Keep it Local

ALTERNATIVE OPTIONS FOR PROVISIONAL PROSTHESES

By: Michael Steffen, DMD; David Wong, DDS; Terry Philbin, DDS Immediate dental implants have become an attractive alternative to conventional implants. While there are many advantages of immediate implants, there are situations where the extraction site does not possess adequate bone or soft tissue thickness to support an implant immediately. In these situations repair of the volumetric defect is required for a more ideal implant placement. When immediate loading is not possible provisionalization of the implant area becomes very important and can be challenging (for example, when a patient is informed of the prospect of wearing a provisional removable prosthesis). It is important that the hard and soft tissues of the implant area drive the entire treatment process rather than just the provisional restoration. In cases, where significant ridge augmentation is required to place and support implants, it is imperative that the provisional restoration not impinge on the bone graft and compromise its stability. In such situations where immediate implantation is not advisable, the soft and hard tissues are best supported by a provisional resin-bonded bridge. A custom-fabricated healing abutment may also be delivered once the implant is placed in order to help guide the soft tissue and assist in shaping the emergence profile of the prosthesis. When determining if an immediate provisional should be considered, the primary stability of the implant is often assessed with either a torque test or an implant stability quotient (ISQ). When primary stability is inadequate, a custom healing abutment may be placed instead of a provisional restoration until the implant has properly healed. The following cases illustrate the use of provisionalization when immediate implants are not advised:

CASE #1: EXTRACTION AND RESTORATION OF COMPROMISED ANTERIOR LEFT CENTRAL AND LATERAL INCISORS (#9 AND #10).

To allow the area to heal without immediate loading, provisionalization was achieved with a Maryland bridge. After an adequate period of healing, the Maryland bridge was removed, the implant and custom abutment were placed, and the Maryland bridge reattached until full stability of the implant was achieved.

Case 1: Figure 1 – Endodontically failing teeth #9-10 Case 1: Figure 2 – Maryland bridge placed after surgery Case 1: Figure 3 – Maryland bridge reattached with custom healing abutment

CASE #2: REPLACEMENT OF MULTIPLE TEETH IN THE ANTERIOR ESTHETIC ZONE LOST DUE TO FAILING ENDODONTIC TREATMENT AND PERIODONTAL DISEASE.

Planned final treatment involved an implant-supported six-unit fixed bridge spanning from #6 to #11. Because of the need for ridge augmentation, immediate implant placement was contraindicated. Provisionalization with a temporary fixed bridge provided somewhat pleasing and functional esthetics without unduly compressing the delicate post-surgical bone grafting sites. Since the space will shrink as the site heals, a second provisional bridge may be indicated following placement of the implants.

CASE #3: EXTRACTION AND IMPLANT RESTORATION OF MAXILLARY LEFT FIRST MOLAR (#14).

In the first two cases, the focus was on balancing the patient’s desire for functionality while restoring both the hard and soft tissues for an ideal final prosthesis. In this case, since primary stability of the implant could not be immediately achieved the Anatotemp SC system, which combines both a prefabricated anatomic healing abutment and a digital impression body, was used. With such a system, several appointments can be saved; once the implant is placed and the healing cap attached it can be scanned all in one appointment. There is no need to remove the healing abutment and place an impression post or scan body once the implant is integrated. This can also be done at the implant surgeon’s office as well, saving several appointments at the restorative dentist’s office.

This article is not meant to discourage immediate-load implant placement. There are many advantages to such an approach. However, when immediate implants are contraindicated because of a lack of adequate implant support, long-term structural changes as healing occurs, a need to repair volumetric defects, etc., some of the provisionalization approaches discussed in this article should be considered.

Case 3 Figure 1 – Anatotemp SC healing abutment and digital impression body in place for implant #14 Case 3 Figure 2 – Final implant-supported prosthesis #14

OKLAHOMA HEALTH PROFESSIONALS PROGRAM

Since 1983, the Oklahoma Health Professionals Program (OHPP) has provided services to over 1,000 physicians and health care providers with alcohol and chemical dependence. OHPP is an outreach program designed to support and monitor medical and allied health professionals throughout Oklahoma who are experiencing difficulty with substance abuse. Grateful acknowledgement is extended to Terry Philbin, DDS for his contributions to this article.

ABOUT THE AUTHORS:

Michael R. Steffen, DMD is a 1985 graduate of the Washington University School of Dental Medicine in St. Louis, and currently maintains a private practice (Steffen Dental) in midtown Tulsa. He is a member of the American Dental Association, the Oklahoma Dental Association, the American Academy of Implant Dentistry, and the American Academy of Cosmetic Dentistry. David H. Wong, DDS is a 2000 graduate of the University of Oklahoma College of Dentistry, Following graduation he completed is a three-year residency in periodontics at the University of Missouri-Kansas City. He is a Diplomate of the American Board of Periodontology and a Fellow in the International Congress of Oral Implantologists. A published author in several peer-reviewed dental journals, he has also reached a mainstream audience in media such as Fox News and the Wall Street Journal. Wong resides in Tulsa with his wife Jennifer and their three children where he also maintains a full-time practice (Route 66 Dental Implants).

The OHPP continues to be a leader nationally in identifying problems, assisting in treatment, and returning to practice health care professionals who have suffered from substance abuse or dependency. OHPP services are confidential and include expert consultation and intervention designed to encourage health care professionals to seek help for substance abuse and behavioral concerns.

When an individual contacts the OHPP about a health care professional or about himself or herself, the director or designated associate director assesses the situation and assists in guiding the health care professional. Participation with OHPP is voluntary and confidential. OHPP will strongly urge a professional who is ill to get help, and although OHPP does not provide direct treatment, we will suggest specific treatment options. We respond to the concerns of families, colleagues, and hospitals by providing coordinated interventions and referrals to treatment.

In addition, OHPP hosts a number of support group meetings open to all health care professionals, students, residents in recovery as well as those seeking peer support.

OHPP recognizes the difficulty of reporting a colleague who may be impaired. Because of the potential risk to patient care, OHPP encourages medical professionals to make referrals if a problem exists, no matter how long there has been a problem.