口腔种植学是口腔教育中较新的学科。虽然现在我们都有共识，种植⽛相关的理论知识，⽆论是治疗⽅案的规划，还是后期的随访和维护，对于每⼀个职业⽛医都⾮常重要。然⽽，在当下全球的口腔医学本科培养体系中，它的覆盖程度还远远落后于其重要性。 在此背景下，香港大学口腔医学院联合⾹港⼤学的线上教育专业团队，历时⼀年有余，设计并制作了这门为期五周的⽹络公开课，旨在传播以循证医学为基础的，客观、全⾯的⽛种植学相关知识。这门课程⾯向全球，双语教学，完全免费。学员将在20 多位全球领先的种植学专家的带领下，完成五个模块，系统地学习⽛种植学。
种植体支持下的过渡义齿修复
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En provenance du cours de The University of Hong Kong
口腔种植学 （Implant Dentistry）
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À partir de la leçon
种植牙的修复
在第四模块，我们将回顾种植体修复的主要途径和选择：单冠，固定桥或义齿。我们将讨论重要的临床选择：螺丝固位还是粘结固位，种植水平还是基台水平。我们还将研究临床应用的具体，学习种植体的取模技术，准备临时修复，以及如何利用这些技巧，达到最佳的美学效果。
Rencontrer les enseignants
Nikos MattheosClinical Associate Professor in Implant Dentistry
The University of Hong Kong
Welcome to the lecture
on implant supported provisional restorations.
In this series,
we will discuss about the significance of
placing provisional restorations in implant dentistry
in daily practice.
First of all, what is the definition?
We know from dental school that a provisional restoration
can be fabricated of composite or acrylic material.
The provisional restorations on implants can be supported
by a plastic or a metal abutment.
These restorations are serving as temporary solutions
until the implant has achieved osseointegration.
Why are provisional restorations important?
The ability to accomplish a successful implant placement
followed by an implant-supported restoration
in the aesthetic area
relies on the knowledge of critical surgical
and prosthetic parameters.
Creating a favourable aesthetic result
in the three-dimensional peri-implant
and soft tissue surroundings
is not only dependent on bone reconstruction techniques
and implant positioning,
but also highly dependent
on a well-performed tooth-like restoration.
In this context, fabricating a precise temporary crown,
also called provisional,
becomes an extremely important step
in the contemporary implant-restorative dentistry
where patients are demanding more and more aesthetic results
in all phases of their treatment.
And we're also trying to minimize
the number of surgical procedures performed.
When can we place them?
This moment relies on the implant placement.
Ideally, we would like to place them
simultaneously with the implant.
In this way, we minimize the number of surgical procedures
the patient will go through.
Sometimes if the implant doesn't have
appropriate primary stability,
we need to wait until the implant is osseointegrated
in order not to compromise this process.
Some authors prefer to condition the soft tissue
before the implant placement with the use of a pontic,
especially if that particular area
received a bone regeneration procedure.
There are different techniques and materials
that we have to take into consideration.
Choosing the appropriate combination
of materials and methods
for the fabrication of a provisional restoration
with high quality
is crucial to guide the tissue and predict
the final aesthetics.
A precise technique provides restoration
that fulfill the peri-implant tissue
and aesthetic requirements
needed to achieve an excellent final restoration.
We can have screw retained
or cement retained provisional restoration.
For the screw retained ones,
the type of abutment can be either plastic or metal.
For the crown, we can either use a prefabricated shell
that we can fill in with acrylic,
we can duplicate a wax up
and have an acrylic shell done in the lab,
or we can use a denture tooth
that we can adopt and reline with acrylic.
For this presentation, we will use the last technique,
the denture tooth technique,
as this provides higher aesthetic results.
There are some key principles
that we need to take into consideration.
Implant stability, measured by ISQ.
This is important because an implant that is spinning
and will receive a provisional restoration immediately
has high chances of failure.
Occlusion.
This can also affect the osseointegration of the implant
as if the forces are high
can produce micro-movements that later on
will jeopardize the osseointegration.
Ideally, we release the provisional restoration
and is out of any occlusion forces
in all lateral and protrusion movements.
Space maintenance.
For an area that will receive the implants later on,
we do know that there is a risk for malposition of the teeth
due to tooth migration or extrusion.
Provisional restoration can be a good solution
to help maintain the space
until the final restoration is in place.
Stability of the soft tissue.
Dr Chu and Dr Tarnow worked extensively
on providing more information
regarding the soft tissue stability
during various moments of connecting the implant
with the provisional restoration,
specifically, looking at the papilla preservation.
Healing time - soft tissue conditioning.
For tissue re-modeling,
provisional implant crowns should be used
for approximately three months
prior to the final restorative procedure.
This can vary based on the tissue biotype of the patients.
Interdisciplinary planning.
The planning of such a procedure
should be done interdisciplinary,
taking into account the position of the final prosthesis
and the location of the implant placement.
Don't hesitate to ask a prosthodontist colleague
for any questions.
Patient compliance.
I always tell my patient, "This is team-work.”
I will try my best to give you the best treatment,
but please take care of it at home
and follow all the post-operative instructions.
Let's review together a clinical case.
We can notice on this slide, the edentulous area -
maxillary central incisor” is missing
and is at the moment restored with a
removable partial denture, also called ‘the flipper”.
A CBCT was exposed,
and in order to evaluate the ridge morphology
and digitally plan the implant.
This slide identifies the need for bone augmentation
during the implant placement.
This slide identify basic steps of the procedure.
Flap elevation,
implant placement,
adding bone graft and membrane.
For this particular case,
we used a collagen membrane
because it will impede the invagination
of the epithelial cells
and also provide a better quality of the regenerated bone.
Primary closure, also as you can see, very important.
Since the patient needed a fixed restoration
on the adjacent tooth,
we used that as an asset to start soft tissue re-modeling
around the implant area.
You can see that we reinforced the provisional bridge
using a wire for the pontic side.
We made sure to create a convex profile
condition the inter-proximal papilla.
Implant uncovery -
minimal exposure,
and then replacing the cover screw with a healing abutment.
Starting to prepare the provisional,
we place the temporary abutment,
we expose a radiograph,
make sure it's seated completely.
We adjust the abutment based on the height available
and then we're starting to prepare the veneer
of the denture tooth.
We reline it with acrylic
and then we make sure we respect
critical and subcritical contours,
concepts that were presented by Dr. Su and Dr. Weisgold.
As mentioned earlier, polishing is very important,
and leave some space for soft tissue
to crawl and fill in the space left.
This is a direct comparison
between before and after treatment,
and you can appreciate
the amount of soft tissue conditioning obtained
with the use of provisional restorations.
This slide identifies a final implant-supported prosthesis.
There are some future thoughts
that we might want to consider.
The research has evolved in a manner
that more and more studies that take into consideration
patient experiences and expectations are now valued.
The topic of patient centred outcome research
will certainly look into ways
to evaluate the aesthetics achieved
with provisional restorations.
In order to facilitate an excellent aesthetic outcome,
interdisciplinary collaboration should be highly considered
as part of daily practice activities.
That's all we wanted to discuss
about the provisional restorations in implant dentistry.
Thank you for your attention.
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