Supracrestal Ceramic Implant Placement as a Soft Tissue–Driven Alternative to Horizontal Regeneration in the Posterior Maxilla: A Case-Based Rationale

This was an interesting case brought to me by a colleague and friend, Dr. João Afonso, who requested a second opinion regarding the rehabilitation of two posterior maxillary molars.

The patient had been informed that the only possible solution would involve extensive bone reconstruction and soft tissue augmentation. While this may often represent the conventional approach, this case highlights how alternative strategies may be necessary when biological, systemic, and patient-centered factors limit the use of regenerative procedures.

Posterior maxillary implant rehabilitation remains a frequent clinical challenge, particularly in patients presenting with combined hard- and soft-tissue deficiencies. Ridge collapse, reduced keratinized mucosa, and limited prosthetic space often lead clinicians toward staged regenerative protocols, including guided bone regeneration (GBR) and soft tissue grafting.

However, in medically compromised patients—or in situations where biomaterial-based reconstruction is not accepted or not tolerated—alternative concepts must be explored.

This clinical case illustrates a supracrestal ceramic implant approach designed to optimize peri-implant soft tissue stability while minimizing surgical invasiveness.

Clinical Background

A patient with relevant systemic comorbidities, including autoimmune disease and Crohn’s disease, presented with the need to rehabilitate teeth 16 and 15 with implant-supported restorations.

Initial Radiographic Situation

Clinical and radiographic evaluation revealed:

• marked horizontal ridge deficiency

• reduced soft tissue volume

• limited keratinized mucosa

• prosthetic demands in a high-load posterior zone

  
  

A conventional treatment plan would typically involve horizontal ridge augmentation using biomaterials and membrane therapy. This was, in fact, the approach proposed by other clinicians.

However, the patient declined any regenerative procedure involving grafting materials and requested a metal-free solution, excluding titanium-based implants.

When such limitations exist, clinicians must search for and present alternative evidence-based strategies.

Importantly, evidence-based dentistry does not simply mean selecting the modality supported by the highest-ranking clinical trial or systematic review. Rather, it represents the integration of:

• the best available scientific evidence

• the clinician’s experience and technical skills

• and the patient’s individual needs, values, and preferences

  
  

  

  Evidence-Based Diagram - The incorporation of multiple variables fo taylor treatments

Treatment Concept: Ceramic Implants and Supracrestal Platform Positioning

Two ceramic implants were placed in a slightly supracrestal position, with the intention of using the polished transmucosal collar as an active component of soft tissue management.

Clinical Pearl — The Four-Wall Question

The first and most important question in cases like this is simple:

“Will the implant be fully contained within the four bony walls?”

If the answer is yes, then the biological need for hard-tissue reconstruction is significantly reduced. In these situations, augmentation is often performed not for implant survival but mainly to optimize the prosthetic emergence profile. This distinction is particularly crucial in the anterior esthetic zone, where tissue architecture plays a critical role.

In the posterior maxilla, however, the indication for horizontal reconstruction becomes more debatable—especially when function can be restored through a less invasive approach.

The Implant will be in 4 wall Bone

In this context, the supracrestal platform concept served several objectives:

• reduction of rough surface exposure risk

• facilitation of soft tissue adaptation around a polished collar

• prosthetically driven emergence profile support despite limited horizontal volume

• partial compensation of ridge collapse through prosthetic platform geometry

  
  

Ceramic implant selection was justified not only by the patient’s preference, but also by the favorable biological profile of zirconia-based materials, including reduced plaque accumulation and high soft tissue compatibility.

Soft Tissue Repositioning Strategy

Surgical Manipulation

Given the limited keratinized tissue band, a flap design was performed to divide and reposition the existing keratinized mucosa toward the buccal aspect.

This maneuver aimed to:

• increase vestibular tissue stability

• promote keratinized tissue formation around the healing abutment

• support a more favorable peri-implant mucosal architecture without grafting

The approach relied primarily on soft tissue displacement and maturation rather than biomaterial-based volume reconstruction.

Healing and Prosthetic Outcome

Healing

At three months post-operatively, clinical evaluation demonstrated:

• stable peri-implant mucosal conditions

• formation of a functional keratinized tissue band

• an acceptable emergence profile for definitive restoration

• successful prosthetic rehabilitation with ceramic crowns

While additional regenerative procedures could potentially enhance soft tissue convexity and optimize emergence contours, the selected approach provided a clinically acceptable functional and aesthetic outcome with reduced morbidity.

Note the buccal repositioning of the buccal flap - keratinized Mucosa

Clinical Implications

This case supports the concept that, in selected posterior maxillary scenarios, supracrestal ceramic implant placement combined with strategic soft tissue repositioning may represent a minimally invasive alternative when horizontal augmentation is not feasible or not desired.

The principle remains clear:

The technique must be tailored to the patient, not the patient to the technique.

Supracrestal positioning demands increased three-dimensional accuracy, but when properly executed, it may contribute to soft tissue stability and prosthetic success in challenging biological conditions.

Final Result

Bone evaluation

Have a nice Day !

Andre