Ensuring a Successful Restorative Outcome Utilizing BioTemps® Implant Provisionals

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Provisional restorations may be fixed or removable and are made from a variety of materials. The most common forms of temporary restorations are fixed bridges supported by retained natural teeth, resin-bonded bridges and removable temporary partials, or flippers. BioTemps represent a fixed solution because they can be cemented or screw-retained. The decision to use a provisional restoration and which type to use depends greatly on the patient's specific needs and preferences. At its simplest, a provisional serves as the interim prosthesis while implants heal and a definitive restoration is fabricated. But if its effectiveness is maximized, a provisional restorative prosthesis provides four principal benefits:

1. Protects the underlying implants or bone-grafted sites from direct occlusal loads
The long-term success of any implant-borne restoration depends heavily on the integration of the supporting implant. A proper provisional must therefore protect the surgical site from occlusal forces during the healing process, preventing micro-movement of the implant and any associated bone grafts. BioTemps are designed to seat passively over healing areas, shielding them from stresses that might adversely affect osseointegration.

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2. Protects the underlying gingival tissues
Along with preserving bone health, a provisional must protect its underlying gingival tissues. BioTemps not only preserve tissue, but they can also be used to shape the associated soft tissue during the maturation phase. They have been shown to promote contoured healing for ovate pontics or anterior extractions, and can help shape the sulcus around implants. The ability to manage and sculpt the surrounding soft tissue leads to greater predictability in the seating of the final prosthesis. This is particularly helpful in the esthetic zone, where elements such as gingival margins and contours, papilla, and final emergence profile play a key role in replicating the proper morphology of natural dentition.

3. Determines the future position, support, shape and shade of the final prosthesis
Beyond helping to establish the health and shape of the supportive tissues, a provisional restoration can act as the blueprint for the final prosthesis. The restorative dentist is therefore able to obtain a hands-on feel for the eventual solution using a working prototype in the actual oral environment. Every aspect of form, fit and function can be evaluated. As an example, screw-retained BioTemps over implants can help create a predictable path of insertion, on which many other elements are based. And it's not just the dentist who will appreciate this "trial run." By experiencing his or her restoration on an interim basis, the patient is given a chance to assess it before undergoing placement of the definitive prosthesis. If either dentist or patient is dissatisfied with the provisional in any way, the appropriate adjustments can be made. Once approved, dimensions and morphology can be precisely transferred to the laboratory via impression for use in the fabrication of the final restoration, increasing the likelihood of patient acceptance during that final visit.

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With all that provisionals can contribute, the question becomes, why forego their inclusion in treatment planning dental implants? One reason is that provisional restorations are often left until the end of an appointment, when time is limited. But time spent in their construction is more than repaid in time saved doing additional procedures, adjustments and remakes in the future. This is especially true of a provisional like BioTemps, which can be prefabricated from an impression or preoperative model and delivered prior to surgery for a simple, efficient chairside reline.

Another reason given for avoiding provisionals is the notion that they are merely a short-term solution; however, implant healing times can require weeks or months, particularly if bone grafts are prescribed. Does the patient really wish to tolerate inadequate esthetics or decreased function for this prolonged period?

A third complaint is the associated expense of a provisional. Given the high costs of many implant procedures, customers may look to trim those costs wherever possible, and a "disposable" temporary may appear to be a good place to start.

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To maximize their effectiveness, provisional restorations should be carefully planned prior to the surgical phase. Various techniques are available to achieve optimal protection and continued function without compromising esthetics. Working together, the restorative dentist and the laboratory should determine which techniques best fulfill the specific requirements of each case. Proper management will contribute to satisfying the patient's expectations and help ensure a successful final solution.

A well-designed provisional restoration is predicated upon four key factors:

1. The ultimate restorative plan
The objective of an implant-supported prosthesis is to provide a functional and cosmetically acceptable form of tooth replacement. Every aspect of a provisional prosthesis should contribute to the realization of this ultimate goal. Anything that might counteract, marginalize or degrade the quality of the definitive restoration should be avoided.

2. The number and location of the dental implants
Implants serve as the foundation for any implant-borne restorative solution. Thus, any provisional must properly consider the structural framework on which it will be laid. For example, it was mentioned earlier that wire, fiber or cast-metal reinforcement is recommended in BioTemps provisional restorations with a pontic span greater than three units. Occlusal forces and potential bone stress are also critical factors that are deeply affected by the underlying implant configuration.

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4. The needs and desires of the patient
The success of a restorative prosthesis relies heavily on the perception of the receiving patient. An unhappy patient makes for an unhappy dentist. While it is the dentist's responsibility to educate and advise the patient as to all options and considerations related to the case, the obligation to listen to and accept the patient's stated goals and preferences remains. This applies to all aspects of the treatment plan, and the role of a provisional is no exception.

CASE 1
The following case depicts the utilization of BioTemps as a full maxillary implant-supported, screw-retained provisional restoration.

Figure 1: Preoperative smile view depicting unattractive smile
Figure 2: Preoperative occlusal view of maxillary arch
Figure 3: Occlusal view of healed maxillary arch after extractions
Figure 4: Atraumatic placement of eight dental implants
Figure 5: Screw-retained maxillary BioTemps placed and access holes covered
Figure 6: Postoperative smile using BioTemps Implant Provisionals

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CONCLUSION
BioTemps Implant Provisionals can play a valuable role in managing clinical situations to ensure success with the final prosthesis. They can be used to evaluate esthetic, phonetic and occlusal function prior to delivery of the final implant restorations, while preserving or enhancing the condition of the peri-implant and gingival tissues. They provide patients with natural-looking temporaries at any stage of implant treatment, and serve as an excellent prototype by which to evaluate shade and contours, leading to greater patient acceptance and a superior definitive restoration. They are also useful as a communication tool between members of the treatment team, which in many cases consists of the restorative clinician, implant surgeons, dental laboratory technicians and the patient. Clinicians should be aware of the different types of provisional restorations and their indications for use when planning implant-retained restorations. If planned and fabricated properly, this temporary prosthesis can become an integral part of the overall restorative solution.