Accepted Manuscript

A New Concept in Maintaining the Emergence Profile in Immediate Posterior Implant

Placement: The Anatomic Harmony Abutment

Richard Akin, DDS, MD

PII: S0278-2391(16)30502-X
DOI: 10.1016/j.joms.2016.06.184
Reference: YJOMS 57340

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 3 November 2015

Revised Date: 5 June 2016
Accepted Date: 17 June 2016

Please cite this article as: Akin R, A New Concept in Maintaining the Emergence Profile in Immediate
Posterior Implant Placement: The Anatomic Harmony Abutment, Journal of Oral and Maxillofacial
Surgery (2016), doi: 10.1016/j.joms.2016.06.184.

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A New Concept in Maintaining the Emergence Profile in Immediate Posterior

Implant Placement:

The Anatomic Harmony Abutment

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Author information:
Richard Akin, DDS, MD
Private Practitioner

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Clinical Associate Professor, Department of Oral and Maxillofacial Surgery
Louisiana Health Sciences Center, School of Dentistry

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614 Connells Park Lane
Baton Rouge, LA 70806 USA
Tel: (225)927-3463

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Fax: (225)927-8507
Email: dr.richardakin@gmail.com
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Abstract
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As the knowledge base in the demanding realm of esthetic management of anterior

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implant sites continues to expand, there exists a void in the literature with regards to
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solutions to accelerate posterior implant protocols. This article will propose a new

protocol utilizing the anatomic harmony abutment for immediate molar implant
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placement. This technique preserves the anatomic emergence form with sutureless

implant site sealing and improves the predictability of final restoration fabrication and
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delivery. The purpose of this manuscript is to describe this concept along with its
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numerous benefits to patients, surgeon’s, laboratories and restorative dentists.

 ACCEPTED MANUSCRIPT

A New Concept in Maintaining the Emergence Profile in Immediate Posterior

Implant Placement:

The Anatomic Harmony Abutment

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Author information:
Richard Akin, DDS, MD
Private Practitioner

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Clinical Associate Professor, Department of Oral and Maxillofacial Surgery
Louisiana Health Sciences Center, School of Dentistry

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614 Connells Park Lane
Baton Rouge, LA 70806 USA
Tel: (225)927-3463

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Fax: (225)927-8507
Email: dr.richardakin@gmail.com
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Abstract
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As the knowledge base in the demanding realm of esthetic management of anterior

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implant sites continues to expand, there exists a void in the literature with regards to
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solutions to accelerate posterior implant protocols. This article will propose a new

protocol utilizing the anatomic harmony abutment for immediate molar implant
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placement. This technique preserves the anatomic emergence form with sutureless

implant site sealing and improves the predictability of final restoration fabrication and
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delivery. The purpose of this manuscript is to describe this concept along with its
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numerous benefits to patients, surgeon’s, laboratories and restorative dentists.

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Introduction

As evidence mounts to support accelerated dental implant protocols in the anterior and

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premolar regions, there has been little attention to improving the treatment workflow

posteriorly. (1-10) Single stage protocols with provisionals are generally well suited to the

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premolar or anterior regions due to the limited occlusal table thus reducing inadvertent

loading during the osseointegration phase. The obvious esthetic benefits and uniform

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post-extraction crestal socket morphology are other reasons that provisionalization of

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these regions lend themselves to accelerated protocols.
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locations, on the other hand, can present significant challenges when immediate implant

placement is planned. These challenges include large extraction sockets which are
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difficult to seal without mucoperiosteal flap reflection, implant preparation sequence

which significantly deviates from typical manufacturer protocols, crestal socket

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morphology not amenable to standard healing abutment placement and the possibility
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of high occlusal forces with inadvertent function when a provisional is planned.

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The technique in this article sets out to solve many of the problems inherent to

immediate posterior implant placement. This is accomplished by extrapolation of

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techniques used to optimize gingival contours through the use of surgeon fabricated
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screw retained provisionalization (11) of anterior teeth and premolars. This technique was

developed in order to solve problems intrinsic to immediate molar implant placement by

creating a logical expedited approach to immediate customized healing abutment

fabrication.
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Although this concept can be used in all locations of the mouth, the procedure

described in this article specifically demonstrates the application of this technique for

the in vivo fabrication of a customized immediate molar anatomic abutment.

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Preoperative Considerations

In a patient that presents with a non-restorable tooth with good apical bone volume and

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approximately 2-3mm of attached keratinized tissue, immediate placement has been

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shown to have equivalent success rates compared to staged approaches. (12-16) This data

is important because familiarity with immediate implant placement with flapless surgery

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is of critical importance when implementing this procedure. Plain radiographs and 3D
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imaging correlated with the physical exam allows for quantification of underlying

alveolar architecture ultimately leads to predictable implementation of this technique.

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(Figure 1, 2)
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It is the author’s opinion that when utilizing all available modern diagnostic tools,
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clinicians should expect this immediate implant/anatomic abutment technique to be

accomplished in greater than 95% of patients for whom it is planned.

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The Harmony Technique

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Tooth removal is performed with tooth sectioning and elevation without the use of
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mucoperiosteal flap elevation or disturbance of the papillary tissue. After removal, the

tooth is inspected to further aid in determining the quantity of furcation bone and as an

additional reference when determining maximum drill depth. After tooth removal, a

surgical length round bur should be used to remove PDL remnants, granulation tissue

and to stimulate socket bleeding. After irrigation, a surgical guide (when indicated) is
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placed and the osteotomy is begun in the appropriate location for ideal restorative

design. Next, the drilling sequence specific to the implant system is used for osteotomy

preparation. The implant is then seated to the appropriate depth with consideration

given to socket anatomy, implant diameter, interocclusal space, desired emergence,

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and bone levels present on the adjacent teeth. (Figure 3)

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Implant selection for this technique requires a bone level implant with a 2-piece

temporary abutment which indexes into the internal surface of the implant. This 2-piece

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titanium or poly-ether-ether-ketone (PEEK) temporary abutment is now micro-etched for

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mechanical retention of composite resin while avoiding the first millimeter of the
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abutment directly crestal to the implant. (Figure 4) Photopolymerizing resin adhesive is

then applied to the abutment and cured. After curing, a bleach shade direct composite
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resin material is molded into a cylindrical shape, adapted to the abutment and then

placed. The direct composite-resin material is contoured in vivo to adapt the composite
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to the gingival margin position. This is performed using an offset blunt spatula-like
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instrument just prior to curing. (Figure 5, 6) The abutment is removed and the final

contouring is performed with light cured composite and polishing wheels. (Figure 7)
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Next, an inverted cone bur (Miltex, USA FG 33 ½) (Figure 7) is used to make a buccal
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orientation mark 1.5mm into the composite to assist the restorative dentist with
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replacement after removal. This orientation mark is filled with Telio® Stains Color Blue

(Ivoclar Vivadent, Germany) and is light cured. After finishing, the abutment will be

smooth with slightly rounded circumferential margins and gentle sloping of composite

0.5mm below the buccal free gingival margin. (Figure 8, 9) Throughout the process of

finishing it is recommended to use a high pressure steam cleaner (Steaman Jr. TM, Bar
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Instruments, CA, USA) to remove blood or other debris. Prior to final seating of the

custom healing abutment, the implant cover screw is temporarily placed while

particulate mineralized bone is placed into any socket gaps. Allograft or Xenograft

material can be prepared with saline or with a biologic modifier as a carrier, and is

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compressed into the residual socket defects using a combination of large and small

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graft condensers. Particulate graft should only be placed to the crestal margin of the

implant at this time because overfilling the site can impede abutment seating. After

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finishing, the abutment is tightened or torqued into position as per the manufacturers

recommendations. After placement further grafting can be accomplished

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circumferentially into the newly developed sulcus to fully support the gingival margin as
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described in the ‘dual-zone’ technique(17). Additionally, a tailored collagen plug

(HeliPLUG®, Integra-Miltex, USA) can be used along the gingival margin between the
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graft and abutment as a short term barrier or to assist with a circumferential seal.
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Procedural Considerations
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With proper implant placement at the central fossa and along the long axis of occlusal
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forces (accounting for the Curve of Spee and Wilson), the abutment will be in ideal

position to preserve socket anatomy. The finished custom healing abutment will have a
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gentle slope from buccal to lingual which is consistent with the underlying alveolar
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morphology in both the maxilla and mandible. As mentioned, full seating of the custom

healing abutment can be impeded by stacked particulate grafting within the gingival

sulcus. This can also occur during composite resin additions to the subgingival

contours of the abutment in the lab. For this reason, it is recommended to avoid

alteration of the first 1mm of the supracrestal portion of the abutment. Leaving 1mm of
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unaltered abutment also serves to leave an unadulterated surface nearest the crestal

aspect of the implant. If a titanium abutment is utilized, a periapical radiograph is

recommended prior to the completion of the procedure to verify complete abutment

seating. This property of titanium as well as its ability to provide a more impervious

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crestal seal are important advantages of this material versus PEEK plastic abutments.

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The abutment access hole should be covered by a material that not only obturates the

access hole but also seals it. Ideally this material would also be tooth colored and

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easily removable. An interim light polymerizing restorative material like Telio CS

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(40)
Inlay® (Ivoclar Vivadent AG, Liechtenstein) is well suited for this use. Teflon tape
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should also be used in the access channel when there is a deeper access hole.

This procedure allows for passive draping of the gingival tissue which reduces the
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need for suture approximation. Occasionally, difficult extractions will require papilla
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reapproximating sutures. It is recommended to use 6-0 or 7-0 polypropylene sutures

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for this purpose.

Postoperative course is similar to any immediately provisionalized implant procedure.

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Typically NSAIDS are adequate for postoperative pain control and the patient is

instructed to finish preoperative antibiotics. The patient is also instructed to avoid

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disturbing the surgical site until the first postoperative appointment in 2-3 weeks.
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Figure 10 and 11 demonstrate the typical clinical and radiographic healing at 3 months

when performing this procedure.

Restorative Phase
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This technique provides the restorative dentist and laboratory technician the final piece

of the restorative puzzle. This final element is the proper transfer of ideal

abutment/restorative contours captured at the time of tooth removal. This concluding

step is accomplished easily at the time of the final impression with a routine custom

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impression coping technique.

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After a new impression coping is seated at the implant site, direct registration of the

emergence form is captured utilizing light polymerizing flowable composite. The

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composite fills the sulcus and is light cured. (18) Next the master impression is made as

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per the restorative dentist’s typical protocol. The custom impression coping is then sent
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to the lab with the master impression for fabrication of an ideally constructed final

abutment and cement or screw retained final restoration. Alternatively, an indirect

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sulcular registration can be performed as described by Hinds. (19)

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Final restorative contours mimics the natural tooth while allowing for predicable
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emergence and gingival embrasure form. (Figure 12, 13 and 14)

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Discussion

Customization of the immediate molar healing abutment is imperative for a number of

reasons. First, because this protocol calls for flapless tooth removal without bone
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removal, the underlying alveolar socket anatomy does not readily allow for stock healing

abutment seating. Second, when stock healing abutments are placed after immediate

molar implant placement, there is the need for flap elevation to close around the

abutment in order to retain particulate grafting(20). Lastly, molar locations are often

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associated with stock healing abutment emergence form mismatch which requires lab

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prediction (or practitioner sculpting) of the emergence profile of the gingival mask. This

can lead to difficulty in seating a fully contoured final custom abutment without

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contouring gingival tissues otherwise leading to a poorly designed final abutment.

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Customized immediate posterior healing abutments not only serve to support local
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anatomy during the osseointegration phase but also allows for straightforward access to

the implant during the restorative phase. After osseointegration, the result is an
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anatomic representation which mimics the emergence profile of the natural dentition

allowing for precise lab reproduction of the definitive abutment. This technique provides
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all of the advantages of implant provisionalization(21) to the posterior region of the mouth
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while reducing the potential disadvantages of providing a provisional crown with an

occlusal surface in this region. Additional advantages include the ability to add and
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subtract gingival support throughout the osseointegration phase while allowing for a
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precise customized socket seal over the immediately placed implant.

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Implementing in-vivo fabrication of the harmony abutment on an immediately placed

molar implant using the technique described in this article brings the advantages of

immediate placement and provisionalization safely to the posterior regions of the mouth.

The goal of this technique is to support existing alveolar anatomy and preserve it during

the osseointegration period.

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Summary

This technique is meant to provide solutions to many of the problems implant surgeons

and restorative dentists encounter when providing dental implant rehabilitation.

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The following solutions are provided by this anatomic harmony abutment:

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1. Stabilization of the gingival architecture immediately after extraction and implant

placement.

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2. Provides a custom seal over the surgical site to retain graft particles.

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3. Maintains the ideal emergence profile for optimal final restorative contours.
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4. Reduces chair time during impression coping seating potentially obviating the need

for radiographic exposure to verify abutment seating.

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6. Decreasing (or eliminating) laboratory approximation of emergence profile when

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shaping the gingival mask during fabrication of the definitive restoration.

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7. Expediting final abutment delivery by retaining the gingival emergence architecture.

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Conclusion
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The loss of a first or second molar is often a patient’s initial experience with implant
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dentistry. This is an important reason to find innovative ways to bring the advances of

immediate provisionalization from the anterior to the posterior. Optimizing outcomes

while minimizing appointments and recovery times is, in and of itself, an important

reason to implement accelerated posterior implant protocols. This is especially true if a

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new solution allows for predictable reduction of surgical visits with outcomes which

improve upon standard mulit-stage approaches.

The anatomic harmony abutment ultimately allows for more predictable final

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restorations by providing the dental laboratory a restorative profile and blueprint for the

definitive abutment thus idealizing the final restoration.

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It is the authors opinion that custom healing abutments and provisionals should ideally

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be placed by the surgeon in order to capture the anatomy present at the time of

extraction and should be viewed upon as the final step in the implant surgery.(22)

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References

1. Lazzara, Richard J. "Immediate implant placement into extraction sites: surgical and restorative advantages." The International
journal of periodontics & restorative dentistry 9.5 (1989): 332.

2. Schwartz-Arad, Devorah, and Gavriel Chaushu. "Placement of implants into fresh extraction sites: 4 to 7 years retrospective
evaluation of 95 immediate implants." Journal of Periodontology 68.11 (1997): 1110-1116.

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3. Szmukler-Moncler, S., et al. "Timing of loading and effect of micromotion on bone dental implant interface: review of
experimental literature." Journal of Biomedical Materials Research 43.2 (1998): 192-203.

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4. Jaffin, Robert A., Akshay Kumar, and Charles L. Berman. "Immediate loading of implants in partially and fully edentulous jaws: a
series of 27 case reports." Journal of Periodontology 71.5 (2000): 833-838.

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5. Paolantonio, Michele, et al. "Immediate implantation in fresh extraction sockets. A controlled clinical and histological study in
man." Journal of Periodontology 72.11 (2001): 1560-1571.

6. Botticelli, Daniele, Tord Berglundh, and Jan Lindhe. "Hard-tissue alterations following immediate implant placement in

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extraction sites." Journal of clinical periodontology 31.10 (2004): 820-828.
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7. Chen, Stephen T., Thomas G. Wilson Jr, and C. H. Hammerle. Immediate or early placement of implants following tooth
extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants 19.19 (2004): 12-25.

8. Chen S, Darby I, Reynolds E, Clement J Immediate Implant Placement Postextraction Without Flap Elevation J Clin Perio Jan
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2009.

9. Mijiritsky E, Mardinger O, Mazor Z, Chaushu G. Immediate provisionalization of single-tooth implants in fresh-extraction sites at
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the maxillary esthetic zone: up to 6 years of follow-up. Implant Dent. 2009 Aug;18(4):326-33.
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10.DeRouck T, Collys K, Wyn I, Cosyn J. Instant provisionalization of immediate single-tooth implants is essential to optimize
esthetic treatment outcome. Clin Oral Implants Res. 2009 Jun;20(6):566-70.

11. Akin, R. Immediate Provisionalization: A Surgeon s Perspective. Selected Readings in Oral and Maxillofacial Surgery 22.4
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(August 2014)

12.Fugazzotto, Paul A. "Implant placement at the time of maxillary molar extraction: Treatment protocols and report of
results." Journal of periodontology 79.2 (2008): 216-223.
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13.Fugazzotto, Paul A. "Implant placement at the time of mandibular molar extraction: Description of technique and preliminary
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results of 341 cases."Journal of periodontology 79.4 (2008): 737-747.

14.Schwartz-Arad, Devorah, and Gabriel Chaushu. "The ways and wherefores of immediate placement of implants into fresh
extraction sites: a literature review." Journal of periodontology 68.10 (1997): 915-923.

15.Degidi, Marco, and Adriano Piattelli. "Immediate functional and non-functional loading of dental implants: a 2-to 60-month
follow-up study of 646 titanium implants." Journal of periodontology 74.2 (2003): 225-241.

16.Esposito, Marco, et al. "Interventions for replacing missing teeth: different times for loading dental implants." Cochrane
Database Syst Rev 21 (2013).
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17. Chu, Stephen J., et al. "The dual-zone therapeutic concept of managing immediate implant placement and provisional
restoration in anterior extraction sockets." Compendium of continuing education in dentistry (Jamesburg, NJ: 1995) 33.7
(2011): 524-32.

18.Polack, Mariano A. "Simple method of fabricating an impression coping to reproduce peri-implant gingiva on the master cast."
The Journal of prosthetic dentistry 88.2 (2002): 221-223.

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19. Hinds, Kenneth F. "Custom impression coping for an exact registration of the healed tissue in the esthetic implant
restoration." International Journal of Periodontics and Restorative Dentistry 17 (1997): 585-592.

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20. Araújo, Mauricio G., Elena Linder, and Jan Lindhe. "Bio-OssO Collagen in the buccal gap at immediate implants: a 6-month
study in the dog." Clinical Oral Implants Research 22.1 (2011): 1-8.

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21. De Rouck, Tim, et al. "Instant provisionalization of immediate single-tooth implants is essential to optimize esthetic treatment
outcome." Clinical Oral Implants Research 20.6 (2009): 566-570.

22.Leziy, Sonia S. Miller, Brahm A. Journal of Cosmetic Dentistry; Summer 2014, Vol. 30 IssueJournal of Cosmetic Dentistry

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Summer 30 (2014): 2.
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Figure Legend:
Figure 1 : Clinical view of tooth #30 on the day of removal.

Figure 2 : Sagittal CBCT image of right posterior mandible.

Figure 3 : Implant placed after tooth removal.

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Figure 4 : Impression coping is micro etched avoiding the 2mm nearest the platform.

Figure 5 : Composite resin is wrapped around the impression coping and adapted to the free gingival margin.

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Figure 6: The composite resin is photopolymerized.

Figure 7 : Lab instruments and burs for final abutment finishing. *See Appendix.

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Figure 8 : Abutment form prior to steam cleaning and final polishing.

Figure 9 : Abutment schematic.

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Figure 10 : Clinical view of abutment at 3 months.

Figure 11 : Radiographic view of abutment at 3 months.

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Figure 12 : Radiographic view of final screw retained restoration at 1 year.

Figure 13 : Clinical view of final screw retained restoration at 1 year.

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Figure 14 : Graphic demonstrating the harmony abutment concept.

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Appendix, Custom Posterior Abutment Materials Worksheet

Abutment Prepartion
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-MicroEtcher II , Danville Materials, CA, USA
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-DVA Purple Butterfly Discs , Dental Ventures of America

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-Lab hand piece, Patterson, USA

-White Flexible Polishing Wheel (Various Manufacturers)

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Crown and Tooth Removal
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-GC Pliers , GC America, IL, USA

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-Straight forceps, H&H, Part #:10-0510-MD1
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-Proximators , Karl Schumacher, PA, USA

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-Root Tip Forceps, H&H, Part #: 10-0650-144S

-Tapered Fissure Burs, Salvin Dental, NC, USA, XXL Carbide

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-Serrated Lucas 85 Bone Curette, Salvin Dental, NC, USA

Implant Site Preparation

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-Lindemann Implant Bur, Salvin Dental, NC, USA

-Power Point Surgical Pilot Drill, Salvin Dental, NC, USA

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-Offset Sinus Lift Ostetomes, offset sinus lift osteotomes

-Salvin Dental, NC, USA, Long Round Bur, Straumann AG, Germany
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-Bone Spreading/Manipulation, Salvin Bone Manipulation Drill Kit, Salvin Dental, NC, USA

Grafting
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-BioOss , Giestlich Pharma AG, Switzerland
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-Puros Particulate Bone, Zimmer Inc. CA, USA
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-Graft Pluggers, HuFriedy, USA: 0/1 Marquette Plugger, 2 Mortonson Plugger

-Molt 2/4 Surgical Curette for Graft Delivery, HuFriedy, USA

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Harmony Abutment Fabrication

TM TM
-Adper Scotchbond Multi-Purpose Adhesive, 3M, MN, USA
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-Filtek Supreme Ultra Flowable Restorative Resin, 3M, MN, USA
TM
-Steaman Jr. , Bar Instruments, CA, USA
TM
-Telio Stain Blue, Ivoclar Vivadent Inc., ON, CA

-Elipar S10 LED curing light, 3M, MN, USA

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Product for Abutment Access Hole Sealing

-Barricaid VLC Periodontal Dressing, Dentsply, USA

There are numerous products that are readily available to obturate the access hole and should have characteristics
of:

1. Can be completely removed with ease using an explorer

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2. Has elastic properties that remain stable in the mouth during the osseointegration period

3. Will remain in the access hole during the osseointegration period

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Photographic setup

-Canon 7D Mark II, 60mm 2.8 Macro Lens

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-Canon Ring Flash MR-14EX II

-Mirrors and Occlusal Contraster, PhotoMed, CA, USA

-Nikon D7200, 100mm 2.8 Macro

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-External LED light with filters (various manufacturers)
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Abutment Finishing Burs

-Brassler Inverted Cone 33 ½ H2

-Brassler Tapered Fissure Bur H375R Fine

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-Brassler Round Diamond Bur Medium 801L

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