The Nonfunctional Immediate Provisional in Immediate Extraction Sites: A Technique to Maximize Esthetics

Abstract

Patients demand the esthetic replacement of missing teeth in an economic and expedient manner. When teeth are extracted, or have been missing for some time, the resorption process often limits the opportunity to replace those missing teeth with dental implants. The technique presented allows the restoration of missing teeth while maintaining the hard and soft tissues. It also prevents the patient from having to wear a removable appliance during the healing phase, and this maximizes the patient’s comfort and esthetics. The new method described here has been used in 55 patients with a success rate of over 98%.

When a single-tooth edentulous space is present, many techniques have been used to restore function and esthetics. The most common methods have been by means of a fixed or removable partial denture. One drawback associated with the use of a fixed partial denture is the necessary reduction of the adjacent teeth. Most frequently, good esthetics can be achieved using this technique; but at times in porcelain-fused-to-metal restorations, esthetic problems can occur due to opacity of the metal.

Removable partial dentures oftentimes do not meet the patient’s desires for esthetics or stability. Improperly designed removable partial dentures can also induce mobility to the abutment teeth. In the early 70s, the development of the resin-bonded bridge to restore a single edentulous space gained widespread prominence. Problems with debonding of the prosthesis and difficulties with hygiene in some patients resulted in a desire for an alternative treatment to the resin-bonded bridge. ^1–3

The long-term success of dental implants gives fully edentulous patients ⁴ a less invasive, more conservative treatment for a single missing tooth. The method of immediately placing an implant into an extraction socket has been documented. ^5–7 More recently, reports are being published on the use of implants placed into immediate function when restoring fully edentulous cases. ^8,9 Presented here is a new treatment option that combines the benefits of both of these techniques and offers the esthetic replacement of a single missing tooth.

Clinical Concerns

Once the root and clinical crown of a tooth are removed, the propensity of the site is to collapse. This is the result of not only the loss of bone (buccal plate), but also of the soft tissue contours, which are dependent on the stability of the bone for their support. When bone loss is not prevented, the bony architecture is not present to support and maintain the interdental papillae. There have been techniques, such as socket grafts, that aid in the replacement or maintenance of these lost tissues. ¹⁰ This typically requires additional surgery, extended healing time, and the need to wear a removable prosthesis.

The Technique: Nonfunctional Immediate Provisional

The following technique allows the clinician to obtain maximum esthetics with a fixed provisional. A key element to its success is the gentle elevation of the tooth root to preserve the alveolar housing around the extraction site (Fig. 1). The use of a periotome or other small elevator to release the periodontal ligament or other soft tissue attachment of the tooth to the surrounding bone has proven to be beneficial. Once the tooth is removed, the existing socket site must be carefully debrided to remove any soft tissue remnants. It is then irrigated with sterile saline. Before the surgical sequence to place the implant, a visual inspection of the site allows the clinician the opportunity to determine the appropriate diameter implant (Fig. 2). For the maximum esthetic result, and to gain the greatest initial stability, it is desirable to choose an implant with a diameter that will completely fill the entire cervical region of the socket. The proper location and orientation of the receptor site is initially predicated by scoring the apex of the socket with a bur in a surgical handpiece (Fig. 3). This provides a recess in the bone at the apices of the socket to guide the pilot drill to the predetermined location. The receptor site is then prepared in the usual sequential fashion at low speed (Figs. 4 and 5). The implant (Spline Twist MP-1, Sulzer Dental, Inc., Carlsbad, CA) is delivered to the site and inserted by means of a handpiece, with final seating using the manual ratchet. The platform of the implant should be placed 1.5 mm below the interproximal bone (Fig. 6). This typically ensures that the threads will be covered and will be at or below the level of the buccal plate. To inspect for any circumferential voids around the implant, gentle elevation of the soft tissue on the facial and lingual can be employed.

Fig. 1: Atraumatic extraction of tooth. Fig. 2 Intact extraction socket. Fig. 3 Preparation of apical recess. Fig. 4 Use of intermediate drill. Fig. 5 Final diameter drill. Fig. 6 Placement of implant. Fig. 7 Seating of abutment. Fig. 8 Provisional crown seated on abutment.

After the removal of the driver mount, the proper cuff height and angle abutment is placed (Fig. 7). The author chooses to use an implant that offers an abutment connection such as the spline for this technique because: (1) the spline interface offers firm fixation; and (2) the abutments have a flare that allows for the development of the ideal emergence profile. These abutments can also be modified to meet the individual clinical needs of the situation, and the shape and flare of the abutment help to develop a provisional restoration that will support the soft tissue contours to maximize esthetics. The provisional crown is then fabricated. In order to prevent occlusal loading during the healing period, the provisional restoration is taken completely out of occlusion when the patient is in centric relations and lateral excursions. After verifying that no occlusal loading is present, the provisional crown is polished and seated with temporary cement (Fig. 8). The patient is instructed to avoid chewing in the area of the provisional. The implant is allowed to heal for the normal period.

Case Report

A patient was referred due to complications involving the maxillary right central incisor (Fig. 8). Upon examination, it was discovered that the mobility of no.8 was caused by an extreme case of root resorption (Fig. 9). The patient was given the choice of trying an immediate nonfunctional provisional prosthesis or a conventional removable prosthesis. The tooth was gently elevated, keeping the soft tissue and hard tissue contours intact (Fig. 10). There was no elevation of the soft tissue. The socket site was checked to make sure that the buccal plate was intact. Identification of the interseptal buccal plate rim was done by direct visualization and palpation. In this case, the site was prepared by harvest instrumentation. This technique employs preparation of the osteotomy with burs (Stryker Surgical, Kalamazoo, MI) that are designed to cut, harvest, and particulate bone at extremely low RPMs (less than 100), without internal irrigation. (Figs. 11–14). The platform of the implant was set approximately 1–1.5 mm below the level on the interseptal bone. This ensured the shoulder of a 1- mm abutment to be approximately 0.5 mm below the level of gingival cuff rim. (Figs. 15–16) This also ensures that the soft tissue will be supported to maintain its position and will allow for maximum emergence of the provisional. The provisional was seated with temporary cement and taken out of occlusion (Fig. 17). It was then allowed to heal for 16 weeks. The position of the papilla was well supported as well as that of the buccal gingival contour, allowing for maximum tissue esthetics and excellent emergence profile (Fig. 18).

Fig. 9: Extracted no.8 showing root resorption. Fig. 10. Intact soft tissue with no flap reflected. Fig. 11. Pilot drill used to begin site preparation. Fig. 12. Intermediate drill to continue site preparation. Fig. 13. Final drill to complete site preparation. Fig. 14. Twist implant inserted using driver mount. Fig. 15. Platform of implant placed below adjacent bony contours. Fig. 16. Fixed abutment modified and seated on implant.

Fig. 17: Provisional crown on abutment. Fig. 18. Labial view of provisional crown supporting the soft tissue contours.

Discussion

This immediate nonfunctional provisional technique has many advantages. First, the patient does not need to wear a removable prosthesis during the healing period. Second, the patient leaves with a fixed provisional or tooth. This alleviates any apprehension that the patient may have about the loss of anterior teeth. Third, preservation of site contours and esthetics is obtained, which allows for the final restoration to be more esthetic. Fourth, this procedure is typically done without reflection of soft tissue, so that the surgical site requires no sutures. This technique seems to have many advantages over the currently employed techniques of single-stage implants and shortened loading times. Because the patient receives a tooth on the same day as surgery, the need for the final restoration to be completed with a shorter healing time for the implant may not be required.

At certain times, it is essential to graft circumferentially about the implant, because the widest diameter implant may not be sufficient to obliterate the socket site. Reflection of tissue can be done gently, being sure not to reflect past the mucogingival junction. This will ensure minimal tissue resorption. The graft material is then placed between the implant and socket space. The tissue is then compressed back to place.

To date, this technique has been used on 55 patients: 19 men and 36 women. The ages of the men ranged from 26 to 55 years and women from 17 to 78 years. All implants were placed from the premolar forward. In the male group, one implant was lost due to trauma. In the female group, one implant was mobile after 6 weeks and required removal. The male was removed from the combine group, resulting in a total of 54 patients. Survival rate to date is 98.15%.

Conclusions

This technique seems to be very effective in replacing missing anterior teeth. Further evaluation is being conducted in a larger population of patients. It demonstrates dramatic promise for the effective replacement of lost anterior teeth. This technique has not been used for posterior teeth beyond the second premolar. It may be effective in these regions as well. However, the increased occlusal force and protection factors must be considered. In any case, most patients are willing to undergo this procedure, especially when it involves a cosmetically visible tooth.