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Adam P. McCormick, D.D.S., FACS, attended dental school at The Ohio State University, graduating magna cum laude, and did a four-year surgical/medical residency in oral and maxillofacial surgery at Virginia Commonwealth University/Medical College of Virginia. He joined a practice near Washington, DC, then started the first oral and maxillofacial surgery program at Roseman University of Health Sciences, the first dental school in Utah. He now cares for patients at Oral and Maxillofacial Surgeons of Utah and has been on humanitarian missions to Honduras, China, Mexico and Ecuador.
The Gingival Cuff Link System is a simple, predictable, and time-efficient methodology that benefits both dental professionals and patients.
Dental implants rank among dentistry’s most successful procedures. With many more practitioners placing implants around the world, this type of dentistry has grown incrementally every year.
Given implant therapy’s rather high out-of-pocket cost to the patient, combined with consumers’ increasing knowledge of this treatment modality, patients have high expectations for outcomes. Patients expect their implant restoration to be esthetically pleasing and mimic the natural dentition. Because time is a premium for all stakeholders, patients want their treatment completed in as few appointments as possible, an objective the clinical team shares.
One area that is critical to the esthetic and functional outcome yet sometimes receives less attention is the formation of the gingival tissue, or emergence profile, created during the healing phase. Most implant manufacturers provide circular titanium or titanium alloy healing abutments, so the gingival tissue forms a circular channel to receive the final crown/restoration.
Which natural teeth emerge from the bone and through the soft tissue in a completely spherical manner? None, of course-each tooth has a unique geometry and emergence profile appropriate for its location in the arch. Some implant companies have created flared healing abutments to improve the emergence profile, but once again, the soft tissue channel that is created is uniform circumferentially and not ideally matched to the tooth being replaced. These healing abutments also do not lend themselves to chair side customization, which is necessary in a high percentage of cases to produce an optimal emergence profile.
An absence of proper emergence profile can have clinical implications. First is the risk that the dental laboratory creates a restoration that matches the spherical geometry created in the soft tissue. This can result in the “popsicle on a stick” crown form, which creates undercuts and food traps for the patient.
If the lab does produce a more natural emergence, the restoration is unlikely to passively fit in the tissue geometry that was formed. This can impinge tissue or require a secondary soft tissue procedure, increasing chair time and patient inconvenience. Ultimately, there is the risk of the restoration not properly seating on the implant. Secondly, a lack of matched emergence profile between the restoration and soft tissue may result in tissue recession over time and deterioration of the esthetic result.
Although it is possible for the clinician to create an anatomically correct custom healing abutment for the site using temporary abutments and restorative materials, this is time-consuming and lacks predictability. One innovative solution involves off-the-shelf custom healing abutments, Gingival Cuff Links from GCL Systems. The brainchild of an oral and maxillofacial surgeon and a general dentist who wanted to improve soft tissue management in implant dentistry, Gingival Cuff Links have changed how I practice.
This product not only addresses the soft tissue but also helps maintain the bone graft, especially in immediate implant placement. Anecdotally, this technology has reduced pain for my patients undergoing a procedure that before required some sort of narcotic, but now involves just a few OTC acetaminophen or ibuprofen tablets.
In my practice, when a molar tooth requires extraction and there is an ability for an immediate implant placement, this technique offers a predictable way to obtain ideal bone and soft tissue healing and decrease bone loss and pain.
I have also noted the practice-building potential as patients discuss with friends and neighbors how they had just one appointment for a tooth extraction and implant placement, with little to no pain. For practitioners who are specialists, it helps general dental colleagues create the ideal emergence profile for a customized abutment and crown. The following example illustrates the technique.
This patient is a healthy 49-year-old man with a non-restorable tooth #14 requiring extraction (Fig. 1).
Tooth #14 was extracted with immediate implant placement (Fig. 2).
Then, the implant screw was placed and a particulate allograft is packed into the socket to fill voids (Fig. 3). Because conventional healing abutments do not properly fill the post-extraction space, there is the potential for bone graft particles to be expelled from the surgical site, even with good suturing technique and the appearance of primary closure.
The Gingival Cuff Link Abutment is seated into the implant (Fig. 4). GCL Abutments are available for most popular dental implant systems and these healing abutments engage the anti-rotational interface of the implant. There are 11 configurations to ensure an ideal geometry is being selected for the given tooth location in the arch. As these abutments are anatomical, their rotational position is important. In addition to allowing for easy handing, the T-handle on the abutment allows the clinician to properly orient the abutment in the correct 360-degree position. The top of the T should be aligned with the adjacent dentition. If there is significant discrepancy, it provides an opportunity for the surgeon to slightly rotate the implant position.
Because the GCL Abutment is fabricated from bis-acryl material, it allows for customization with the use of flowable composite material that will bond to the abutment. In this case, small gaps were closed with additional composite material (Fig. 5). This would not have been possible with a metallic healing abutment.
The GCL Abutment is then removed and placed on an implant body analog for easy modification (Fig. 6). The remaining gaps/voids are filled with more flowable composite. The use of flowable composites also allows us to change the shade of the GCL Abutment in the esthetic zone if necessary.
Once the final desired geometry has been achieved, the T-handle is removed
with a dental bur. In this immediate implant case, it was desirable to ensure the healing abutment was out of occulsion to prevent any unwanted micromovement of the dental implant. Therefore, the occlusal aspect of the GCL Abutment was removed with a bur (Fig. 7). The versatility of the GCL Abutment would also allow the clinician to create a provisional crown if desired by either adding composite material or incorporating a crown shell.
The final GCL Abutment is seated and torqued into place per the implant manufacturer’s recommendations (Fig. 8). Note that given the ideal adaptation to the gingival margins, there was no need for suture. The access hole is covered with Barricaid® periodontal light-cured surgical dressing or a pink flowable composite.
The seal between the GCL Abutment and the gingival margin eliminates the loss of particulate bone graft and minimizes pain for the patient (Fig. 9).
The patient arrived for a follow-up appointment one month post-placement of the GCL Abutment. A proper emergence profile was created for this molar location (Fig. 11). Given the nice adaptation of the gingival tissue to the GCL Abutment, there was no loss of the particulate bone graft and bone volume was maintained. An implant level impression can now be taken allowing the dental laboratory to fabricate a final crown with a matched emergence profile to what was created with the GCL Abutment.
Gingival Cuff Links™
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