IMMEDIATE PROVISIONAL ON TEETH OR IMPLANTS: determining chronology and restoration contouring

1. INTRODUCTION

After extraction of an anterior tooth, the patient usually requests its immediate replacement. A provisional prosthesis can be made to supply the esthetics of the region. This has a direct influence on tissue remodeling after surgery to maintain or reconstruct tissue architecture.

Before extraction, it is essential to plan the type of provisional restoration that the patient will receive. Ideally, the implant and the provisional are placed immediately after tooth extraction. However, it is necessary to explain to the patient that other alternatives may be necessary.

The condition of the adjacent teeth should be analyzed before surgery because it will not always be possible to immediately place a provisional over the implant. The provisional restoration can be fixed or bonded to the adjacent teeth. Primary implant stability, occlusion, and tissue appearance are some of the factors that will determine the possibility of an immediate provisional restoration over the implant.

Regardless of which temporaryis going to be used, it must be customized to prevent changes and improve soft tissue conditions. Incorrect contouring of the provisional restoration can compromise all surgical efforts to achieve adequate tissue contour and a natural emergence profile.

Given the possibility of tissue manipulation, an understanding of and integration between surgical and restorative procedures are necessary to obtain more predictable results.

OBJECTIVES

At the end of the chapter the reader should be able to:

Determine if the immediate provisional will be tooth- or implant-retained.
Understand the techniques and indications for making an immediate provisional.
Know the ideal provisional anatomy to obtain a suitable gingival contour.

2. SCIENTIFIC BACKGROUND

The use of provisional restorations aims to prepare, contour, and stabilize peri-implant soft tissues during and after osseointegration and graft incorporation. It aims to provide comfort to patients in their day-to-day life and allows evaluation of esthetic parameters before the final restoration is made¹^–³. In esthetic areas, a provisional should be placed immediately after extraction. In non-esthetic regions, it can be done according to the expectations of the patient. Placement of an immediate provisional over teeth or implants will depend on the surgical and restorative treatment plan.

For the immediate provisionalization of the implant, we must consider the type of soft tissue defect, the final implant torque, and the patient’s occlusion. Torque should be measured on completion of implant placement and, if less than 32 N/cm², immediate provisional restoration is not recommended⁴^,⁵ (Figs 01A–F). Initial studies on the technique demonstrated a high risk of implant loss if primary stability was lower than this value⁶. Failure in osseointegration is due to micro and macromovement that can occur when the provisional is placed. Instead of establishing direct contact between implant and bone, fibrous tissue is formed around the implant, characterizing its failure⁷^,⁸. To avoid this type of complication, which increases treatment time, placement of a provisional on the adjacent teeth or a provisional device is recommended during osseointegration and graft incorporation.

01. A–F Immediate implant installation after extraction with final installation torque (A–C). Immediate provisional confection (D). Screwed on provisional restoration (E). Tissue appearance after 6 months, showing maintenance of the tissue contour (F).

In addition to implant stability, it is necessary to assess occlusal and tissue aspects before immediate provisional restoration (Figs 02A–C and 03A–C). The patient should have a stable occlusion, no signs of parafunction, and no loss of posterior occlusal stability. In the presence of extensive bone or gingival defects, a provisional should not be installed directly in the implant. The closure provided by the graft-associated flap aids the reconstruction of lost tissues. In different cases, it is necessary to correctly indicate the type of provisional and be prepared for complications that may occur during surgery, which will change the initial planning (Table 01).

02. A–C Lack of occlusal stability can lead to tooth damage. Patient with impaired tooth 12 and absent molars.

03. A–C Patient without occlusal stability, with little interocclusal space due to deep bite. Initial fracture on tooth 22 and, after 8 months, fracture on tooth 21.

PROVISIONAL RESTORATION	SUPPORT	TECHNIQUE
	Orthodontic appliance	Removable or fixed appliance with provisional in the edentulous region
Tooth-supported	Adjacent teeth	Adjacent teeth are used as support and the provisional is attached with a fixed or adhesive partial denture
	Teeth and ridge	The edentulous region is provisionally rehabilitated with a removable partial denture
Implant-supported	Prosthetic abutment	Placement of abutment and provisional restoration

Table 01. Different provisionalrestoration techniques for different clinical situations

2.1. TOOTH-SUPPORTED IMMEDIATE PROVISIONAL RESTORATION

Before an extraction in an esthetic area, it should be determined if it is possible to immediately place a provisional and what type of retention the provisional will have. Implant placement, whether immediate or delayed, should be performed in the ideal three-dimensional position. If there are bone or soft tissue deficiencies that impair the correct positioning of the implant or proper tissue healing is not feasible, the delayed approach should be used (Figs 04A–E). Also, if rehabilitation planning involves the need for orthodontic movement, the timing of implant placement should be determined by all the professionals involved in the treatment (Figs 05A–C).

04. A–E Patient with a porcelain chip in the crown of tooth 21, with the presence of a fracture and large periapical lesion in tooth 22, that does not allow immediate implant placement (A, B). Minimally traumatic extraction and bone graft were performed; a provisional fixed partial prosthesis (C) on teeth 21 (abutment) and 22 (cantilever) was made. After 6 months, an adequate soft tissue contour and bone regeneration were observed (D, E). Surgical procedure: Dr Fausto Frizzera; restorative procedure: Dr Quézia Godinho.

05. A–C Patient requiring extraction of tooth 23, with inadequate occlusion and prior orthodontic treatment. There is a defect with presence of adequate soft tissue and palatine bone. The implant should be installed only after orthodontic treatment and tissue regeneration.

Provided that the proper conditions are present, the implant can be placed immediately after extraction. The stability of the implant and the characteristic of the socket defect will indicate which type of surgical approach will be performed:

Cover screw and implant coverage
Standard or custom healing abutment
Interim implant

When adequate primary stability is not achieved, with less than 10 N, or an extensive bone defect of more than 1 wall is present, the ridge should be grafted, and the implant covered. If stability exceeds 15 N, it is possible to install the healing abutment, which allows the maintenance of soft tissue or even promotes tissue gain and should be totally free of masticatory function or any type of load⁹^–¹¹ (Figs 06A–I). The healing period will depend on the implant surface treatment and the recommendations of the system used. If bone and gingival grafts are required, the time for reopening and loading the implant should be 3–6 months for tissue maturation.

06. A–I Patient with abscess on tooth 15 and extensive bone loss. Clinical and tomographic evaluation, verifying the possibility of immediate implant placement (A–E). Immediate implant placement and healing abutment (45 N/cm² stability) and bone and gingival graft (F–H) were performed. A provisional was made supported by the restoration of the adjacent tooth. Six months after surgery with the implant-supported provisional (I). Surgical procedure: Dr Fausto Frizzera; restorative procedure: Dr Marco Masioli.

In these situations, the immediate provisional is supported by adjacent teeth with a fixed partial prosthesis or by a fixed or removable orthodontic appliance (Figs 07A–I to 09A–G). A fixed partial prosthesis is recommended when adjacent teeth are already prepared for a fixed restoration. Healing abutments may be recommended instead of covering the implant because it avoids a second surgical procedure and assists in maintaining the tissue contour¹².

07. A–I Extraction of tooth 11 and initial provisional manufactured with the extracted tooth crown (A–E). After soft tissue healing, tooth 21 was prepared due to the presence of extensive restorations and a fixed partial prosthesis (F, G) was made. This type of restoration allows better conditioning of gingival tissue (H, I).

08. A–C Absence of lateral incisor and provisional restoration supported by mobile orthodontic appliance. This type of restoration provides good esthetic results. However, it does not condition the soft tissues and can still become a patient complaint for the inconvenience of using a removable prosthesis.

09. A–G Extraction of tooth 11 due to root resorption and active infection, followed by socket preservation with bone and gingival graft. Because the patient was undergoing orthodontic treatment, the extracted tooth was prepared for use as a provisional in the appliance.

2.1.1. REOPENING OF THE IMPLANT

After a period of graft incorporation and implant osseointegration, it is necessary to evaluate the condition of the tissue (ideal, deficient, or excess) and implant positioning to define how to reopen the implant.

A circular scalpel technique can be used. Initially, the center of the implant is located with a probe. The circular scalpel is then adapted, the incision made, and the mucosal tissue cap removed. This technique is recommended when there is adequate tissue thickness, and there is no need to improve the peri-implant tissues (Figs 10A–L and 11A–G). This technique allows immediate manufacture of the provisional over the implant, which favors gingival healing in an adequate contour. If there is excess tissue, it may be surgically removed or the tissue can be conditioned using the provisional.

10. A–L Implant installed inside the socket, where a bone and gingival graft had been performed and sealed with a provisional made using retention and reinforcement tape (Ribbond) (A–C). Due to the satisfactory amount of soft tissue (D, E), a circular scalpel was used to reopen the implant (F–I).

11. A–G Removal of the healing abutment and preparation of the provisional abutment (A). The gingival margin of tooth 13 was more coronal than tooth 23; an overcontour was made to compress and condition the gingival tissue (B–E). Final photo after conditioning the temporary gingival tissue (F, G).

A technique indicated for defective regions is to reopen them with a lingual incision, where the flap is moved to the buccal area with the objective of promoting an increase in volume¹³. At this point, a healing abutment (Figs 12A–G and 13A–K) or the provisional itself can be placed (Figs 14A–D). Depending on the magnitude of the defect, a connective tissue graft may also be used (Figs 15A–G to 17A–P). Regardless of the technique used, it is essential that the provisional has satisfactory esthetic characteristics, an adequate contour, and a high degree of adaptation and polishing to allow a better response of the peri-implant tissue¹⁴.