A Simplified Approach

to the Immediate Provisionalization of an Implant in the Esthetic Zone

Abstract

n recent years, studies on accelerated and immediate implant loading protocols have demonstrated promising results.

These accelerated protocols can reduce total treatment time and improve patient satisfaction. This article illustrates the immediate provisionalization of an implant on tooth No. 8.

he approach to loading dental implants has been modified in recent years. The original Brnemark implant protocol called for an undisturbed healing period of several months before implants were exposed and loaded.1 Early or premature loading was thought to prevent osseointegration and result in implant failure.2 There has been an increase in the number of reports and studies on accelerated and immediate loading protocols (ie, shortened healing periods as well as implants provisionalized or loaded directly at the time of placement). The success rate for these new protocols appears to be similar to the originals.3,4 Furthermore, these procedures can reduce total treatment time and, in many cases, allow the patient to wear a fixed prosthesis, improving overall satisfaction. This article illustrates the immediate provisionalization of an implant on tooth No. 8.
Mariano A. Polack, DDS, MS Prosthodontist, Private Practice Gainesville, VA Phone: 703.753.8753 Email: mpolack@comcast.net Web site: www.dentaldesigngainesville.com

Case Presentation
A 46-year-old woman presented with an interim removable partial denture replacing tooth No. 8 that had been extracted 3 months earlier (Figures 1 to 4). Her chief complaint involved replacing the missing maxillary incisor and enhancing the esthetics of her smile in that area. The denture tooth on the removable prosthesis was excessively wide mesiodistally, and lacked symmetry with tooth No. 9. The patient did not desire veneers or other type of indirect restorations for the remaining maxillary incisors. After reviewing the findings and treatment options, the patient chose to have an implant-retained crown to replace tooth number 8. In addition, composite resin restorations would be applied on the mesial and distal as-

Figure 1 Preoperative extraoral view.

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Figure 2 Preoperative radiograph.

Figure 5 Postoperative radiograph control depicting adequate bone levels.

Figure 6 Immediate postoperative view after implant placement. Notice the composite resin added to the interproximal aspects of teeth Nos. 7 and 9. Figure 3 Preoperative intraoral view. Note the inadequate appearance of the denture tooth.

Figure 4 Preoperative intraoral view, close up. The edentulous space is excessively wide and needs to be corrected by adding composite resin to the adjacent teeth before implant placement.

Figure 7 Provisional screw-retained crown before polishing and finishing.

pects of teeth Nos. 7 and 9, respectively, to balance the mesiodistal width of both central incisors. At the first appointment, a diamond bur was used to roughen the mesiofacial aspect of tooth No. 7 and the distofacial aspect of tooth No. 9. A small bevel was created with a fine diamond, and these areas were etched and bonded. Composite resin was applied approximating the

mesiodistal width of the edentulous site of No. 8 to that of tooth No. 9. The composite restorations were then polished, finished, and a polyvinyl siloxane impression was made to fabricate a polymethyl methacrylate provisional crown. The interim removable partial denture was adjusted to accommodate the composite restorations, and the patient was referred to the oral surgeon for implant placement.

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Discussion
The tendency in implant dentistry is to decrease treatment time through shorter surgical and restorative protocols.5 This is achieved by shortening the amount of time between implant placement and rehabilitation, reducing the number of appointments. Accelerated protocols can eliminate the need for a removable prosthesis and enhance treatment efficiency as well as patient satisfaction.6 Primary stability is the main factor allowing immediate provisionalization or immediate loading.7 This is typically associated with an implant insertion torque greater than 35 Ncm, which is believed to keep micromovement below 150 m.2 Greater mobility is assumed to bring about fibrous encapsulation; however, no clinical trial to date has compared the effect of different levels of stability on implant survival.8 Presently, there is limited scientific data to validate immediate provisionalization and/or loading for every clinical situation.9 Therefore, anatomic, host, and biomechanical factors as well as the experience of the operators should be taken into account when evaluating the feasibility of these procedures.

Figure 8 Immediate intraoral postoperative view. The provisional crown was shortened to prevent contact during protrusive movements. Minimal soft-tissue trauma allowed for uneventful healing.

Figure 9 Immediate extraoral postoperative view shows enhanced esthetics.

Conclusion
As illustrated by the case presented, the immediate fixed provisionalization of an implant in the maxillary anterior region eliminates the need for a removable prosthesis and reduces the number of surgical appointments, thereby increasing comfort and esthetics, and shortening total treatment time.

A regular-diameter implant was placed into the edentulous site with a flapless technique. Adequate primary stability was achieved and a healing abutment was connected to the implant. The patient was referred back on the same day to the prosthodontist for immediate provisionalization (Figure 6). The healing abutment was removed, a provisional abutment was connected to the implant, and an electric handpiece was used for gross reduction. A thin mix of polymethyl methacrylate was placed inside the provisional crown that was seated over the abutment and allowed to set. In this manner, a screw-retained crown (Figure 6) was fabricated. Next, all centric and eccentric contacts were eliminated and the provisional restoration was polished to a high shine. A 30-Ncm torque wrench was used to connect the crown to the implant and the access hole was sealed with gutta-percha and composite resin. After the procedures, minimal soft-tissue trauma was evident, and a pleasant extraoral esthetic result was achieved (Figures 7 to 9).

References
1. Albrektsson T, Brnemark PI, Hansson HA, et al. Osseointegrated titanium implants. Requirements for ensuring a long-lasting direct bone-to-implant anchorage in man. Acta Orthop Scand. 1981;52:155-170. 2. Brunski JB. Biomechanical factors affecting the bone-dental implant interface. Clin Mater. 1992;10:153-201. 3. Schnitman PA, Whrle PS, Rubenstein JE, et al. Ten-year results for Brnemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Implants. 1997;12:495-503. 4. Randow K, Ericsson I, Nilner K, et al. Immediate functional loading of Brnemark dental implants. An 18-month clinical

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follow-up study. Clin Oral Implants Res. 1999;10(1):8-15. 5. Francetti L, Agliardi E, Testori T, et al. Immediate rehabilitation of the mandible with fixed full prosthesis supported by axial and tilted implants: interim results of a single cohort prospective study. Clin Implant Dent Relat Res. 2008;10: 255-263. 6. Polack MA, Mahn DH. The use of a customized prefabricated zirconia abutment and zirconia crown in the restoration of an immediately provisionalized implant in the esthetic zone. Compend Contin Educ Dent. 2008;29:358-362.

7. Esposito M, Grusovin MG, Achille H, et al. Interventions for replacing missing teeth: different times for loading dental implants. Cochrane Database Syst Rev. 2009(1):CD003878. 8. Roccuzzo M, Aglietta M, Cordaro L. Implant loading protocols for partially edentulous maxillary posterior sites. Int J Oral Maxillofac Implants. 2009;24(suppl):147-157. 9. Weber HP, Morton D, Gallucci GO, et al. Consensus statements and recommended clinical procedures regarding loading protocols. Int J Oral Maxillofac Implants. 2009;24 (suppl):180-183.

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