You Can’t Restore an Implant Like a Tooth.

"Every implant we place is a biological decision. Every crown we design is a mechanical consequence of that decision.

In this case, we intentionally chose a supracrestal strategy to protect marginal bone and move the microgap away from the osseous envelope. Biologically sound. Predictable. Controlled.

But biology always sends the invoice to prosthetics.

When we reduce prosthetic space, we increase design responsibility. And that is where many restorations fail — not because the implant was placed incorrectly, but because it was restored as if it were a natural tooth.

This case is a reminder of a simple principle: You cannot design blindly. You must design with awareness of where your microgap is, where your biology begins, and where your occlusion ends.

Implant placement and prosthetic execution are not separate disciplines. They are chapters of the same story." - Andre Chen

Good morning everyone,

This is a very interesting case that we received from another laboratory, related to the rehabilitation of supracrestally placed implants, where the emergence profile is primarily determined by the implant platform rather than by an intermediate abutment.

In this treatment strategy, we intentionally positioned the microgap outside the marginal bone envelope, which offers clear biological advantages. By moving the microgap away from the marginal bone crest, we potentially reduce inflammatory influence at the bone–implant interface and better preserve marginal bone stability.

However, this biological decision increases prosthodontic difficulty, because we have less prosthetic space available to develop an ideal emergence profile.

The Initial Error

The crown we received reflects something that unfortunately happens quite often: a near copy-paste of the contralateral tooth, replicating identical anatomy on an implant-supported crown.

The problem is that in a supracrestal configuration, there is insufficient prosthetic space at the platform level to create an emergence profile comparable to that of a natural tooth.

The result was an artificial cervical appearance — essentially a “shelf” emerging from the implant platform and abruptly transitioning to match the adjacent teeth.

👉 This is the first fundamental mistake: We cannot restore a posterior implant assuming it will have the same emergence profile as a natural tooth.

Subcrestal vs. Supracrestal Placement

There are clinical situations where a more natural emergence profile can be achieved:

• Immediate post-extraction implants with soft tissue modeling

• Horizontal bone regeneration cases with volume reconstruction

  
  

In such scenarios, implants are often placed subcrestally, making it easier to develop a progressive emergence profile.

However, this approach comes with biological and technical trade-offs:

• The emergence profile is often achieved through vestibular mucosal over-contouring

• The biological width forms at the abutment level rather than at the implant

• The microgap is positioned within the bony envelope, frequently below the marginal bone crest

  
  

In other words, we gain prosthetic space but place the microgap in a more biologically sensitive area.

In most posterior cases, this level of overtreatment is unnecessary.

If the crown is properly designed:

• Masticatory efficiency will be identical

• Comfort will be equivalent

• Clinical predictability remains high

  
  

The key objectives are:

• No cervical food impaction

• Optimal peri-implant hygiene conditions

  
  

Food Impaction and Excessive Buccal Contour

In this case, the excessive buccal dimension of the crown was immediately evident.

This over-contouring created a clear food retention zone — which was, in fact, the patient’s primary complaint: food consistently trapped beneath the implant crown.

Occlusal Table vs. Total Tooth Dimension

It is essential to distinguish between:

• The total bucco-lingual dimension of the tooth

• The occlusal table dimension

  
  

These are not the same.

The occlusal table must be respected both bucco-lingually and mesio-distally.

The space between the occlusal table and the external contours determines the shape of the embrasures.

Marginal ridges should present a smooth angle — approximately 45° — allowing the formation of a functional, hygienic, and biologically stable interproximal triangle.

In this case, the total tooth dimension almost coincided with the occlusal table dimension — clearly incorrect and improvable.

Marginal Ridges and Occlusal Interferences

Another frequent error is misaligned mesial and distal marginal ridges relative to adjacent teeth.

This can lead to:

• Premature contacts in maximum intercuspation

• Interferences during protrusive and lateral movements

  
  

When this occurs, there are two possible outcomes:

1. Extensive chairside occlusal adjustments

2. Or worse, persistent interferences that may compromise the implant over time

   
   

⚠️ Some implants fail due to occlusal trauma — not because of primary biological failure, but because anatomical design principles were not respected.

This case clearly illustrates that risk.

Lingual Embrasures and Contact Points

Lingual embrasures are frequently neglected.

In a properly designed molar:

• A small hygienic triangle should exist between the premolar and molar

• The first molar has a different contact relationship with the premolar compared to its contact with the second molar — this detail is critical

• The mesial bucco-lingual dimension (adjacent to a premolar) should be slightly narrower than the distal dimension (adjacent to another molar)

• A proper embrasure must allow keratinized tissue stability and hygienic access

  
  

Another important consideration: Excessive contact pressure can create compression on adjacent teeth, leading to premature contacts or even distal tooth displacement.

If these principles are not respected:

• Lingual discomfort appears

• Hygiene becomes difficult

• Food retention increases

This case showed deficiencies in this aspect as well.

End-to-End Occlusion Risk

Another common mistake when copying contralateral anatomy is ending with an end-to-end molar occlusion.

We know that:

• The palatal cusp of the maxillary molar points slightly toward the buccal

• This respects the Curve of Wilson

If an end-to-end occlusion is created:

• Buccal cusps no longer deflect the cheek properly

• The patient begins to bite the cheek in that area

With one molar, it may go unnoticed.With two, complaints are almost inevitable.

Case Correction

The correction strategy included:

• Redesigning the emergence profile to eliminate the cervical shelf

• Realigning marginal ridges

• Reducing the occlusal table

• Adjusting the total bucco-lingual dimension

• Creating proper hygienic embrasures

• Carefully controlling contact pressure to avoid excessive force on adjacent teeth

  
  

Final Outcome

The final result achieved:

• Harmonious occlusal integration

• Biomechanical stability

• Improved hygiene accessibility

• Functional comfort

• And a crown that the patient barely perceives as implant-supported

Implants are not teeth.

And the moment we forget that, problems begin.

We can move the microgap, we can change the depth, we can choose supracrestal or subcrestal positioning — but biology will always demand respect, and biomechanics will always expose shortcuts.

A supracrestal strategy protects bone.But it demands intelligence in prosthetic design.

You cannot copy a contralateral molar and expect harmony.You must design for the implant you placed — not for the tooth you wish was there.

Emergence profile is not decoration. Occlusion is not negotiable. Embrasures are not optional.

When contour, contact, and occlusion are respected, the implant disappears functionally. When they are not, the patient reminds you every day.

Biology first. Design with intention. Restore implants like implants — not like teeth.

Have a Nice Carnival !

Andre and Sofia