Esthetics Through Provisional Restoration of Implants
Harold S. Baumgarten, DMD; Howard P. Fraiman, DMD; and Stephen J. Chu, DMD, MSD, CDT
Q: Is the provisional restoration of implants in the estheticzone advantageous?
Harold S. Baumgarten, DMD
Clinical Professor, Periodontal Prosthesis, Postdoctoral Program, Department of Periodontics, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania; Private Practice, Philadelphia, Pennsylvania
A provisional restoration provides esthetics, maintains masticatory ability, and preserves space. Different provisional restorations can provide these functions. However, patient preference and the patient’s esthetic zone can influence the clinician’s choice of provisional restoration. The location of the esthetic zone varies for each patient. In many patients, the esthetic zone is limited to the display of the incisal third or half of the anterior teeth, making any of the possible provisional restorations sufficient for providing the desired functionality. However, the patient’s preference for a fixed or removable restoration will ultimately dictate the clinician’s course. If the esthetic zone involves any gingival display, placing a provisional restoration on the implant is not only advantageous, but also mandatory for achieving a final esthetic result.
A number of scenarios can present themselves when an implant needs to be placed in the esthetic zone. The first, and one that has the potential for esthetic success, is immediate implant placement in an extraction socket coupled with immediate provisionalization. The provisional restoration seals the socket and provides protection for the blood clot around the implant, while also supporting the labial gingival margin and interdental papilla. The goal is to maintain the gingival architecture noted upon patient presentation. Once this architecture is lost, reestablishing it can be quite difficult.
The second scenario is placement of an implant in a healed ridge, and a third scenario is exposure of an implant when the implant is placed using a two-staged approach. In both situations, we are starting with a flat, healed gingival architecture. An esthetic scalloped gingival architecture must be created. A provisional restoration placed on the implant during surgery provides the contour around which the tissue can heal. Slight changes in contour can have a major impact on the location of the labial gingival margin and the shape and peak of the interdental papilla. Merely placing a healing abutment at the time of implant exposure removes that element of control the clinician needs to maximize the esthetic result.
Fabricating a provisional restoration on an implant in an esthetic zone that involves gingival display can be a demanding procedure. Providing an esthetic final result is key.
Howard P. Fraiman, DMD
Cliincal Associate Professor, Periodontal-Prosthesis, Department of Periodontics, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania; Private Practice, Philadelphia, Pennsylvania
Replacing a missing tooth in the esthetic zone is performed for esthetics, not function. Surely, an individual can survive with a missing tooth or even several missing teeth in the esthetic zone. Although the patient may not be able to incise every food type, enough variety is available that a person could conceivably obtain adequate nutrition and lead a healthy lifestyle.
If esthetics is the main reason for tooth replacement, then everything should be done to optimize the result of replacing the missing tooth. Several therapies exist for replacing a missing tooth: removable prosthetic, traditional fixed bridge, resin-bonded bridge, and dental implant. Each choice presents its own techniques for creating the restoration and achieving optimal success. When choosing the dental implant for replacing a missing tooth, provisionalizing the implant at the time of placement becomes paramount to achieving esthetic success.
Placing an implant can be structured in one of two ways. One is the delayed approach, when a tooth has been extracted and a healed alveolar ridge is present. The second method is a tooth extraction followed by implant placement in the fresh extraction site. In both situations, provisionalizing the implant becomes key to esthetic success. The preference is extracting a tooth, placing an implant, and provisionalizing.
The key to success in the esthetic zone is not only having an integrated implant but also replicating the appearance of the gingiva around the implant to match what it would look like around a natural tooth. This can be accomplished by reconstructing the gingival architecture following a period when a tooth is missing and not replaced, but an easier goal is preserving the gingival architecture at the time of extraction. When placing an implant after a tooth has been missing for some time, the goal is to reconstruct the essentials of the gingival architecture form, which include the illusion of a papilla, scalloped gingival form, and the prosthetic tooth emerging from the gingiva. Achieving this can be accomplished by provisionalizing the implant and allowing the gingiva to heal around the provisional. Thus, the essentials of gingival form are maintained.
If reconstructing the gingival form becomes critical for esthetic success while using the delayed approach, then during the immediate approach, it makes sense to preserve the gingival form at the time of extraction and implant placement. Placing a provisional at the time of implant placement when performing the immediate approach allows the gingival apparatus to heal around the provisional. The difference is the healing process. In the immediate approach, the provisional supporting the existing gingival architecture is key, enabling for the optimal esthetic result rather than having to later reconstruct the gingival architecture. If the implant is placed and later provisionalized, this then becomes similar to placing an implant in a healed ridge and means the gingival architecture needs to be reconstructed. Preservation of the gingival architecture is much more achievable than reconstruction in terms of achieving the optimal esthetic result. Provisionalization of an implant as early as possible is not only advantageous but also critical to esthetic success.
Stephen J. Chu, DMD, MSD, CDT
Adjunct Clinical Professor, Department of Prosthodontics, New York University College of Dentistry, New York, New York
Immediate tooth replacement with an implant placed into an anterior extraction socket benefits the patient because the provisional restoration provides immediate esthetic restitution. The hopeless tooth is removed and instantaneously replaced with an implant and screw- or cement-retained temporary crown. Also, the efficiency it provides helps the clinician; the same number of clinical procedures is condensed into fewer patient appointments, thereby streamlining the overall treatment time.1-4
The dental literature has shown that the survival rates for such procedures are about 96% and are comparable with delayed implant placement in healed or augmented edentulous sites.5,6 The key is esthetic outcomes and collapse of the thin labial bone plate with associated midfacial recession.
Clinical research has shown implant position and diameter are critical for providing gap distance, which leads to the potential for new labial plate formation.7,8 The thin labial bone plate will remodel after tooth removal; however, new bone can develop through blood-clot formation between the implant surface and residual labial plate.9
The use of hard-tissue graft materials is beneficial to maintain or minimize ridge dimensional change (<0.5 mm) because these products act as scaffolding to maintain the blood-clot effect during healing. The question that remains is determining the most appropriate graft material to best achieve such outcomes.
In regard to increasing peri-implant soft-tissue thickness, extending the graft material into the soft-tissue area or zone above the implant-abutment connection can be equally effective as placing a soft-tissue graft, either autogenous or allograft, in that zone. A horizontal gain of about 1.0 mm in soft-tissue thickness can be achieved with such techniques.10,11 The risk is soft-tissue graft failure (20%) or irritation with a hard-tissue graft (HTG). The type and particle size of the HTG is important for helping the clinician to avoid such issues.
The prosthetic value and role of the provisional restoration in the aforementioned techniques are graft containment and protection throughout healing. The provisional restoration acts as a physical and biologic seal if cleaned or disinfected prior to placement. The same results can be achieved with the fabrication of a custom healing abutment, which is essentially the provisional restoration without the coronal clinical crown. A tooth-supported transitional restoration such as an Essix or resin-bonded retainer should be used for tooth replacement to avoid unnecessary occlusal loading of the implant.
The use and fabrication of a provisional restoration immediately following tooth extraction and immediate implant placement is of great value and benefit to the patient and clinician, respectively, because it provides: 1) instantaneous tooth replacement for cosmetics and speech, and 2) hard-tissue graft containment and protection for maintenance, soft-tissue gain, and preservation of the periodontal architecture for, ultimately, esthetics.
1. Wöhrle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: fourteen consecutive case reports. Pract Periodontics Aesthet Dent. 1998;10(9):1107-1114; quiz 1116.
2. Kan JY, Rungcharassaeng K, Lozada J. Immediate placement and provisionalization of maxillary anterior single implants: 1-year prospective study. Int J Oral Maxillofac Implants. 2003;18(1):31-39.
3. De Rouck T, Collys K, Wyn I, Cosyn J. Instant provisionalization of immediate single-tooth implants is essential to optimize esthetic treatment outcome. Clin Oral Implants Res. 2009;20(6):566-570.
4. Tortamano P, Camargo LO, Bello-Silva MS, Kanashiro LH. Immediate implant placement and restoration in the esthetic zone: a prospective study with 18 months of follow-up. Int J Oral Maxillofac Implants. 2010;25(2):345-350.
5. Block MS, Mercante DE, Lirette D, et al. Prospective evaluation of immediate and delayed provisional single tooth restorations. J Oral Maxillofac Surg. 2009;67(11 suppl):89-107.
6. Cooper LF, Raes F, Reside GJ, et al. Comparison of radiographic and clinical outcomes following immediate provisionalization of single-tooth dental implants placed in healed alveolar ridges and extraction sockets. Int J Oral Maxillofac Implants. 2010;25(6):1222-1232.
7. Caneva M, Salata LA, de Souza SS, et al. Influence of implant positioning in extraction sockets on osseointegration: histomorphometric analyses in dogs. Clin Oral Implants Res. 2010;21(1):43-49.
8. Caneva M, Salata LA, de Souza SS, et al. Hard tissue formation adjacent to implants of various size and configuration immediately placed into extraction sockets: an experimental study in dogs. Clin Oral Implants Res. 2010;21(9):885-890.
9. Tarnow DP, Chu SJ. Human histologic verification of osseointegration of an immediate implant placed into a fresh extraction socket with excessive gap distance without primary flap closure, graft, or membrane: a case report. Int J Periodontics Restorative Dent. 2011;31(5):515-521.
10. Chu SJ, Salama MA, Garber DA, et al. Flapless postextraction socket implant placement: part 2. The effect of bone grafting and/or provisional restoration on peri-implant mucosal tissue height and thickness–a retrospective study. Int J Periodontics Restorative Dent. 2015;35(6):1-10.
11. Rungcharassaeng, K, Kan JY, Yoshino S, et al. Immediate implant placement and provisionalization with and without a connective tissue graft: an analysis of facial gingival tissue thickness. Int J Periodontics Restorative Dent. 2012;32(6):657-663.