AKDental]

Hey guys, I havent been on lately and didn't even see the responses till now but thank you so much
for your input and help with my questions. I really very much appreciate it and want to say this is the reason
why i use this forum(I don't post to anything else at all, NOTHING, no facebook twitter dental-whatever tiktok).
And by far this has been one of the best resources for me to solve the many issues that i come across
with my lab. Some of the things that dentists and dental manufacturers tech support and google, hehe, cannot
answer will almost definitely be answered here. Awesome! Thank you doug and Brett Hanson for the info and the chart!
Funny side note: I dont recall how many different dentists that Ive asked about the gum thing. But A few just straight out said, "huh?"

 

[CoolHandLuke]

the more you push tissue, the more it CAN blanche from lack of circulation. its like pressing your thumb on your forearm really really strongly for 5 minutes, after you remove it you will have a white mark while the blood comes back. same thing in the gums, except because its a permanent movement the tissue will stay white forever, and due to lack of blood eventually die and wither away.

so always ask the doctor if they have prepared the site for you by using their gum laser or have installed a healing cap on the implant. the healing cap can give you more information about the condition of the tissue when the abutment will be delivered because you will be able to know the width of the cap and can work within or upon that envelope.

good luck.

 

[RileyS]

One thing I learned at a Spears course was tissue control and abutment/crown pressure. Tighter pressure will cause the gum line to obviously shorten as it’s being pressed that direction. If the crown is too tight then it will usually end up receding a bit more over the near future. And it will never drop again without surgical grafting. This can be beneficial if the tissue level is more incisally located than the adjacent teeth and you can help create a more even gumline by pushing it. But if it’s already short of the adjacent tooth’s emergence line then too much pressure is only going to increase that step in the gumline.
Proly didn’t make sense the way I wrote it but…

 

[ztech]

Here is a good research paper that goes into the optimal shape and result for implant restorations. It would be helpful for some of your younger and receptive older clients also.