Technique for the Temporization of an Anterior Implant

INTRODUCTION
The temporization of a dental implant following surgery, particularly in the anterior region, is a necessary procedure. The provisional phase of treatment allows for surgical healing, preservation of the gingival architecture, and most importantly, replacement of a tooth in the edentulous space for patient acceptance. Although there are several techniques available for the temporization of implants, the process has proved to be time consuming and frustrating for both the clinician and practitioner.
This article details the Tempcap abutment (Research Driven) and the process for a simple and effective technique for temporization of an anterior Straumann implant.

Background
Following the surgical placement of a dental implant, there are several crucial factors that must be met to maximize healing and osseointegration of the implant body to bone. First, there should be minimal forces exerted on the implant body, permitting proper healing of the osseous complex and thereby preventing a nonosseous union.¹ Secondly, the gingival architecture must be meticulously managed in order to prevent contamination of the surgical site, minimizing the risk of peri-implantitis and possible failure.² Lastly, there must be sufficient time allowing for the process of osseointegration.³
The temporization of a dental implant in the anterior region is an essential procedure, restoring the aesthetic concerns for the patient. The important factors regarding the process of temporization include maintaining the gingival architecture and promoting gingival health.⁴ Violation of these factors could compromise the success of the implant surgery and restorative result.³
Several methods exist for the temporization of dental implants. The traditional technique involves fabricating a removable partial denture, or flipper, to replace the missing tooth. This technique is problematic, as the denture has to be properly fabricated to minimize forces on the healing cap and/or healing implant body. Other factors negating this procedure include the additional costs incurred from a temporary prosthesis, poor patient acceptance due to bulkiness and speech impediment issues, and the overall hygienic concerns of the denture.
Another technique for temporization consists of utilizing an abutment that is covered with a cylindrical acrylic material. After placement, the clinician prepares the abutment similar to that of a crown preparation using conventional dental drills. A temporary acrylic crown is then fabricated to fit over the shaped acrylic material. Next, the temporary crown is cemented onto the prepared acrylic abutment. This technique has several negative issues. The preparation of the plastic abutment can transfer micro-vibrations and heat to the implant body, possibly negatively affecting healing and inhibiting osseointegration. Intraoral preparation of the acrylic abutment contaminates the surgical field, increasing the possible risk of postsurgical infections. The procedure can be time consuming and unpredictable, as drilling the acrylic abutment causes melting of the material more then shaping. Lastly, the bonding of the temporary crown to the acrylic abutment is weak, with the frequency of bond failure being relatively high.

HEALING CAP AND TEMPOARY ABUTMENT COMBINED

Figure 1. Tempcap (Research Driven) a healing and temporization abutment combined.	Figure 2. Tempcap and Straumann dental implant combined.
Figure 3. Retentive pin projections.	Figure 4. Tempcap compatibility with existing instrumentation.

Figure 5. Temporized crown complex with Tempcap and Straumann implant.

The Tempcap is a healing cap and temporization abutment combined into one unit (Figure 1). It has an all-metal construction with a threaded section to permit threading into the implant body (Figure 2) and it contains 2 to 3 retentive pin projections (Figure 3). Tempcaps are available in different widths and heights, to correspond with implant body diameters and required thickness to preserve the gingival architecture, respectively. Tempcaps are compatible with existing instrumentation and do not require any special tools (Figure 4). The function of the Tempcap is to allow for optimal gingival healing, prevent contamination of the surgical field, minimize forces and microvibrations on the implant body, and facilitate the simple yet successful temporization of the dental implant (Figure 5).

Laboratory Procedure
The technique for temporization is simple and efficient and will be described regarding the temporization of tooth No. 11 (Figure 6). The Tempcap is placed into the implant body following surgery (Figure 7). The clinician then torques the Tempcap to recommended specifications (Figure 8). Impression sheaths (Figure 9) are then placed over the retentive pin projections (Figure 10) to prevent the temporary crown from being locked in. An automixed bis-acrylic provisional material (such as Integrity [DENTSPLY Caulk]) is then loaded into a prefabricated vinyl polysiloxane (VPS) temporization impression (it is assumed that the clinician has created a VPS template for temporization) (Figure 11). The VPS and dual-cured acrylic is placed over the Tempcap and held for 60 seconds (Figure 12). The VPS matrix is then removed. The temporary crown is then removed from the VPS matrix or off the Tempcap (Figure 13), and light-cured for 30 seconds. The temporary crown is then shaped and polished out of the oral cavity (Figure 14). Confirm the emergence profile, marginal fit, occlusion and aesthetics by simply seating it back on the Tempcap. Seating and removing the temporary crown can be performed repeatedly (Figure 15), due to the impression sheaths (Figure 16). Once the crown has been shaped and polished, cement the crown onto the Tempcap with any provisional cement (Figure 17). Ensure that the occlusion has been refined (Figure 18) and verify the aesthetics (Figure 19).

Figure 6. Master cast of implant placement at site No. 11.	Figure 7. Tempcap abutment on master cast at site No. 11.
Figure 8. Tempcap abutment tightened with torque wrench.	Figure 9. Impression sheaths.
Figure 10. Impression sheaths placed on the retentive pins.	Figure 11. Temporary matrix loaded with a bis-acrylic provisional material (Integrity [DENTSPLY Caulk]).
Figure 12. Provisional material and matrix placed over Tempcap.	Figure 13. Preliminary temporary crown on Tempcap.
Figure 14. Shaping and polishing of temporary crown.	Figure 15. Reseating the temporary on the Tempcap.
Figure 16. Impression sheaths imbedded in the temporary crown.	Figure 17. Application of temporary cement (Tempbond [Kerr]) into temporary crown.

CASE REPORT
Clinical Procedure
A 68-year-old healthy male had tooth No. 11 removed. A Straumann Standard Plus 4.8 mm wide neck, 12-mm length SLA implant was placed immediately into the extraction site (Figure 20). Surgical placement was not ideal, due to a protrusive angulation. Following surgery, a Tempcap abutment was utilized for temporization (Figure 21). Impression sheaths were placed over the retentive pin projections. A VPS matrix was loaded with a bis-acrylic provisional material (such as Integrity or Protemp Plus [3M ESPE]) and placed intraorally (Figure 22). The matrix was removed, and then the temporary crown was shaped and polished. Next the temporary crown was cemented onto the Tempcap using a provisional cement (Tempbond [Kerr]). Finally, the occlusion was checked and the patient was dismissed (Figure 23).
The patient returned for an unremarkable postoperative appointment one week after surgery. The patient then returned for a 10-week assessment. Clinical evaluation and radiographs confirmed osseointegration. The Tempcap and temporary crown were removed. Standard impression protocols were performed and a final PFM restoration was placed.

Figure 18. Occlusal view of temporary crown in position.	Figure 19. Polished temporary crown on Tempcap.
Figure 20. Postsurgical view of immediate implant placed at site No. 11.	Figure 21. Tempcap placed onto immediate implant.
Figure 22. Temporary matrix loaded with bis-acrylic composite provisional material (such as Integrity or Protemp Plus [3M ESPE]).	Figure 23. Final polished temporary crown on Tempcap.

The patient has been followed for 3 years without complications; there has been a minor reduction in crestal bone level noted.

DISCUSSION
The Tempcap abutment and technique for temporization has several advantages over traditional methods. The technique is simple and efficient, for both the clinician and patient, taking just a few minutes to perform the temporization process. The all-metal construction of the Tempcap optimizes gingival healing and sulcus formation around the implant neck. The technique allows for all shaping and polishing to be done outside of the patient’s mouth, thereby eliminating the transfer of microvibrations and heat to the implant body. Extraoral finishing also minimizes contamination of the surgical field, optimizing healing and surgical success. The impression sheaths allow the clinician the ability to remove and reseat the temporary crown onto the abutment repeatedly, allowing for optimal emergence profile, marginal fit occlusion and aesthetics. The retentive pin projections allow for ideal retention of the temporary crown to the abutment. The Tempcap and procedure are cost-effective, since the healing and temporization abutment are combined into one. The necessity of another removable prosthesis is also eliminated. Lastly, the Tempcap has a unique design feature: the retentive pin projections are held to the healing cap with an exact force. If the patient subjected the temporary crown to a force in excess of that of the pin strength, then the retentive pins would be the point of failure. This safeguard ensures that the Tempcap becomes the weakest link, thereby protecting the vital osseointegration union of the implant body to bone.²
The Tempcap has been utilized for the temporization of an anterior Straumann dental implant in both laboratory and clinical settings. The Tempcap has the capability to work with any dental implant system in any position of the mouth. Although the Tempcap has been utilized for temporization during the healing period, there is the potential for the Tempcap to be used as a final abutment. Of course, this application would require the Tempcap’s pin projection strengths be increased.
The Tempcap has undergone studies to assess its ability to work with CAD/CAM units. A recent investigation assessed the ability of an E4D (D4D Technologies) optical scanner to register the Tempcap. A CAD/CAM restoration was then designed using available software. A restoration was then milled on an E4D unit, in both IPS Empress (Ivoclar Vivadent) and IPS e.max (Ivoclar Vivadent). Results indicated that the Tempcap can be successfully scanned, prosthesis can be designed, and a resultant final pressed restoration can be milled. Currently, researchers are considering making the Tempcap out of an aesthetic material, such as lithium disilicate utilizing CAD/CAM technology. Laboratory and clinical studies are required to further these investigations.

CONCLUSION
The Tempcap and temporization technique allow for the simple and efficient postsurgical temporization of dental implants. Although presented as a temporization technique, the Tempcap has the potential to be used as an abutment with a final restoration. Preliminary investigations also suggest that the Tempcap can be used with CAD/CAM systems, allowing for convenient in-office laboratory procedures to be performed. These advances simplify the procedure and reduce the cost, ultimately allowing a greater accessibility for both patients and clinicians.

References

1. Mijiritsky E, Mardinger O, Mazor Z, et al. Immediate provisionalization of single-tooth implants in fresh-extraction sites at the maxillary esthetic zone: up to 6 years of follow-up. Implant Dent. 2009;18:326-333.
2. Mijiritsky E. Plastic temporary abutments with provisional restorations in immediate loading procedures: a clinical report. Implant Dent. 2006;15:236-240.
3. Romanos GE. Bone quality and the immediate loading of implants—critical aspects based on literature, research, and clinical experience. Implant Dent. 2009;18:203-209.
4. Vela-Nebot X, Rodríguez-Ciurana X, Rodado-Alonso C, et al. Benefits of an implant platform modification technique to reduce crestal bone resorption. Implant Dent. 2006;15:313-320.

Dr. Kalman is a Master of the International Congress of Oral Implantologists. He is a full-time assistant professor at the Schulich School of Dentistry, University of Western Ontario. He can be reached at (519) 661-2111 ext 86097, at kalmanz@rogers.com or at researchdriven.ca.

Disclosure: Dr. Kalman is the co-inventor of the Tempcap and owner of the intellectual property.