Platform Switching and Implant Emergence Profile Design with Dr. Melissa Seibert

Dr. Melissa Seibert: Hey, I want to tell you about something I put together for you. I created a free PDF guide that walks you step by step through the injection molding technique. I love this technique because it is one of the best ways to get predictable, beautiful, and highly aesthetic anterior composites.

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And to make it even simpler, I've included the link for you right here in the show notes.

Hey, welcome to Dental Digest. This is a podcast with a mission of enabling you to stay on the cutting edge of evidence-based dentistry.

I'm your host and also presenter for today, Dr. Melissa Seibert. Today, we're going to be talking about implants. More specifically, I'm actually going to be answering some hot topics in implants.

I'm going to be talking about the concept of platform switching, and then how you can achieve the most aesthetic outcome possible with your implants. These topics were actually first originally discussed during one of the Elevated GP Q&A sessions, and it came up time and time again.

How do I prevent my implants from looking like pumpkins on a stick? And what the heck is platform switching? Now, I'm guessing if our community had these questions, then you probably do too.

You don't necessarily even have to be placing implants for this to resonate. I really think that every general dentist should feel very comfortable with restoring implants. So we're going to be talking about these concepts today.

I've got something that you're going to love. If you've been loving the podcast and want to dive deeper into mastering implant dentistry, this is your chance. I'm giving away access to one of my on-demand courses completely free.

This course is packed with everything you need to know about implant occlusion, platform switching, and creating that stunning aesthetic emergence profile that sets your work apart. Here's how to grab it. Leave a rating for the podcast.

Take a quick screenshot and send it my way. You can either direct message me on Instagram. My Instagram handle is dr.melissaseibert, or send it to me in an email at dr.melissaseibert at gmail.com. Once you get the screenshot, I will send you access to the course so you can start learning right away.

It's my way of saying thank you for supporting the podcast and being part of this amazing community. And I can't wait to hear what you think.

So first let's talk about the concept of platform switching.

You might have heard this as a bit of a buzz term, but what does this actually mean? This is where there's actually a horizontal offset between the implant abutment and the implant platform.

It's actually quite small. Your implant restorations might actually already have built-in platform switching and you might therefore be restoring platform switch implants and didn't actually even know it.

Why do we want there to be an offset between the abutment and the implant platform? Well basically the restorative fixture, this implant abutment, is a little more centralized. There's a little bit of a space, a horizontal space, between the implant platform and the abutment.

Well the reason for this is that there is a microscopic micro gap between the abutment and the implant platform.

And it's so often the case whenever there are gaps that exist in the human body that are exposed to the outside environment, bacteria loves to fester. So if we can take this bacteria-laden micro gap and bring it in a little more centrally, this means that this bacterial infiltrate is a little bit further away from the hard and soft tissue.

And this is advantageous because this decreases the local inflammation that could be occurring.

Inflammation is not ideal. We want to do what we can to decrease inflammation, especially when the inflammation is close to our implants. Inflammation manifests in things such as poor aesthetic outcomes, where we're seeing a loss of black triangles, unaesthetic uneven gingival profiles, and attachment loss.

So we want to do what we can to decrease this inflammation so that we can get an idealized aesthetic outcome. How much of an offset do we actually want? Well, too much of a thing can be a bad thing.

We really want that offset from the platform switching to be about 0.25, so a quarter of a millimeter, to 0.5 or half of a millimeter on each side.

What that looks like is about 0.5 to 1 millimeters of an offset total. If there's too much of an offset, believe it or not, this can actually lead to mechanical compromise of the tooth. So we really want to reach that idealized window.

A very natural question that might arise is, does platform switching decrease the risk of peri-implantitis? The preponderance of evidence shows that this can really decrease attachment loss, but we don't have as much robust data that this actually decreases peri-implantitis.

That's not to say that it doesn't, it's just not as substantiated. However, platform switching is still incredibly valuable because this can decrease the attachment loss that's happening over time.

Now it's not actually very much, and for as much as you've probably heard about platform switching, you would think that this would actually preserve multiple millimeters of marginal bone loss over time, but it's more so that it's about 0.2 to 0.6 millimeters over time, which in my mind's eye is still a worthwhile variable to achieve.

I don't know if you were really taught this in dental school, but I certainly was, that within the first few months and within the first few years of implant placement, it's acceptable to see a few millimeters of marginal bone loss. That's normal, nothing to worry about.

But today we know that that's not acceptable and that's not quite the case. We want to minimize as much bone loss as conceivably possible. And the way to do so isn't just one sort of technique in the design of your implant or the implant placement, but it's actually the amalgamation of a number of variables, and platform switching happens to be one of them.

Now, as I alluded to earlier, many implant systems fortunately already have built-in platform switching. So the best thing to do if you are placing or restoring implants is just to find out if your implant system has it.

If it does, that's fortunate for you because there's not very much you have to do from there. It's almost an afterthought, which I can really appreciate.

If your implant system does not have built-in platform switching, then you have a few options. You can have a custom abutment design or you can manually platform switch.

If you are having your restorations restored by a great lab technician, they should already know how to create a custom abutment that is platform switched. But if your lab technician is new and you're really having to describe for them what you need them to do, or you want to be QC'ing your restorations, which every clinician should be QC'ing your restorations, trust but verify, you want to be looking to make sure that it's appropriately platform switched.

Remember, too much platform switching is actually a bad thing.

Now, examples of custom abutments, this can be things such as the Atlantis abutment or the Nobel Procera abutment. If you though yourself want to actually be doing manual platform switching, what you'd be doing is selecting a narrower abutment.

So, for example, if you were doing a five millimeter diameter implant platform, then you'd be looking for a 4.1 millimeter abutment.

This actually though can begin to get a little technically complicated. It can require a little mental gymnastics. And so if I can prevent myself from having to do this, I like to.

Some things that you have to be noting in order to do this is that are they mechanically compatible? So, yes, the implant abutment diameter might be 4.1 and the implant platform might be five millimeters.

But in many instances, despite that difference, the components themselves are actually able to engage. You want to ensure that this is still the case and you want to be checking, is this something approved by the manufacturers?

Sometimes if you are doing this or if you were using third party parts, which many people do, you might be voiding the implant warranty.

Now, I'm going to be really transparent here. I'm not sure how significant it really is to be voiding the implant warranty. That's just full transparency.

I'm not really sure how many clinicians actually need to be calling upon and utilizing that warranty. But if you are doing that, it's something worth noting.

Let me ask you something. When you graduated dental school, did you imagine yourself taking on advanced, challenging cases and doing the kind of dentistry that excites you on your commute into work? Advanced endo, implants, aesthetic cases, et cetera?

Or do you find yourself stuck in dentistry that feels repetitive, boring, confusing, and maybe even unfulfilling? Are you frustrated by unpredictable failures, crowns debonding, patients unhappy, and not even sure why it's happening?

Today, are you the dentist that you want to be?

Now, imagine becoming the exceptional, comprehensive dentist you've always wanted to be. The kind of dentist that practices with clarity, confidence, and consistency, who thinks beyond bread and butter procedures.

They're respected, referred to, and fulfilled because the work is both meaningful and challenging.

That's what we build inside of Elevated GP. We build exceptional, comprehensive dentists who step into the clinical version of themselves they've always wanted to become.

Inside our program, you will find live CE lectures every month that cover the topics our community wants most. From implants, to occlusion, to treatment planning, to anterior composites.

We also have monthly live Q&A sessions where we tackle your toughest cases together, teaching you not just what to do, but how to think.

We also have an exclusive community where you can bring your real clinical challenges and get thoughtful, evidence-based answers without the noise of a random Facebook group. I believe that iron sharpens iron.

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Now let's shift gears here and let's talk about implant emergence. How do you prevent the dreaded pumpkin on a stick phenomenon?

Well, if you have ever seen this happen in dentistry where you have a very unesthetic emergence of the implant crown to the implant, there's a few reasons that this could be happening.

So the first could be that the implant is not properly positioned apically. Ideally, we want the implant platform to be about three to four millimeters apical to the proposed free gingival margin.

So what does this actually look like? Well, let's say that we are placing an implant at number eight and we want it to have an idealized soft tissue architecture that is aesthetic and appropriate with number nine.

Well, first we want to identify where the free gingival margin of number nine is, and then that implant platform for number eight should be positioned about three to four millimeters apical to number nine.

You can, however, position the implant too far apically, and that can also result in adverse outcomes. If the implant is positioned too far apically, it might not be cleansable.

We could have pocket formation and bacteria loves to harbor there. So this could lead to unesthetic outcomes or peri-implantitis. So we really want to be staying within that three to four millimeter window.

I really appreciate, though, when I'm actually given frameworks that quantify things so that I'm not guessing.

So let's talk about how the implant crown should be designed so that we get the most idealized, predictable, soft tissue support, and we can get a really aesthetic outcome.

Well, there are three different zones to the implant crown, the E zone, the B zone, and the C zone.

The E zone is the aesthetic zone, the B zone is the bounded zone, and then the C zone is the crestal zone. I'm actually going to describe for you each of those dimensions, their positioning, and what they should look like.

If you are really ideally recreating these zones, or your lab technician is, then you're going to get an aesthetic outcome.

Now, you might be asking, why is this relevant to me? I'm not actually the one designing my implant crowns. But again, let's go back to the idea that you should be QCing all of your lab work.

And it's really unsettling in dentistry when you have a not so ideal outcome, but you don't know why.

So let's say you've ever restored an implant crown and the emergence profile is just not what you want, but you can't put your finger on it. Well, this EBC concept can be very helpful.

And again, this can also be very helpful for you to QC the implant crowns that your lab is giving you to ensure that these are ideal and aesthetic.

The first zone is the E zone. This is the zone most closest to the incisal or occlusal edge. And I also want to talk about the positioning of these EBC zones.

Where are these occurring? Well, these zones are really effectively all occurring subgingival. This is what gives that implant crown that running room so it can develop the emergence profile.

These zones do not apply to the supragingival clinical crown that you're seeing. This is really what's all happening underneath the soft tissue to create the most ideal, most aesthetic, harmonious soft tissue profile.

The first zone is the E zone. This is one millimeter subgingival zone that is apical to the free gingival margin.

Ideally, we want our E zone to match the shape of the crown of the previously extracted tooth or contralateral tooth. So we really actually, if number eight was extracted or lost, we want to match that same shape and that same profile of number eight.

So of that region of the clinical crown of number eight, that is one millimeter subgingival, we want to be recreating that anatomy and that profile.

So that's the E zone. Really, this zone should be convex. It should not be straight and definitely not concave.

If it is, the soft tissue is not going to have the support that it needs.

Now, departing from the E zone, we're going to go to the B zone, the bounded zone. This zone is about one to two millimeters thick, and this is concave.

And this needs to be concave so it can support the soft tissue. This B zone is really where we sort of get our classic implant appearance, where if you've ever seen implant crown for the first time, it might be a little bit jarring.

And you might say, this looks nothing like a natural tooth. Why does this look so different? Well, a lot of this is actually attributed to the B zone, where that concavity exists to support the soft tissue.

If it is too convex, the soft tissue might be positioned too far apically and not where you want it. In fact, getting these zones just right is how we get those really beautiful, predictable free gingival margins, where we haven't just landed the white aesthetics, but we've also landed and done an exceptional job with the pink aesthetics.

So again, this B zone is about one to two millimeters thick, and it's concave.

Now, finally, we've departed from the B zone, and now we have the C zone. This is the most apically positioned zone.

This is going to be, of course, underneath the E zone and the B zone. It's about one to 1.5 millimeters thick. This should be straight or slightly concave.

It cannot be convex. Imagine what could happen if it's convex. This is going to displace and cause a lot of chronic inflammation of the hard and soft tissue.

It really needs to not disrupt the hard and soft tissue, and it needs to provide adequate support.

Now, you might be adding up these numbers that I just presented to you for the E, B, and C zone, where the E zone is one millimeter, then the B zone is about two millimeters, then the C zone is about one millimeter.

That all adds up to four, and now you can begin to see why we need our implant to be positioned about four millimeters apical to the adjacent free gingival margin.

It's to support that implant running room and to give us time to develop that E, B, and C zone.

Today, just to recap, we talked about the popular term of platform switching, and then we talked about how to develop the implant emergence profile.

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