Prosthodontic Temporization Procedures in Implant Dentistry

Armamentarium

  • Appropriate sutures

  • Diagnostic tooth arrangement

  • Implant analogs

  • Intraoral radiographs

  • Local anesthetic with vasoconstrictor

  • Materials for impressions (irreversible hydrocolloid or polyvinyl siloxane)

  • Provisional implant abutments

  • Provisional restorative material

  • Teflon tape

  • Torque device with driver tips

History of the Procedure

The earliest noted use of dental implants occurred in the Mayan culture. Specimens have been found with seashell fragments inserted into the alveolar processes. Modern prosthetic replacement of the dentition emerged with the creation and evolution of dental materials, notably vulcanite, acrylic, gold, and porcelain. Many types of materials are used in contemporary restorative implant dentistry. The material chosen depends on a number of factors, including cost, esthetics, durability, and function, which must be taken into consideration along with the patient’s preference.

History of the Procedure

The earliest noted use of dental implants occurred in the Mayan culture. Specimens have been found with seashell fragments inserted into the alveolar processes. Modern prosthetic replacement of the dentition emerged with the creation and evolution of dental materials, notably vulcanite, acrylic, gold, and porcelain. Many types of materials are used in contemporary restorative implant dentistry. The material chosen depends on a number of factors, including cost, esthetics, durability, and function, which must be taken into consideration along with the patient’s preference.

Indications for the Use of the Procedure

Implant restorations may be used to replace single teeth or multiple teeth or to restore complete dental arches. With appropriate occlusal design and osseous support, these restorations can provide functional and esthetic outcomes that satisfy the patient and have long-term clinical success. Provisional restorations can be an important part of the process; they satisfy esthetic and functional needs during healing and provide a template for the final prosthesis.

Fixed provisional restorations on implants provide a scaffold for the development of soft tissue contours and are a valuable aid in communication with the dental laboratory. Although not necessary for every case, provisional restorations are very helpful in areas of high esthetic demand and should be strongly considered as part of the plan at the time the scope and sequence of treatment are developed.

Provisional restorations may also be made as removable prostheses. Although these can meet cosmetic and functional needs, they are seldom assets in developing soft tissues for the final restorations. Dentists should be familiar with these prostheses and their limitations because circumstances may prevent the use of fixed provisional restorations during the healing phase after implant placement.

Provisional restorations may always be placed on implants after integration is completed. In the traditional sequence, this is between 2 and 6 months. The length of time to integration depends on the site, healing capacity of the patient, presence or absence of graft materials, and nature of the implant surface. The surgeon must provide guidance in this area to the restorative team.

In some circumstances it is possible to deliver a provisional restoration at the same time as the implant. An individual temporary restoration may be placed on an implant that has a high insertion torque level, indicating good primary stability. There should not be any contact in centric occlusion or during excursive movements of the mandible. Although the restoration may not have contact in centric occlusion, it is possible to generate significant force on a bolus of food. Therefore, the patient must be instructed to refrain from chewing on that side until integration is complete.

Multiple implants (typically four or more, which can be connected across the midline) may also be restored provisionally at the time of placement. These restorations may be used immediately in function; however, the patient should be advised to eat a soft diet until integration is complete.

If all the criteria for immediate placement of a fixed provisional restoration are not met, the dentist and the patient must decide whether to use a removable prosthesis during implant integration. If no provisional restoration is used, a vacuum-formed orthodontic retainer is helpful for preventing tooth movement during the healing phase. It is easy to include a prosthetic tooth in this appliance. An advantage of this type of appliance is the full support offered by the remaining teeth; an occlusal load is never transferred to the surgical site ( Figures 26-1 to 26-3 ).

Figure 26-1
Surgical site immediately after extractions.

Figure 26-2
Graft material in place.

Figure 26-3
Provisional in place, no tissue contact.

Alternatively, a provisional prosthesis may be a traditional acrylic removable partial denture (“flipper”), although flexible materials, such as Valplast (Valplast International, Long Beach, New York) or Flexite (Flexite, Mineola, New York) may be easier for the patient to insert and remove ( Figures 26-4 and 26-5 ). Care should be taken to avoid pressure on the tissue immediately over the site of surgery.

Figure 26-4
Removable partial denture (RPD) as provisional (buccal aspect).

Figure 26-5
RPD as provisional (tissue aspect).

It is also possible to use a provisional fixed partial denture (FPD) with adjacent natural teeth as retainers. A disadvantage of this procedure is the need to prepare the adjacent teeth for restorations that may not be otherwise indicated. A Maryland-type FPD may be used as a provisional; however, it requires removal during the restorative phase and is often associated with damage to the adjacent teeth during debonding and with widening of the restorative space of the implant.

Limitations and Contraindications

Provisional restorations on individual implants are contraindicated at the time of implant placement if the forces of occlusion cannot be eliminated or if patient compliance is not likely. Provisional restorations on multiple implants are contraindicated at the time of implant placement if any of the potential implants supporting the prosthesis do not have sufficient primary stability and if there is no cross-arch stabilization.

Although the benefits of same-day immediate implant provisional restorations are appealing to many patients and dentists, they have significant costs that often limit their use. The laboratory and professional fees associated with these procedures can be substantial and must be considered during the treatment planning process.

If the surgeon or restorative dentist is inexperienced in the process of making implant provisional restorations, this can be a limiting factor. The problem can be overcome by obtaining proper support from a qualified dental laboratory and by performing meticulous advance planning. The significant benefits of using provisional implant restorations in the esthetic zone make this collaboration extremely worthwhile.

Abutments for temporary restorations may be made of titanium or polyether ether ketone (PEEK). Both materials have intaglio surfaces that mate well with implant platforms and provide adequate stability. PEEK abutments are approved for intraoral use for up to 6 months. Titanium cylinders may be preferable if the restoration is expected to be in place for a longer period. PEEK abutments are minimally radiopaque, making it difficult to use radiographs to evaluate full seating. If this is a concern, titanium may be preferred ( Figures 26-6

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Jun 3, 2016 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Prosthodontic Temporization Procedures in Implant Dentistry
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