Implant-Supported Prosthetics in Aesthetically Significant Areas: Features of Gingival Attachment Formation

This article discusses the specifics of aesthetic implant placement. Specifically, it covers the routine procedures dentists perform every day and how modern technologies help achieve previously unattainable precision. It also discusses several innovative solutions that can streamline the prosthetic workflow.

Only clinical skill combined with modern technology can consistently deliver clear and predictable results. This is true in any field, but in this article, we will explore several elegant solutions from Galip Gürel, DMD, from Turkey, using specific clinical case studies. Let’s start with a case of anterior dental implants.

Why Custom Healing Caps Are the Gold Standard for the Anterior Region

The anterior region is especially important. Here, aesthetics are crucial in addition to functionality, and achieving this is not easy, as the alveolar ridge in the anterior region is quite thin. It is easy to lose the buccal bone plate, and with it, the soft tissue. The papillae will recede or disappear completely, and over time, the implant will not only become exposed but can also be lost due to peri-implantitis.

The fact is that bone grafting and soft tissue grafting may not produce the desired result if the gingival contour has not been perfectly shaped. Therefore, prosthetics in the aesthetic zone require special skill.

The first clinical case involves a patient who first visited a dentist back in 1997.

The patient received a post-retained crown on tooth 11 and returned much later to have his smile line corrected.

The decision was made to correct the dental arch with veneers. Everything was perfect during the mock-up and APT stages. The photo below shows the APT (Aesthetic Pre-evaluative Temporary) stage.

Initially, the plan was to preserve the post-and-core and slightly prepare the core to fabricate a new crown identical to the one obtained at the APT stage.

The process is shown below; the first photo shows teeth being prepared for the placement of Porcelain Laminate Veneers.

The next picture shows the veneers already bonded and the prepared post-and-core for the new crown.

The last photo in the series shows the finished result: veneers and a new crown on tooth 11.

And everything would have been fine if the post hadn’t broken in 2016, see the series of photos below. Nothing could be done with the remaining root, only removal of the root fragments and placement of an implant.

The good news is that the crown itself was preserved, meaning it was now possible to take a scan for the future restoration. This data can be saved digitally for future use.

In 2016, digital technology had advanced so much that the crown was temporarily placed back into position to allow a digital scan to be taken using an intraoral optical scanner.

A surgical guide was also created using the same data. The implant placement procedure is shown below.

Note the final stage, namely, how the wound was closed after tooth extraction and implant placement. For this, a connective tissue graft was taken from the palate and partially de-epithelialized.

The epithelial layer was removed on the palatal and vestibular parts of the graft but was preserved on the tissue island left exposed directly over the socket of the extracted tooth.

The graft “wings” were then placed into a subepithelial envelope, and the graft itself was secured with sutures. The healing process proceeded without complications.

The healing process went without complications, and after just one week, we see this result.

However, immediate loading of the implant was impossible. To cover the defect as a temporary solution, a provisional crown was bonded using the Maryland bridge technique (see photo below). The appearance isn’t perfect, but it’s better than a missing incisor in the aesthetic zone.

Digital Workflow for Emergence Profile and Custom Abutment Design

After the completion of osseointegration, the gingiva was uncovered with a tissue punch, and a scan body was connected to the implant; see the images below.

In this case, a digital scan was acquired, but instead of a scan body, a classic impression coping could have been placed, and a conventional impression could have been taken using the closed or open tray technique.

But digital technology offers more possibilities. In this case, the goal was to model a customized emergence profile to preserve the interdental papillae. The crown shape of the extracted tooth served as the baseline.

This is where CBCT and intraoral optical scanning data came in handy.

The digital design of the crown and the custom abutment was developed in the slide below.

A temporary screw-retained crown was fabricated using the TELIO CAD milling process. As can be seen in the image, the soft tissue adaptation is perfect.

Digital technology was also used to create the definitive crown. The specialists used a backward planning approach; the crown shape and the required emergence profile were predetermined. Based on this, a custom abutment was designed and then milled (see slide below). The crown material is shown as translucent, the abutment as opaque.

After the crown and abutment dimensions were finalized, the files were sent for milling. The crown and abutment were fabricated separately.

The abutment was then cemented to a Ti-base and was ready for crown placement.

The next step is cementing the crown to the abutment. There are several techniques and bonding agents for cementing different materials, so we won’t go into detail.

Since all cementation procedures are performed extraorally, the risk of excess cement contacting the peri-implant soft tissue is completely eliminated. The transition zone is cleaned and polished. The smooth, polished surface is ideal for contact with the epithelial portion of the soft tissue attachment.

Why Implant Placement Should Be Guided in the Aesthetic Zone

Let’s reiterate why it’s important to place implants using a surgical guide. Many specialists prepare the osteotomy using a guide and then place the implants freehand.

If cement retention is planned, this isn’t as critical. However, with screw retention, the precise angulation and placement of the implant are much more important.

Firstly, there is less risk of screw access hole misangulation.

Secondly, it’s easier to adhere to the 1.5 mm rule, which dictates there should be at least 1.5 mm of bone between the implant and the adjacent vital tooth. This rule applies to both screw- and cement-retained restorations.

In addition, the advantages of screw retention include minimal trauma to the soft tissues during the try-in and delivery stages.

In this case, we have a custom abutment, and there are specific nuances to shaping the emergence profile. In the posterior region, standard healing abutments are more commonly used, which are placed immediately after implant placement and are not removed. The gingival cuff is formed once and is not disturbed again until shortly before the definitive restoration is delivered.

The screw-retained method combined with double platform switching allows for maximum crestal bone preservation. This is especially important in the anterior region. Here, it’s crucial to maintain the maximum height of the interproximal bone peaks between the teeth and the implants. The interdental papillae rely on these bone peaks for support. If the patient loses these bone peaks, problems with gingival attachment and black triangles are inevitable.

Returning to our case, the illustration below shows the soft tissue architecture before the failure of the previous restoration and on the day the new prosthesis was delivered. For clarity, a radiograph is superimposed on the image, showing the crestal bone level around the implant.

The image above, taken on the day of crown delivery, shows slight swelling and mild inflammation of the gingiva, meaning the papillae have not yet taken their final shape. However, the situation improves over time, as confirmed by images taken one week and three months after crown placement.

We examined not just a successful clinical case from Dr. Galip Gürel, but a masterpiece where digital technology enabled the achievement of the highest precision and beautiful aesthetics.

Standard S-Type Abutments as a Rational Alternative

As we’ve already mentioned, fabricating a crown and custom abutment using CAD/CAM methods is quite expensive, and not every patient can afford it. XGATE Dental’s straight S-type Multi-Unit abutments offer a predictable, reliable, and more affordable alternative for aesthetically demanding areas. Being the smallest in the line (with a platform diameter of just 3.5 mm), they embody the Tissue-First Design engineering concept. This ultra-thin geometry allows for the preservation of maximum soft tissue volume, which is critical for creating a natural emergence profile and supporting the interdental papillae.

A special advantage of the system is the international XGATE Dental standard – exceptional versatility: S-Type provides seamless integration with over 50 different implant platforms, regardless of the manufacturer’s brand. The S-Type prosthetic workflow is thoughtfully designed down to the last detail and fits perfectly into a modern digital workflow: intuitive color-coding of abutments based on gingival cuff height (1.0 mm – yellow, 2.0 mm – blue, 3.0 mm – pink, 4.0 mm – green) eliminates communication errors between the surgeon and the dental lab. Combined with special narrow sleeves (2.9 mm in diameter), the system leaves more space for the restorative material itself and even allows for angled screw channels.

At the same time, the connection maintains a zero-tolerance machining level: a zero micro-gap prevents bacterial infiltration, reliably protecting the crestal bone. Importantly, by choosing the standard S-Type solution, the clinic does not sacrifice the advantages of digital dentistry. All prosthetic components are integrated into verified CAD/CAM libraries (Exocad, 3Shape, Shining3D). This allows for the design of restorations with pinpoint precision. Scan-to-Fit allows users to change components in a digital environment without taking additional impressions and achieve absolute aesthetic success time after time.

IMPORTANT! Multi-Unit abutments are only indicated for multiple-unit restorations (bridges). Ti-base abutments are indicated for single-tooth restorations; see the illustration below.

We hope the material in this article was interesting, stay tuned for the next publications.