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Immediate Custom Implant Provisonalization: A Prosthetic Technique

June 1, 2012
by Gerard J. Lemongello Jr., DMD


Surgical and restorative techniques that can reduce the loss of hard and soft tissues are desirable. The use of a custom fabricated provisional will provide a mechanism by which preservation of hard and soft tissue can be achieved. This article will explore two different scenarios where the fabrication of an immediate custom provisional and provisional abutment can be utilized to guide tissue and improve implant restorative esthetics. The use of a provisional after traditional healing and immediately following surgical implant placement will be previewed.

Dental implants are routinely utilized to replace missing teeth. Dental implants have excellent success rates and several advantages over fixed or removable alternatives for tooth replacement.1-3 Preserving the integrity of the adjacent teeth, the remaining alveolar bone and soft tissue are some of the advantages.16 Implant restorations do present some difficult challenges. Preserving the desired gingival and osseous architecture can be difficult. Numerous treatment techniques have been developed to aid in the preservation of hard and soft tissue.1 The framework for the development of healthy aesthetic soft tissue is the osseous tissue. Soft tissue contours are dependant on the supporting hard tissue structures. Preservation of the interproximal bone level of adjacent teeth is essential to the support of the interdental papillae.2-3

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In order to be successful with the possibility of the most predictable outcome proper treatment planning, surgery, provisionalization and fabrication of the final restoration must be properly orchestrated and carried out. Each phase of the process must be considered prior to initiating treatment. Many patients facing the traditional approach of extended treatment time of surgery and prolonged healing might choose a non surgical treatment option. This often leads to the placement of a traditional fixed bridge prosthetic. A traditional fixed prosthesis in the presence of natural adjacent teeth may not necessarily be the patients’ best option. If we can provide a treatment modality that would eliminate the extended surgical, healing and treatment time with the placement of an immediate custom fabricated fixed provisional we can better serve our patients’ needs. Given the option of a reduced treatment time many patients will choice implant restorations over traditional fixed prosthetic. Our goal should be to minimize the duration of treatment and preserve soft and hard tissue structures. Maintenance of the gingival and osseous architecture around an implant can be a challenging task. Surgical and restorative techniques that can reduce the loss of hard and soft tissues are desirable. The use of a custom fabricated provisional will provide a mechanism by which preservation of hard and soft tissue can be achieved.4

Immediate implant placement has been advocated to preserve alveolar height and width since 1989.5-7 Immediate implant placement is recommended due to its ability to reduce tissue loss after tooth extraction.8-10 Utilization of a custom provisional abutment and immediate provisionalization allows the ability to maintain gingival and alveolar structures. It provides optimal aesthetics during the healing phase and the benefit of eliminating the use of a removable prosthetic provisional. The fixed custom fabricated provisional will guide tissue growth during the healing phase.11 If immediate provisionalization is not possible due to lack of implant stability achieved at the time of surgery, the use of a removable provisional prosthetic may be necessary during the initial healing phase. A properly constructed removable provisional prosthetic also can be used to guide soft tissue during the healing phase as a transitional appliance. Once initial healing is complete fabrication of the custom fabricated provisional and provisional abutment can be performed with great success. Once healed, the tissue can be sculpted and the custom fabricated provisional and provisional abutment can be fabricated to support the new tissue position.

The challenge to produce implant supported restorations that mimic nature and not discernable from the natural dentition is an evolving process. The techniques and materials in implant surgery and products available continue to advance. A predictable aesthetic final restoration is the goal of implant placement and maintaining the hard and soft tissue is critical to achieving this result.6,12

Immediate provisionalization provides a number of clinical and patient benefits. Reduced chair time, elimination of additional surgery, immediate non-occlusal loading, bone preservation and aesthetic benefits are achieved by receiving an aesthetic provisional the day of implant surgery. The provisional can be placed at the surgical appointment or the patient can return within 24 hours or up 72 hours after surgery. The patient benefits with an immediate aesthetic result eliminating other forms of removable provisionalization. The provisional can be of 2 types: laboratory fabricated, whether computer guided or traditionally fabricated with stone and lab components, or custom fabricated by the restoring or surgical clinician. Although a laboratory fabricated provisional is a viable treatment modality, a custom fabricated provisional provides added flexibility in tissue guidance. It also eliminates additional unnecessary laboratory expense. The treating clinician can customize the provisional to the circumstance as it presents. Prefabricated laboratory provisionals, although well planned, may still fall short of the tissue requirements that present chair side. Working with stone models in the laboratory environment, although a good simulation, is still not as accurate as what the circumstance presents chair side. Preplanning is mandatory whichever modality chosen. The position of the implant has to be pre-determined with information derived from the diagnostic work up phase of treatment. This must include study models, radiographs and clinical findings determined during the patient examination. Once this information is derived a diagnostic wax-up can be performed to aid in the fabrication of the necessary surgical guide and provisional matrix to guide the fabrication of the provisional. The surgical guide will be used at the time of surgery while the provisional matrix will be used to guide the fabrication of the provisional chair side. Proper provisionalization and proper final restoration of the implant is derived from the proper implant placement determined from preplanning.

Benefits of an immediate custom fabricated provisional include duplicating the emergence profile of the extracted tooth. This will allow the gingival embrasure form to be supported maintaining soft tissue contour and guide tissue healing. Recreating the interproximal papilla following the extraction and implant surgery is difficult. The key to maintaining the interproximal papillae is to preserve the gingival embrasure form at the time of surgery.2 Proper soft tissue guidance and support is necessary in the development of natural soft tissue contours and support of interproximal papillae.

The immediate custom fabricated provisional technique also addresses the placement of the restorative margin position. With the utilization of cement retained implant restorations, creating the restorative margin position at the time of surgery ensures a predictable tissue position for the final restoration. Use of a long term provisional for weeks or more may be a prudent way to guide soft tissue dimensions and marginal predictability.

CLINICAL CASE REPORT
The custom implant provisional technique is utilized primarily in two clinical treatment scenarios. The technique can be utilized immediately following surgical implant placement and is the ideal situation. This technique is equally effective when immediate implant loading is not possible due to the surgical limitations when implant stability is not achieved. In this situation the custom implant procedure can be performed after t
raditional healing time has occurred with equal effectiveness. The cases presented will illustrate use of this technique in these situations.

CLINICAL REPORT: CASE 1
A 24-year-old healthy female presents with multiple failing restorations throughout the maxillary and mandibular arches (Fig. 1). A comprehensive examination was performed and comprehensive treatment presented. The patient was interested in improvement in her smile with the minimal treatment necessary. Treatment of the maxillary anterior four teeth restoratively and whitening of the remaining anterior dentition was presented and accepted since complete restoration and smile makeover was not possible. The patient understood the compromise of incomplete treatment and realized additional treatment in the future would be necessary to restore her dentition to health.

Teeth #7 and #10 presented with existing aging recurrent decay crowns. Both teeth were structurally compromised with large oversized posts. An attempt at re-treatment was deemed heroic leaving these teeth with a poor long term prognosis. The treatment plan consisted of implant replacement for teeth #7 and #10 custom abutments and all ceramic crowns for teeth #8 and #9. The use of the 3i certain implant (3i Implant Innovations Inc., Palm Beach Gardens, FL.) and platform switching would be utilized to preserve bone.17 A diagnostic work up including mounted models was performed. From the mounted models a surgical guide was fabricated for use by the Periodontist to aid in surgical placement. Diagnostic wax up of teeth #7 – #10 was performed and a putty matrix (Sil-tech Ivoclar/Vivodent Amherst, NY) was created to facilitate fabrication of the chair side custom provisional and custom provisional abutment. An attempt would be made to proceed with removal of the teeth with immediate implant placement and immediate placement of a custom provisional and provisional abutment. An esthetic provisional removable appliance was fabricated based on the diagnostic wax up as a precaution should immediate placement of the provisional not be possible due to implant instability at the time of surgery. Implant stability was not achieved at the time of surgery and the removable provisional was adjusted and inserted as to not traumatize the surgical site. A traditional approach of six month healing to allow for osseointegration of the implants without disturbance was employed.13-15 After 8 weeks of initial primary tissue healing of the surgical site for teeth #7 and #10, teeth #8 and #9 were treated with traditional prosthetic principals and new all ceramic crowns were fabricated and placed. With the final restoration in place a significant esthetic improvement was achieved during the remaining 5 month healing time for osseointegration and allowed the patient the ability to preview what esthetic outcome could be achieved. After osseointegration and second stage surgery was complete the patient presented to initiate final implant supported restoration of teeth #7 and #10.

CLINICAL TECHNIQUE: CASE 1
The patient presented with the second stage healing screw in place (Fig. 2). The goal is fabrication of the custom provisional and custom provisional abutment. Once these have been placed we can initiate fabrication of the final restorations. The purpose of the custom fabricated provisional and provisional abutment is to create the final tissue contours and emergence profile for the final restoration. Once created, impression of the properly formed tissue contours can be captured in the final impression and communicated to the dental laboratory and reproduced in the final restoration. Without the custom abutment the final impression would simply capture the incorrect circular emergence profile of the surgical healing screw. No information would be transferred to the laboratory to guide fabrication of the final restoration.

The healing screw is removed and a provisional abutment (Temporary Cylinder 3i Implant Innovations Inc., Palm Beach Gardens, FL) is placed to identify and assess required alteration to achieve appropriate tissue contour, support and emergence profile (Fig. 3).

The provisional abutment is then prepared with a high speed hand piece and significant water coolant to prevent any thermal transfer to the implant body. The provisional abutment is prepared to reflect traditional preparation design for full coverage of a lateral incisor (Fig. 4).

Block out material is placed in the screw access opening so the provisional material will not flow into the access opening. Luxatemp (Zenith/DMG) is then injected around the prepared provisional abutment. The putty matrix (Sil-Tech Ivoclar/Vivodent) fabricated from the diagnostic wax up is filled with the material and placed in the mouth and allowed to set (Fig. 5).

The matrix is then removed after initial curing of the provisional material and the provisional and the provisional abutment are removed to prepare for custom alteration and finishing (Fig. 6).

The provisional is then contoured by adding Luxaflow (Zenith/DMG) light cured composite around the abutment side of the provisional. This process is repeated as the provisional is contoured to create the proper emergence profile. Material is similarly added to the neck of the provisional abutment and contoured until the final provisional and provisional abutment contours are achieved (Fig. 7).

Once the provisional and provisional abutment are properly contoured they are tried in and any final adjustments are made for tissue support and emergence profile. The provisional abutment screw is placed and tightened to the proper torque and the provisional is cemented with provisional cement and the occlusion adjusted (Fig. 8).

Depending on the tissue contour the final impression can be taken at this point or the patient can be re-appointed in two weeks to allow tissue contour to be stable. In this case the patient was re-appointed. After two weeks the patient presented for final impression. The provisional and provisional abutments were replaced as before and the patient re-appointed for placement of the final restoration. A laboratory prescription was completed and the final impression, bite registration, facebow transfer, models of the provisional and photos of the provisional were forwarded to the laboratory. The laboratory was instructed to fabricate custom metal abutments and all ceramic crowns. Stock abutments can be used but most of the abutments available do not allow custom subgingival contour of the ceramic. Instead, like the surgical healing abutments they provide a circular rather than an anatomical emergence profile. The custom abutments can be created to mimic the subgingival contour created by the provisional abutment. The ceramic shoulder should extend ½ mm subgingival to the free gingival margin. The completed final custom abutments and crowns were forwarded for insertion. Upon receiving the abutments and crowns they were inspected for accuracy (Fig. 9).

The patient presented for placement of the final crowns and custom implant abutments. The provisional and provisional abutments were removed. The custom implant abutments and crowns were tried in for accuracy (Fig. 10).

Once accuracy was verified the final implant abutments screws were torqued to place. A polyvinyl block out material was placed in the screw access opening

The crowns were cemented with dual cure composite cement (Variolink Veneer Ivoclar/Vivadent Amherst, NY).

CLINICAL REPORT: CASE #2 
A 52-year-old women presents for evaluation complaining of a loose crown on tooth #9 (Figs. 29-31). The history includes significant trauma to tooth #9 at a young age resulting in endodontic treatment, post and core and crown placement. Since childhood endodontic re-treatment has been performed as well as an apicoectomy. The patient also does not like her “gummy smile” and short teeth. Comprehensive examination reveals probable post and root fracture. Comprehensive restorative treatment is presented to restor
e the hopeless tooth #9 and improve esthetics by reducing the gummy smile with longer teeth. The patient is consulted on the reclined vertical tooth position and resulting deep bite with restricted envelope of function causing wear of the mandibular anterior teeth. The patient is consulted on complete treatment and understands the compromise of less than ideal treatment. The patient is interested in minimal treatment required to restore her teeth. The patient is consulted on restoring teeth #6 – #11 at this time and understands the need for additional treatment in the future to restore proper anterior guidance. Models mounted in CR by facebow are fabricated to analysis the occlusion and fabricate a Sil-Tech (Ivoclar/Vivadent Amherst, NY) putty matrix to aid in fabrication of the provisional restoration. The patient presented for the fabrication of the provisional #6 – #11. A provisional was fabricated utilizing a putty matrix and Luxatemp (Zenith/DMG Hamburg, Germany). The provisional would act as the surgical guide for implant placement and crown lengthening surgery. Tooth #9 was treatment planned for extraction, bone graft and immediate placement implant. A 3i Certain Prevail (3i Implant Innovations Inc. Palm Beach Gardens, FL) was chosen to preserve bone by use of its platform switched design.17 This would be followed by immediate fabrication of a custom provisional abutment to guide tissue healing and provide proper tissue support and emergence profile.1 The patient is appointed to provisionalize teeth #6 – #11. This will aid in esthetic design and act as surgical guide for implant and crown lengthening surgery

CLINICAL TECHNIQUE: CASE 2
The goal is fabrication of the custom provisional and custom provisional abutment. Once these have been placed we can initiate fabrication of the final restorations in approximately 8 weeks. The purpose of the custom fabricated provisional and provisional abutment is to guide tissue during the healing phase and create the final tissue contours and emergence profile for the final restoration. Following extraction and immediate implant placement the patient presents for fabrication of a new provisional and immediate custom provisional abutment. The patient presents with the surgical healing screw in place 24 hours after surgery (Figs. 32,33).

The surgical healing screw is removed and the ProFormance provisional abutment (3i Implant Innovations Inc. Palm Beach Gardens, FL) is tried in to assess the need for custom alteration of the abutment to achieve proper soft tissue support and emergence profile (Figs. 34-36).

The abutment is removed and Luxaflow (Zenith/DMG Hamburg, Germany) composite is added to the subgingival area to initiate formation of the subgingival collar. Luxaflow (Zenith/DMG) is added with a slight greater contour than observed during abutment try in (Figs. 37-41).

The provisional abutment is then tried in again to assess the tissue support and subgingival emergence contour of the added material. The abutment is shaped to ideal tissue support and subgingival contour (Figs. 42,43).

Once contour has been established the provisional abutment is seated in place and prepared chair side to the fundamentals of traditional prosthetic crown preparation and contour (Figs. 44,45).

A shoulder is prepared ½ mm subgingival to the free gingival margin to guide invisible margin placement of the final restoration. The abutment is then removed and inspected for any additional refinement prior to placement (Figs. 46.47).

The abutment screw is placed and torqued to the prior tightness. The provisional can then be fabricated in the traditional manner using the original putty matrix fabricated during the diagnostic phase. Once the provisional is in place the patient is dismissed and appropriate healing time is allowed prior to final impression for fabrication of the final restorations (Figs. 48,49).

A polyether impression, facebow transfer, stick bite, maxillary and mandibular provisional stone models, and a set of photographs of the stump shade and provisional were then sent to the laboratory, along with complete instruction for fabrication of the zirconium implant abutment (ie, Atlantis, Zimmer Dental, Carlsbad, CA) and zirconium ceramic crowns to precisely match the provisional (Fig. 50).

A customized zirconium abutment was fabricated in order to capture the identical contours of the custom-fabricated provisional abutment.

Zirconia abutments were chosen due to their precise fit and excellent results in the aesthetic zone; these restorations eliminate the appearance of metal margins and require no modifications prior to delivery. (Fig. 51).

As the clinician’s restorative armamentarium continues to expand based on evolving technological advancements, the ability to deliver functional and aesthetic results with predictable longevity will also expand, allowing optimal results following implant placement. The final restorations were evaluated on the working model for accuracy. Once proper fit and occlusion were established using an articulating device, the patient’s provisional restoration and custom-fabricated provisional abutment was removed, and the zirconium abutment was placed on the implant fixture, secured with a gold screw, and torqued to 20 N. Digital radiography was used to verify fit and integration. The zirconium ceramic crowns were tried in and inspected for accuracy, contour, and shade match. Once the restorations were determined to be acceptable, the screw access hole was filled with a polyvinylsiloxane bite registration material, and the crowns were cemented. The occlusion was adjusted to provide anterior stops of even intensity, with anterior and incisal guidance (Fig. 52).

CONCLUSION
In case 1, the use of a custom fabricated provisional and provisional abutment was presented after traditional healing. In case 2, the use of a custom fabricated provisional and provisional abutment was presented after immediate implant placement. In both cases the fabrication of an immediate custom provisional and provisional abutment was utilized to guide tissue healing and improve implant restorative esthetics.

Numerous treatment techniques have been developed to aid in the preservation of hard and soft tissue. Our goal should be to preserve the hard and soft tissues and minimize the duration of treatment. The use of a custom fabricated provisional, custom fabricated provisional abutment, and custom fabricated final abutment with the appropriate anatomical contours can allow the creation of imperceptible restorations that mimic nature. OH

ACKNOWLEDGEMENT
The author would like to thank Dr. Robert Holt of West Palm Beach, FL. for his exceptional expertise in implant surgical placement and Peter Kouvaras Laboratory for the aesthetic result.

Dr. Gerard J. Lemongello Jr. graduated from the University of Florida, College of Dentistry and has been in private practice since 1987. His focus is on cosmetic and comprehensive restorative and reconstructive dentistry. He is a member of the American Dental Association, Florida Dental Association, Academy of General Dentistry, and an Accredited member of the American Academy of Cosmetic Dentistry. Dr. Lemongello is a Senior Clinical Instructor with the Rosenthal Institute’s Aesthetic Advantage Continuum at New York University. He is Co-chairman of the Comprehensive Esthetic and Restorative Clinic at the Atlantic Coast Dental Research Clinic in West Palm Beach. He has also held numerous positions on the board of the Atlantic Coast Dental Research Clinic and presided as President for two terms.

Dr. Lemongello has published numerous articles in leading dental journals. He also lectures nationally on complex treatment planning, aesthetics and implant dentistry as well as other contemporary dental topics.

Oral Health welcomes this original article.

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