logo 17 • CAMLOG Partner Magazine • March 2018 allowed the mucosal portion of the split flap to be closed without tension, resulting in a significant tissue increase with complete plastic coverage of the implant region. The connective tissue transplanted in this manner brings with it the genetic information for the long-term formation of keratinized gingiva at the implantation site. Postoperatively, there is often swelling present which, in combination with soft tissue augmentation, causes a visual reduction in the clinically visible adjacent crowns (Fig. 22). It is essential to inform the patient about this and to adjust the temporary restoration accordingly. After ten weeks, the new soft tissue situation had been fully established (Fig. 23). This also corresponded to the initial state for the subsequent implant prosthetic measures for soft tissue shaping. At this point in time, all hard and soft tissue augmentation treatment steps have been completed. It must be ensured that the soft tissue even has an oversized reconstruction if possible, to ensure sufficient reserves for soft tissue shaping. Gingiva forming Following the implantation, the intraoperative impression of the implant was taken with an individual tray (Fig. 24). This served as the basis for the fabrication of an individual healing cap (Fig. 25). This healing cap is milled from either plastic or zirconium oxide, based on the scanned prosthetic set-up of the tooth to be replaced, and bonded with a temporary abutment. The healing cap, inserted after surgical exposure using a displacement procedure, protrudes about 2 mm beyond the gingival margin and has its widest extension at the emergence point (Fig.26). The objective of this individual healing cap is to shape the emergence profile of the subsequent implant abutment in the gingiva. For this purpose, the axial incision must optimally replicate both the orovestibular and the mesiodistal dimensions of the crown anatomy at the gingival level (Fig. 27). We consider the introduction of the concept of an individual healing cap to be the decisive link in our esthetic treatment protocol between the surgical rehabilitation of the implant site and the prosthetic replica of an anatomical crown. The retention time of the individual healing cap in the mouth for gingiva forming varies from individual to individual and between eight to twelve weeks can transpire before the implant impression can be taken. Individual abutment and implant crown After removing the individual healing cap, it was necessary to ensure that the delicate gingiva funnel was not deformed while the impression of the implant was being taken. For this reason, a prefabricated impression post was wrapped in lowviscosity plastic and hardened in the gingival funnel (Fig. 28). The model thus obtained reflects the implant situation with the gingival emergence profile of the future crown at the same time. On this basis, an individual abutment was fabricated that fulfils three essential tasks: color-coded individualization of the tooth core; final manipulation of the gingiva through varying subgingival design; maximum basal width comparable to a prepared natural tooth crown with approx. 1 mm subgingival crown margin (Fig. 29). Our master casts are always fabricated Fig. 23: Ten weeks after soft tissue augmentation. Initial situation for tissue shaping. Fig. 24: Intraoperative implant impression with individual tray. Fig. 22: Postoperative swelling one week after soft tissue augmentation. Fig. 28: Implant impression with customized impression post for stabilization of the gingival funnel. Fig. 29: Individual abutment in situ. Fig. 30: Ceramic veneered zirconium oxide crown on the master cast without gingival mask. 16 CASE STUDY
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