Of the 100’s of articles I have written, this is one topic that is often not well understood by dentists or patients. So what is shaping, grooming, forming and training of gums around dental implants?
It is the process of getting the gum line around your front tooth dental implant to look as natural as possible. What makes the gum look natural? I will focus on some of the really important items:
1. The evenness of one gum line to the adjacent teeth gum line
2. The triangle of gum tissue “papilla” to be filled in. This is located between your gum.
3. The volume of gum on the outside of the implant.
4. The 3-dimensional placement of the surgical portion of the implant.
5. The health of the adjacent teeth
6. Genetically thick or thin gum and tissue
On this particular patient I was replacing her upper right lateral incisor. I took many pictures over the course of a few months to monitor the gum healing. Read the captions to follow along the progress. You will see how the gum changes over several months!
When you have a front tooth dental implant it is very important that you get a temporary made on the implant so that the gums can be made to follow the new shape of the tooth. If you have been missing a tooth for a long time, then the gum tissue is flat. It takes time to develop this gullwing shaped arching effect from one tooth gum line to the next. Sometimes surgical correction is needed but most of the time shaping the temporary properly and giving it 2-6 months will allow it to happen on its own.
Your implant has to be put into a good position for this to work. If the angle of the implant is too far forward and the head of the implant is too close to your lips, the implant will end up being long looking. Sometimes there are no other options because your jaw may angle outwards in the bone is so thin that there is no leeway and placing the implant closer to your tongue. But, ideally the implant should be placed just behind the edges of the upper front teeth. So, the first step in having a great gum line is having a very well placed implant in the bone in the first place!!!. Sometimes computer guided surgery helps but not always because there are errors.
There must also be a lot of bone on the outer wall of the implant. 1-2 mm or more of extra bone on the outside of the implant with good, thick gum tissue on top will allow for proper volume of gum so the tooth looks like it is coming out the gum rather than laying on top of the gum. This is not always possible and sometimes a gum graft needs to be done in combination with a bone graft in order to achieve the final volume. The implant must not be too large. Smaller, longer implants are often best in the front teeth areas.
In my practice, your dental implant gum line begins taking shape from the time the tooth is extracted. Your tooth must be very carefully extracted as to preserve as much of the gum is possible from being lost during the extraction process. Sometimes an extraction and immediate non-load dental implant is needed and sometimes staging the implant over time and doing a socket bone preservation graft is better.
If the implant is stable enough to have a same day temporary crown put directly on the implant it needs to be shaped a certain way. The implant temporary that I make for your implant usually has a “negative facial contours.” This allows the gum line not to be pushed away but rather create a thicker “cuff” of tissue around the base of the implant. If the temporaries placed on the same day that the implant is placed then thick gum training and shaping begins on that day. If the implant has to be buried or a large bone graft was done, this process will begin later on.
You can see in some of the photographs how the temporary crown is created by hand and attached by a screw to the replica green implant. This allows me to do all of the forming and shaping outside of your mouth. The sides or interproximal areas of your teeth are shaped in such a way to promote the triangle of gum tissue to grow to the proper flossing contact height. In some cases the temporary needs to be removed a few times and material either added or subtracted from it in just the right spot to move the gum line to the desired position. Most of the front teeth dental implant temporaries I make are held in with a screw rather than cement to make this easier for you.
Growing the triangle gum papilla to the proper height is often dictated by your adjacent teeth. If the tooth on either side has bone loss, even minor, the gum is much less likely to fill in completely leaving a small black triangle. This can be preplanned in advance in many situations. Oftentimes the crown can be made with a little bit of extra porcelain to fill in the black hole or sometimes the tooth right next door would need a tiny filling to close the space up. As long as it does not make your smile look asymmetric, often times this can work well. Ideally all the gum grows back to original height. It is also important that your dental implant be placed at the right depth. There is kind of a “sweet spot” or the implant is not too deep and not too shallow…..it is very much an art and can be very “touchy” and delicate.
Oftentimes front teeth require custom abutments to be made to follow the highs and lows of the scalloping gum tissue. The custom abutment also helps and supporting what is called the “emergence profile” of the tooth. This is the transition from where the implant is in the bone to where the gum line begins. In 2016, your tissue training, molding/grooming can be re-created into a 3-D printed model using an intraoral scanner like the trios 3. This prevents the gum from collapsing during the ‘molding’ digital or conventional impression.
I understand there are a lot of fine details, but it takes a lot to make a front tooth look great! It is all about the gums and not so much about the white porcelain part of the tooth. This is what separates good from great dental implants that are done right the first time. This process of shaping the gum line can take from just a few days to more than a year to complete. Each case is very unique.
Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry