Running Time: 58 min
Release Date: August 16, 2013Subtitle:
So hello, and welcome to our fifth section on Dental Implants A to Z making the correct provisional. How do we manage the patient during the time of implant healing, soft tissue development? This to me is one of the most important things and often neglected part of implant dentistry. With regular conventional dentistry, there’s always some sort of an acrylic provisional thrown in on top of the natural tooth. This requires a lot of thinking, a lot of planning. And the reality is a lot of expense. There’s a lot of issues that we need to address to get the great outcome that we’re looking for. So what are the value of provisionals? Really the use of a correct provisional allows the patient to reasonably maintain their normal life. And that’s my goal for the patient, for me to take care of them while they’re healing while this treatment is progressing. We hear too many times like the radio, teeth in an hour, and that’s a wonderful thing to do. But very few patients can really have that. So we need a way to manage the patient as they are correcting some really large defects another issue that might be going on in their mouth. So we want the provisional to allow healing to occur in the most beneficial and healthy way. Many cases need more than one provisional to successfully maintaining the patient during this healing phase. So we need to plan for them. The costs are significant. We want the patient to understand why we’re doing these things. The more they understand the value, the reasons why we’re doing these things, whether it’s just to shape the tissue, whether to give them the ability to chew and talk and lead a normal life, I believe patient’s acceptance and appreciation of the treatment goes up. So what are the options? Just a list, and then we’ll go through very exactly. We can do removable partial dentures, Essix temporaries which is one of my favorites nowadays, direct bonding, Maryland bridges, temporary bridges, orthodontic brackets, transitional mini implants, fixed implant supported provisionals. All these things really take care of the patient during the healing phase. But the fixed implant supported provisional is really what we think about a lot of times to allow development of the soft issue, evaluate patient acceptance of the final treatment that we’re doing for them, and to manage the patient as other work is going on. The treatment partial, maybe it’s the most standard way to manage the missing tooth, we don’t want to prep these virgin adjacent teeth, so we make a treatment partial. It may be the worst provisional that we can use once the implant is placed or a bone graft is placed because of the pressure it could put on the soft tissue and the implant beneath it. But they are useful. They also allow kind of an evaluation of the patient, the final outcome, by removing acrylic surrounding that denture tooth, putting it in the mouth, and letting the patient see what’s going on. They’ll identify the defect of the soft tissue and they might start to understand the challenge that they face in terms of reconstruction, which is more than just giving them a tooth. An Essix temporary is really to me a surprise in how accepted it is by patients. They’re used to seeing people doing Invisaline or something else and having something over their teeth. They slip this in and immediately they have what looks like teeth. We use them for one or maybe two teeth in the anterior segment. And they really do work well and have a much higher patient acceptance rate than I normally would expect. Years ago it was fairly standard for us to bond. And here’s a denture tooth bonded between two porcelain crowns. This takes a lot of patient time, chair time. It takes a lot of revisiting of the issue. If the surgeon needs to do something and I have to remove the bonded provisional, that’s an issue. Every time it’s removed you have to be so careful not to remove porcelain or enamel on adjacent teeth, effectively broadening the space of the final restoration. So this is not one of our favorite restorations now from a really restorative point of view. But from a biologic point of view, the fact that you could make a provisional that doesn’t press on the tissue does have its advantages. I’ve heard of Maryland bridges being used for provisionals. Personally, I have never used them. We have used orthodontic brackets. Here’s a treatment partial where the whole palatal was cut away. The orthodontist placed some brackets on the treatment partial and it was put on to the arch wire. So a nice way to manage a little bit larger case. I’ve never done this intentionally. It was always in cohorts with doing orthodontic treatment. Many times, especially for redoing an adjacent crown, we’ll use that natural tooth to support a cantilever pontic or a three unit bridge whatever we need to do to give a good provisional. And I think this is a very good provisional. I have considered prepping teeth sometimes just to make a support to a provisional restoration. I can’t say that I’ve done it, but there are cases the only way to provisionalize that patient is maybe to use the natural teeth. And it would add cost to the patient, of course, but it might be the best way to manage a case. Here’s the use of a transitional or mini implant to support a small anterior bridge. This is so challenging, I think, from a surgical point of view placing that transitional implant, which might affect the bones surrounding our implants, if they have a problem they lose bone. They might transition to the good implants next to it. How much bone do we have? Do we have room for this? Boy, this is not my favorite way to manage it, but we have used it and we have used it well. And that brings us really to the fixed implant supported provisional and why we might use them. The primary uses, I think, are for patient management issues. We can show the patient what the final restoration may look like. They don’t have to wear anything removable. They can have a tooth almost immediately sometimes. We can protect the healing side all those issues, we can allow the tissue to grow more ideally. If we don’t have a good situation, we can experiment maybe with this implant supported provisional trying to find what does work for the patient and find what they’ll accept. But that’s a lot of time and a lot of cost involved in doing that. But we might realize that we really can’t restore a case with using a provisional appropriately with the way the implant was placed. Whether we do delayed or immediate implant support provisionals, there’s a lot of different options. Some things are designed just for the immediate provisional some are final abutments that we use for the provisional. So there’s a lot of options, and we’ll try to go through some of them. So when do we time this implant supported provisional? We can do it at the time of the first surgery. We can take the impression on that day and essentially inserted that provisional within an hour. I mean, we can make an immediate provisional, that’s not an issue. We also might take the impression on the day that the implant is placed but delay the placement of that provisional for months or weeks, whatever we choose to do. So taking an impression early and being ready with the provisional certainly has its advantages. If it’s a two stage procedure and the surgeon has to open the case up to take an impression or allow us to have access to the implant, we could take an impression on that day. That’s very reasonable. I don’t necessarily try to make the provisional while the patient’s waiting. There are reasons, in fact, even to wait maybe a week or two to allow primary healing of the soft tissue around the healing abutment before we place our provisional. After the tissue has healed around the healing abutment really the question we need to ask is, do we still need an implant supported provisional? The value might be, as I said, to gain patient approval before finishing, to allow further healing of the soft tissue, pushing, moving the tissue, considering grafting, whatever we might need to do. So those secondary surgical procedures may be appropriate. And really to evaluate a questionable implant, you just don’t think something is right. So we put on his implant supported provisional and wait a while to make sure the implant is indeed stable before we do the final restoration. The contraindications for doing an immediately loaded restorations are significant though and we have to respect. We don’t always try to do an immediate provisional. Now, I said immediate loading here, but that’s not our goal to load a provisional immediately. But let’s face it, there is some loading that occurs. We need a certain level of stability of the implant so the report from the surgeon has to be that the implant was placed with at least that 35 to 45 newton centimeters of stability. We should have patients that don’t have a heavy parafunctional habit, they have guidance on adjacent teeth not right on top of our implant crown. So at least minimize centric and excentric contacts. We need a patient that is compliant. So the non-compliant patient is a reason not to do an immediate provisional. And really what is the reason we should do an immediately finished, immediately loaded provisional in the non aesthetic zone? And the only reason would be a full arch where we end up doing it there. So the question I’d like to ask is, can we always provisionalize? We saw earlier in this course this case where we had the situation where the surgeon, in fact Dr. Jovanovic, needed to do a very large bone graft, needed to advance the buckle flap, lots of sutures, lots of tissue. How can we put a provisional in there? Originally, this case had a bonded pontic. If we tried to bond that pontic back in place, it’s going to put pressure on this new tissue as it swells over the next 24 hours where we will lose tissue. And we don’t want that to happen. So we will not bond a pontic back in there. A treatment partial for me would really be the worst thing we could possibly do and have even worse outcome than bonding a pontic. And so the only thing I really might consider is the Essix with a great deal of adjustment to keep the pressure completely away from this new tissue. In this case, you’ll remember, the patient went with nothing. So there are times you involve the patient in the treatment, they understand the value of not putting pressure on the surgical site immediately, and you’ll be surprised who really manages it. So for us, a provisional prostheses should be strong, durable, and last throughout the duration of their treatment phase. A provisional should allow or even promote the healing of the bone and soft tissue and not negatively effect the adjacent teeth. So let’s go through these provisionals as we might use them. So the removable partial denture, I can tell you I rarely use them today. But there are times when you don’t have a choice. If I have the whole six through 11, how else am I going to keep teeth for the patient? But I’m going to be very careful and very good with my instructions to the patient how they can use this. If they’re pressing it into the tissue, if they’re causing ulcerations and irritations, we’ll have problems. There have been cases in the past where we’ve needed to do a cast partial denture. We needed to strengthen the support that came from a casting. We planned for the bone grafting. But, of course, it’s a much more expensive provisional to do for the patient. In terms of removable appliances, the Essix splint is probably our number one go to provisional. Now, there’s different types of removable treatment partial. Here the tooth is removed, an implant was placed immediately. And so just instead of making a directly connected provisional, we made the treatment partial just fit over the top of it. You are still loading that implant though. So we need to be very careful about that. To make it look good, it will load the implant. So I won’t do this on a case where I don’t get a good report back from the surgeon that says they have at least that 35 to 45 newton centimeters of stability. You know, personally I’ve never tried to make the pontic of a removable device fit into an extraction site to maintain the contour. But here’s an example of that. And if the patient is really compliant and keeps the treatment partial in place, there is the possibility of developing somewhat of an ovate pontic because of that. The Essix provisional for us is for short or long term. I’m surprised at the patient compliance. We do need in terms of just practicality of making this device to create some mechanical retention of the pontic. It can be multiple teeth, but we haven’t done one really for more than two anterior teeth. We have used existing fractured clinical crown, and I’ll show you an example of that. We can premake pontics extraorally on the model or intraorally. We can premake extra pontics and the suck downs just in case the patient loses one. So if they’re off somewhere, they have that kind of a comfort zone of having something to fall back to. And we can actually adapt this. Maybe we go into a case where we’re hoping to do an implant supported provisional so we’ll have the Essix ready. And we can use that same pontic to make the implant supported provisional if it works out that way. So basically, we’re looking to make a pontic of this sort. So here’s an example of a case. And even if you’re not ready to do the implant supported case, if you’re not ready to place the implant, you’ve got a patient that just broke their tooth off subgingivally. They’re stressed out, they’re unhappy. So we can take an impression, maybe we can place that crown back into the mouth and take an alginate of it directly right there. In this case, we picked up the pontic or the broken tooth right into the alginate impression, poured a stone model. We thought we’d make a separate pontic, but we don’t really need to. We put the crown right back on the model, a little Vaseline on the model. We use the Essix material, the medium strength, sucked it down on top. And you notice on the lingual side, the pallatal side of the crown, we made a little groove. We even removed a little bit of the porcelain so that we could achieve a bit of retention. We want the sucked down material to go into that crown to hold it in place. Otherwise, they tend to pop out. So we went ahead and did a suck down. And my only other little point that you might do is don’t let the material sag too far as it’s heating. Really about a half an inch is about all you need before you go ahead and suck it down, or you’ll end up with little flaps of material that is harder to make comfortable for the patient. And so this really effectively picked up their own tooth, their porcelain crown, so the patient was very satisfied with how it looked. This is at about four months into it. And a little staining occurred. I could take it out and clean it. But this is reasonable, and the patient was very satisfied. Here’s an example of doing it really extraorally where we made an impression of the tooth was still in place. We were going to remove this tooth later. We did a suck down. After on the model, we trimmed a little groove on the pallatal side of the crown. The suck down picked that up. I prepped the tooth that was going to be extracted to leave a kind of a center core open so that we could convert this into an implant supported pontic if we chose to do that. The suck down fits over it. We can evaluate that we have enough thickness for acrylic. We used our jet acrylic, our pressure pot. We did a couple layers of acrylic. In between those layers, to cut it back and do some grooves into the bottom layer of acrylic, add a lighter incisal. And you can really make a pontic that looks quite nice. It looks very aesthetic. And if I choose to use this for my implant supported provisional, I have an opening inside that makes it a little easier to transfer. This little trough on the pallatal side helps stabilize the pontic in place as the patient takes it in and out. If I choose to use this purely as an Essix, I’ll just quickly filled us with some more acrylic or composite, clean it off, and off the patient goes. So how about fixed provisional cement retained. And we will revisit here for a second some of the issues that we see with cementation, with excess acrylic. I really believe strongly that we trust that common sense inside of us. And I’ve been told techniques and I’ve seen techniques and that little voice inside me says, jeez, this just can’t work. It’s got issues. And sooner or later those issues are of paramount importance to us. And so we look at the case here with a nice custom CAD/CAM kind of abutment so the margin follows the tissue very nicely, nicely scalloped. And we can get a very good result. But if we have issues, if the abutment or the topography doesn’t follow, if we’re going to have to cement significantly subgingivally like maybe with a solid abutment. Someone says, oh yeah, just use that for your provisional abutment. But look how far subgingivally we may be cementing, that is an issue. And we have problems, I think, that we have to respect. Different anatomy, certainly this flat case, much more predictable, easier to clean interproximally than this case with this big scallop. Without a scalloped margin, we’re going to have a difficult time cleaning the cement. These are, I think, the worst scenario. The implant was placed, everything went wonderfully, we put some sort of provisional in place. And then, there’s the surgeon calls or you call the surgeon with hey, there’s a big abscess here. And we realize that cement was pushed not only down on to the abutment but maybe even to that space between the implant and the unhealed extraction site. So this is a really horrible outcome. Retaining cement is a problem when we can’t clean it. Here’s just an example of a labial extension to the crown and the cement margin is not so deep as it is laterally placed very difficult to remove the cement. Another just abscess formation from a cement retention. Keeping cement subgingivally can lead to significant bone loss. We can’t afford that. And another thing I’d like to point out, because I don’t know how many times I’ve seen techniques where you just fill the polycarbonate crown with some acrylic and just shove it right on that temporary abutment in the mouth. Well, this is an example of shoving the acrylic a little too far. We see the acrylic wrapping through the Bio-Oss and down into the threads. I can’t really imagine trying to explain to a patient why they had to have their implant removed. This make sense if we’re shoving acrylic subgingivally if we’re shoving cement subgingivally on an immediate case where we have gaps between the implants and the bone this is going to happen. So let’s go back to the more reasonable situations. Can we use a solid 360 degree margin Snappy Abutment for a provisional? Well, here the tissue’s healed pretty nicely. We’re not trying to do maybe an immediate provisional, but we get to a point where we want to evaluate the aesthetics. We do need to be sure that the acrylic does bond well to the little cap or coping that goes over the top of the abutment for the provisional. We can do an intraorally if maybe the tissue’s healed and everything is fine. And we’ll make a provisional. Here we didn’t try to shove the acrylic subgingivally, and we’ll fill that gap extraorally, polish it, use a minimal amount of cement, and put in place and allow the patient to evaluate the aesthetics and drama of what we’ve accomplished. So we’ve talked about cement retained provisionals. The impression time can be at the first surgery at uncovery after healing around the healing abutment. So we will use, I hope, an impression coping to take a good impression. Here we’re fabricating CAD/CAM abutments that we use for the final crown. And at this point, I think it’s very important that you talk to the laboratory and tell them you don’t want these margins placed subgingivally. They really should be right at the tissue margin. You allow the patient to wear they’re provisional for maybe the next six months, at least four months. If the tissue retracts a little bit, you can always just prep the margin a little bit before you make your final crown. If you start off with those margins significantly subgingival, where do you go from there? You’d have to make a new abutment which can become quite expensive. So the final provisional crowns are placed. We allow the tissue to develop and finalize. And as long as we’re not more than about a half a millimeter subgingivally, we can use these abutments to do our final crowns. If they are supragingival and you don’t want that, you prep them a little bit right down to the tissue and we’re perfect. There is immediate temporary abutments from Nobel Biocare. I’m very careful with how I use these. Their has a certain 360 degree height and a plastic coping that goes around it. If I’m going to use this, to be honest, I never use cement. We go ahead and adapt the crown to them after the abutment is placed, we get the acrylic around that kind of plastic cylinder. Try not to shove acrylic intraorally. You can see why I don’t really like this. And then just the friction of the plastic coping on the abutment is all I use. I’m not going to try to cement this subgingivally, whether it’s an anterior tooth or a posterior tooth. Some people ask about vent holes for cement. And especially a hole of this size, such a small amount of cement is going to go out of that, I really don’t think it’s going to save you from any problems. So I don’t get too excited about that. They can also be used posterialy and even be screw retained usually though cemented. And this case, of course, is cemented. We could use multi unit abutments and make a screw retained three unit bridge. But here we’re just using these provisional posterior abutments and cementing a bridge. But I don’t like to cement subgingval with this type of abutment. Now, you don’t see as much anymore, but this is an interesting device that Nobel Biocare had from their Procera Ethetic Abutment Kits, where there was a series of abutments ready to go that you would try in and pick and then select according to which one would be perfect for any given patient. Then we would go ahead and place them intraorally. After the implant was placed, maybe use a Sharpie or a indelible pen, mark them where we want to adjust it. Take it back out of the mouth, there was a little handle to hold. It you would prep it and go through until you had the correct anatomy to cement the crown. And what I like about this case, you notice the margins aren’t shoved way subgingivally? Why do that at this point? There’s no reason. And then a very careful fabrication of the crown is made. After the tissue is healed, this is a beautiful case because we have excess tissue. We can even choose to push the margin a little bit more and create a better aesthetic result of the adjacent tooth. Now let’s talk about screw retained fixed provisionals. Here’s an example of a case, and I really like this case because we’re not trying to be perfect aesthetically. We’re using the provisional to allow the maximum development of the tissue surrounding the screw retained provisional. I like screw retained provisionals because I can push the tissue if I choose to do it. It’s very easy to under contour them, then take them out of the mouth, add more acrylic, put them back in as I need. So I can get it just the way I want. I don’t have to worry about where that cement line might be. I don’t have to worry that the clinical provisional crown is going to fall off the abutment. So it works very well. And I’ll be able to adapt them as I need to. To do that there’s a number of different cylinders. It’s really based on which abutment I have. I’ll choose the cylinder that matches my individual implant. And we can do that for a bridge. There’s an non-engaging version for a single tooth, there’s an engaging version. So, of course, I’ll choose the engaging version for any single teeth and for whatever implant that I’m using. We have plastic, we have titanium. I like the plastic better for ease of use. But for being biologically compatible, probably the titanium ones are better. And I will choose them first just for that reason, especially on immediate placement cases. So let’s go through an older case, but I think really one that demonstrates the ways that we can not only manipulate the soft tissue emergence profile, give the biology the opportunity to do its best, and then record the shape of that provisional to make the final impression and final crown. So here we see a case with a bonded provisional. This happens to be the daughter of a friend of mine, a periodontist. He placed the implant for us or actually on his own. And then someone else bonded this provisional in place. And then asked me to restore it. One thing I notice right at the beginning of this was that the healing abutment was a little bit loose. And we saw some granulation tissue, a little irritation there. And so the question always is should we remove that? And I have a very conservative point of view. I just want to make sure the healing abutment is tight whenever I’m done. And then hopefully the tissue resolves on its own. You can see in this case it didn’t. So this case has been sitting here for really months healing around the healing abutment. We had to remove the bonded pontic, clean up the enamel really carefully on the adjacent teeth, and we’re going to take an impression of the implant position. We’ll take that impression just with any closed tray impression coping that works with that implant. As always, we’re going to make sure it doesn’t touch the adjacent teeth and it’s dry before we take our impression. We can then pour a very accurate model, and we can work with the lab to achieve a provisional that would be maybe the best, most aesthetic one, but then we have to adapt that. And by that I mean we’re going to look at the shape of it. We don’t want to push too far mesiodistally pushing the tissue. So we lose the potential to grow an interproximal papilla. We also don’t want to push too hard labially, so again we would lose tissue apically. So here’s our case. We’ll go ahead and remove that healing abutment. And then we’re going to seat our provisional. Now just for those of you that are used to seeing our provisionals, you can tell that the healing abutment or the implant itself was a bit more apical than we normally would like. This is more like 3 and 1/2 millimeters. So we’d want to be extra careful on this case not to over push the tissue, because we don’t have the bony support we usually like to have to maintain that issue. As we seat the provisional, you notice we didn’t try to fill the interproximal voids. If we fill them now, we don’t give the patient the biology, the opportunity to grow the tissue. What defines the height of that tissue? The height of the bone on the adjacent natural teeth. And if we measure the bone, really we have a very good opportunity to fill these sites. The bone is really within five millimeters or so of this desired contact area. But we see this ischemia as we see the crown. And we realize we’re probably pushing too hard buckily, labially. We’re going to cause some tissue loss if we maintain this. So we took the provisional back out of the mouth, and we went ahead and we looked at the contour and we decided to under contour it a bit more in that area. So just quickly remove some of the acrylic and reduce that labial contour. We seated the crown. Notice we didn’t have a lot of ischemia in the area. So we’re going to give that tissue the opportunity to grow. We’re going to wait at least a month and see what happens. And the patient returns after that point, we just want to see what we have and decide where we’re going to go from that point. And we notice at this point that things do look a little bit better. We’re starting to develop some tissue between the natural tooth and implant. We haven’t lost anything labially in fact. We can’t even push a little bit, because this tooth almost looks a little bit short compared to the central and the canine. But most importantly what we want to do is push the tissue slightly interproximally just to try to develop that interproximal tissue. Because it is so far under contoured. So what I do is I very quickly remove the provisional. And its screw retained so it’s easy for me to do that. I remove it. I air abrade whatever surface I want to add to, a little bit of bonding resin, a little bit of flowable composite, polish it, and put it right back in. I don’t want excessive ischemia. We’ll just push the tissue. Once that crown is replaced, we’ll wait again another three to four weeks. And a little bit of that rend of that granulation tissue was still there. At this point, I actually did kind of remove it and allowed it to continue to heal for a full six months. At the end of that six months, we reevaluate our tissue. What does it look like? We have been able to develop some interproximal tissue. We filled that site fairly nicely. It probably closed in a little bit, but not bad. Maybe posterioraly we’re cell deficient slightly. But at this point after six months, I feel like we’ve pretty much gone as far as we can go. Biologically, the tissue response to the amount of bone beneath, we’re really not going to develop a lot more than this. So the challenge that I have is that I would like to be able to record the exact subgingival shape of this provisional so I can translate to the laboratory so they can give me the right crown. An impression coping is much narrower than the provisional I’ve ended up with. I could sit there and put the impression coping into the mouth and quickly inject something like light cured composite that I can cure and then take an impression. Sometimes the tissue is so fibrotic I can put the impression coping on as long as I work quickly, inject impression material, and take a quick impression. And that gives me the shape. But one thing that I’ve done in the past is I’ve taken the provisional out of the mouth, connected it to an analog, seated that provisional into something that sets quickly like Blu-Mousse Super-Fast that sets in 30 seconds as a vinyl polysiloxane, remove the provisional, put it back in the mouth, mark which side is the buckle, for example, so I’ll know, put the impression coping into this little situation, add some GC Pattern Resin to fill the discrepancy between the impression coping and the actual shape of the provisional. And now, I have an open tray coping that’s customized subgingivally to give me the exact emergence profile that I’ve worked the last six months to achieve. So this works, to me, very smoothly, very easily, and it gives the lab all the information that they might need to take this provisional. And remember, we started off somewhat here, we allowed it to progress until the biology of the patient had the opportunity to develop that tissue completely, and then seven months later a final crown that really gave the patient back everything they lost. I mean, maybe we could have pushed that tissue a little bit more labially. But if they ever lose any, this is a screw retained crown and it’s going to look great. And really that’s what happens over the next 10 years that crown still looks great. The tissue looks good, it’s healthy. There wasn’t a margin to irritate that tissue. I think it really was an outstanding, very biologically stable outcome. So I’d like to, if I could with you, take a few minutes and go through kind of an analysis of what I think are the best ways to manage immediate screw retained provisional restorations. There’s a lot of different ways to do it. Of course, we could do cemented. We’ll talk about that. So we’re going to do immediate screw retained provisionals. Here’s the first case we might look at. And this is kind of a classic way of doing it. The surgeon will generate an implant index, and then I don’t need to do as much intraorally. So basically the implant is placed by the surgeon. They will generate an index from that implant placement. I need to have on hand a model that shows me the shape of the tooth I want to have, usually a suck down of some sort, an analog, a provisional cylinder, and an abutment screw. So the surgeon sends to me their index that fits on the adjacent teeth that engages an impression coping that they connected to the impact. What I see as the challenge is trying to fit this index to the model. You know, I trim away as much as I can of the index. I trim away really as much as I can of the model to minimize the interferences that might keep it from seating completely. Once we feel like we’ve done that, we’ll go ahead and seat that, use some stone to adapt the analog to this model. And that should give us the implant position. We remove the index. Go ahead and put our provisional cylinder in place, using our suck down realize how much we have to adjust. Maybe put a cotton pellet to block the access hole. Fill the suck down with some acrylic resin and make a provisional. And then on this case, I can tell you going to the mouth it was traumatic. It didn’t just screw right to place. Just whatever slight discrepancies from the index to the way it fit on my model there was a discrepancy to the fit of this provisional. So it hit in the mesial position. There was an opening to the distal. It made it much more stressful than I would have liked it to be. Was it a good provisional? Yeah, it worked fine. Aesthetically it looked better with time. The most challenging thing with this case was making a final crown that matched this very bizarre porcelain color. I offered actually to redo the natural crown for free just to try to make an implant crown that matched it. It was incredibly difficult. And this was really as close as we could come. And so we’ll go ahead and make the crown. Here in this case, a final screw retained crown, not a great color match but it was a challenge. This is another case that was really interesting plus from the point of view of patient management. The patient was at actually Disneyland and fell and broke their front tooth. Whatever dentist they sent her to said, OK, well, we’ll extract that tooth and we’ll prep the other two teeth and we’ll do a bridge. While she was in the chair, she called me and said, Dr. Perri, what should I do? And I said, don’t let them prep your other teeth unless there’s a reason. Come see me. And fortunately, I work with a great surgeon. We analyzed what was going on. The very next day she was in his office and having that tooth removed and an implant placed. So basically a beautiful implant placement. The other two teeth, a little chip on the mesial incisal of number nine, but other than that no problems at all. Implant placed, a healing abutment intact, and it was sent back to me. Now what am I going to do? I’ve done a lot of different things and I want to try putting in the zirconium abutment and doing a cemented crowd. Because that’s what everybody does, right? That’s what’s easy. So I went ahead and did this. And what else? Everyone puts acrylic in the mouth. So I took my suck down, I carefully put it over the top of the zirconium abutment. Actually after I adjusted the zirconium abutment so it wasn’t hitting any bone or anything, it was in very nicely. And I put the acrylic resin in place. I was careful not to seat it hard. I didn’t have excess acrylic in there. When I took it out of the mouth, you can see the acrylic didn’t even go all the way down to the margins. So in the laboratory I put the new pontic on top, I added acrylic to adapt the acrylic provisional to the zirconium abutment, and it fit so tightly I couldn’t even remove it. So I decided to make it screw retained. That’s easy for me. And I did have worries. I really worried that maybe this wouldn’t stay connected and it would fall off. That didn’t happen, but something else did. This is the way I inserted it. It’s screw retained, no cement. I did put acrylic in the mouth. But it looks great. I mean, I think we really took good care of the patient. You notice after adjusting the zirconium abutment, there’s no pressure on the bone. Even though the cement margin is subgingival, it’s not a cement margin because we connected it extraorally and then made a screw access hole to put the crown in and out. Much easier than that first technique. It screwed right to place, had perfect interproximal contacts, really there was no issue. And then the patient came back like three weeks later. What’s going on here? Where is this granulation tissue coming from? Could be from a lot of things. But, of course, my worry is that it came from acrylic resin going subgingivally or maybe that the crown there was some sort of inflammatory process from bonding resin. I don’t know. But I think you need to react to these things very abruptly, and that, of course, demonstrates itself when you look at the x-ray. Three weeks after the provisional insertion this is what the bone looks like. And it doesn’t look bad. But when you look back at the original picture, look at how much bone loss has occurred in three weeks. Maybe not true bone loss, but certainly radiolucency development in the bone that was there. We have to react to this. And what we chose to do was remove that provisional. The surgeon cleaned up that granulation tissue because there may be microscopic particles of grafting material, of acrylic resin, embedded in that. Get it out of there. Let it heal. We waited a significant length of time, over a month. The tissue looks great. I decided to remake a provisional. We put it back in the mouth, kept it screw retained, and now we’re going to wait up to six months to be sure that everything looks good. And indeed, that’s what happened. Because of the type of tissue and the scalloping, I decided to do a screw retained all ceramic crown. This is a kind of a CAD/CAM abutment that we can bake porcelain directly to. We placed it intraorally. And look at the tissue now, the nice scalloping that we see, no worries about cement line. We’ve obturated all the spaces well. And we ended up with what I think was a good insertion. Now by waiting, I think, six months and remember getting that granulation tissue out of the mouth, the bone is actually improving. We look at what the bone looked like here at the final insertion five months after implant placement. And remember, the amount of bone that we lost just three weeks into this situation. So we see improving bone. We see a patient that’s very happy with the outcome. Six months after the final insertion the tissue is gorgeous. And I think even more importantly, if we look at the bone here at the final insertion five months after implant placement, well, look what it looks like six months after the final insertion. The bone has continued to improve. So zirconium abutment, a platform shifted implant, and very good technique, I think, led to an improvement and a recapture of the bone that we were starting to lose. The next case just brings up the idea that whenever we work on a single tooth like this one, there’s nothing we can do but an implant. But placing that implant might bring to reality that we also have to look at adjacent teeth. So here we see a situation where we’re already exposed the margin, point this out to the patient before we get into surgery. And I just pretty much told the patient and we had to redo that crown. Because I want both of them to match well. I’d like to redo all four if it was a perfect world, but we can’t do everything we’d like to do. So we’re going to take out this broken root. We’re going to place the implant with the good protocols that good surgeon understands. We’re not going to press the labial edge of the implant against the bone. We’ll leave about a millimeter space. They’ll graft bone into that site, place the implant about three millimeters apical to the desired emergence profile. And then, I asked the surgeon on this case to return it to me with an impression coping in place. We’re going to use the impression coping as a healing abutment. And I’d like the largest diameter that the surgeon feels will fit. Because they have the ability before they suture to place this impression coping and make sure it’s seated completely. The only concern I have here, especially if the patient’s been sedated, we’ve got to have a one inch thick wad of two by two gauze so they can’t press on the impression coping with their mandibular teeth. So the patient shows up in my office. I can take an impression. I don’t try to inject impression material subgingivally, but I take an impression. I don’t have to remove that impression coping. I have another one available. I connect to an analog, I snap it into the impression, I use some soft tissue material to make it a little easier to remove the impression coping. I usually put a little Vaseline on my soft tissue material, but we didn’t so the impression material stuck to it a little bit. We removed the impression coping and immediately we have a very nice mesiodistal shape. We have a very nice position of the implant and soft tissue that I can maneuver around a little bit. We’ll connect our provisional cylinder, we’ll adjust it as necessary, fill the suck down with some acrylic resin, seat it on the model, and polish. A very nice provisional that’s very smooth and very hygienic to the patient. And then we have not removed this impression coping to this point, so we haven’t invaded that implant immediate site but one time now. So we’ll take out the impression coping and immediately carefully place the clean provisional. And with very little trauma to the tissue or to the patient we’re able to eliminate a lot of the steps that lead to problems. In this case, this really looks like it’s going to be good. We have excess tissue, a nice provisional that goes down to the head of the implant. And we haven’t invaded that space with anything. After waiting six months, the bone has stabilized, the tissue looks good. We’re going to go ahead and remove the crown on the adjacent teeth. We’re going to take a final impression. We’ll make two crowns, seat one on the natural tooth, one direct screw retention onto the implant. And we’ll have our final crown. And this to me, I think, is really one of the best ways we can go about achieving the best aesthetic outcome for the patient when we’re dealing with eight and nine as we are in this case. Sometimes though remember, I just want to add this so we don’t forget. The report from the surgeon is well, we did an immediate implant placement, but the bone wasn’t stable enough. The implant wasn’t stable enough in the bone to allow an immediate provisionalization. So we make an Essix. We have it ready to go. We already have our suck down. We have a pontic. We go ahead and give them that to wear for whatever length of time. Then hopefully, we can go ahead and make our final restoration. Now the last case, I’ll just show you a little fine tuning of our whole technique. And this is really the technique that I like where the crown or the implant is placed after the tooth is removed. The surgeon places an impression coping for me, and it’s left in place. I take very carefully an impression without injecting impression materials subgingivally. I have a separate impression coping exactly the same as what’s in the mouth, connect it to an analog, and pour a model. After I do a soft tissue shape, I put a little Vaseline on the Gingitech, pour the model, remove the impression coping from the model, go ahead and add my provisional cylinder, adjust it as necessary. And then, I like to use a little plastic cone or a coffee stirrer whatever you might have to fill the screw access hole. Cut a little hole in the suck down. So I immediately when I add my acrylic resin have access to the abutment screw. And it just makes everything a little cleaner and work a little faster. After the acrylic is set, it’s very simple to pull out the coffee stirrer, undo the screw, polish the provisional. When it’s highly polished and shaped the way I want, and always remember under contour labial as much as necessary. Now, for the first time, remove the impression coping, seat the provisional, and six months later put in your final crown. And I think for us this has become extremely predictable, and we’ve had very good results from doing it this way. The thoughts to consider for immediate provisionals, the most difficult thing really is the coordination between the surgeon and our restorative office, especially if the patient has to drive a significant distance. But we like to do it in our office. The patients need to understand that it’s not just a temporary. They think a temporary should be free. This is a device that will maintain the shape of the soft tissue, help integrate the implant by preventing the invasion of things into that site by having a good seal between the provisional even if it’s just a pressure seal between the provisional and the soft tissue surrounding it. We need to always be prepared to do a non-implant supported provisional, which usually process in Essix temporary. I almost always prefer screw retention, even if the screw retention hole is coming through the labial, because I have more control. I don’t have to worry about cement. I don’t have to worry about a margin. I don’t have to worry about that provisional falling off, which we all know what happens if we’re going six months with a provisional in place. I try to streamline the whole process by having the surgeon place the impression coping of one that I have in my office. And then when the patient comes in, I can take an impression. I don’t have to remove the impression coping, go ahead and make the provisional, and I only invade the implant site one time to seat my final provisional. I can use a lab to do all these things, because it’s much harder than it might seem. It’s time consuming. You’re busy in your practice, you might have a laboratory technician do this whole thing for you, which is quite reasonable. I was going to talk just a little bit more about using a screw retained provisional to shape the pontic spaces. We’re going to create an ovate pontic. And the best way to do that is with a screw retained provisional. We must have an accurate impression to do this. So don’t think, oh, it’s a provisional. I’m just going to stick on some plastic copings and take and impression. It’s really not worth your time. We’re going to try to create the correct emergence on top of implants with this technique and also create ovate pontics. So our initial impression allows us to create extraorally in the laboratory an acrylic provisional. I’ve learned that we can push these pontics within one millimeter of the bone underlying. We might not do it all at once if it’s too much pressure on the tissue. But we can keep pushing that tissue until we create the ovate shape or the emergence profile we’d like to see for this pontic. We’ll under contour initially the acrylic over the top of our implants and then add a little contour as we would like to push the tissue apically if we need to. But we’d never start off with over contoured labial shape above our implants. Usually waiting about six months, we create the ovate shape we’d like to see. We create the emergence profile we’d like to see over the top of our implants. And we’re ready to take a final impression. Especially on this case, because the tissue is very fibrotic and very stable. We just seated impression copings and went ahead and took our final impression to make the final bridge. The last thing we’re going to talk about today is the immediate full arch implant supported provisional. It’s fixed. It will be loaded. So we need usually anywhere from four to six implants. But it really is a wonderful advantage to the patient if it’s reasonable. The most difficult thing for a patient that’s never had a denture is to have to wear a denture for the next six months. So if we can avoid that, I think it’s a very good thing. So just to simplify this as much as possible, we begin with the patient as they return from the surgeon. We have an existing denture. We see the healing abutments in place from the surgeon with the sutures holding it in place. And we want to take and connect the existing denture to these implants. How do we do it? Can we do it in an hour? Yeah, usually we can. Can we do it extraorally? Yes, but today I’m going to show you a technique for doing it intraorally. So we need a patient’s existing denture or an immediate denture. We need a intra oral hard line reline material which sometimes surprises people. But I’ll show you why. We need non-engaging temporary cylinders that will connect to the implants themselves. We use GC Pattern Resin, a pressure pot, pink acrylic, and a lab handpiece. So here we see the healing abutments in place. But remember, since the patient was wearing their denture or the immediate denture we fabricated, we don’t really know how it will fit in the mouth. The surgeon might have done a significant alveolectomy, they’ve placed healing abutments. We need to fit that denture over the top of these healing abutments. First, we want to just make sure it seats completely. The immediate denture we fabricate will have minimal extension posteriorly, because we really don’t want to have a big cantilever. We’ll thin the teeth as much as possible, so we’ll have as much acrylic resin as possible. But how do we fit it really intraorally? We take and put some blue wax inside the denture. This picks up where the healing abutments are. We’ll mark these points of contact, and we’ll adjust the acrylic resin so there’s no contact between the denture and the healing abutments. Then we can go back and do a hard reline of the denture. We like to use Kooliner, which can be used intraorally. We do that so the denture is well positioned in the mouth. And we also then identify exactly where all the healing abutments are. Once we see that, we can drill through the denture so we have an access hole to each of the implants. While that’s being done, if you have someone else that’s helping you in the laboratory, we go ahead and remove each healing abutment and connect a temporary cylinder. We could use titanium provisional cylinders or we could use plastic. We prefer the titanium, but they are a little bit more work. Sometimes the plastic are easier. Now our denture should fit easily around these provisional cylinders. There should be no contact of the denture to the cylinders. So take time to be sure that there’s about a one millimeter gap around each of these cylinders. Because we did a hard reline, the dentures should fit very stably. We can check with the occlusion by having the patient bite together while we’re holding the denture. And then the trick really is to hold the denture with one hand in place and then carefully take the GC Pattern Resin and loop the cylinders to the denture all the way around. We’re not trying to push GC Pattern Resin all the way down to the bottom of the cylinder, just lute the coronal portion of the cylinder to the denture itself. After we remove the denture by loosening the abutment screws that are holding the provisional cylinders in place, the first thing we have to do once the denture is removed, is replace the healing abutments all the way across the arch. Once that occurs, we can go to the lab and we need to fill the gaps between the provisional cylinders and the denture. We throw it in a pressure pot, we let the acrylic cure. And then we have to remove the flanges, reduce the cantilevers, narrow the dentures buccolingually, and create kind of an ovate shape in between the denture so it’s cleanseable. I also like to take away enough acrylic so it’s easy for the patient to clean. Once that’s happened, it should be fairly simple to go back to the mouth, remove the healing abutments, and screw the new fixed provisional in place. Hopefully we’ve removed enough acrylic that there’s no impingement on the tissue, you’ve reduced the distal cantilevers to the absolute minimum. Check our occlusion. If we’ve done the job right, we’ve had little to do to adjust the occlusion. And we can go from there. We can do this in the maxilla as well. It’s usually more of a challenge because of usually the implants are placed a bit more palliatively and we have a harder time to create that aesthetic look, but it can be done. The value of the technique is that we don’t have to do any soft lining during the healing phase, which I just love. The patient gets immediate gratification. And then don’t just dismiss that as being unimportant. The patient walking out of your office an hour after implant placement with fixed teeth is a great selling point to the whole procedure. If not done immediately though, I want to point out that you can’t wait a week. That’s the worst time to invade the implant site. The implants will be their weakest at one week. So we’re going to do it within a day or we don’t do it all. Or at release we wait probably a couple months. And also the restorative dentist on the fast track to the final restoration, because you can evaluate the aesthetics, the vertical dimension, the aesthetic position. And later, when we’re ready to mount up the case, we can take our impression of the implants the way we always do it, pour the model, and then we can take that provisional out of the mouth put it on the model and mount the case at the correct VDO in just a few seconds, which is wonderful. So after the model is fabricated, the provisional is used to evaluate VDO, centric relation, to mount the case up. All those are very valuable. And there’s certainly a fee for this. I mean, it’s an hour or two hours of intense work to pick this up, to process it, to shape it. So don’t forget to include a fee to do this for the patient. So thank you very much for your time that we’ve spent here with the provisionals. Certainly for me, after impression taking this is the most important aspect of taking care of the patient and getting them to the final restoration that makes them most happy with the work that we do for them. So thank you very much.