10.1 INTRODUCTION

Dental implantology requires restoratively driven implant dentistry, in that treatment should be assessed and planned relative to the proposed restoration. This underpins concept implant dentistry [1–6].

Implant restoration fundamentally involves impression taking and/or intraoral scanning, prosthesis design and fitting, and ensuring the implant it is in harmony with the surrounding tissues. Complexity can be inherent within each particular stage or be introduced through inaccuracies.

Before commencing this phase of the treatment, the restoring dentist must confirm the specific objectives of the restorative treatment plan with the patient in writing, including any limitations or restrictions caused by the final position of the implants (B).

The following should be confirmed before commencing the restorative treatment:

• Verification of implant integration using clinical and radiological means, including resonance frequency analysis where appropriate (B).
• Exclusion of any surgical complications such as pain, numbness, altered sensation, implant mobility or crestal bone loss (B).
• Assessment of the correct three‐dimensional position of the implants and their suitability to support the preplanned restorative design (B).

The use of postsurgical and restorative checklists is highly recommended (A).

Referral to a specialist or a more experienced colleague should be considered if the following conditions make the completion of the preplanned prosthodontics treatment difficult or complicated:

• Complex reorganisation of the occlusal scheme is indicated (C).
• There are higher than anticipated aesthetic and functional demands or expectations (C).
• Preplanned surgical treatment objectives have not been fully achieved (B).

10.2 SOFT TISSUE MANAGEMENT

For an implant restoration to be classified as aesthetic, the soft tissues need to closely mimic the healthy periodontium. Thus, it is important to have a full understanding of the peri‐implant soft tissues and the differences between them and the gingival tissue (B).

The position of soft tissue is determined by the underlying bone. Recognising the tissue biotype aids in predicting the likelihood of soft tissue loss. Thin biotypes with highly scalloped gingival margins and prominent papillae are more susceptible to tissue loss after extraction. Square teeth are linked to thicker biotypes, simplifying treatment as they require less soft tissue infill.

A distance of less than 5 mm between the contact point and the bone encourages soft tissue infill. Additionally, Grunder notes that the restorative condition of the adjacent tooth significantly influences papilla height, with unrestored teeth providing the most predictable outcomes. Adjacent implants typically achieve only 3.4 mm of tissue infill from the bone to the contact point, according to Tarnow, making aesthetic optimization in these scenarios more challenging.

The presence of keratinized tissue around an implant is crucial for peri‐implant health. Clinical studies indicate increased bone loss and reduced soft tissue health when keratinized tissue is thin or missing, suggesting that the absence of keratinized tissue complicates the situation. However, the evidence supporting these findings is limited (Figure 10.1).

Figure 10.1 illustrates a clinical case focusing on soft tissue management prior to implant placement and guided bone regeneration surgery. Initially, the patient’s soft tissue condition required attention before proceeding with the surgery. To address this, a minimally invasive flap combined with a tunnelling technique was employed. Following this, a palatal subepithelial connective tissue graft was performed and the area was sutured using a resin‐bonded provisional. After 8 weeks, the patient exhibited successful postoperative healing. The next phase involved performing guided bone regeneration in conjunction with implant placement, followed by flap closure through sutures. The abutment was connected using either a minimal U‐flap or a healing abutment, which helped establish the implant’s emergence profile. The patient was monitored over a 7‐year period following the surgery [7].

Morton et al.’s consensus statement indicates that soft tissue augmentation can effectively replace lost tissue. However, the need for soft tissue grafting adds complexity to the procedure. Systematic reviews by Rotundo et al. and Poskevicius and Galindo‐Moreno show that soft tissue gains are achievable during implant placement, but also emphasise that some tissue loss occurs during the remodelling process.

An evidence‐based assessment and management protocol for the quality and quantity of peri‐implant soft tissue is essential at the restorative stage for both predictable long‐term aesthetics and plaque control (B).

10.3 IMPLANT ABUTMENT AND SUPER STRUCTURE

The restoration is determined by a properly prepared treatment plan. The type, design and material that the abutment and framework are fabricated from is decided prior to the restoration phase (B).

However, there are many factors that influence the final prosthetic solution. These are influenced by the angulation of the implants, the platform height of the implant and the height of the soft tissue. The clinician must justify the type, design and material of the abutment and superstructure for each individual implant site. This must be done within the context of the occlusal forces, the need for retrievability, the aesthetics and the patient’s ability to maintain the peri‐implant soft tissues (see Figure 10.2) (B).

Figure 10.2 describes two types of dental implant systems: the taper joint‐type and the external hex joint‐type. These systems differ primarily in their joint configurations and orientation axes. The orientation is represented by three axes: the X axis indicates the mesio‐distal direction, the Y axis refers to the tooth direction and the Z axis corresponds to the bucco‐lingual direction. The key distinction between the two systems lies in their joint types: the taper joint‐type system employs a taper joint, while the external hex joint‐type system utilizes an external hex joint for the connection.