When clinicians present the available treatment options to patients, they must be able to convey the process of how that case will be provisionalized. The type of provisional and how it will affect a patient’s lifestyle during treatment is often a part of whether or not a patient accepts a treatment plan.
This month’s topic is Provisionalization for Implant Dentistry. This is, in my opinion, one of the most important topics that Implants Today covers throughout the year. How an implant case is provisionalized should be one of the first treatment planning and clinical decisions made. The method and timing of provisionalizing an implant case affects not only a patient’s lifestyle during the implant healing period but also the clinical success of the case.
The method of provisionalization needs to be known early on when treatment planning an implant case. When clinicians present the available treatment options to patients, they must be able to convey the process of how that case will be provisionalized. The type of provisional and how it will affect a patient’s lifestyle during treatment is often a large part of whether or not a patient accepts a treatment plan. Some considerations for provisionalization include how the provisional will affect a patient’s aesthetic, phonetic, and dietary situations as well as lifestyle with respect to appointment scheduling. As with all treatment planning in implant dentistry, a comprehensive dialogue with the patient is required. It is through this communication process that the clinician will gain a thorough understanding of each patient’s unique needs and desires, and only then be able to customize a provisionalization plan to properly match the situation at hand.
From a clinical standpoint, provisionalization starts with determining if a case is going to be a full-arch case or a quadrant case. The next question is whether or not the case will be an immediately loaded one-stage procedure or a 2-stage procedure. When a case consists of one implant or a quadrant of implants, nonfunctional immediate loading can be done. According to Dr. Carl Misch, nonfunctional immediate loading occurs when implants are placed out of occlusion and function during the 3- to 6-month implant healing period. This will allow a patient to have nonfunctional aesthetic teeth. The presence of either natural teeth or integrated implants is needed for this to happen. The patient will have to be cognitive of avoiding the area that is being nonfunctionally loaded and to chew only soft foods there. Nonfunctional immediate loading is often utilized in the aesthetic zone when a single tooth is being replaced. Various abutments can be used for this, ranging from plastic PEEK abutments (BioHorizons) to titanium-angled or straight stock abutments. Especially in the aesthetic zone, nonfunctional immediate loading offers an excellent way to form the soft tissue around an implant right from the time of surgery. It is obviously important to ensure there is adequate keratinization around the implant at the time of loading, since that is the only planned opportunity to do so. In my practice, I utilize a permanent cement, being sure not to allow any cement into the sulcus. Using a permanent cement avoids the micromovement from a loose provisional crown, which could lead to implant integration issues. If using a permanent cement, the removal of the provisional—when it is time to take impressions—will necessitate the clinician to drill through the provisional and then to unscrew the abutment.
If a single-implant or quadrant case is going to be done as a 2-stage procedure, then the options are as follows: (1) a flipper appliance, (2) Maryland bridge, or (3) bonded tooth (or teeth). If a flipper appliance is being used, then it is important that the appliance be relieved from the tissue surface to avoid interfering with implant integration. In the aesthetic zone, a flipper is not the ideal form of provisionalizing a case, as these appliances do not predictably form an ovate pontic as well as either a bonded tooth or Maryland bridge. While a bonded tooth or Maryland bridge offer stability toward ovate pontic formation and tissue shaping, there are disadvantages. The first disadvantage is the vulnerability of the bonded tooth or Maryland bridge debonding at an inopportune time. For this reason, I usually create a second (backup) flipper. The other issue with these bonded options is that more chair time is needed to rebond the tooth or Maryland bridge.
Full-arch provisionalization has 3 options consisting of (1) a denture, (2) immediately loaded implants, or (3) staging a full-arch case using existing teeth that will be later extracted.
A denture certainly offers simplicity from a full-arch provisionalization standpoint, but some patients are not amenable to wearing a denture. This is the point at which dialogue with a patient becomes important. When a denture is being utilized for full-arch provisionalization, a soft chairside reline of the denture (ie, COE-SOFT [GC America]) is done over the healing caps at uncovery.
Immediate loading of a full arch requires adequate implant stability. In my practice, I immediately load around 90% of the time on the mandible, and about 60% of the time on the maxilla. We use Implant Stability Quotient (ISQ) readings from the Osstell unit (Osstell). When we have a reading of 60 or higher and we are splinting implants, immediate loading is the chosen protocol. Otherwise, we do the case as 2-stage and bury the implants. Immediately loading a full-arch case can substantially reduce the amount of appointments needed for completion of the case. We often complete full-arch screw-retained immediate load cases in 4 total visits. As long as there is adequate implant stability at surgery, the literature shows success rates for immediate loading equal to, or better than, 2-stage with a full arch. When a patient is wearing an acrylic full-arch provisional, the patient’s diet must be soft in nature during the implant integration period. In my practice, I deliver the screw-retained full-arch provisional prosthesis the day after surgery instead of the same day.
After doing this next-day delivery for many years, my team and I have found 4 major advantages. First, by taking an impression at the time of surgery and placing healing caps, there is less chair time and less stress for the doctor and patient. Instead of spending the entire day with the patient delivering a chairside relined provisional, the patient is home at rest and the doctor is seeing other patients. Second, when a laboratory creates a full-arch provisional versus one fabricated at the chair, the provisional is more refined, aesthetic, and stronger than a chairside reline. Third, when this refined provisional is delivered the next day, the tissue at the surgical site has shrunk, there is no bleeding, the delivery is painless for the patient and, in general, the task takes less than an hour for the doctor. The fourth advantage is that the doctor’s schedule is now more controlled. An all-day surgery and delivery can be unpredictable with respect to the time needed. Through a next-day delivery, the appointment times are very predictable and can be scheduled appropriately for the doctor and patient.
The last option for full-arch implant provisionalization, which consists of utilizing existing teeth that will be extracted, can work very well. However, this clinical protocol makes the case more complicated, requires additional appointments, and often makes the provisionalization process more challenging. The option of saving teeth for full-arch provisionalization is better suited for cement-retained full-arch bridges where there is not any alveoloplasty being done. This is what Misch classifies as FP1. When alveoloplasty is needed, saving teeth becomes more of an issue and becomes problematic when timing the different stages of an implant case.
In this month’s Implants Today, we are featuring the work of 2 contributing authors. First, Implants Today editorial board member Dr. Justin Moody’s article entitled “Dental Implant Provisionalization Options” brings to light many of the points that I have made here in this and is backed up by excellent clinical images. Justin also offers even more insights related to this very relevant topic. In “Using an Integrated Digital Approach to Treatment Planning,” Dr. David Little presents an alternative to utilizing flippers for a complicated anterior extraction/implant case. The “snap-on” option allows for much more stability than a traditional flipper, with regard to forming soft tissue and also to avoiding stress on healing implants.
Clearly, as the reader can discern from the information presented here and in this issue’s Implants Today articles, provisionalization of implant cases is vital to the treatment planning protocol. Many considerations need to be taken into account, including how the case will be staged, the number of implants planned, the patient’s desires and lifestyle, and much more. The proper provisionalization plan for each unique case must be made early in the treatment planning process so that the parameters can be conveyed to a patient. The choice of how a case will be provisionalized can even be a factor in whether or not a patient will accept the recommended treatment. Treatment planning implant dental cases involves both surgical and prosthetic decisions.
One last thought about the importance of a provisional restoration is that often the provisional restoration becomes the guide for the final prosthesis with regard to aesthetics, occlusion, and more. Once again, provisionalization is a key component in dental implant treatment that affects the entire case.