David B. Rosen, D.M.D.- Practice Limited to Periodontics & Dental Implants
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David B. Rosen, D.M.D.- Practice Limited to Periodontics & Dental Implants
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Fixed Provisionals for Developing Periodontal Restorative Solutions Rapid technological development has been a hallmark of the last five to ten years of restorative dental practice. AS a periodontal services practice our role in supporting your practice has been, first, to retain sufficient natural dentition for functional restorations and, second, to develop adequate osseous tissue for tooth replacement systems. Increasingly as a profession we are moving towards non-removable tooth replacements. When implants first began we chose sites for them based on the amount of available bone in a site. As we searched to increase the application of implants the emphasis switched to developing sites which had inadequate bone. Currently, this type of therapy is an expensive combination of supporting bone development, implants and fixed ceramometal restorations. This combination of treatments has been readily embraced by patients who have experienced the loss of alveolar ridges from long term wear of removable appliances. Now, as periodontally involved dentulous patients perceive the benefits of esthetics and function from implant borne restorations, it becomes necessary to provide interim functional and esthetic replacements while implant sites are being developed. In three specific situations we would rely on your expertise to prepare provisionals for maximum esthetics. The first situation we often encounter is multiple adjacent tooth periodontal involvement necessitating extraction of several teeth. Usually loss of these teeth results in less ridge height than desirable for implant placement. With the presence of periodontal defects the remaining alveolar ridge almost always experiences shrinkage from the loss of narrow interproximal and facial bony plates. At the time of extractions there is seldom adequate soft tissue to do immediate osseous ridge augmentation with full soft tissue closure. What is required in this instance is a provisional replacement which is esthetic, avoids ridge pressure and lasts the 6-7 months necessary for the original extraction sites to cover with soft tissue and allow osseous ridge augmentation. One method which has effective is the immediate bonding of extracted tooth crowns into the edentulous space. The second situation for special provisional use is the immediate provisional placed on an implant at the time of implant placement or on the integrated implant which is ready to be restored. With both approaches the provisional crown provides proximal contours to develop interproximal papillae prior to placing the final crown. Current implant site development in the esthetic zone (maxillary arch #4-#13) dictates the presence of adequate soft tissue coronal to bone to develop interproximal papillary height by continually widening the provisional restoration until normal papilla height is achieved. As the provisional is contoured to normal interproximal shape the papilla is reformed provided the depth of the implant and the thickness of the soft tissue has been developed. This method has produced high levels of esthetics. The third area where your provisionals aid the periodontal repair process is the protection of interproximal healing. A prime example of this is the crown lengthening case. When we adjust the biologic width to produce adequate crown length and gingival protection for the tooth it often follows Endodontic care necessitated by recurrent caries. Invasion of the biologic width dictates an apical positioning of the gingival complex and necessitates protection of the interproximal tissue during healing. The presence of a provisional restoration post-surgically maintains the proximal space and helps develop gingival contours. This is particularly true in the anterior esthetic zone, but may also reduce food impaction in the process. We appreciate working with you to develop long term solutions of fixed restorative care for your patients. If we can assist further in the planning and implementation of restorative solutions through the creation of additional osseous support or proper tooth-borne relationships please contact our office.
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