Enhanced CPD DO C RestorativeDentistry

Graeme Bryce

Nicholas Diessner, Ken Hemmings and Neil MacBeth

Solutions for Implants Placed with

Prosthetic Inconvenience
Abstract: A prosthetically-driven approach for dental implant placement offers the most predictable means of achieving a biologically
stable and aesthetic implant-supported restoration. Optimal dental implant placement may be limited by local factors and complicate the
prosthetic reconstruction. This article aims to offer guidance on the surgical and prosthetic options available to manage suboptimally-
positioned dental implants.
CPD/Clinical Relevance: This article is relevant to dental clinicians placing and restoring dental implants, and those who are considering
them in treatment planning.
Dent Update 2019; 46: 1003–1014

The popularity of implant-supported
restorations has led to the development of
increasingly innovative clinical techniques
to provide successful and aesthetic tooth
replacements. Successful implant outcomes
are underpinned by positioning the fixture
at the optimal vertical and horizontal
position within the alveolar bone,
encouraging the development of a healthy
peri-implant soft tissue collar1 and reducing
the risks of peri-mucosal complications.2
Graeme Bryce, BDS, MSc, MEndoRCS,
MRD RCPSG, FDS(Rest), Consultant in
Restorative Dentistry, Defence Primary
Health Care Centre for Restorative
Dentistry (email: graemebryce001@
hotmail.com), Nicholas Diessner, MSc,
Dental Technician, Defence Primary Health
Care Centre for Restorative Dentistry, Ken
Hemmings, BDS, MSc, DRD RCS, FDS RCS,
ILTM, FHEA, Consultant in Restorative
Dentistry, Eastman Dental Hospital, 256
Gray's Inn Road, London WC1X 8LD and
Neil MacBeth, BDS, MSc, FFGDP, MGDS,
MFGDP, MFDS, FDS(Rest), Consultant in
Restorative Dentistry, Defence Primary
Health Care Centre for Restorative
Dentistry, Evelyn Woods Road, Aldershot,
GU11 2LS, UK.
December 2019 DentalUpdate 1003
The importance of this implant-tissue
association has led to the development
of ‘prosthetically driven’ surgical
protocols, where the optimal prosthetic
tooth position2 is used to determine the
correct spatial position for the implant
fixture.
Failure to achieve the
ideal horizontal and vertical spatial
relationships can lead to problems.
Horizontal misalignment within the
buccal plane may increase the risk
of alveolar bone loss3,4 and mucosal
recession2,5,6 (Figure 1). In contrast,
palatal placement risks an inferior
emergence profile of the prosthetic
crown.7 Inappropriate mesial-distal
implant position may also affect the
shape and size of the interproximal
papilla,8 with failure to achieve a
1.5−2 mm peripheral bone margin,
resulting in loss of the papilla height,
reduced thickness of the gingival collar
and an undesirable embrasure form and
emergence profile.
With regards to vertical
apical-coronal malpositioning, deep
implants (>2 mm) can result in an
increased risk of bone resorption, tissue
shrinkage, a compromised aesthetic
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outcome and long-term maintenance
issues.9 Conversely, superficial fixture
placement (<2 mm) can also lead to
aesthetic complications as it may create
a more acutely angled emergence profile
of the prosthetic restoration and risk
exposure of the abutment and possibly
the fixture10 (Figure 2).
Comprehensive patient
assessment and treatment planning,
in combination with a good surgical
technique, can normally mitigate against
the risk of implant malposition. A
diagnostic wax-up of the final prosthetic
restoration can help determine not
only the ideal shape of the restoration,
but also optimally guide the implant
position. However, despite meticulous
planning, the ideal fixture position may
be inherently compromised by the
presence of adverse anatomical features
(neurovascular bundles, maxillary
sinus, adjacent teeth alignment) or
alveolar bone and soft tissue defects,
resulting in a challenging prosthetic
reconstruction. The early identification
of cases, where the prosthetically-driven
protocol cannot be followed, allows
for investigation of different prosthetic
solutions. Close liaison with the dental
 RestorativeDentistry
a at the expense of the ability to construct
Figure 1. UR3 implant placed too deep and in
too buccal a position with subsequent soft tissue
recession and metal abutment show.
b an adequate tissue thickness around the
a may sometimes be difficult after this
b laboratory technician at this stage can
Figure 2. (a, b) These CAD images illustrate two
different emergence profiles resulting from
implant placement. The abutment in (a) has a
tapered design (marked in blue), leading to the
emergence at the mucosal margin (marked in
red). The abutment in (b) has been placed too
shallow and has resulted in an abrupt crown
margin emergence (measured as 90˚). Such an
angulation may impinge upon the aesthetics of
the crown emergence and creates a plaque trap
that impacts upon the implant mucosal health.
1004 DentalUpdate December 2019
Figure 3. (a, b) Case 1: This hypodontia case
illustrates failed block bone grafting with
resultant vertical and horizontal bone defects
that necessitated buccal angulation of both
the UR5 and UR3 fixtures. Subsequently, the
provisional restorations can be seen to have
a reduced band of KM and the mucosa is
erythematous and oedematous.
ensure that the subsequent prosthesis is
both harmonious with the mucosal tissues
and aesthetically acceptable, minimizing
the risk of longer-term prosthetic and peri-
implant complications.9
This article uses clinical cases
to present both clinician and dental
technician with solutions for implants
placed in sub-optimal positions.
Soft tissue strategies
The consequences associated with
implants placed in a sub-optimal position
are particularly severe in the aesthetic
zone and can be further complicated
when the individual has a thin and
scalloped biotype, a tapering tooth form11
and less than 2 mm of keratinized mucosa
(KM).12 It has been suggested that patients
with a thin scalloped biotype require
placement of the implant shoulder more
palatally, in order to reduce the risk of
titanium show through,13 but this may be
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an optimal prosthetic emergence profile.
Simple management of a
buccal placed implant may involve the
use of a two-stage protocol, which aims
to distribute the residual mucosal tissue
electively. In the maxillary area, the
alveolar crestal secondary stage incision
can be placed palatally and the reflected
flap displaced towards the buccal aspect
of the fixture. This protocol promotes
the retention of keratinized mucosa, at
implant neck. However, primary closure
procedure, as it can be dependent on
the tissue thickness and the extent of
the displacement. Delayed healing by
secondary intention, with increased risk
of recession to the adjacent teeth, can
result if the tissues cannot be closely
approximated.
A variety of surgical peri-
implant mucosal augmentation
techniques have been promoted,
with the aim of either improving the
prosthetic emergence profile of the
restoration and/or reducing the risk of
soft tissue recession.14 These techniques
attempt to increase either the volume of
connective tissue at the site, resulting in
increased vascularity to the region and
enhancement of the body’s regenerative
response,15,16 or the development of a
more robust and stable zone of keratinized
mucosa. Reported augmentation
techniques are wide-ranging and include
the use of autogenous tissue-free gingival
grafts (FGGs),17 connective tissue grafting
(CTG),18 xenogenous (porcine-derived
products such as MucoGraft®19) or
allografts (Alloderm®). Although opinions
on the optimal soft tissue augmentation
approach differ, the use of autogenous
grafts (CTG/FGG) has been found to
be effective at increasing the mucosal
thickness and KM.20
The early identification of
implant fixtures, positioned with an
angulation that may predispose to soft
tissue loss, is crucial for early intervention
to promote successful management. Case
One (Figures 3−6) details the use of an
apically repositioned flap in combination
with a FGG, to increase the KM and
improve soft tissue health around two
buccal-orientated implants.

a a
b improved peri-implant soft tissue health
Figure 4. (a, b) Case 1: To stabilize the peri-
implant soft tissues, an FGG was harvested from
the palate and sutured onto the buccal aspect.
b aspect and same-day laboratory manufactured
Figure 5. (a, b) Case 1: The definitive restoration
was a hybrid bridge with screw retention on the
UR3 implant and a gold cast custom abutment,
with a margin lying 0.5 mm below the soft tissue
collar, for the UR5 fixture.
Prosthetic management
at second stage surgery:
abutment selection
Temporary abutments include cover
screws, healing abutments and provisional
crowns. Surprisingly, little research is
December 2019 DentalUpdate 1005
b
Figure 6. Case 1: The final outcome shows
associated with the increased width of KM
around the implant-retained bridge. However,
the limitations of the buccal angulation of the
implants with metal show at the neck of the UR3.
Figure 7. (a, b) Case 2: This case details
incorrectly placed implants within the UR2 and
UL2 sites with subsequent labial mucosa shine
through of the implant collar.
available to guide the clinician on
appropriate abutment choice, with
most guidance originating from case
reports or manufacturer guidelines.
Conventional parallel-sided healing
abutments have been augmented
with a range of contoured, aesthetic
or adjustable abutments that aim to
improve soft tissue adaptation around
the coping during early healing. Such
contoured healing abutments may
mitigate against the risk of soft tissue
recession around implants positioned
with an increased buccal emergence.
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RestorativeDentistry
Figure 8. (a−c) Case 2: The case was managed
using a CTG roll-flap technique, with connective
tissue rolled from the palatal to the buccal
provisional crowns. This avoided the need for the
placement of healing abutments that may have
encouraged soft-tissue recession.
Alternatively, enhanced soft tissue
healing can be achieved by using
same-day provisional crowns, provided
chairside or through the laboratory, if
close support is available. The early use
of provisional crowns has been found
to improve the mucosal profile around
the definitive prosthetic structures.21,22
Adaptation and individual molding of
the provisional crowns (see Case Two)
can be an effective means of preserving
and manipulating the soft tissues until
the desired mucosal emergence profile
and papilla contours are achieved.23
Case Two details a clinical
example of implants that were labially
angulated due to lack of bone (Figure
 RestorativeDentistry
Figure 9. Case 2: The 2-year review shows a thick
soft tissue collar around the crowns, masking
the underlying implants. However, the custom
abutments were unable to disguise the poor
positioning of the implants, with the emergence
of the crowns lying apical to the gingival zenith line of the ideal crown shape.
of the adjacent central incisors. Alternative
treatment options would have been explantation a
with block bone grafting to facilitate improved
positioning.
a available restorative space, aesthetic
b screw retention include a reduction in
Figure 10. (a, b) Screw-access channel lying
within the cingulum plane of a canine crown. This
position negatively impairs the technician’s ability
to contour the crown effectively to provide both
an occlusal contact and dynamic guidance.
Figure 11. Case 3: Conventional screw-retained
implant placement in UL1 site with access cavity
within the cingulum of the restoration.
1006 DentalUpdate December 2019
Figure 12. Case 3: The shallow placement of the
implant has challenged the emergence profile as
illustrated by the dimensional disparity between
the ‘red’ line of the emergence profile and ‘black’
b disadvantages. The major benefits of
Figure 13. (a, b) Case 3: The subsequent
provisional crown had a labial cantilever of labial
crown margin and a poor emergence profile,
with the soft tissue collar lying below the gingival
margin of the adjacent UR1 tooth.
7). Clinical options to manage the case
included explantation and repositioning
of the implant or, as detailed, soft tissue
augmentation at second stage surgery
using the combination of immediate
provisional crowns (Figure 8a) and a
roll-flap connective tissue graft (Figure
8b and c). The definitive management
of the case employed UCLA cast custom
abutments with cement-retained crowns.
Despite the aesthetic compromise, the
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mucosal tissues were stable at the
2-year review (Figure 9).
Definitive restoration
The definitive implant restoration can
be manufactured as either a one-piece
screw-retained structure starting at the
implant level, or in two components,
using an angulated or custom abutment
and cemented crown. Although both
techniques are successful, the use of
an angulated abutment allows the
clinician to use a variety of abutment
orientations to support the prosthetic
structure. Influencing factors include:
the type of implant (bone level or
trans-mucosal designs), the implant
configuration (internal or external
hex), divergent implant direction, the
demands and desired prosthetic
outcome.
Implant level abutments
Dental implant fixtures can be restored
with screw-retained or cement-
retained crowns, with each technique
having individual advantages and
the inter-occlusal vertical space required
for restoration and simplification of
prosthetic retrieval. Retention of an
access foramen may, however, be at
the expense of impaired control over
occlusal contacts.24
Successful planning for
screw-retained restorations requires
the adoption of a prosthetically-driven
surgical protocol, where the vertical
screw access emerges within the
cingulum envelope of the implant
crown (anteriorly) (Figure 10) or inter-
cuspal fossa (posteriorly).
Within the aesthetic
zone, adoption of this protocol can
result in the implant being palatally
positioned in the alveolar ridge, with
the requirement to use a labially
cantilevered crown, to achieve
alignment in the arch. Cantilevering
the crown in this manner can increase
the difficulty associated with creating a
natural emergence profile, particularly
when the technician attempts to
recreate a desired ‘triangular’-shaped
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 RestorativeDentistry
Figure 14. Addition of composite to the
provisional restoration until a satisfactory
emergence was achieved.
Figure 15. Addition of composite onto an
impression coping to capture the emergence
profile.
Figure 16. The emergence of the provisional
profile was subsequently copied and captured
within the definitive digital model (outlined in
red) constructed screw-retained crown.
anterior crown against the circular
cross-sectional shape of the dental
implant. Again, the use of provisional
crowns, with additions or alterations,
can help manipulate the soft tissue
collar until the desired emergence
profile is achieved (Case Three: Figures
11−13). The preferred soft tissue
contour, produced by the provisional
restoration, can then be captured with
1008 DentalUpdate December 2019
Figure 17. Translation of labial emergence profile
from adjusted provisional to definitive crown.
Figure 19. (a, b) Stock abutment with
inappropriate marginal height, lying above the
mucosal collar (Figure 9) and post-technician
adjustment.
Figure 18. Improved aesthetics achieved by a
adjusted emergence profile of definitive crown.
either an impression coping customized
through the addition of a composite
material (Figures 14 and 15), or through
a direct impression of the provisional
crown emergence surface. Both
techniques allow the developed soft b
tissue profile to translate directly into the
definitive restoration (Figures 16−18).
Small subsequent changes in emergence
profile are well tolerated by the mucosal
tissues in most circumstances, resulting
in transient blanching of the adjacent
soft tissues which normally resolves
after a few minutes. Large changes to
the emergence profile may promote
apical displacement or recession of the Figure 20. (a, b) UCLA in process of wax-up.
mucosal tissue and unwanted aesthetic
gingival changes.
The use of angulated
abutments and cement-retained crowns damage to the implant. Abutments for
can facilitate restoration of implants cement-retained crowns can be either
that are not restorable via conventional prefabricated standard abutments or
screw retention. In addition to custom made, where they are designed
purported improved aesthetics, cement to promote an idealized mucosal peri-
retention may add a stress-breaking implant collar.
cement interface between the crown Stock/standard abutments
and abutment, reducing the risk of are relatively inexpensive and are
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 RestorativeDentistry

available in an array of angle-correction

sizes (ranging from 12°−30°), to simplify
the prosthetic manufacturing process.
However, their use is limited, as they
can only be used when their design
correlates with the requirements for the
abutment margin and its relationship
with the mucosal tissue collar (Figure
19). Sometimes, significant angle
correction, in combination with a
superficial implant fixture placement,
Figure 21. CADCAM design of same abutment.
can result in visibility of the abutment
structure affecting the aesthetics of the
prosthetic restoration. Use of standard
angled abutments can also result in
a deep abutment/crown interface
Figure 23. Nobel® angulated screw channel.
that predisposes to both sub-gingival
cement extrusion and an uncleansable
junction, with increased risk of peri-
implant disease.
In contrast, custom
abutments can limit the risks associated
with the creation of this interface,
through the manufacture of an
abutment/crown margin that lies 0.5
mm to 1 mm below the peri-implant
Figure 24. Head of an angled screw-driver
mucosal collar (Figure 20). Custom
(Neoss®, Harrogate, UK).
abutments can also help to manage
the complex 3D emergence profile
requirements, when implant fixtures
have been placed too deep or shallow.
Custom abutments
may be waxed-up and cast (UCLA)
or manufactured using CADCAM
processes (Figure 21). Cast custom
abutments have good survival rates,25,26
Figure 25. Two part zirconia with metal base held
predictability and can allow the crown
to the implant by the Nobel Biocare Omni® screw.
to be cemented with a provisional
cement, aiding retrieval if required.
However, their use is more expensive,
owing to the high costs associated the implant.29 In addition, fractures of
with the components and cast metals, zirconia abutments have been reported
in addition to their labour-intensive when it is used in thin sections.30
manufacture.
CADCAM abutments retain Figure 22. Co-Axis® implant with prosthetic
angle-correction.
Angle correcting implants
many of the benefits of cast custom
and abutments
abutments but are cheaper and, from
a laboratory perspective, more time- Implant companies have sought
efficient to construct.27 CADCAM innovative solutions to the conundrum
tissues or a higher risk of recession has of merging the biological benefits
also facilitates the use of additional
been seen as advantageous as its white achieved when adopting a cement-
materials such as zirconia, titanium and
cobalt chromium. Zirconia has been coloration can mask unwanted aesthetic retained implant placement orientation
viewed as an attractive sub-structure changes. However, concerns have also and the benefits of a screw-retained
material as it has excellent strength, been expressed relating to potential prosthetic solution. Implants with
comparative marginal fit and aesthetic damage to the implant hex through angled prosthetic correction of 12, 24
properties.28 Its use in situations micro-movement fretting of the harder and 36 degrees (Co-Axis®, Southern,
involving patients with thin mucosal zirconia on the softer titanium alloy of Centurion, RSA) offer solutions to
December 2019 DentalUpdate 1009
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 RestorativeDentistry
a a
b b
c Figure 27. (a, b) Case 5: Use of mucosal-coloured
Figure 26. (a−d) Case 4: The use of multi-unit
abutments to correct angulation from implants
placed for an All-on-Four® rehabilitation (Nobel
Biocare). The definitive CADCAM framework
has employed mucosal-coloured composite
to disguise the soft tissue loss and give the
appearance of papilla.
optimize placement within bone whilst
retaining screw-retained retrievability
(Figure 22).
Recently, manufacturers have
introduced a modification to the retaining
screw head, allowing a matching screw-
driver to engage with the head at an
angle tilted to 25 degrees from the path
1010 DentalUpdate December 2019
a
b
porcelain to disguise loss of inter-dental papilla.
Figure 28. Case 6: This case shows unrestorable
implants within the UR1 and UR2 sites.
of screw insertion (Figures 23 and 24).
Such systems may allow the implant
to be placed in the ideal buccal-lingual
direction to optimize aesthetics whilst
retaining the benefits of screw-retained
retrieval. In addition, the flexible
nature of these systems allows metal
interface with the implant and zirconia
substructure to support the restoration,
redressing the reported problems with
implant/zirconia interfaces (Figure 25).
Multi-unit abutment
restoration
Multi-unit abutments can facilitate
restoration of multiple divergent
implants with both fixed and removable
prostheses. Multi-unit abutments are
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Figure 29. (a, b) Case 6: The implants were
explanted using 3i BioMet® (Palm Beach, Fl, USA)
Implant Removal Kit and a further two implants
placed.
Figure 30. Case 6: 3i BioMet® Implant Removal
Kit.
stock components and generally allow
angle correction of between 12 and 30
degrees, in full-arch, implant-supported
restorations. They are used as a
transitional or intermediate component,
to establish a common screw orientation
of the abutment structure at a preferred
vertical level to facilitate restoration of
the patient. Their use has been found
to be associated with longstanding
bone stability31 and allow for simplified
prosthetic outcomes.32
Multi-unit abutments once
fitted, are left in situ, with subsequent
impressions and fit of the prosthetic
components occurring at the newly
determined transitional abutment level.
The increased height of the abutment
platform increases visibility and ease
of access to the prosthetic interface,
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 RestorativeDentistry

a check-jigs on the abutments, making subsequent cost to the patient.

b to use smaller diameter retaining
Figure 31. (a, b) Case 6: Definitive screw-
retained prosthesis restoring the implants.
whilst reducing the risk of trauma to
the peri-implant mucosal collar during
the rehabilitation pathway. The reduced
need to disrupt the mucosal margin may
be of particular benefit in patients with
reduced KM, for instance, in implant-
supported over-denture cases. In
addition, the use of these components
allows the clinician to check the seating
of impression copings visually and
impression-taking and cast-verification
simpler. Patient comfort may also be
improved, with reduced requirement for
local anaesthesia at the clinical stages
of prosthesis construction and easier
cleansability.
The major limitations
associated with the use of multi-unit
abutments relate to the requirement
screws, that have reduced maximum
torque value (with increased risk of
loosening of the superstructures) and
the requirement for sufficient inter-
arch vertical restorative space, to house
both the multi-unit abutment and the
definitive prosthetic structure.
The use of angled multi-
unit abutments have facilitated the
development of novel approaches to
full-arch reconstructions, such as All-on-
FourTM (Nobel Biocare, Zurich-Flughafen,
Switzerland) (Case Four: Figure 26). This
approach facilitates the placement of
larger implants in divergent orientations
that avoid the anatomical limitations
associated with the inferior dental nerve
and maxillary sinus. The ability to place
implant fixtures which do not conform
to the prosthetically-driven protocol
can help to avoid the needs for grafting
procedures and can allow for longer but
fewer implants to be used, reducing the
Porcelain/composite soft
tissue replacement options
The replacement of extensive vertical or
horizontal alveolar/mucosal tissue defects
cannot always be easily managed with
bone and soft tissue grafting procedures.
If the tissue loss is accepted, then the
prosthetic structure may need to cope
with an increased inter-arch distance,
longer teeth, a reverse smile line,
rectangular tooth forms, inverted tooth
axes, and lack of support for the upper lip.
Alternatively, dental
technicians can use an array of techniques
and materials (including pink ceramic,
acrylic or composite) to replace gingival
tissues. Small defects (single or two-unit
cases) can often be simply managed using
small additions of pink ceramic (Case Five:
Figure 27) or larger teeth compensating
for reduced proximal tissue. More severe
defects, involving multiple implant
sites, may include sizable composite
layering techniques as detailed in Case
4 (Figure 26). Hybrid techniques, such
as the use of a mucosal coloured screw-
retained base with individual cemented
crowns, have also been advocated as a
means of replacing larger defects, whilst
reducing the maintenance burden.
Such prostheses require careful liaison

Implant Orientation Biological Implications Prosthetic Complications Laboratory Technician

Challenges

Deep (>5 mm peri-implant Deep uncleansible periodontal
pocket) pocket
Soft tissue recession
Peri-implantitis
Increased abutment length
Risk of abutment exposure
 Manufacturing a tapered
abutment to achieve a natural
emergence profile.
 Gauging the correct amount
of pressure that the abutment/
restoration can apply to the
soft tissue (biotype is difficult to
determine from models).
 A removable soft tissue
model is required.

Shallow (<1 mm peri-implant Unsatisfactory emergence  Achieving contact points that

pocket) profile manage the papillae to reduce
Risk of implant exposure the aesthetic limitations posed
by dark triangular spaces.
 Managing an acute
emergence profile angle.

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Implant Orientation
Buccal
Palatal
Table 1. Overview of implant orientation and potential clinical and laboratory challenges.
with a technician to ensure that the
substructure design is: cleansable,
provides support for the overlying
materials to enable replication of the
gingival form and that sufficient intra-
arch distance space remains to allow
placement of suitably sized teeth.
Explantation
Historically, removal of unrestorable
dental implants was challenging, often
involving significant bony trauma.
The introduction of implant removal
kits has simplified explantation and
allows removal of fixtures with minimal
destruction to the surrounding bone
tissues. In cases (Case Six) where
sub-optimal implant placement has
compromised the immediate or
longer-term outcomes (Figure 28),
explantation (Figures 29 and 30) and
placement of new implants may be
a preferable solution (Figure 31).
However, these kits cannot be used in
December 2019 DentalUpdate 1013
Biological Implications Prosthetic Complications
Mucosal recession Mucosal shine through of
implant
Unsatisfactory emergence
profile
Cleansability of pontic Labial cantilever of crown
situations of abutment screw fracture or
damaged fixture head.
Conclusion (Table 1)
Implant treatment is a complex
procedure with multiple factors
associated with a successful functional
and aesthetic outcome for the
patient. Implant placement using
an ideal prosthetic protocol is not
always feasible and, in particular, may
present challenges to the creation
of an abutment that is in harmony
with the soft tissues. Meticulous
treatment planning and close liaison
with laboratory technicians can ensure
that successful outcomes can still be
achieved in sub-optimally positioned
dental implants.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent
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RestorativeDentistry
Laboratory Technician
Challenges
 Managing the aesthetics of
the prosthesis labial face – the
reduced space often leads
to over contouring of the
restoration.
 Managing the alignment of
the prosthesis in relation to the
surrounding dentition.
 The creation of a greying of
the mucosal tissues around the
margin (if metal is used).
 Hard to match emergence
profile of teeth.
 Gauging the correct amount
of pressure that the abutment/
restoration can apply to the soft
tissue.
 Intrusion of the abutment/
restoration onto the palatal/
lingual aspect leading to
over-contour of the palatal
restoration surface.
was obtained from all individual
participants included in the article.
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