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SURGICAL AND PROSTHETIC FACTORS

Vertical soft tissue augmentation

Vertical mucosal tissue thickness was shown to be the factor having impact on bone stability. It was showed that platform switching does not reduce crestal bone loss, if soft tissues at the implant placement are thin. It is suggested that thin tissues might be thickened during implant placement, thus reducing bone resorption. Special guidelines how to work in vertical thin mucosal tissues are necessary. This can be carried out simultaneously with implant placement using an autograft, a xenograft or a dermis-derived allograft. Collagen-matrix xenografts result in less augment of volume, since some recession is likely to occur, however bone stability is improved.

Implant depth

It has been suggested in the literature that implant position to the bone crest might influence bone stability. Therefore, depending on implant design, implant placement can be supracrestal, crestal or subcrestal. Subcrestal placement is suggested to cause controlled bone remodelling, but not bone loss. It is interesting to note, that not all implants can be placed subcrestally. In addition, implant-abutment connection stability becomes very important, if located subcrestally. On the contrary, if implant has polished part, it must be placed supracrestally.

Tisue thickness

The findings indicate that initially thin crestal mucosal tissues can cause marginal bone loss after implant placement and 1 year follow-up. If the initial tissue thickness is less than 3 mm, bone loss up to 1.45 mm can be expected within the first year of function. In thick tis sues (3mm or more), significant marginal bone recession could be avoided, leaving only minor boss loss up to 0.2 mm. Optimal thickness is considered 4 mm, maximum – 5 mm in vertical direction.

Implant design

Two main implant design factors responsible for crestal bone stability were identified, namely the microgap or implant-abutment connection and a polished implant collar. The microgap, if placed at the bone level or subcrestally, produces an infiltrate of inflammatory cells in the connective tissue at the implant-abutment connection, which results in alveolar bone loss. Another factor associated with the microgap is the instability of the implant-abutment interface. It is suggested that micromovements of abutments can be linked to bone loss around implants. The implant polished collar can stimulate crestal bone loss associated with a lack of loading.

Screw / cement?

Current recommendations allow clinicians to place cementation margins up to 2 mm subgingivally. Recent research has proved that the deeper the position of the margin, the greater amount of residual cement is left undetected. The relation between position of cement excess in the peri-implant sulcus, periodontal status of the patient and severity of peri-implant disease is explained. To avoid cement excess, finished implant restoration with occlusal opening is cemented on titanium base in laboratory and restoration is attached to the implant by an abutment screw

Metal / zirconium?

Zirconium as a material is considered the best for peri-implant soft tissues. However, it’s evident that it must be treated in special manner – to be polished enough. So the polishing of the material allows adhesion of the epithelium cells, which provides the protection. It’s important not to make “Zr without Zr” restorations, when veneering porcelain covers Zr and does not allow the direct contact between soft tissues and zirconium. In that way the biocompatibility effect might be reduced.

Veneering material

Although veneering materials do not have direct influence on crestal bone stability, nevertheless, it is important to select appropriately. Not only biological, but also technical requirements are important as well. A special technique, which combines Zr and E-max will be presented, where Zr stands for soft tissue condition and monolithic ceramics for strength.

Emergence profile

For a long time, the emergence profile of the implant restoration was not considered a factor for zero bone loss, but it is now known that the shape of the restoration can affect the maintenance of crestal bone stability. This is more important for implants that are placed subcrestally rather than at bone level, and the shape and height of the titanium base of the restoration has the greatest effect.

Vertical soft tissue augmentation

Implant depth

Tisue thickness

Implant design

Screw / cement?

Metal / zirconium?

Veneering material

Emergence profile

Media

Articles

Influence of Abutment Material on Stability of Peri-implant Tissues: A Systematic Review

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Biologic Width Around Implants. An Evidence-Based Review

PDF

Computer-guided implant therapy and soft- and hard-tissue aspects. The Third EAO Consensus Conference 2012

PDF

Long-term stability of peri-implant tissues after bone or soft tissue augmentation. Effect of zirconia or titanium abutments on peri-implant soft tissues. Summary and consensus statements. The 4th EAO Consensus Conference 2015

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All articles