We have been placing implants in our practice since 1987. During that time, we have been privileged to see the many changes in techniques as well as materials. Perhaps the most important implant design changes in the last few years are:

• changes in the design of the implant fixture that gives a better emergence profile in esthetic areas
• variety in sizes of implant fixtures - both in width and length
• angled abutments that allow us to best place implant fixtures in quality bone
• Zirconium, or tooth-colored, abutments which give better esthetics in anterior replacement cases
• Atlantis or computer-designed custom abutments, providing the ideal platform on which to build a crown 

We continue to follow our implant cases, and have developed our own internal statistics, so that when we give you a recommendation, you can be sure it is based on our long term evaluation of our mutual patients. Over the years, dental implants have gone from being suggested as a way to "anchor" and give support to lower dentures, to an almost routine recommendation to replace any missing tooth. From an approach of never connecting an implant with natural teeth, we now have many successful bridges incorporating implants and natural teeth as abutments. Sinus grafting is routine. Split ridge techniques allow us to put implants into narrow ridges. And, with the new materials, we can often "collapse" the treatment time so that when we would previously have performed many serial procedures with long waiting times between, we can now shorten dramatically the time between implant placement and finished restoration. (Please see "Recent Cases in Implants, Using Trephine Drill and Osteotomes" for a recent case illustrating this technique.)

Do you remember that originally, patients with newly placed implants were left without any type of provisionalization for as long as two months - or more - before a removable temporary provisional would be placed. Now, no patient walks out of our office without having "teeth" in esthetic areas - unless, of course, that is their choice. Perhaps this is the single most important change in implant placement over these decades.

Immediate Implant Placement with Immediate Provisionalization

The ability to place implants into extraction sites is not new; but in many cases, recent advances have paved the way for immediate provisionalization. By placing an immediate provisional crown, we allow the patient to have an esthetic immediate replacement for the extracted tooth - without the need for a removable appliance (flipper). Another advantage is that placing an immediate provisional crown preserves the gingival profile and papillae around the missing tooth. When the final permanent restoration is placed, the emergence profile has been preserved, allowing a more esthetic final result.

Immediate provisional crowns can be placed when the implant has excellent primary stability in the extraction site. Normally, this means there needs to be at least 3 mm of bone apical to the extraction site, with a good quality of bone present. Even though the provisional crown can be placed immediately, it is kept out of occlusion to allow the implant to properly integrate into bone, and the patient is instructed that this provisional restoration is purely for esthetics and phonetics.

Even in those cases where it is not feasible to immmediately provisionalize an implant, we can often place the crown of the extracted tooth in a suck-down stent, giving the patient an immediate replacement for the missing tooth to serve until a more "permanent" provisionalization can be made.

Immediate provisional crowns can be placed for single tooth implants, and immediate provisional bridges can also be used when multiple implant placement is required to restore several missing teeth. These bridges serve to preserve gingival contours and provide the patient with an esthetic fixed provisional restoration during implant integration. (Please see "Recent Cases in Implants, Immediate Placement of Implants and Immediate Provisionalization" for a recent case illustrating this procedure.)