2nd Stage Surgery
In spite of the pre-plan desired result prior to Stage I surgery, treatment-planning options must be reassessed after implant integration or at 2nd Stage surgery and prior to the restorative phase. Proper soft tissue management often dictates the success of the restoration and the final esthetic result. Surgical procedures utilizing guided soft tissue healing (repositioned flap, gingival grafts, gingival augmentation and gingival contouring) must be considered after implant integration. Following the integration period, uncover the implant healing cap, if the cap has not self exposed. The location can be determined by palpation of the soft tissue or sounding with a periodontal probe. To surgically expose the healing cap, use either a tissue punch or a scalpel, taking care to preserve an adequate amount of attached keratinized gingiva. Remove the healing cap.
Note: It is absolutely imperative that all bone and soft tissue be removed from the coronal aspect of the implant body to guarantee complete seating of the abutments. The presence of soft tissue, bone fragments, or debris between the implant and abutment can lead to incomplete abutment seating. During the surgical uncovering, do not use a bur or drilling instruments, as they may compromise the implant-abutment junction. To verify proper abutment seating, a periapical x-ray should be taken to evaluate the abutment-implant interface. Any noticeable gap is indicative of improper seating and the abutment should be removed. The entrapped tissue or debris is removed, if present, and the abutment connection repeated and confirmed with a new radiograph. Suturing may be required to adapt the soft tissue around the abutment or the implant neck. The prosthetic margin on the neck of the implant should be 1-2mm apical to the soft tissue level. A provisional restoration may be placed at the second stage appointment. A tissue retraction abutment may also be utilized to prevent the soft tissue covering the top of the implant during the prosthetic construction. The final restoration may placed after soft tissues have matured (6-8 weeks).