The Akin Harmony Abutment Technique
As the knowledge base in the demanding realm of anterior esthetic management of implant sites continues to expand, there exists a void in the literature in relation to solutions to accelerate posterior implant protocols while simultaneously maintaining the implant emergence form. This article will propose a new protocol, called the “Akin HarmonyAbutment” or "AHA!" technique, for immediate molar implant placement with simultaneous immediate preservation of emergence form and implant site sealing using a sutureless technique. The purpose of this manuscript is to describe this concept along with its numerous benefits to patients, surgeons and restorative dentists. This paper will also retrospectively review the outcomes of 101 consecutive immediate molar implant sites, reporting an overall success rate of 98.01%.
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An Immediate and Sutureless Technique
As evidence mounts to support accelerated dental implant protocols in the anterior and premolar regions, there has been little attention to improving the treatment workflow posteriorly. Single stage protocols with provisionals or healing abutments are generally well suited to the premolar or anterior regions of the mouth due to the limited occlusal table reducing function when placing a provisional and uniform post-extraction crestal socket morphology when using a healing abutment. These regions also lend themselves to reduced occlusal loading during provisionalization phases. First and second molar locations, on the other hand, can present significant challenges when immediate implant placement is planned. These challenges include a large extraction socket which is difficult to seal without mucoperiosteal flap reflection, an implant preparation sequence which significantly deviates from typical manufacturer protocols and crestal socket morphology not amenable to healing abutment placement.
The Harmony Technique sets out to solve many of the problems inherent to immediate posterior implant placement by extrapolation of techniques used to optimize gingival contours through the use of surgeon fabricated screw retained provisonalization of anterior teeth and premolars. The Harmony Technique was developed in order to solve problems intrinsic to immediate molar implant placement by creating a logical expedited approach to immediate customized healing abutment fabrication.
Although the technique described can be used in all locations of the mouth, the procedure described in this article specifically demonstrates the implementation of the ‘Harmony’ abutment for in vivo fabrication of a customized immediate molar anatomic abutment. The customization of the immediate molar healing abutment is imperative for a number of reasons. First, because the ‘Harmony’ protocol calls for flapless tooth removal without bone removal, the underlying alveolar socket anatomy does not readily allow for stock healing abutment seating. Second, when stock healing abutments are possible after immediate molar implant placement, there is often the need for additional closure around the abutment in order to retain particulate grafting when utilized. Lastly, molar locations are often associated with stock healing abutment emergence form mismatch which then requires lab prediction (or practitioner sculpting) of the emergence profile of the gingival mask. This can lead to difficulty seating a final abutment without contouring gingival tissues or to a poorly designed final abutment.
The Harmony Technique not only supports local anatomy during the osseointegration phase but also allows for straightforward access to the implant during the restorative phase. After osseointegration, the result is an anatomic representation which mimics the emergence profile of the natural dentition allowing for precise lab reproduction of the definitive abutment. This technique provides all of the advantages of implant provisionalization to the posterior region of the mouth while reducing the potential disadvantages of providing a provisional crown with an occlusal surface in this region. Additional advantages include the ability to add and subtract gingival support throughout the osseointegration phase while allowing for a precise customized socket seal over the immediately placed implant.
Implementing in-vivo fabrication of an anatomic abutment on an immediately placed molar implant using the technique described in this article brings the advantages of immediate placement and provisionalization safely to the posterior regions of the mouth. The goal of this technique is to support existing alveolar anatomy and preserve it during the osseointegration period.
The AHA! concept is meant to provide solutions to many of the problems implant surgeons and restorative dentists encounter when providing dental implant rehabilitation.
The following solutions are provided by this technique:
- Stabilization of the gingival architecture immediately after extraction and implant placement.
- Providing for a custom seal over the surgical site to retain graft particles.
- Maintaining the ideal emergence profile for optimal final restorative contours.
- Reduction in chair time during impression coping seating potentially obviating the need for radiographic exposure to verify abutment seating.
- Decreasing (or eliminating) laboratory approximation of emergence profile when shaping the gingival mask during fabrication of the definitive restoration.
- Expediting final abutment delivery by retaining the gingival anatomy.
The loss of a first or second molar is often a patient’s initial experience with implant dentistry. This is an important reason to find innovative ways to bring the advances of immediate provisionalization from the anterior to the posterior. Optimizing outcomes while minimizing appointments and recovery times is, in and of itself, an important part reason to implement accelerated posterior implant protocols. This is especially true if a new solution allows for predictable reduction of surgical visits with outcomes which improve upon standard two stage protocols. The ‘Harmony’ posterior implant solution fits all of the parameters.
Conclusion
It is the author's opinion that custom healing abutments and provisionals should ideally be placed by the surgeon in order to capture the anatomy present at the time of extraction and should be viewed upon as the final step in the implant surgery.
This technique ultimately allows for more predictable final restorations by providing the dental laboratory with a restorative profile and blueprint for the abutment thus idealizing the final restoration.
