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 809

Assessment of Peri-implant Soft Tissue

Adaptive Pressure and Time After
Provisional Restorations

Jiang-Wu Yao, DDS, MS1 Due to a significant amount of soft

Hom-Lay Wang, DDS, MSD, PhD2 and hard tissue resorption after
tooth extraction, it remains challeng-
ing to achieve pleasant anterior im-
plant esthetics that fulfill a patient’s
esthetic expectations.1 Furthermore,
Using interim restorations to remodel the peri-implant gingiva contour has the literature shows that there are
been a common procedure in esthetic implant treatment. During the interim different anatomical structures be-
restoration delivery, the pressure between the restoration and gingiva typically tween implants and natural teeth,2
causes ischemia. Adequate restoration should allow the tissue to recover from
so achieving an esthetically pleasing
ischemia over a certain time. To assess the time needed for peri-implant soft
tissue recovery, interim restorations were delivered on 25 single implant sites implant restoration requires greater
2 weeks after stage-two surgery, and the gingiva appearance changes after clinical and technical understand-
delivery were recorded for 15 minutes using a video camera. Gingiva color ing. For example, in an ideal es-
changes along the time were measured and analyzed. The color differences thetic implant restoration case, the
between peri-implant mucosa at 10 min and 0 min, as well as between adjacent surrounding implant mucosal mar-
tooth gingiva, were all within a clinically acceptable range of color difference.
gin, color, texture, and contour of
The adaptive pressure technique by two-stage contouring exhibited an optimal
peri-implant soft tissue profile within 10 minutes of the adaptive time. Int J the peri-implant soft tissue should
Periodontics Restorative Dent 2019;39:809–815. doi: 10.11607/prd.4063 be harmonious with the adjacent
and contralateral teeth and/or im-
plants.3 To fulfill the goal of achieving
a pleasing esthetic anterior implant
restoration, factors such as buccal
bone thickness,4 mucosa thickness,2
implant position,5 and the contour
of the abutment and prosthesis6
should be properly controlled since
they are known to influence the level
of the peri-implant mucosal margin
and soft tissue. Despite efforts to
develop an ideal profile by subtract-
Prosthodontic Department, Xiamen Stomatological Hospital, Xiamen, China.
1
ing or adding restorative materials
Department of Periodontics and Oral Medicine, University of Michigan,
2

School of Dentistry, Ann Arbor, Michigan, USA.

for provisional restoration, there is
no information currently available on
Correspondence to: Dr Hom-Lay Wang, Department of Periodontics and how much pressure and how much
Oral Medicine, School of Dentistry, University of Michigan,
time is required to obtain the ideal
1011 North University Avenue, Ann Arbor, MI 48109-1078, USA.
Fax: (734) 936-0374. Email: homlay@umich.edu
peri-implant soft tissue profile.7 The
aim of this study was to develop and
 Submitted August 12, 2018; accepted December 20, 2018.
 ©2019 by Quintessence Publishing Co Inc. validate the adaptive pressure for

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810

Fig 1  Two weeks after implant uncovering, before soft tissue Fig 2  Tissue blanching can be found after a nonfunctional screw-
modeling. retained provisional crown with interproximal convexity was tried in.

modification of the provisional crown wavelength (LiteTouch, Syneron) A screw-retained implant-

contour in peri-implant mucosa and
to determine the adaptive time by
means of measuring color changes
between the peri-implant mucosa
and gingiva of an adjacent tooth.
Materials and Methods
The experiment was carried out in
Xiamen Stomatological Hospital
and was approved by the Institu-
tional Review Boards of the Xiamen
Medical College. Subjects with a sin-
gle maxillary anterior-zone (canine
to canine) implant in need of sec-
ondary implant surgery and resto-
rations were included. Patients with
thin pheno-biotype, determined by
use of a probe inserted in the buc-
cal sulcus of adjacent teeth, were ex-
cluded. A total of 25 patients (aged
from 23 to 38 years) were ultimately
enrolled. The keratinized mucosa
thickness around an implant site was
greater than 2 mm in all patients.8
Informed consent forms were ob-
tained from all subjects.
An Er:YAG laser with a 2,940-nm
was used in the second phase of
implant surgery. The treatment was
performed using the angled hand-
piece with a 1.3 × 19-mm tip in
contact mode. A previously made
surgical template was used as a
guide to locate the healing cap. A
laser with a frequency of 10 Hz and
a pulse power rating of 150 mJ was
used to uncover all implants. No
anesthesia was applied because
the laser-performed second-stage
surgery showed little bleeding and
minimal pain or discomfort.9
After the tissue covering the im-
plant was removed, the healing cap
was replaced with a standard-sized
healing abutment (4.0 × 4.0 mm,
Zimmer Biomet), allowing healing
by secondary intention. Two weeks
later, a digital impression was made
using CEREC Omnicam scanner
(Dentsply Sirona) to obtain a digital
model. During the appointment for
the digital scan, the implant site’s soft
tissue thickness was measured 2 mm
below the facial gingiva margin using
a caliper. Tissue thickness > 2 mm
was still present in all subjects.
supported interim restoration with
gold-hued titanium abutment was
fabricated. Resin (Filtek Supreme,
3M) was used to shape the trans-
mucosal part of the restoration.10 In
the first tissue modeling stage, the
convexity of the interproximal con-
tour was increased to squeeze the
interdental papillae while the facial
region was kept in a concave form.
This allows the buccal soft tissue to
easily fill the concave space and the
height of papillae to be increased.
The second tissue modeling
stage began 2 weeks later (Fig 1).
Patients were recalled and the res-
torations were retrieved. The con-
vexity of the buccal transmucosal
restoration was increased to push
the gingival margin apically to the
level of its contralateral tooth (Fig
2).11 Once the restoration was de-
livered, a video of the implant site
was recorded for 15 minutes using
a digital video camera (FDR-AX100,
Sony). Frames were extracted from
the 4K video at 1-minute intervals
between 0 and 10 minutes and
at 15 minutes (Fig 3). The color

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 811

a 0 min b 1 min c 2 min

d 3 min e 4 min f 5 min

g 6 min h 7 min i 8 min

j 9 min k 10 min l 15 min

Fig 3  Images from the 4K video, extracted at 1-minute intervals from 1 to 10 minutes and at 15 minutes, show gingival color change of
the peri-implant mucosa and neighboring tooth.

parameters (lightness [L x*], green-
red [ax*] and blue-yellow [bx*]) at
the mesial, midfacial, and distal as-
pects of peri-implant mucosa were
measured by a software program
(Adobe Photoshop 7.0).12 The same
measurements were assessed
around the natural tooth contralat-
eral to the implant site. Each test
point was 2 mm from the gingival
margin. The L x*ax*bx* value at the
same site was assessed three times,
and the mean values were calculat-
ed for future statistical analysis. The
color differences (ΔEx*) between
the peri-implant mucosa and the
natural tooth were calculated ac-
cording to the Commission Interna-
tionale de l´Eclairage standard, as
follows13:
ΔEx* = [(ΔL x*)2 + (Δax*)2 + (Δbx*)2]1/2
Where L x* is lightness, ax* is
green-red (–ax* = green; +ax* = red),
and bx* is blue-yellow (–bx* = blue;
+bx* = yellow).
An ΔEx* ≤ 3.7 is interpreted as
a clinically acceptable level of no
color difference.14 The subscript in
ΔEx* represents interval time; for ex-
ample, ΔE0–15* is the color difference
obtained between 0 and 15 minutes
after trying in the provisional crown.

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812

(AT) were analyzed using one-way

Table 1 Comparative Measurement Color Changes (Mean ± SD)
analysis of variance (ANOVA) and
Between Gingiva of the Adjacent Tooth and the
Peri-implant Soft Tissue at 9, 10, and 15 Minutes SNK-q (Student-Newman-Keuls) test.
The level of significance was set at
Groups ΔLx Δax Δbx ΔEx* α = .05.
AT 67.0 ± 1.0a 24.0 ± 1.0a 11.3 ± 0.5ab –
9 min 64.3 ± 1.1 a 20.6 ± 1.1 b 10.1 ± 0.5a 4.5 ± 0.8a
10 min 65.7 ± 0.7a 20.6 ± 1.0b 12.1 ± 1.0b 3.7 ± 0.9b Results
15 min 65.3 ± 0.7 a
20.8 ± 0.6 b
12.4 ± 0.5b
3.7 ± 0.9 b

AT = adjacent tooth; SD = standard deviation. ΔE9-AT* was significantly different

Within the same column, values with different superscript letters are statistically significantly from ΔE10-AT* and ΔE15-AT* (P < .05)
different (P < .05).
and was greater than the clinically
acceptable level of 3.7 (Table 1).
Table 2 Comparative Measurement Color Changes (Mean ± SD)
Among ΔL x*, Δax*, and Δbx* be-
Between the Peri-implant Soft Tissues at 0, 10, and
15 Minutes tween control and test sites, only
Δax* showed a significant difference
Groups ΔLx Δax Δbx ΔEx* between the AT gingiva and peri-
0 min 69.3 ± 1.9a 9.4 ± 2.3a 6.0 ± 1.2a – implant mucosa. There was no ob-
10 min 65.7 ± 0.7 b 20.6 ± 1.0 b 12.1 ± 1.0b 3.6 ± 0.9a vious discrepancy found between
15 min 65.3 ± 0.7b 20.8 ± 0.6b 12.4 ± 0.5b 3.5 ± 0.6a ΔE10-AT* and ΔE15-AT* (P > .05). The re-
SD = standard deviation. sults imply that peri-implant mucosa
Within the same column, values with different superscript letters are statistically color 10 minutes after contouring
significantly different (P < .05).
under adaptive pressure presents
similar color appearance to the AT
18 gingival color. No significant differ-
16
ence was present between ΔE0–10*
and ΔE0–15* (P > .05), but both were
14 y = –1.2127x + 13.293 lower than the clinically acceptable
12 R2 = 0.8612
Color difference

color difference (Table 2). Among

10 ΔL x*, Δax*, and Δbx*, all color param-
8 eters showed significant differences
in the peri-implant mucosa between
6
0 and 10 minutes and between 0
4
and 15 minutes. Therefore, the cor-
2 relation between ΔE0–10* and adap-
0 tive time was determined, as shown
0 1 2 3 4 5 6 7 8 9 10
in Fig 4. The ANOVA results shows
Adaptive time (min)
a correlation R2 was 0.8612, which
Fig 4  Correlation between color difference of the peri-implant mucosa and adaptive time. means there was high correlation
between color difference and adap-
tive time. The slope in regression
The correlation between ΔEx* in 0 15 minutes in peri-implant soft tis- equation presented a negative cor-
to 10 minutes and time was ana- sues and between 9, 10, and 15 relation. Under adaptive pressure
lyzed using linear regression. The minutes in peri-implant soft tissue to peri-implant soft tissue, crown
color changes among 0, 10, and and gingiva of the adjacent tooth length at 0 and 10 minutes revealed

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no significant difference, with the
values of 8.9 ± 0.3 mm and 9.0 ±
0.3 mm, respectively.
Discussion
Adaptive Pressure Technique
Three methods have been used to
obtain the proper crown profile and
contour in provisional restorations.
The selective pressure method15
applied higher pressure in the inter-
proximal area to support the papil-
lae, while lower pressure was used
in the undercontoured buccal gin-
gival area to prevent recession. The
dynamic compression technique7
involves over-contouring first, then
subtracting volume in interproximal
and cervical areas to create space
for peri-implant soft tissue. The
critical and subcritical contour tech-
nique11 was applied by manipulating
contours in the critical (1 mm below
the gingival margin) and subcriti-
cal (emergence profile apical to the
critical zone) zones.11 All described
techniques3 lack quantitative deter-
minants of the location for contour
modifications and timing.
The adaptive pressure tech-
nique adopted in this study was
used to over-contour the mesial and
distal regions to mold interproximal
papilla. This is because applying
pressure on the interdental tissue
resulted in narrowing the embrasure
space, leading to increased papilla
height.5,16 It has been reported that
terminal branches of larger vessels in
the bone periosteum at the implant
site provide blood supply for the
peri-implant soft tissue,17,18 though
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Fig 5  Definitive restoration was fabricated on the base of harmonious gingival appearance.
limited blood vessels were noted
in peri-implant soft tissues lateral
to the implant areas. Therefore, the
adaptive pressure technique con-
trols soft tissue contouring within a
physiologic tolerance. Alteration of
the contour does not alter the gin-
gival margin level significantly be-
cause the ischemic reaction fades
away within 10 minutes. When the
tissue-modeling stage is complete,
the final restoration can be fabri-
cated based on good pink esthetics
(Fig 5).
Adaptive Time of Ischemic
Reaction
The adaptive procedure of the isch-
emic reaction during the facial soft
tissue contouring adjustment was
shown in 12 frames, extracted at
1-minute intervals from 0 to 10 min-
utes of the video and at 15 minutes
(Fig 3). The regression equation be-
tween ΔEx* and adaptive time pre-
813
sented a negative correlation and
no significant difference was noted
between ΔE0–10* and ΔE0–15*, which
meant the color in the peri-implant
soft tissue gradually recovered from
white to pink within 10 minutes. This
implies that the shortest time for
blanching disappearance was 10
minutes, indicating the time needed
for the peri-implant soft tissue to
bear pressure from a placed resto-
ration. This is consistent with several
studies that recommended either
10,19,20 15,7,15,21 or 20 minutes22 of
contouring time. The ischemic reac-
tion caused by exaggerated convex
contouring over a longer period of
time might result in gingival edema,
inflammation, and recession, and
even avascular necrosis.23 Figure
4 clearly shows that there are two
stages in the adaptive procedure of
ischemic reaction: the fast stage, in
which blood quickly fills in the peri-
implant soft tissue during the first
4 minutes, and the slow stage, in
which the gingival tension gradually
Volume 39, Number 6, 2019
814
returns to normal over the following
6 minutes. This information provides
details regarding the time needed
for peri-implant soft tissue molding.
Color Change in Peri-implant
Mucosa and the Tooth Gingiva
An ideal peri-implant mucosal
color must match that of the adja-
cent teeth, provided they have the
same tension. The mucosal color at
9 minutes in peri-implant showed
more yellow than that at 10 and
15 minutes. Both values of ΔE10-AT*
and ΔE15-AT* were 3.7 ± 0.9, which
is equal to the clinically acceptable
value for color difference (3.7).
The mucosal color in peri-
implant soft tissue at 9, 10, and 15
minutes showed more red color
than that of the AT gingiva. Al-
though Paniz et al24 reported color
differences between peri-implant
soft tissue and gingiva of natural
teeth based on spectrophotom-
eter assessment, this difference
was not observed in a subjective
evaluation completed by five den-
tal professionals (prosthodontist,
periodontist, general dentist, den-
tal hygienist, and dental assistant).
Results from the present software
program assessment confirmed
the spectrophotometric evaluation
performed by Paniz et al. There are
many factors influencing the peri-
implant soft tissue color, such as
the thickness of the facial gingiva,
abutment material, and peri-implant
soft tissue architecture.25 To control
these confounding factors in the
present study and ensure consistent
color measurements, a gold-hue
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abutment was selected and it was
required that all subjects have a soft
tissue thickness > 2 mm at the im-
plant site. According to a study by
Sala et al, when the gingival thick-
ness is larger than 2 mm, a gold-hue
abutment has no impact on gingival
color.26
Conclusions
This study shows that using an im-
mediate restoration to mold soft
tissue, both in the interproximal
papillae and midfacial mucosa, is
a feasible technique to achieve
the needed esthetic outcome. The
present data also indicate that, in
peri-implant soft tissue molding,
10 minutes of adaptive time is ad-
equate for soft tissue recontouring
without changing the color appear-
ance or soft tissue margin level. Fu-
ture studies in this field are needed
to further confirm the validity of this
novel approach.
Acknowledgments
The authors declare no conflicts of interest.
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