Dental Technique for Chairside Fabrication of a Customized Healing Abutment: A Case Report

ABSTRACT

Although novel technologies offer many opportunities, they are neither available nor easily accessible anywhere and anytime, and they are more costly. This article describes a technique for chairside fabrication and delivery of an immediate custom healing abutment utilizing both digital and conventional means.

1. Introduction

Osseointegration and implant survival have reached high rates, and both clinicians' and researchers' attention has drifted towards aspects of implant therapy that are decisive in terms of success [1]. Surgical trauma, inter‐implant distance, platform‐bone level relationship, occlusal overload, or impact of maxillofacial growth are among factors that have been correlated with biological or technical complications, compromising the final result [2, 3, 4, 5, 6].

Achieving an aesthetically pleasing prosthesis remains challenging, as both the appearance of the prosthetic restoration (“white aesthetics”) and the harmony of the surrounding gingival tissues (“pink aesthetics”) must be considered [7]. The correct shade and shape of the restoration, as well as the formation of the emergence profile offer the opportunity for the restoration to match the remaining dentition and contralateral teeth in terms of mucosal contour and color [8].

Peri‐implant emergence profile has also been related to the stability of the crestal bone [7, 8]. Proper emergence profile contour along with adequate soft tissue thickness has been shown to play a crucial role regarding plaque accumulation, bleeding on probing, and stability of the peri‐implant tissue [8, 9, 10]. Moreover, the delivery of a properly contoured provisional restoration or healing abutment has been shown to reduce soft tissue collapse [11].

Many clinical reports have tried to provide techniques for the successful delivery of properly contoured customized healing abutments, either with an immediate or delayed implant placement [12, 13]. After the recent technological advances, fabrication of CAD/CAM healing abutments is now feasible [14]. However, novel digital technologies are often inaccessible due to cost or regional limitations. Therefore, the purpose of this article is to describe a technique for chairside fabrication and delivery of an immediate custom healing abutment utilizing both digital and conventional means.

2. Case History/Examination

A 58‐year‐old male patient presented to the Postgraduate Dental Clinic of a University seeking dental rehabilitation. The chief complaint was the compromised aesthetics of the anterior cantilever bridge from #12 to #11, which the patient had received 23 years ago (Figure 1). The medical record did not indicate any systemic disease or medication use.

FIGURE 1.

Initial situation. The aesthetics of the anterior prosthesis are compromised.

3. Differential Diagnosis, Investigations and Treatment

After thorough clinical and radiographic examination, tooth 12 was characterized with poor prognosis due to extensive secondary caries and compromised periodontal status. Cone beam computed tomography (CBCT) imaging revealed the need for guided bone regeneration (GBR) concurrently with the extraction of the right lateral incisor, due to hard and soft tissue deficiencies at the tooth 11 and tooth 12 sites before implant placement. The patient agreed to the proposed implant‐supported fixed prosthesis.

The right lateral incisor was extracted and GBR was performed at the edentulous area (Figure 2). Elevation of a full thickness flap was performed after a horizontal incision on the center of the edentulous ridge. The area was thoroughly cleaned from granular tissue which had penetrated the buccal osseous ridge. The periosteum was released to ensure proper closure without the presence of tension. A combination of allograft and xenograft was placed after the positioning of a resorbable collagen membrane which was stabilized with the use of two pins. The area was covered with a free gingival graft which was deepithelialized extraorally. The flap was sutured with the use of 6–0 polyamide sutures. To protect the area and provide the patient with an aesthetic prosthesis, an interim metal‐acrylic resin‐bonded bridge was delivered with teeth 21 and 13 serving as abutments. Six months after the GBR, a new CBCT was performed which revealed adequate bone substrate for implant placement in the position of the right lateral incisor while the area of the right central incisor still appeared with a deficit. Thus, the treatment plan included placement of one implant at the position of tooth 12 and delivery of a cantilevered implant‐supported fixed prosthesis. To deliver an aesthetically pleasing restoration and avoid repeated area disturbance, the decision for immediate placement of a customized healing abutment to optimally form the soft tissues was made.

FIGURE 2.

GBR surgery to augment bone substrate and delivery of the interim resin‐bonded bridge without tissue contact initially.

Two impressions were made, one of the clinical situation prior to implant placement and one of the waxed‐up model. The two impressions were scanned in the laboratory and were superimposed along with the CBCT. A virtual wax‐up could also be performed, but for the technique described, physical models were required. Optimal implant position was planned for the delivery of a screw retained restoration, and a surgical guide was ordered. Use of a surgical guide was decided to ensure accurate transfer of the digitally designed plan intraorally. The fit of the surgical guide was checked both intraorally and on the cast, which would serve as the working cast. In this case, the cast that was used for the fabrication of the interim resin‐bonded bridge was used.

Given that the implant was planned to be placed 4–5 mm apically to the desired most apical point of the crown contour, the labio‐palatal and mesio‐distal dimensions of the contralateral tooth from 2 until 5 mm transverse sections coronally to the implant platform were checked. After placing the surgical guide, the position of the implant to be placed was marked on the dental cast. The morphology depicted in the CBCT cross sections in terms of shape and dimensions at the position that was about to receive the implant was replicated with a laboratory motor. Attribution of the correct dimensions was checked with a periodontal probe (Figure 3).

FIGURE 3.

Correct shape and size attribution on the cast is measured with a periodontal probe to accurately replicate the CBCT cross sections.

After achieving the desired morphology, the surgical guide was placed and the cast was drilled through it until reaching and perforating its base. A silicone index made from the wax‐up plan, after adding small protrusions on the teeth adjacent to the edentulous area to ensure proper seating, was filled with self‐polymerizing acrylic resin and placed on the working cast (Figure 4). After complete polymerization, the acrylic was removed and adjusted to secure proper seating. While seated on the cast, it was completely drilled through the hole that was previously made in the cast (Figure 5).

FIGURE 4.

Wax‐up and transfer of the protrusions added to ensure proper seating to the acrylic.

FIGURE 5.

Cast drilling through the surgical guide and reverse drilling of the acrylic to ensure accurate association with the abutment intraorally.

An implant of standard diameter (4.1 × 12 mm) was placed intraorally through the surgical guide, and the initial stability allowed for the delivery of a healing abutment (Figure 6). The pins placed during the GBR procedure were left in place to avoid a more extensive flap elevation at this aesthetically critical area. In this case, a poly‐ether‐ether‐ketone (PEEK) scan body was utilized because of the material's biocompatibility and limited dimensions [15]. The scan body's surface was processed to achieve a rough surface for the resin to engage and for the acrylic to be placed without any interference that would impede proper seating.

FIGURE 6.

Implant placement through the digitally fabricated surgical guide.

Acrylic's proper position was assured intraorally by checking the protrusions on the adjacent teeth, and it was activated by applying flowable composite. A mark was made 1 mm above the mucosa to ensure that the healing abutment would not be covered by soft tissues. The abutment–acrylic complex was unscrewed and cut at the marked area. Small alterations to achieve proper morphology, soft tissue support, and a polished surface were applied. In case an implant is placed immediately after tooth extraction, the morphology of the healing abutment should support the post‐extraction socket. The customized healing abutment was placed to confirm correct three‐dimensional soft tissue support, proper gingival zenith level, and the interim restoration was delivered with care so as not to interfere with the soft tissues (Figure 7).

FIGURE 7.

Implant placement and abutment delivery after ensuring presence of adequate torque. The acrylic was activated intraorally to deliver the customized healing abutment.

After 4 months, the interim restoration was removed and an implant‐level impression that captured the acquired emergence profile was made. An implant‐supported interim restoration replicating the custom healing abutment's morphology at the critical subgingival area was delivered to properly shape the pontic area and check function and aesthetics (Figure 8). Addition and removal of material took place every 2 weeks in order to accurately replicate the morphology of the contralateral tooth's gingiva [16]. After achieving acceptable tissue contour, the final impression was made.

FIGURE 8.

Tissue configuration before and after interim prosthesis delivery. Every modification should be followed by a two‐week waiting period.

4. Results

The final, fixed, screw retained, cantilevered, zirconia restoration was checked extraorally for proper design and connector size attribution, tried intraorally, and examined clinically and radiographically to check fit, occlusion, contact points, tissue support, and aesthetics, which were acceptable (Figures 9 and 10). Special care was given to check both static and dynamic occlusion and eliminate contacts on the cantilever, given that the major force is subjected to the central incisor. The prosthesis was delivered by covering the access hole with a temporary filling material, and the patient was asked to evaluate it during the next few days. At the final appointment, the patient evaluated the prosthesis as excellent, both functionally and aesthetically. Since the final result was approved both by the clinician and the patient, the prosthesis was delivered by re‐applying the torque suggested by the manufacturer, and the access hole was filled with a permanent filling material. Since the restoration is screw retained, it shall allow easy retrieval if needed in the following recall appointments, enabling easy repair or maintenance with minimal biological and technical complications [17].

FIGURE 9.

Delivery of the final prosthesis after thorough investigation of occlusion, function, and aesthetics.

FIGURE 10.

Radiographs of the treatment sequence. (A) Initial situation. (B) Delivery of the customized healing abutment immediately after implant placement. (C) Delivery of the provisional restoration 4 months later. (D) Radiographical evaluation of fit at the final prosthesis delivery appointment.

The technique applied in this case manages to combine the availability of means present in conventional protocols with the increased accuracy offered by digital planning and static navigation through surgical guides. The protocol described delivers a fully customized healing abutment immediately after implant placement, thus eliminating the need for surgical reinterventions or multiple connections—reconnections to gradually shape the abutment, thereby conforming with the biological principles and the one abutment—one time concept [18] (Figure 11).

FIGURE 11.

Timeline of the individual treatment stages.

5. Discussion

Literature has examined the clinical effect of customized healing abutments. Comparison of customized and conventional healing abutments favors the former in terms of probing depth and papilla maintenance [19]. Studies have also shown a better trend regarding aesthetic outcomes, peri‐implant soft tissue preservation, and lower patient discomfort [20]. According to some reports, there is also a positive effect in terms of bone loss, while there are no documented biological or aesthetic disadvantages associated with their use [21, 22].

The role of pink aesthetics in the overall evaluation of a single‐unit implant‐supported restoration has been extensively discussed in the literature [23]. Research has given birth to the anatomical classification of the emergence profile into the crestal, bounded, and aesthetic zones in an apico‐coronal direction [24]. Guides and checklists have been published, aiming to describe the specifications that each of the aforementioned areas should meet [24]. Tissue preservation or augmentation [25], reduced dental plaque or bleeding on probing [10], reduced marginal recession [26], and enhanced aesthetics are among the advantages of the described approach [24].

Repetitive incisions and flap elevations are known to negatively affect soft tissues and result in gingival recessions. In order to avoid such clinical problems and provide the patient with an aesthetic prosthesis, the described protocol was generated and applied. This paper describes a technique for chairside fabrication and delivery of a customized healing abutment immediately after implant placement. Several similar attempts have been published with a variety of protocols that utilize either conventional or digital means [13, 27]. Several techniques have been described for the delivery of customized healing abutments. The need for immediate placement of a customized healing abutment in this case excluded all the techniques incorporating delayed‐loaded implants [28]. These cases benefit from the advantage of a given, final position of an already placed implant. Most of the existing reports that aim to design an abutment for an implant to be placed using exclusively digital means share a common limitation, which is the need for impeccable knowledge of the CAD‐CAM software programs and the learning curve for the 3D‐printing protocols [3]. On the other hand, some of the reports not using digital means describe the fabrication of a healing abutment immediately intraorally using the post‐extraction socket, which is neither time‐effective nor accurate [29]. Reports utilizing an existing tooth at the implantation area also could not be applied in this case since the extraction of the tooth characterized with poor prognosis preceded the final CBCT and GBR procedures [30].

The described technique aims to overcome all the abovementioned restrictions by applying a flexible, hybrid protocol incorporating both digital and analog means for predictable results. It can be applied in any case where an immediate customized healing abutment is needed, regardless of the presence of a tooth at the implantation site, which is a prerequisite in other similar techniques described in the literature. The main objectives and advantages of the described technique are the reduction of both the intraoral procedures' time and tissue disturbance, accuracy enhancement by applying a thorough planning sequence, and assurance of the applicability in any case, time, and region by avoiding sophisticated means. Even the abutment used was a readily available PEEK scan post, thereby offering freedom regarding components' utilization, apart from the biological benefits of this material. If any of the means described are not available, the clinicians may alter the protocol for it to be applicable to the planned case. On the other hand, novel, emerging technologies could be incorporated in this protocol to omit analog procedures. Although this technique could be applied without the use of a CAD/CAM surgical guide, according to available data, static computer‐assisted implant placement shows better accuracy regarding both trueness and precision, as well as shorter surgical time and less patient discomfort [14, 31, 32].

This technique also entails certain limitations. The presence of a surgical guide is crucial to transfer the three‐dimensional position of the implant in the working cast before intraoral implant placement. Lack of adequate knowledge regarding CAD/CAM software programs might impede the success and applicability of the described technique. Moreover, it demands certain skills to accurately transfer the planned implant position and sculpt the cast in the edentulous area in a way that replicates the morphology of the contralateral tooth at the cross section of interest. Digital workflows provide the opportunity to perform the abovementioned task in less working time and with fewer skills needed. However, these novel technologies are not always and everywhere available and are more costly. Since the abutment is immediately placed and intraorally activated, adequate torque value and flexibility to perform certain procedures in the surgical field are absolute prerequisites for the success of this technique.

This report aimed to describe a technique for chairside fabrication and immediate delivery of a customized healing abutment. The predictability of the presented technique lies in the use of a surgical guide for implant placement, which allows for the a priori knowledge of the intraoral three‐dimensional final position of the implant and the ability to replicate it at a cast. Moreover, most of the work needed has been performed in advance, so the time needed during surgery is minimal. Although novel technologies offer many opportunities while minimizing treatment time, they are neither available nor easily accessible in every country, region, institute, clinic, or time and are more costly. Thus, clinicians should be able to combine them with conventional techniques. Given that a treatment strategy such as the one described is implemented, biologically, functionally, and aesthetically predictable results should be anticipated. The technique can be performed chairside, and even though it does not demand the use of digital or sophisticated means, it offers sufficient accuracy and predictability.

Author Contributions

Dimokritos Papalexopoulos: conceptualization, data curation, methodology, project administration, writing – original draft. Christos Partalis: methodology, writing – original draft. Panagiotis Ntovas: formal analysis, writing – review and editing. Panagiotis Tsirogiannis: resources, writing – review and editing. Stefanos Kourtis: supervision, validation, writing – review and editing. Nikitas Sykaras: project administration, supervision, writing – review and editing.

Ethics Statement

The authors have nothing to report.

Consent

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

Conflicts of Interest

The authors declare no conflicts of interest.

Papalexopoulos D., Partalis C., Ntovas P., Tsirogiannis P., Kourtis S., and Sykaras N., “Dental Technique for Chairside Fabrication of a Customized Healing Abutment: A Case Report,” Clinical Case Reports 13, no. 10 (2025): e70890, 10.1002/ccr3.70890.

Data Availability Statement

The data presented in this study is available on request from the corresponding author.