a multifunctional, provisional, implant-retained

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34 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 85 NUMBER 1

The widespread use of dental implants in partially

edentulous areas has brought about a need forimproved techniques that will enable the restorativedentist to provide predictable, implant-supportedrestorations that are both functional and esthetic.1-4

Often, the restorative clinician fabricates several pros-theses in the course of treatment.5,6 These include aprovisional prosthesis before surgery,5,6 a radiographicstent,7-12 a surgical stent,12-17 an implant-supportedprovisional prosthesis,4,18 and the definitive implant-supported prosthesis.19

The provisional prosthesis should be durable andfunctional because it is used during the presurgicalevaluation phase and the surgical healing period.6,7,20

This provisional prosthesis aids in determining theesthetics, phonetics, and occlusal relationship of thefinal restoration.5,6 Both removable and fixed provi-sional partial dentures have been used.5,20

One critical step in the ultimate success of the defin-itive implant prosthesis is the positioning of theimplants relative to each other and to the occlusalplane.6 To determine the quality and quantity of thebone at the ideal implant sites, a removable radio-graphic stent often is fabricated.7-16,20 Many designs of radiographic stents for different imaging techniqueshave been described.7-16,20 The removable radi-ographic stent usually is modified to serve as a surgical

stent.10,12-16,20 Improvements in the design of many

removable stents include the incorporation of multiplefunctions.12,15,16 Stents that provide information onangulation and position10,14,15 and depth of theimplant21 as well as stents that act as mouth props,tongue retractors, and occlusal rim markers have beendescribed.13 After stage II surgery, the restorative den-tist often fabricates implant-supported provisionalrestorations.4,18

The purpose of this article is to describe a provi-sional implant-supported fixed partial denture (FPD)

with a removable pontic segment. The procedure forfabricating a cast metal-reinforced, heat-processed,acrylic resin provisional FPD has been described previ-

ously.22 The modification to this basic design is theincorporation of patrix-matrix components into thecast metal framework adjacent to the edentulous space.The lingual cast metal reinforcement of the pontic seg-ment also is extended to the buccal side. The pontic of the provisional implant FPD can be modified with aradiopaque marker as an alternative to the traditionalremovable radiologic stent. The provisional implantFPD can be used by the surgeon as a surgical guideduring stage I surgery. The pontic segment of the pro-

visional implant FPD is cemented in place betweenstages I and II surgery. At the time of stage II surgery,the surgeon can use the prosthesis to locate the coverscrews of the implants. Finally, the restorative dentistcan convert the pontics into an implant-supportedprovisional restoration and proceed in fabricatingdefinitive restorations.

PROCEDURE

A 41-year-old white female patient in good health was selected to demonstrate this procedure. Thepatient was treatment planned for metal-ceramicrestorations on the maxillary left second molar andmaxillary left canine and an implant-supported pros-

A multifunctional, provisional, implant-retained fixed partial denture

Francis F. Tung, DMD, MPH,a Allyn J. Coleman, DMD, MS,b Tai-Nien Lu, DDS,c andLeonard Marotta, MDT, CDTd

College of Dentistry, New York University, New York, N.Y.

This article describes the modification of a procedure for fabricating a laboratory-processed, metal-

reinforced, acrylic resin provisional restoration that becomes an implant-retained fixed partialdenture. The modification involves the incorporation of patrix and matrix components into a castmetal framework. The prosthesis can be used as an alternative to a removable radiologic stent andsurgical guide. It can function as a surgical guide during implant placement and help retract thebuccal mucogingival flap during implant placement. The prosthesis also can be used as an aid inlocating the implant during stage II surgery. Finally, the pontics can be converted into an implant-supported provisional restoration immediately after the implant prosthetic components areattached to the uncovered implants. (J Prosthet Dent 2001;85:34-9.)

Presented as poster presentation at the 49th Annual Meeting of theAmerican Academy of Fixed Prosthodontics, Chicago, Ill.,February 25, 2000.

aAssistant Professor, Division of Reconstructive and ComprehensiveCare; Assistant Director, Advanced Education Program inProsthodontics.

bAssistant Professor, Division of Reconstructive and ComprehensiveCare.

cGraduate Student, Advanced Education Program in Prosthodontics.dClinical Assistant Professor, Advanced Education Program in

Prosthodontics.



TUNG ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

JANUARY 2001 35

thesis to replace the maxillary left first premolar, sec-ond premolar, and first molar. The patient was referredto an independent radiologic clinic for a computerizedtomography scan of the edentulous area between themaxillary left canine and maxillary left second molarbefore presentation of the final treatment plan.

1. Maxillary and mandibular complete arch impressions were made with an irreversible hydrocolloid material(L. D. Caulk Division, Dentsply International Inc,Milford, Del.) and immediately poured in type IIIstone (Microstone, Whip Mix Corp, Louisville, Ky.)to make diagnostic casts. The casts were mounted ona semiadjustable articulator by using an average-axisface-bow and an interocclusal centric relation record.Diagnostic wax patterns were completed and dupli-cated. On a duplicate of the maxillary diagnostic cast,crown preparations were simulated on the canineand second molar.

2. A metal-reinforced provisional implant FPD was

fabricated as described by Emtiaz and Tarnow.22The modification involved casting a matrix-patrixplastic pattern as an integral part of the metalframework. Any commercially available matrix-patrix pattern may be used. A dental surveyor wasused to position the patrix plastic pattern at theinterproximal surfaces adjacent to the edentulousspace and to assure the parallelism or path of placement of the matrix component. A wax pat-tern of the framework was finished on theduplicate of the maxillary diagnostic cast made

with simulated crown preparations (Fig. 1). The wax connector pattern should be 3 to 4 mm buc-

cal to the gingival crest of the edentulous ridgeand at least 3 mm in height. The buccal surface of the wax connector has multiple retentive beads,

whereas the palatal surface is smooth.3. Sprue formers were attached to the wax pattern,

which was cast (Rexillium III, Jeneric/PentronInc, Wallingford, Conn.), divested, polished, andfitted to the working cast (Fig. 2). The metal wassubjected to airborne particle abrasion by using50 µm aluminum oxide and silicoated (Siloc,Heraeus Kulzer, Wehrheim, Germany) before theapplication of heat-polymerized hard acrylic resinmaterial (Vitacrilic, Fricke International, VillaPark, Ill.) (Fig. 3).

4. The provisional prosthesis without the pontic seg-ment was placed on the working cast, and the centerof the desired screw access location was marked onthe crest of the edentulous ridge (Fig. 4). The mark-ing was enlarged to the full size of the implantshoulder diameter. The cast was secured on the den-tal surveyor adjustable table, and the table was tiltedin relation to the surveyor rod at the end of the ver-tical spindle until the rod was at the center of themarkings. The removable pontic segment was

Fig. 1. Duplicate cast of maxillary diagnostic cast withunderprepared left second molar and left canine. Waxedframework pattern with patrix (P ) facing edentulous space.R indicates retentive beads on buccal surface of connector.C indicates smooth palatal surface of connector.

Fig. 2. Cast framework seated on duplicate cast. Arrows indicate matrix component (with retentive projections) fit-ted to patrix counterparts.

Fig. 3. Provisional FPD with main piece and pontic segmentunconnected.



THE JOURNAL OF PROSTHETIC DENTISTRY TUNG ET AL

36 VOLUME 85 NUMBER 1

reseated onto the framework. A slow-speed hand-piece with a No. 6 round bur (SS White Burs, Inc,Lakewood, N.J.) held parallel to the surveyor rod

was used to remove acrylic resin material from theocclusal table toward the gingival crest tissue sur-face, creating a channel. The channels were filled

with a radiopaque marker such as gutta percha. Amalgam may be used as an alternative (Fig. 5).The pontic segment may be painted with barium

sulfate, or a metal tube may be placed into the cutchannel as an alternative radiopaque marker.5. After preparation of the natural teeth abutments,

the processed provisional prosthesis was tried in, andthe intaglio surface of the abutment retainers wererelined with an autopolymerizing hard acrylic resin(TRU-KIT, H. J. Bosworth Company, Skokie, Ill.)and reseated onto the prepared abutments. Excessmaterial was removed, and the prosthesis was pol-ished and cemented with provisional cement(Temp-Bond, Kerr Corp, Romulus, Mich.) (Fig. 5).

6. The patient was referred to the radiologic clinic forpresurgical imaging. If redirecting is needed after

careful analysis of the radiographic images, therestorative dentist can fill the old channels withautopolymerizing hard acrylic resin and thenredrill the channels on the basis of the informationfrom the radiographic images. The new channelsshould be filled with the same marker, and a new radiograph should be taken to verify channel ori-entation. On the day of stage I implant surgery,the movable portion of the provisional FPD wasseparated, and the radiographic marker material

was removed from the channels.7. The buccal cusp was used as a reference point

after the movable portion of the provisional

FPD had been separated from the main piece(Fig. 6). After the mucogingival flap was raised,the surgeon used the provisional FPD as a surgi-cal guide (Fig. 7). The movable portion wasreinserted into the main piece, and the channels

were widened to accommodate the small twistdrill chosen by the surgeon (Fig. 8). The buccalfacings were used to help retract the buccalmucogingival flap away from the bony ridge(Fig. 9). The pontic segment was removed, anda guide pin was placed to verify parallelism (Fig.10). After the stage I surgery, the provisionalFPD was recemented with a eugenol-based pro-

vis ional cement (Temp-Bond, Kerr Corp).Because the edentulous ridge area had been sur-gically altered and sutures had been placed, somerelief of acrylic resin material from the undersideof the pontic segment was necessary. The remov-able piece (pontic) of the provisional FPD wascemented during the healing phase.

8. At stage II surgery, the surgeon removed themovable piece of the provisional implant FPD,again by using the buccal cusp as a referencepoint, to locate the implant site and remove the

Fig. 4. Marks (M ) estimating implant positions on cast.

Fig. 5. Relined and polished provisional implant FPDcemented intraorally. Channels cut on pontic segment were

filled with radiopaque marker materials (gutta percha oramalgam).

Fig. 6. Preoperative view with associated piece removed.




JANUARY 2001 37

soft tissue to expose the implant cover screw. Afterplacement of healing caps, some relief on theunderside of the removable piece of the provi-sional implant FPD was necessary.

9. After appropriate prosthetic abutment placement,the removable provisional FPD required some fur-

ther modification (Fig. 11) and became animplant-supported provisional prosthesis (Fig. 12).If necessary, the buccal metal support frame may becut off of the mesial and distal abutments’ retainer.

DISCUSSION

The proposed provisional prosthesis is made of alaboratory-processed, metal-reinforced acrylic resin.Successful treatment outcome and sequence requireattention to detail before, during, and after treatmentplanning. The prosthesis is capable of functioningfrom the time of presurgical radiographic imagingthrough the surgical stages until insertion of the defin-

itive fixed and implant-supported restorations. If clinicians prefer, they can custom mill their ownmatrix-patrix designs. This prosthesis eliminates theneed to fabricate a removable partial prosthetic tem-plate for the presurgical imaging stage, a separatesurgical template, and provisional restorations until thedefinitive prosthesis is delivered. The prosthesis ponticarea does not put undue pressure on the soft tissuethat covers the edentulous surgical site. When 1implant is used to replace 1 missing tooth, the buccalcusp reference point during the surgical phase givesthe surgeon an ample amount of latitude.

One disadvantage of this modified design may be

the cost of making the prosthesis. However, thelong-term cost-effectiveness and benefit of the pros-thesis far outweigh this disadvantage. In the casepreviously described, the design was further modi-fied to incorporate the matrix-patrix pattern onto aresin-bonded prosthesis framework (Fig. 13). Notooth preparation is necessary with this design. It isrecommended that the clinician use resin cement tobond the prosthesis to a nonetched enamel surfaceon the abutment teeth.

SUMMARY

A modified procedure for fabricating a multifunc-tional, provisional, implant-retained FPD has beendescribed. The provisional FPD can serve as a presur-gical imaging template, a surgical guide during stagesI and II implant surgery, and a tooth-supported pro-

vis ional FPD that can be conver ted into animplant-supported FPD after stage II surgery.

REFERENCES

1. Branemark PI, Zarb GA, Albertsson T. Tissue-integrated prostheses:osseointegration in clinical dentistry. Chicago: Quintessence; 1985.

2. Watson RM, Davis DM, Forman GH, Coward T. Considerations in

design and fabrication of maxillary implant-supported prostheses. Int JProsthodont 1991;4:232-9.

3. Garber DA. The esthetic dental implant: letting restoration be the

guide. J Oral Implantol 1996;22:45-50.

Fig. 8. Implant twist drill guided by cleared channel on

movable pontic segment.

Fig. 9. Prosthesis helps retract buccal mucogingival flap.

Fig. 7. Midcrestal incision. Full thickness mucogingival flapreflected buccally.



THE JOURNAL OF PROSTHETIC DENTISTRY TUNG ET AL

38 VOLUME 85 NUMBER 1

4. Garber DA, Belser UC. Restoration-driven implant placement withrestoration-generated site development. Compend Contin Educ Dent

1995;16:796, 798-802, 804.5. Zinner ID, Small SA, Panno FV. Presurgical prosthetics and surgical

templates. Dent Clin North Am 1989;33:619-33.

6. Murrell GA, Davis WH. Presurgical prosthodontics. J Prosthet Dent1988;59:447-52.

7. Verde MA, Morgano SM. A dual-purpose stent for the implant-support-

ed prosthesis. J Prosthet Dent 1993;69:276-80.8. Stellino G, Morgano SM, Imbelloni A. A dual-purpose, implant stent

made from a provisional fixed partial denture. J Prosthet Dent

1995;74:212-4.9. Basten CH, Kois JC. The use of barium sulfate for implant templates. J

Prosthet Dent 1996;76:451-4.

10. Takeshita F, Tokoshima T, Suetsugu T. A stent for presurgical evaluationof implant placement. J Prosthet Dent 1997;77:36-8.

11. Lam EW, Ruprecht A, Yang J. Comparison of two-dimensional orthora-

dially reformatted computed tomography and panoramic radiographyfor dental implant treatment planning. J Prosthet Dent 1995;74:42-6.

12. Engleman MJ, Sorenson JA, May P. Optimum placement of osseointe-

grated implants. J Prosthet Dent 1988;59:467-73.

13. Adrian ED, Ivanhoe JR, Krantz WA. Trajectory surgical guide stent forimplant placement. J Prosthet Dent 1992;67:687-91.

14. Mizrahi B, Thunthy KH, Finger I. Radiographic/surgical templateincorporating metal telescopic tubes for accurate implant place-

ment. Pract Periodontics Aesthet Dent 1998;10:757-65.15. Lee SY, Morgano SM. A diagnostic stent for endosseous implants to

improve conventional tomographic radiographs. J Prosthet Dent

1994;71:482-5.

16. Burns DR, Crabtree DG, Bell DH. Template for positioning andangulation of intraosseous implants. J Prosthet Dent 1988;60:479-

83.17. Johnson CM, Lewandowski JA, McKinney JF. A surgical template for

aligned placement of the osseointegrated implant. J Prosthet Dent

1988;59:684-8.18. Dixon DL, Breeding LC. Surgical guide fabrication for an angled

implant. J Prosthet Dent 1996;75:562-5.

19. Wilkinson MR, Woody RD. A soft tissue simulated cast for implant pros-thesis. J Prosthet Dent 1992;68:553-4.

20. alZallal M, Morgano SM. The implant-supported, heat-processed

provisional fixed partial denture. Am J Dent 1991;4:260-4.21. Modica F, Fava C, Benech A, Preti G. Radiologic-prosthetic planning

Fig. 10. Guide pins placed to show location and angulationof implant site relative to prosthesis.

Fig. 11. Screw-retained implant temporary abutment

connected to recovered implant. Arrow indicates space(S ) between temporary abutment and original ponticsegment. Autopolymerizing hard acrylic resin materialwas applied in space to connect implant provisionalabutment to pontic segment.

Fig. 12. Extraoral view of screw-retained implant provisionalabutment connected to prosthesis.

Fig. 13. Modification of resin-bonded prosthesis used as pro-

visional implant FPD when adjacent teeth were caries free.Associated piece is partially separated in horizontal direction.




JANUARY 2001 39

of the surgical phase of the treatment of edentulism by osseointe-grated implants: an in vitro study. J Prosthet Dent 1991;65:541-6.

22. Emtiaz S, Tarnow DP. Processed acrylic resin provisional restoration withlingual cast metal framework. J Prosthet Dent 1998;79:484-8.

Reprint requests to: DR FRANCIS F. TUNG

DIVISION OF RECONSTRUCTIVE AND COMPREHENSIVE CARE

COLLEGE OF DENTISTRY

NEW YORK UNIVERSITY

345 E 24TH ST

NEW YORK, NY 10010

FAX: (212)995-4889E-MAIL: [email protected]

Copyright © 2001 by The Editorial Council of The Journal of Prosthetic

Dentistry.0022-3913/2001/$35.00 + 0. 10/1/112495

doi:10.1067/mpr.2001.112495

A comparison of laser-welded titanium and conventionalcast frameworks supported by implants in the partially edentulous jaw: A 3-year prospective multicenter study

Jemt T, Henry P, Lindén B, Naert I, Weber H, Bergström C.Int J Prosthodont 2000;13:282-8.

Purpose. This study evaluated the clinical performance of laser-welded titanium implant-sup-ported fixed partial dentures (FPDs) and compared these prostheses with conventional castimplant-supported FPDs in a prospective, multicenter study design.Material and methods. Four prosthetic specialty centers participated in the study over 5 years.This publication covered the first 3 years of follow-up on 2 separate groups of patients. Forty-twopatients were divided into 2 groups of 21 patients each. Group 1 patients exhibited bilateral pos-terior edentulism and were randomized. A conventional cast implant-supported FPD withporcelain veneers was inserted on one side intraorally, and a laser-welded titanium implant-sup-ported FPD with low-fusing porcelain veneers (Procera Porcelain, Nobel Biocare) was insertedintraorally on the opposite side. The conventional cast frameworks served as controls. All group2 patients had been provided with conventional cast implant-supported FPDs at least 1 year ear-lier; these prostheses were in need of replacement. The old prostheses were replaced with

laser-welded titanium implant-supported FPDs with low-fusing porcelain. Patient ages rangedfrom 18 to 75 years at the onset of the study. No patients had received any intraoral grafts or radi-ation in the head or neck region, and none were drug and/or alcohol abusers. Thirty patients

were smokers. The patients were provided with 170 Brånemark system implants and abutmentcylinders (Nobel Biocare). Sixty-two teeth were replaced with both types of frameworks in group1, and 68 teeth were replaced in group 2. After insertion of the prostheses, the patients werescheduled for annual follow-ups. Clinical and radiographic data from 3 years of follow-up visits

were gathered and analyzed. Prosthesis and implant survival rates were evaluated by means of lifetable analyses. Wilcoxon’s ranked sum test was used to analyze the marginal bone loss in relationto the height of the abutment cylinder clinically. A Chi-square test was used to evaluate fracturesof porcelain in both test and control prostheses. To accomplish radiographic analysis, mean val-ues between the mesial and distal measurements were recorded.Results. Two patients from group 1 were lost to follow-up during the first 3 years, and 1 patient

from group 2 was withdrawn each consecutive year. Only 1 implant failed, and all prostheses werefunctioning after the third annual follow-up. Similar clinical performance was exhibited with the 2framework designs. Few complications were noted. One abutment and 9 porcelain units fractured.Four prostheses had loose gold screws. In group 1, marginal bone loss was similar for both pros-thetic designs. On average, no bone loss was observed in group 2 patients. Neither placement of theprosthesis margin nor the prosthesis design was significantly related to resultant marginal bone loss.Conclusion. During this 3-year follow-up study of 42 partially edentulous patients, the clinicalperformance of laser-welded titanium implant-supported FPDs was similar to the performance of conventional cast implant-supported FPDs. 41 References. —DL Dixon

Noteworthy Abstractsof theCurrent Literature

a multifunctional, provisional, implant-retained

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