Provisional restoration options in implant dentistryDocument Transcript
CLINICAL REPORT Australian Dental Journal 2007;52:(3):234-242Provisional restoration options in implant dentistryRE Santosa* Abstract healing period, patients may have to wear a removable Unlike their use in conventional crown and bridge, provisional prosthesis prior to delivery of the final provisional restorations during implant therapy have prosthesis, especially in the aesthetic zone. In the non- been underutilized. Provisional restorations should aesthetic zone, clinicians may decide not to construct be used to evaluate aesthetic, phonetic and occlusal provisional restorations. function prior to delivery of the final implant In some cases, patients are able to have a provisional restorations, while preserving and/or enhancing the condition of the peri-implant and gingival tissues. restoration constructed after the treatment planning Provisional restorations are useful as a phase and delivered as early as the day of implant communication tool between members of the placement.4 However, in restorative driven implant treatment team which, in most cases, consists of the placement,5,6 hard and soft tissue augmentation is restorative clinician, implant surgeons, laboratory routinely performed to optimize the implant site prior technicians, and the patient. This article describes to surgery, effectively extending the treatment time. and discusses the various options for provisionalization in implant dentistry. Clinicians Any provisional prostheses would then need to be should be aware of the different types of provisional strong, durable and aesthetic to last throughout the restorations and the indications for their use when duration of the treatment. A traditional provisional planning implant retained restorations. prosthesis may consist of an existing or newly Key words: Provisional restorations, dental implant, constructed removable provisional denture which can custom impression. be utilized until delivery of the final prosthesis. (Accepted for publication 27 April 2007.) However, removable provisional prostheses may place undesirable pressure upon these graft sites, hampering the healing process.4,7,8 Therefore, provisionalINTRODUCTION restorations that are fixed to the adjacent teeth or that Implant supported restorations for partially and fully completely eliminate the possibility for soft tissueedentulous patients are a well-accepted and predictable contact may be more beneficial for implant integrationtreatment modality. Success rate of implant retained and soft tissue maintenance. Tooth borne or fixedprostheses for complete and partial edentulism has provisional restorations may also satisfy patients’been shown to be over 90 per cent.1-3 With the increase aesthetic, functional and psychological demands. Onein treatment acceptance for dental implants, both of our roles as clinicians is to provide functional andpatients and clinicians have greater expectations aesthetic provisional restorations that allow for thetowards implant therapy. Patients facing loss of their smooth transition of patients from natural dentition toteeth may experience apprehension towards losing their implant based restorations.8,9social image or daily function. Hence, patients oftenexpect to have their implants loaded with some type of Function of provisional restorationsfixed prosthesis similar to their natural dentition much According to The Glossary of Prosthodontic Terms,10earlier. Clinicians also expect their restorations to be a provisional prosthesis is a prosthesis designed tofunctional, aesthetic, and in harmony with the enhance aesthetics, provide stabilization and/or functionsurrounding hard and soft tissues. Today, implant for a limited period of time, and should be replaced byintegration is given with the greater knowledge of the a definitive prosthesis after a period of time.biological basis for treatment and improvements In restoration-driven implant placement,5,6 implantsprimarily associated with implant morphology. are positioned in relation to anticipated requisites ofTraditionally, for conventional loading protocols, the the restorative phase rather than the availability ofimplants are left unloaded for 3 to 6 months to allow bone. Provisional restorations can be used as athe osseointegration process to take place.1 During this diagnostic restoration to evaluate the position and*Private Specialist Prosthodontist, formerly ITI Scholar, Centre for contours of the planned definitive restoration prior toImplant Dentistry, University of Florida, Gainesville, Florida, USA. surgical implant placement and during the healing234 Australian Dental Journal 2007;52:3.
Table 1. Provisionalization prior to implant loadingType of support Prosthesis typeRemovable Partial acrylic dentures Essix applianceFixed tooth supported Archwire supported pontic Resin bonded pontic Resin bonded, cast metal framework bridgeFixed implant supported Transitional implantsphase. A provisional restoration immediately placedwith ovate pontics extending into the extractionsockets can also be used to preserve the pre-extractionsoft tissue morphology.11 They can guide the healing ofthe peri-implant tissue and allow the clinician to Fig 1. Modified removable partial provisional denture. The denturedetermine any necessary phonetic or aesthetic adjust- was modified during implant placement to allow proper healing of the underlying implants. The patient had low smile line.ments. The clinicians may use information such asshade, crown and soft tissue contours from theprovisional restoration as a communication tool to thelaboratory. Provisional implant restorations also allow leading to implant exposure, marginal bone loss,the patient to visualize and evaluate the end restorative and/or failed integration. Often provisional denturesresult, thus assisting in acceptance and/or guiding of are adjusted to minimize contact with the healingmodifications required for the definitive restoration. implants (Fig 1). There are alternatives to tissue borne provisionalTypes of provisional restorations restorations. An Essix appliance12,13 (Fig 2) may be used Provisional restorations in implant therapy can be in as a removable prosthesis in these cases, as well as inthe form of removable or fixed prostheses. Removable limited interocclusal space or deep anterior overbite.provisional prostheses are generally tooth and/or soft This prosthesis is made from an acrylic tooth bonded totissue borne. Fixed provisional restorations can be a clear vacuform material on a cast of the diagnosticsupported by adjacent teeth or implant retained. They wax up. The prosthesis provides protection to thecan be fabricated chairside, using similar techniques as underlying soft tissue and implant during the healingin conventional prosthodontics; or in the laboratory on phase. Limitations of this provisional restorationworking casts; or as a combination of indirect-direct include its inability to mould the surrounding softtechnique, where a provisional shell is fabricated before tissue, and lack of patient’s compliance can cause rapidthe patient’s appointment, reducing chairside time. occlusal wear through the vacuform material. However,Provisional restorations may be constructed prior to some patients may not like to wear, or are unable totooth extraction, during socket healing, prior to tolerate, a removable provisional prosthesis, thus fixedimplant placement, or during osseointegration period provisional prosthesis are sometimes necessary.(Table 1). Provisional restoration could also beconstructed after implant loading, allowing maturation Tooth supported provisional restorationsof peri-implant soft tissue, and during construction of Fixed tooth supported provisional restorations in thethe final prostheses. upper anterior region include the use of orthodontic brackets and archwire on several teeth adjacent to theProvisionalization prior to implant loadingRemovable prosthesis Removable partial acrylic dentures have commonlybeen used during post-extraction and throughout theimplant therapy. They are simple to construct,relatively inexpensive, and easy for the surgeon orrestorative clinician to adjust and fit. Patients thatrequire staged treatment with serial extractions mayhave teeth added to their existing removable dentureswith minimal cost. However, they may reduce theeffectiveness of any additional surgical bone andgingival augmentation procedure used to optimize theimplant site. Care must be taken to prevent the gingivalportion of the provisional partial denture fromcontacting the healing soft tissue or an exposed healingabutment. Soft tissue borne prostheses used during Fig 2. An Essix appliance replacing upper central incisors. The teethhealing may cause uncontrolled implant loading were spot cured to the clear vacuform template material.Australian Dental Journal 2007;52:3. 235
a b c d e f Fig 3a. Pre-operative radiograph. The patient had generalized refractory periodontitis, especially in the maxillary arch. Fig 3b. Pre-operative facial view. One of the patient’s chief complaint was the anterior crowding and the vertical drifting of maxillary anterior teeth. Fig 3c. Diagnostic wax up of the planned restoration illustrating anticipated contours of the final restoration. The alignment of anterior teeth was altered to provide straighter, more aesthetically pleasing teeth. The incisal lengths of maxillary incisors were reduced, decreasing the horizontal and vertical relationship of the anterior teeth. Fig 3d. Facial view of prepared teeth immediately after extraction. Strategic teeth were maintained to retain the provisional prosthesis. The implant sites were previously selected and the non-strategic teeth were removed according to the diagnostic wax up. Fig 3e. Provisional acrylic restoration prior to insertion. The provisional restoration is relined with compatible self cure resin to fit over the prepared abutment teeth. Fig 3f. Fixed provisional restorations cemented on strategic natural abutments. The molars have been retained temporarily to maintain the vertical dimension of occlusion.implant site with an attached pontic. An alternative resin and/or ultra high molecular weight polyethylenemethod is the use of resin bonded provisional pontic, ribbon (Ribbond Bondable Reinforcement, Ribbon;which are tooth supported and retained by acid etching Ribbond Inc, Seattle, Wash., USA).8,14 These prosthesesthe neighbouring teeth. Sometimes small retentive may continue to be reused as provisionals after angrooves within enamel on the adjacent teeth can be appropriate implant healing period. The archwire/resinused to increase retention of the pontic. The pontic can retainer can be removed and reattached between thebe in the form of an acrylic tooth, porcelain, or different surgical and prosthetic stages. They can alsodecoronated extracted tooth. The resin bonded acrylic be used to guide the surgeon during grafting proceduresor natural tooth may be reinforced with composite and as a template for the final restoration.236 Australian Dental Journal 2007;52:3.
provisional restoration, and the transitional implants are backed out of position using a ratchet arm and insertion tool used in the reverse mode (Fig 4). Post-implant placement Implant retained provisional restorations Provisional restorations may be used at the time of implant placement or after an appropriate healing period. The term “immediate restoration” is used when a prosthesis is fixed to the implants within 48 hours without achieving full occlusal contact with the opposing dentition, whereas “immediate loading” is when the prosthesis is fixed to the implants in occlusion within 48 hours.17 Fig 4. Immediate provisional implants were placed and strategic teeth were maintained to support long-term telescopic provisional There are several benefits to members of the restoration. The 14-year-old patient requested a long-term fixed treatment team and patient in using an immediate provisional restoration until the definitive implants are placed. provisionalization technique. Immediate provisional- ization offers the patient improved comfort and A resin bonded, cast metal framework prosthesis function during the implant healing period comparedsuch as Maryland Bridge is suitable for long-term with a conventional denture.4 There are also fewerprovisionalization in the anterior region, especially in denture adjustments postoperatively with no need foryoung patients.8 This type of provisional is difficult to tissue conditioning or relining.reuse throughout the implant procedure as the bond The decision to immediately restore or load dentalstrength between the metal retainer and the enamel can implants is usually made during the treatment planningbe unpredictable during removal and reattachment phase. The treatment can only be confirmed clinicallybetween procedures. Furthermore, the laboratory costs at the time of implant placement with appropriateare relatively high. assessment of implant stability, bone quality, and In some cases, a staged extraction and implant general site health. In a recent consensus review,18 fourplacement approach can be adopted.8,15 In this implants in an edentulous mandible, rigidly splintedtechnique, the implant sites are selected, and teeth that with a fixed restoration on a framework (acrylic and/oroccupy these sites are extracted while the remaining metal) or hybrid prosthesis, can provide patients with ateeth are used to support a fixed provisional restoration. reasonable degree of confidence for evidence-basedUsually, natural abutments with poor prognoses are treatment. Primary stability of these implants is crucialused as interim abutments and can be extracted when in the decision for immediate provisionalization.9,19 Thethe implants have integrated. The teeth supported implants need to be well distributed across theprovisional restoration is then converted into an mandibular arch to provide cross-arch stabilization.implant supported provisional restoration. This The final implant positions are based on the proposedindirect–direct technique is often used in a full arch restoration through the use of templates/surgical guide.situation, where the patient’s dentition is failing due to In immediate loading of edentulous mandible, theperiodontal disease (Figs 3a–3f) or when the adjacent patient’s existing denture can be converted into screwnatural teeth require fixed prosthesis at the same time.8 retained provisional fixed hybrid prosthesis. The technique involves the placement of temporaryTransitional implant provisional restorations cylinders onto the implants and the modification of In extended partial edentulous areas where there are patient’s existing mandibular denture. These cylindersno or limited natural abutments to support a are luted to the rest of the denture using self cure resin.provisional restoration, one or more transitional The denture is then converted into an immediate load,implants may be used.16 These transitional implants are screw retained provisional hybrid fixed prosthesis withloaded immediately to support the provisional minimal cantilever and occlusal contacts (Figs 5a–5c).restoration. They can be used to support fixed A lingual wire may be used within the acrylicrestorations or to retain complete mandibular dentures. framework to provide reinforcement. The provisionalCare should be taken in planning the position of these hybrid restoration will need to remain during theimplants and with their maintenance post-loading. recommended period of implant healing to allow theThey should not interfere with potential implant sites, implants to fully osseointegrate.17or be placed in poor quality bone. When the depth of This technique may also be used in early or delayedavailable bone is less than 14mm or the amount of loading implant protocols. The provisional hybridcortical bone is insufficient to provide stabilization, the restoration may have multifunctional uses. It can beimmediate provisional implant may be contraindicated.16 used as a verification jig (Fig 5d) to determine theOnce the implants integrate, the supporting provisional passivity and accuracy of the master impression,restoration will be converted into implant supported providing all the implants are relatively placed parallelAustralian Dental Journal 2007;52:3. 237
a b c d Fig 5a. Patient’s existing complete mandibular denture was modified to accommodate temporary cylinders on the implants. A duplicate of the denture was used as radiographic and surgical guide for the planning and surgical phase of the treatment. The three dimensional positions of the implants were determined from the diagnostic wax up and clinical and radiographic examination. Fig 5b. Try in of the mandibular denture over the temporary cylinders. Fig 5c. Self cure resin was used to attach the denture and the temporary cylinders. The denture flange was then trimmed and the fitting surface was adjusted to allow proper hygiene. Fig 5d. The provisional hybrid was used as verification jig over the master cast. The soft tissue moulage was removed to verify the fit of the provisional on the subgingival implant restorative margins. Fig 5e. The same provisional hybrid was articulated with a bite registration material, against the previously articulated study cast. on the final prosthesis. The decision whether to cement or screw retain a provisional or final implant restoration would be dependent on the clinical situations and clinicians’ preference towards the method of fixation. Most implant companies have prefabricated abutments for cement retained restorations. These e abutments come in various heights to allow enough space for the metal and porcelain in crown construction. They also have a slight taper and an indexingto each other. It can also be used to articulate the component providing resistance form for the overlyingimplant master cast to the opposing study cast (Fig 5e), restorations. The abutments are torqued onto theand records the laterotrusive functional envelope via implants, left in situ and a complementing pick-upcustomized incisal pin guidance. coping component may be used for impression and transfer of the abutment position to the master cast.Cement retained provisionals A plastic protection cap, usually cylindrical in shape, Clinicians have the option to either cement or screw may be cemented on the prefabricated abutment untilretain their final implant restorations.20,21 There are the delivery of the final prosthesis. This technique isadvantages, disadvantages and limitations for each often used by clinicians in non-aesthetic regions of theoption and it is important to understand their influence mouth.238 Australian Dental Journal 2007;52:3.
b a d c e f Fig 6a. A cement on, prefabricated abutment was torqued to the recommended value, six weeks post-placement. The abutment was chosen to allow adequate space for crown construction within the available interocclusal space. Fig 6b. A denture tooth with appropriate shade and shape was selected to fit the edentulous space. The acrylic tooth was then hollowed out to fit over a practice implant analog and abutment extra-orally. Fig 6c. The denture tooth was relined intra-orally using self cured acrylic resin to capture the indexing component of the abutment. Fig 6d. The relined denture tooth was fitted over the practice implant extra-orally. Note on the deficiency from the implant margin to the acrylic tooth due to tissue impingement. Fig 6e. The deficiency was filled in and the excess material trimmed to the appropriate emergence profile. Fig 6f. The provisional crown was cemented with provisional cement. Aesthetic provisional restorations can be constructed subgingivally, especially in the anterior aesthetic regionfor such abutments during the period between impres- of the mouth. Access to the deeply placed implantsion and prosthesis delivery.8 The provisional shoulder can be difficult, and excess residual cements arerestorations are usually made from a prefabricated difficult to clean and may cause peri-implantcustom shell (prefabricated preformed acrylic crowns; inflammation.22 Alternatively, a temporary mesovacuform template from the diagnostic wax up; abutment would allow a machined connection athollowed out denture tooth; or even a hollowed out implant shoulder, and customized cement margin thatdecoronated clinical crown) relined using self or light can be modified to allow a slightly subgingivalcured resins intra-orally to capture the indexing restorative margin for ease of cement removal. Thiscomponent of the abutment, and then completed extra- abutment can be modified intra- or extra-orally,orally to fit the implant restorative margins (Figs 6a–6f). prepared using diamond bur with accessible cement levelTo facilitate treatment, the crown form can be waxed placed just below the gingival margin, and correction ofup, or selected, sized, and trimmed ahead of time to fit any angulation problems to retain the provisional crownthe edentulous site on the study cast. can be made. A cementable provisional crown is then Care should be taken during the cementation constructed using conventional crown and bridgeprocedure where the crown margin is placed deep technique (Figs 7a and 7b).Australian Dental Journal 2007;52:3. 239
a a b bFig 7a. A temporary meso abutment, one piece temporary abutment Fig 8a. A screw retained provisional crown was made at chairside fits directly into the implant body. The abutment is made of PEEK from the patient’s existing partial denture, attached to the (Polyetheretherketone) plastic and titanium inlay. temporary cylinder using additional self cure resin. The excess Fig 7b. Unaltered temporary meso abutment on the soft tissue temporary cylinder is reduced to follow the palatal contour of the working cast. The abutment can be prepared in the laboratory or existing partial denture and patient’s occlusion. chairside with altered cement margin and corrections of any Fig 8b. Facial view of screw retained provisional restoration on angulation problems. tooth 11 site. The provisional restoration was hand tightened.Screw retained provisional prostheses final prosthesis must be able to imitate the natural Screw retained provisional restorations would tooth crown form when emerging from the gingivaleliminate the possibility of having any temporary tissues with narrow margins to fit the implant head.cement present in the peri-implant tissue. This can be This transition zone between the implant shoulder toachieved using temporary cylinders directly placed on the gingival crest, often up to the contact points isthe implant level. The provisional crown can then be shaped by the subgingival part of the provisionalbuilt up in the laboratory on the master cast or restorations. The transition zone can be up to 5mmchairside by using self or light cure resin or composite deep, especially in the palatal and interproximal tissuesresin according to the diagnostic wax up. The of teeth in the aesthetic zone. The peri-implant tissuestemporary cylinder often has to be adjusted to fit intothe occlusion (Figs 8a and 8b). The most important advantage of provisionalrestorations at the start of the restorative procedure isin shaping of the peri-implant tissues.8,23 This processwill establish a natural and aesthetic soft tissue formthat will help the laboratory fabrication with ananatomically appropriate soft tissue model.24-26 A well-shaped peri-implant tissue including interdentalpapillae will facilitate seating of the final prosthesis.The provisional restoration can be modified overseveral appointments to achieve the desired emergenceprofile (Fig 9).Communication with laboratory using provisionals One of the challenges faced by the restorative Fig 9. Moulded soft tissue from screw retained, 3 unit fixed acrylic provisional bridge. Peri-implant tissue was shaped with screwclinician is the circular shape and small diameter of the retained provisional restoration for 4 weeks prior. The pontic shapeimplant compared to the root of a natural tooth. The was moulded using additional resin during the healing period.240 Australian Dental Journal 2007;52:3.
a a b b Fig 10a. Resultant emergence profile shaped by the provisional restoration in Fig 8, after approximately 4 weeks of provisionalization. The mature peri-implant tissue has an oblong shape compared to the circular implant restorative collar. Fig 10b. A custom impression coping with screw on impression coping replicated from the provisional restoration was placed over the implant prior to final impression. cmust be permitted to adapt to the dimensions of theprovisional restoration. Following the shaping and maturation of the peri-implant tissue, the clinician needs to transfer thisinformation to the working cast.27,28 This may beaccomplished with a custom impression coping or byretrofitting the provisional restoration to the workingcast (Figs 10a and 10b). The customized impressioncoping allows the clinician to capture the moulded softtissue with the appropriate emergence profile onto themaster cast. In aesthetic cases, the shade and surfacecharacterization of the provisional restorations can be daltered using composite modifiers (Figs 11a–11d). Fig 11a. Screw retained, 3 unit fixed acrylic provisional bridgeShades and surface characterization on the provisional constructed to replace the modified removable partial denture fromrestoration can be used by the treatment team, Fig 1. The provisional restoration had a monochromatic shadeincluding the patient to evaluate the desired shade of similar to the pre-existing denture teeth.the final restoration. Fig 11b. Colour modifiers for tooth shading characterizations. The modifiers can be mixed together and incorporated into the provisional acrylic/composite resin crown to mask discolourationCONCLUSION and/or create surface characterizations. This article discussed the role of provisionalization in Fig 11c. Aesthetic provisional restoration with customized shade characterization.implant therapy from the removal of teeth, through Fig 11d. Laboratory shade prescription for the final ceramicimplant placement to the final implant restoration. restoration, incorporating the custom shade characterization.Australian Dental Journal 2007;52:3. 241
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