Case Presentation: Immediate implant provisional #9.

I got an emergency call from a long-standing patient a week ago on Saturday.  We did a smile makeover with porcelain restorations for him 17 years ago, and he’s been a regular patient ever since.  He told me that he bit into a candy that he expected to have a soft center.  It didn’t.  And, he heard a “crack,” then his front tooth was loose.

I met him at the office and determined he fractured the root.  The crown of the tooth was still hanging on by some soft tissue.  No pain, though.  Since it was a Saturday, and I was working alone, I simply splinted it with some flowable composite to try to stabilize it until Monday.

We discussed his options:

  1. Endo, post, and crown.
  2. Extract and implant.
  3. Fixed bridge.

He decided he wanted a more predictable long-term result and chose the implant.

On Monday, we got a pre-op impression and sent him over to the periodontist for extraction and immediate implant placement.  I used the pre-op model to make a Siltec putty matrix for a provisional.

On Tuesday, he had the extraction and implant placed. 

He drove over to my office immediately after that.  The periodontist also placed a provisional abutment (PEEK material).

I shortened the provisional abutment a bit and roughened it with a diamond.  I made sure I could seat the Siltec matrix without it hitting the abutment.  I packed the screw access hole in the abutment with Teflon tape.  Then I filled #9 in the Siltec matrix with Luxatemp and seated it for at least 3 minutes, allowing the material to lock on to the provisional. 

Pull the matrix off and this is left behind.  Not too pretty…. YET!

Next step is to cut an access to the screw through the provisional.  Remove Teflon. 

Unscrew and remove the provisional and abutment as one piece.

As you can see, the Luxatemp did not make it all the way down to the base of the abutment, leaving some voids.  Flowable composite to the rescue! 

Outside the mouth, I filled in the blanks with flowable composite, shaped and polished for a smooth emergence profile, ideal for soft tissue healing and supporting the papillae.

Screw it back in the mouth and make sure the soft tissues are being supported.  Add composite (outside the mouth) as needed.

Plug the screw access in the abutment with Teflon again, and seal over with composite.  Polish, stain, and glaze as needed to match the other teeth.  Make sure the provisional is completely out of occlusion in both centric AND excursions (lateral and protrusive).  That’s why the provisional is a bit shorter than the other central. 

Now wait for healing and integration.  Restore when ready!

Consider how daunting a proposition it is to tell a patient, “We’re going to take out your FRONT tooth and make a temporary.”  That’s some scary shit.  A back tooth?  No problem.  My VERY FRONT tooth?!?  No bueno!

But, if you can confidently create provisionals with this level of esthetics… You are a dental god!  It looks like it grew there!  It’s a huge builder of confidence in your patients.  Of course, you need to factor your time (and expertise) into the fee.  I charge a separate fee for the provisional.

I’ve written about similar cases before here.

And here.

Comment below!

This entry was posted in Case Presentation, Clinical Technique and tagged , , . Bookmark the permalink.

Leave a Reply

Your email address will not be published. Required fields are marked *