Provisional restoration options in implant

dentistry
Today, implant integration is given with the greater knowledge of the biological
basis for treatment and improvements primarily associated with implant
morphology. Traditionally, for conventional loading protocols, the implants are left
unloaded for 3 to 6 months to allow the osseointegration process to take place.
Hence, patients often expect to have their implants loaded with some type of fixed
prosthesis similar to their natural dentition much earlier.
According to The Glossary of Prosthodontic Terms, a provisional prosthesis is a
prosthesis designed to enhance aesthetics, provide stabilization and/or function for
a limited period of time, and should be replaced by a definitive prosthesis after a
period of time.
Provisional restorations can be used as a diagnostic restoration to evaluate the
position and contours of the planned definitive restoration prior to surgical implant
placement and during the healing phase.
A provisional restoration immediately placed with ovate pontics extending into the
extraction sockets can also be used to preserve the pre-extraction soft tissue
morphology.
They can guide the healing of the peri-implant tissue and allow the clinician to
determine any necessary phonetic or aesthetic adjustments.
The clinicians may use information such as shade, crown and soft tissue contours
from the provisional restoration as a communication tool to the laboratory.
Provisional implant restorations also allow the patient to visualize and evaluate the
end restorative result, thus assisting in acceptance and/or guiding of modifications
required for the definitive restoration.

Types of provisional restorations

Type of support

Prosthesis type

Removable

Partial acrylic dentures

Essix appliance
Archwire supported pontic
Resin bonded pontic
Resin bonded, cast metal framework
bridge
Transitional implants

Fixed tooth support

Fixed implant supported

Removable prosthesis:Removable partial acrylic dentures have commonly been used during post
extraction and throughout the implant therapy. They are simple to construct,
relatively inexpensive, and easy for the surgeon or restorative clinician to adjust
and fit. However, they may reduce the effectiveness of any additional surgical bone
and gingival augmentation procedure used to optimize the implant site. Care must
be taken to prevent the gingival portion of the provisional partial denture from
contacting the healing soft tissue or an exposed healing abutment.Soft tissue borne
prostheses used during healing may cause uncontrolled implant loading leading to
implant exposure, marginal bone loss, and/or failed integration. Often provisional
dentures are adjusted to minimize contact with the healing implants.

Essix appliance may be used as a removable prosthesis in these cases, as well as

in limited interocclusal space or deep anterior overbite. This prosthesis is made
from an acrylic tooth bonded to a clear vacuform material on a cast of the
diagnostic wax up. The prosthesis provides protection to the underlying soft tissue
and implant during the healing phase. Limitations of this provisional restoration
include its inability to mould the surrounding soft tissue, and lack of patients
compliance can cause rapid occlusal wear through the vacuform material.

Tooth supported provisional restorations

Orthodontic wire brackets and archwire on several teeth adjacent to
the implant site with attached pontic for fixed tooth supported
provisional restorations in the upper anterior region.
Resin bonded provisional pontic, which are tooth supported and
retained by acid etching the neighbouring teeth. Sometimes small
retentive grooves within enamel on the adjacent teeth can be used to
increase retention of the pontic. The pontic can be in the form of an
acrylic tooth, porcelain, or decoronated extracted tooth. The resin
bonded acrylic or natural tooth may be reinforced with composite resin
and/or ultra high molecular weight polyethylene ribbon (Ribbond

Bondable Reinforcement, Ribbon;Ribbond Inc, Seattle, Wash., USA).

The archwire/resin retainer can be removed and reattached between the
different surgical and prosthetic stages. They can also be used to guide
the surgeon during grafting procedures and as a template for the final
restoration.
A resin bonded, cast metal framework prosthesis such as Maryland
Bridge is suitable for long-term provisionalization in the anterior region,
especially in young patients .This type of provisional is difficult to reuse
throughout the implant procedure as the bond strength between the metal
retainer and the enamel can be unpredictable during removal and
reattachment between procedures. Furthermore, the laboratory costs are
relatively high.
In some cases, a staged extraction and implant placement approach
can be adopted. In this technique, the implant sites are selected, and
teeth that occupy these sites are extracted while the remaining teeth are
used to support a fixed provisional restoration. Usually, natural
abutments with poor prognoses are used as interim abutments and can be
extracted when the implants have integrated. The teeth supported
provisional restoration is then converted into an implant supported
provisional restoration. This indirectdirect technique is often used in a
full arch situation, where the patients dentition is failing due to
periodontal disease or when the adjacent natural teeth require fixed
prosthesis at the same time.

Transitional implant provisional restorations:In extended partial edentulous areas where there are no or limited natural
abutments to support a provisional restoration, one or more transitional
implants may be used. These transitional implants are loaded
immediately to support the provisional restoration. They can be used to
support fixed restorations or to retain complete mandibular dentures.
Care should be taken in planning the position of these implants and with
their maintenance post-loading. They should not interfere with potential
implant sites, or be placed in poor quality bone. When the depth of
available bone is less than 14mm or the amount of cortical bone is
insufficient to provide stabilization, the immediate provisional implant
may be contraindicated. Once the implants integrate, the supporting
provisional restoration will be converted into implant supported
provisional restoration, and the transitional implants are backed out of
position using a ratchet arm and insertion tool used in the reverse mode .

Post-implant placement:Implant retained provisional restorations

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.
Primary stability of these implants is crucial in the decision for immediate
provisionalization. The technique involves the placement of temporary cylinders
onto the implants and the modification of patients existing mandibular denture.
These cylinders are luted to the rest of the denture using self- cure resin.

Cement retained provisional:A plastic protection cap, usually cylindrical in shape, may be cemented on the
prefabricated abutment until the delivery of the final prosthesis. This technique is
often used by clinicians in non-aesthetic regions of the mouth.
Most implant companies have prefabricated abutments for cement retained
restorations. These abutments come in various heights to allow enough space for
the metal and porcelain in crown construction.

Screw retained provisional prostheses:Screw retained provisional restorations would eliminate the possibility of having
any temporary cement present in the peri-implant tissue. This can be achieved
using temporary cylinders directly placed on the implant level. The provisional
crown can then be built up in the laboratory on the master cast or chairside by
using self or light cure resin or composite resin according to the diagnostic wax up.
The temporary cylinder often has to be adjusted to fit into the occlusion.