Straumann® ProTalk Ep. 29 (Clinical Edition) with Algirdas Puišys: Immediate implants done right – why performance matters more than timing

Defining success in the emergence profile

Algirdas defines a successful outcome in immediate posterior implants through precise control of the emergence profile. He aims for a 30-degree angle from the implant–abutment connection to the gingival exit point, based on scientific literature. Clinically, he accepts up to 45 degrees as a red zone limit, particularly on the buccal and lingual aspects where risks increase. He emphasizes that exceeding this threshold compromises tissue stability and long-term outcomes. He explains that this angle is measured from the point where the abutment exits the implant platform to where the crown emerges from the gingiva. This geometric clarity ensures that the prosthetic design guides surgical execution. Rather than placing implants first and adapting later, he starts with the desired restoration and works backward. The implant position, depth, diameter, and length all follow the prosthetic vision. From the very beginning, digital planning plays a central role. CBCT data and intraoral scans are shared with the dental technician to visualize the final outcome before surgery. Implant placement is defined three-dimensionally, often at least three millimeters apical to the buccal gingival margin. For Algirdas, success in posterior regions is not less demanding than in the esthetic zone; in some cases, it is even more critical for longevity.

Avoiding common pitfalls in daily practice

One of the most frequent mistakes he observes is overcontouring individualized healing abutments. In the past, he fabricates composite healing abutments that are simply too large, pushing soft tissue instead of shaping it gently. While the tissue may initially heal well, recession often follows once the final crown applies additional pressure. He stresses that clinicians should build, not push. His workflow evolves over time. He moves from standard healing abutments to customized composite designs, then to zirconia abutments on titanium bases, and finally back to standard rounded abutments in many cases. Today, he combines conventional components with digital workflows and chairside 3D printing when needed. The key condition remains correct implant positioning – ideally centered in the socket – to allow flexibility and predictable healing. A major turning point in his career comes when he reexamines the debate around immediate implant placement. After deeply analyzing the literature, he realizes that timing is not the real issue – performance is. Immediate placement is not inherently dangerous; poor execution is. When clinicians follow strict biological and prosthetic principles, immediate implants offer fewer surgeries, less invasiveness, and higher patient comfort. The difference lies in respecting guidelines and controlling every step.

Prioritizing biology and soft tissue stability

Experience also teaches him to rethink implant diameter selection. Earlier in his career, he prefers wider implants to maximize stability, sometimes at the expense of surrounding bone and soft tissue. This approach occasionally leads to compromised outcomes or even aborted placements. Today, he favors narrower implants, preserving bone walls and soft tissue thickness. He shifts from “more metal” to “more biology.” Soft tissue management becomes one of his greatest passions. He increasingly recognizes that healthy, thick soft tissue can compensate for minor bone deficiencies around the implant neck. While bone and soft tissue ideally work together, he sees that aggressive bone augmentation significantly increases complication rates. In selected cases, soft tissue augmentation alone provides stable, long-term results with fewer risks and higher patient satisfaction. He also finds deep professional satisfaction in treating peri-implantitis conservatively. Through meticulous hygiene protocols and supportive therapy, he sometimes observes bone remineralization without surgical intervention. For him, this represents true medicine – restoring health rather than simply replacing components. His journey reflects continuous learning, humility, and an unwavering commitment to improving outcomes through biology-driven, digitally supported dentistry.

Key take-aways

• Start with the final restoration and let prosthetics guide surgery
• Focus on performance, not timing, in immediate implant placement
• Preserve biology: prioritize soft tissue health and thoughtful implant selection

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