PLACEMENT METHODOLOGY.
Implant placement is carried out by using the disposable 1.5-mm twist drill in the regular implant handpiece with external irrigation. The burs are demarcated with laser etching and are long enough to approximate the 14.0-mm preparation in the bone.
After the initial receptor site has been created, one of the paralleling pins is positioned in the same manner used for positioning and preparing conventional implants. With each successive receptor site preparation, an additional paralleling pin is placed. Upon completion of the osseous preparations, the assembly of the insertion wrench into the ratchet arm is carried out.
The immediate provisional implant’s sterile packaging is opened, and the abutment head is placed into the insertion wrench. The implant is then carried to the osseous receptor site, aligned within it, and ratcheted into position until the implant shoulder is even with the crest of the alveolar ridge. If dense bone is encountered and the immediate provisional implant can only be partially seated, the retrieval tool may be used in conjunction with the ratchet to remove the implant. The author suggests that a 2-mm twist drill then be used to drill through the dense outer cortical bone. The implant can then be reinserted.
When all the implants have been placed, the paralleling pins can be inverted so that the wide end of each pin telescopes over the abutment head. This provides an elongated projection of the alignment of each implant relative to the others. If an alignment adjustment is needed, the bending tool in conjunction with the stabilizing tool can be used to bend the implant at the neck.
When this has been accomplished, the paralleling pins can be removed and the mucoperiosteal flaps repositioned and sutured with the suture material and design of choice. The author prefers a single interrupted or figureof- eight suture placed completely around the implant neck to evert the margin of the soft tissue. If interrupted sutures are used, these should be in as close proximity to the mesial and distal of the implant neck as possible to tightly adapt the soft tissues to this region of the implant.
When the case has been completed, attention can then be turned to fabricating the temporary prosthesis. The procedure can be carried out in one of several ways in the edentulous jaw. If the patient has an existing denture, the denture flanges can be removed and the tissue-bearing surface of the denture can be hollowed out by using appropriate acrylic-cutting burs. The transfer copings are seated on the abutments. Autopolymerizing methylmethyacrylate is then placed into the denture. When the denture is positioned over the copings, the patient is asked to bite into centric relationship. When the acrylic is set, the prosthesis is removed, excess margins are trimmed, and the denture is polished and checked for an appropriate fit. There should be no impingement on the surrounding tissues. The prosthesis can then be secured with Improv temporary cement (Nobel Biocare), or the patient can wear it as a removable appliance.
One alternative to this technique is the use of a processed acrylic type of prosthesis. This can be generated from an Omnivac (Dentiform, Harvey Lake, PA) suck-down made on a study cast of a diagnostic wax-up or duplicated from an existing prosthesis. Once again, when the case has been completed surgically and the soft tissue suturing has been finalized, autopolymerizing acrylic can be placed into the prefabricated splint. It can then be positioned over the previously placed copings, and the same method of pickup as described above can be carried out. As with the previous method, the prosthesis can be cemented or worn as a removable appliance.
A third option is the use of a direct procedure for either partially or fully edentulous patients. Once again, at the completion of the surgery, copings are placed on the implants. An impression is carried out using a lightbodied material, and the copings are picked up in the impression. A bite registration of the jaw relationship must be taken for this type of appliance. After the retrieval of the impression from the oral cavity, the immediate provisional implant analogs are placed into the copings in the impression and the master cast is fabricated. When this is done, the model is separated from the impression and mounted on a semi-adjustable articulator. The laboratory can then fabricate the prosthesis on the mounted model. When the prosthesis is completed, it can be cemented into place using Improv cement (Nobel Biocare) or it can be used as a removable appliance.
At the second stage (uncovering of the implants), the patient is anesthetized with local infiltration anesthesia. An incision is not necessary for removal of the immediate provisional implants. Instead, the ratchet arm and inserting tool are simply used in the reverse mode, and the immediate provisional implants are backed out of position.

CASE REVIEW.
As of the writing of this article, the author has completed 12 cases using a total of 53 immediate provisional implants. This series included four male and eight female patients. The average age was 59.5 years. In seven cases, the provisional implants were placed in the full-arch mandible. Five cases were full-arch maxillary reconstructions.
The average number of immediate provisional implants used per case was 4.4. The immediate provisional implants were in place for an average duration of 4.58 months. In one maxillary case (case No. 2), one immediate provisional implant was removed prematurely because of mobility and functional discomfort. One immediate provisional implant in a mandibular case (case No. 8) was osseointegrated at Stage II surgery. A small incision was made, the mucoperiosteal tissues were reflected, and the implant was cut at the crest of the ridge with a high-speed bur and handpiece. The implant body was left in place with no consequences or complications. It remained as a ridge-maintenance device. All patients are advised preoperatively that this situation can occur.

SUMMARY.
The immediate provisional implant system has made a considerable difference within the framework of the author’s practice, where increasing consumer awareness and quality-of-life issues have been evident for at least the past five years. Patients today are not willing to go without prosthetic appliances either in the immediate postoperative period or over the course of the six, twelve, or eighteen to twenty-four months that it takes to complete some of the more sophisticated and complex cases.

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