Gum recession around implant abutment: recommendations?

I once heard Carl Misch that it was fine for the restoration to not reach the prefabricated margin of the abutment, but I refuse to do that. For the simple reason that radiographically it is the only way I have to verify an adequate seal. It is more likely that there is a gap at the margin in your situation than if you had extended the margins to reach the predefined area on the abutments. You can prescribe the margins to be 0.5 to 1.0 mm subgingival, and if you do not want to pay for custom abutments, then you need to select the proper prefabricated abutments so you are able to access and remove all excess cement and do not create a cement problem for your patient. The gingival recession could be caused by many factors and is difficult to tell you without more information and details. Good luck!

Thanks for posting. My 2020 new year resolution is more perio training. Predictability only comes with great keratinized tissue. So I’m excited to see what our fellow colleagues have to say for this case. From what I see, you have open margins. Just like with crown prepped teeth, you will have an open gap where you will find bacteria growing and bone loss around your implant. You also have open contacts which will also worsen your food traps. Thirdly, gingiva seems a little thin bucally. I would make sure patient is using a soft brush and not being to aggressive when she’s brushing around that facial corner. That hard brushing is like a tissue eraser especially when it’s soft. I have a case like this I cemented a year ago with open margins. Didn’t really notice it until recall. Patient had such great keratinized tissue that it completely covered the defect and bone stayed where it was. I’m still remaking the bridge though. You do not want open margins around your implants and open contacts with adjacent teeth. I would definitely remake the bridge and consider grafting some keratinized tissue from palate. Thanks for sharing.

The implants were subcrestal so the abutments are subgingival. It has nothing to do with the abutment selection and the fit of the prosthesis. If you could make the impression correctly, then an appropriate abutments could have been made. My lab advised me that sometimes it is very hard to extend the ceramic crown to fit abutment margin, but most importantly it should be sealed. YOU should advise your lab. and not the other way around. If you need advise, you must call another dentist who is more experienced or has a specialty to help you out. there is nothing wrong with that. The bridge fit very well. NO IT DOES NOT FIT WELL. Tt is obvious you do not know what a good fit mean. Would you have cemented that bridge if it was a tooth with that much gap? Implants are very solid and no bone loss noticed. BONE loss has nothing to do with stability of dental implants. BUT you do have bone loss based on the xrays you have provided. and keep in mind, NO BONE LOSS NO RECESSIONS. the is a direct correlation between the level of the bone and gingival level. My question: is the gum recession due to the gap or not? Subgingival gap leads to plaque accumulation and that leads to gingival recession and bone loss. in this case it may or may not be the direct result in this short period of time. but you must never release a patient with that kind of restoration. it is not a good fit. We call it supervised neglect. I would like to bring up this question for you, Were you concerned about the proximal Gap between the canine and the 1st bicuspid? And what should I do now? You either have to start over with a new good impression. Ideally implant level and have the framework remade. OR you have to refer the patient to a prosthodontist. DO you have any photo of the impression you had made, the one you sent to the lab? how about a photo of the master cast? that can tell us a lot how good the impression was. you need to realize Your lab cannot do any better than what you have provided to him.

Don't beat yourself up but do remake the bridge, it could have been something as simple at the contact was too tight . taking a radiograph at try in is important. When you take the bridge off look at the marginal gingiva relationship to the tissue. Are they correct?

PerioProsth is spot on in his or her reply. I don't think your lab is being honest with you. They have no tissue in the way when they work with your abutments. Think you are in for a redo unfortunately. IGood luck.

The above advice is all excellent and constructive. You should take note. There are ways to make implant crowns and bridges so that they can be screw retained – irrespective of the angulation of the implant/s. My advice is to use screw retained. I know this is not popular in some countries but I can assure you it makes long term maintenance much easier and repairs/modifications much easier and cheaper. It also avoids the problems caused by excess cement. Having said this, my advice is to send the patient to a prosthodontist to get you out of a potentially very difficult medico legal situation. With due respect – and I do not want to criticise here but simply offer concerned help, the case you have presented has not been treated to a satisfactory standard as best I can tell. Although you have not presented enough information to allow readers to assess exactly what has gone wrong, it is obvious there are some substantial problems. This may be due to clinical issues or poor lab work. But in the end even if it is due to the lab, it is for the clinician to assess the standard before insertion and as such it is the clinician’s responsibility. To be honest and blunt, some of the advice you have been offered is absolutely correct but is basic implant training. You should know all the above before you start a case like this and more importantly you should ensure that the guidelines presented are followed. That is your duty of care. I emphasise I do not want to sound arrogant or condescending, so please realise I want to help you and the patient. We all make mistakes and some days our treatment is not as good as other days (for many reasons). The important lesson is to learn from our mistakes and failures. Success is built on failures – so long as you learn from them. I therefore suggest that you take action to correct the problems this patient has and just as importantly make sure that you get some advice from a practitioner who can provide guidance to improve your expertise for future cases. Not only will this be good for you, but it will help future patients and help you build a better and more successful practice. Implantology might sound simple and easy but it is actually quite complicated and there is a lot to learn and know – especially if you treat multi-unit cases. Unfortunately it will cost you to correct the problems for this patient, but if you learn from it, then it may be the cheapest implant training course you do. Especially if you intend to treat many more cases like this one.

The abutment is not seated and then prosthesis is also not fully seated. This maybe should have been an abutment level impression to confirm a passive fit of prosthesis.

Just curious to know what game plan is for the lower. You have a heavy bruxer with no posterior occlusion. What are they wearing during the day and what’s going on at night?

Mispositionned abutment? The bridge is not acceptable. such gaps are absolutely not normal. Before redoing the bridge, remove it, place the abutments on the model ane try the bridge. If it is OK, put the abutments back in place witha jig to make sure that they are in the proper position. The simple rotation of an abutment by 30 or 60 degrees depending on connection systems can make it so that the bridge wont sit correctly. Whatever you decide to do, do not leave the patient that way. It is not acceptable and I am sure that as a professional you are not happy with the result and your patient deserves better. Good luck

I don't think that you need to re-make the bridge. Exposure of the abutment occurs quite frequently, since, despite the presence of an implant which transmits force to the bone that houses it, crestal resorption can and does occur. It may be able to be prevented by using a smaller diameter implant, by grafting the buccal of the site with a mineralized alloplast or xenoplast and by providing a thick zone of connective tissue over the buccal of the site. I think that placing a gingival graft will stop further recession. YMMV

As a periodontist, any gap will lead to bacterial attraction and eventual peri-implantitis. Also, I am concerned that you already have bone loss to the third thread on the distal of tooth 21. Both of these are not good situations.

I'm sure you wouldn't except this fit on a crowned tooth. The major differences as far as fit are that "yes, it won't decay" yet you have little control over the cement with this level of misfit and hence excess cement will damage the weak soft tissue to implant hemi desisomess. All implant prosthetics should fit the abutment margin in my opinion. A CAD/CAM abutment would solve this easily with ( as noted above) the margin 1/2mm below the tissue and screw retention. I wonder why you splinted a 4 implants? 2- 3 unit bridges are easier to get proper fit on. This could account for why the Left central has more bone loss than typical. Keratinized tissue is essential with 1 1/2 to 2mm thickness and 2-3mm in height. I agree, a remake is in order as is ALOT more implant training, with all respect.....we've all made mistakes!!! Lots of them.

This looks more like a hybrid prosthesis on the facial.

Get some help from your local Prosthodontist- most will be willing to assist you OR the Implant Rep that the Implant System is based off of. They will have the proper abutments Ana copings to take a implant level impression of the 4 abutments. You must capture the implant to gingiva interface in the impression without bleeding or inflammation - if not use a Diode Laser to get proper impressions. Once that is done ask the lab to send you a metal try in for the bridge or a bisque bake try in - unless it’s all Zirconium you want, then your out of luck.

This is one of those cases where it is difficult to place the gingival material in a biologically acceptable manner. It is bound to get in the way of good cleansing and make it hard to maintain gingival health about the implants. There is not enough "Running Room" between the ridge and the teeth to place a gingival portion which can be cleaned. It's a very common problem, a decision needs to be made at the outset as to whether this needs to be a "Crown and Bridge" or a "Hybrid " case. These days lots of cases seem to get an extensive ridge reduction to generate the room for a more biologically acceptable restoration. There is another issue as well, the choice of a Hybrid case is often based on finances (or lack of). This case may be one of those where it may not be possible to get the desired aesthetics with a Crown and Bridge result, nor to provide a healthy result with a hybrid solution. The type of case needs to be determined BEFORE the implants are placed.

I think a periodontal problem exists here because crowns on abutments do not have enough interdental space to allow interdental brush to be placed for cleaning. Remember the design of the bridge when you prepare natural teeth! Separation between crowns! Oral hygiene maintenance must be enabled. I agree with dr. Jeff. Iz looks like a hybrid prosthesis

Hi dear colleague Did you have passive insertion before cementation ??

I would suggest to do a soft tissue graft in the area to thicken the gum line, and take an impression with impression posts and analogs, I can tell you didn't do an impression like that. This way you can ensure the bridge is sealing flush with the abutments and the lab can fix any detail. Do the bridge screw retained ( with chimneys ), not cemented, so you can remove it anytime is needed without breaking it apart.

It doesn’t fit! Remake preferably screw retained by a reputable lab and take X-rays at every adjustment of the contacts and occlusion Until ALL abutments etc are fully seated. And adjust the occlusion again using Misch’s “implant protected occlusion principals”. ...and if this sounds too complicated...please refer. For the patients best interest.