A Simplified Approach

to the Immediate Provisionalization of an

Implant in the Esthetic Zone

Abstract

I
n recent years, studies on accelerated and immediate implant loading protocols have demonstrated promising results.
These accelerated protocols can reduce total treatment time and improve patient satisfaction. This article illustrates the im-
mediate provisionalization of an implant on tooth No. 8.

T
he approach to loading dental implants has been
modified in recent years. The original Brånemark
implant protocol called for an undisturbed heal-
ing period of several months before implants were ex-
posed and loaded.1 Early or premature loading was
thought to prevent osseointegration and result in implant
failure.2
There has been an increase in the number of reports
and studies on accelerated and immediate loading proto-
cols (ie, shortened healing periods as well as implants pro-
visionalized or loaded directly at the time of placement).
The success rate for these new protocols appears to be
similar to the originals.3,4 Furthermore, these procedures
can reduce total treatment time and, in many cases, allow
the patient to wear a fixed prosthesis, improving overall
satisfaction.
This article illustrates the immediate provisionaliza-
tion of an implant on tooth No. 8.
Case Presentation
A 46-year-old woman presented with an interim re-
movable partial denture replacing tooth No. 8 that had
been extracted 3 months earlier (Figures 1 to 4). Her chief
complaint involved replacing the missing maxillary incisor
and enhancing the esthetics of her smile in that area. The
denture tooth on the removable prosthesis was excessively
wide mesiodistally, and lacked symmetry with tooth No.
9. The patient did not desire veneers or other type of in-
direct restorations for the remaining maxillary incisors.
After reviewing the findings and treatment options, the
patient chose to have an implant-retained crown to re-
place tooth number 8. In addition, composite resin
restorations would be applied on the mesial and distal as-

Mariano A. Polack, DDS, MS

Prosthodontist, Private Practice
Gainesville, VA
Phone: 703.753.8753
Email: mpolack@comcast.net
Web site: www.dentaldesigngainesville.com
Figure 1 — Preoperative extraoral view.

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 Figure 2 —
Preoperative radiograph.
Figure 3 — Preoperative intraoral view. Note the inadequate ap-
pearance of the denture tooth.
Figure 4 — Preoperative intraoral view, close up. The edentulous
space is excessively wide and needs to be corrected by adding
composite resin to the adjacent teeth before implant placement.
pects of teeth Nos. 7 and 9, respectively, to balance the
mesiodistal width of both central incisors.
At the first appointment, a diamond bur was used to
roughen the mesiofacial aspect of tooth No. 7 and the dis-
tofacial aspect of tooth No. 9. A small bevel was created
with a fine diamond, and these areas were etched and
bonded. Composite resin was applied approximating the
2 Dental Learning / June 2010
Figure 5 — Postoperative radi-
ograph control depicting ade-
quate bone levels.
Figure 6 — Immediate postoperative view after implant placement.
Notice the composite resin added to the interproximal aspects of
teeth Nos. 7 and 9.
Figure 7 — Provisional screw-retained crown before polishing
and finishing.
mesiodistal width of the edentulous site of No. 8 to that of
tooth No. 9. The composite restorations were then polished,
finished, and a polyvinyl siloxane impression was made to
fabricate a polymethyl methacrylate provisional crown. The
interim removable partial denture was adjusted to accom-
modate the composite restorations, and the patient was re-
ferred to the oral surgeon for implant placement.
Vol. 4, No. 6 (Suppl 1)

Figure 8 — Immediate intraoral postoperative view. The provisional
crown was shortened to prevent contact during protrusive move-
ments. Minimal soft-tissue trauma allowed for uneventful healing.
Figure 9 — Immediate extraoral postoperative view shows en-
hanced esthetics.
A regular-diameter implant was placed into the eden-
tulous site with a flapless technique. Adequate primary
stability was achieved and a healing abutment was con-
nected to the implant. The patient was referred back on
the same day to the prosthodontist for immediate provi-
sionalization (Figure 6).
The healing abutment was removed, a provisional abut-
ment was connected to the implant, and an electric hand-
piece was used for gross reduction. A thin mix of
polymethyl methacrylate was placed inside the provisional
crown that was seated over the abutment and allowed to
set. In this manner, a screw-retained crown (Figure 6) was
fabricated. Next, all centric and eccentric contacts were
eliminated and the provisional restoration was polished to
a high shine. A 30-Ncm torque wrench was used to connect
the crown to the implant and the access hole was sealed
with gutta-percha and composite resin. After the proce-
dures, minimal soft-tissue trauma was evident, and a pleas-
ant extraoral esthetic result was achieved (Figures 7 to 9).
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Discussion
The tendency in implant dentistry is to decrease treat-
ment time through shorter surgical and restorative proto-
cols.5 This is achieved by shortening the amount of time
between implant placement and rehabilitation, reducing
the number of appointments. Accelerated protocols can
eliminate the need for a removable prosthesis and enhance
treatment efficiency as well as patient satisfaction.6
Primary stability is the main factor allowing immedi-
ate provisionalization or immediate loading.7 This is typ-
ically associated with an implant insertion torque greater
than 35 Ncm, which is believed to keep micromovement
below 150 µm.2 Greater mobility is assumed to bring
about fibrous encapsulation; however, no clinical trial to
date has compared the effect of different levels of stabil-
ity on implant survival.8
Presently, there is limited scientific data to validate im-
mediate provisionalization and/or loading for every clinical
situation.9 Therefore, anatomic, host, and biomechanical
factors as well as the experience of the operators should be
taken into account when evaluating the feasibility of these
procedures.
Conclusion
As illustrated by the case presented, the immediate
fixed provisionalization of an implant in the maxillary an-
terior region eliminates the need for a removable prosthe-
sis and reduces the number of surgical appointments,
thereby increasing comfort and esthetics, and shortening
total treatment time.
References
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2. Brunski JB. Biomechanical factors affecting the bone-den-
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results for Brånemark implants immediately loaded with
fixed prostheses at implant placement. Int J Oral Maxillofac
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4. Randow K, Ericsson I, Nilner K, et al. Immediate functional
loading of Brånemark dental implants. An 18-month clinical
Dental Learning / June 2010 3
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4 Dental Learning / June 2010
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