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DENTAL IMPLANTS

J Oral Maxillofac Surg62:1131-1138, 2004

Single Tooth Immediate Provisional

Restoration of Dental Implants:

Technique and Early ResultsMichael Block, DMD,* Israel Finger, DDS,

Paulino Castellon, DDS, and Denise Lirettle, RDH

Purpose: Patients desire efficient restoration of missing teeth. Immediate provisionalization of implantsat the time of placement can provide the patient with a tooth-like restoration. Our hypothesis is that

preoperative fabrication of the implant abutment and provisional restoration can provide successfulimmediate provisionalization of implants, if specific diagnostic criteria are used for patient selection.

Patients and Methods: This hypothesis is evaluated by prospectively following 74 implants thustreated for 6 months to 2 years. A technique is presented to illustrate a simple and reliable method toprovisionally restore a single tooth restoration. The method involves preoperative placement of animplant analog into a model, preparation of the abutment on the model, and fabrication of a provisionalcrown out of occlusion. At the time of surgery, the implant is placed according to the prescription of therestorative dentist, the surgeon places the abutment and provisional crown, and the final restoration isfabricated after the implant integrates.

Results: Seventy of 74 (94.6%) restorations have been successful with up to 2-year follow-up, which issimilar to single tooth implants treated using a 2-stage protocol.

Conclusions: Single tooth immediate provisionalization implants are effective techniques when spe-cific diagnostic criteria are used.

2004 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 62:1131-1138, 2004

Patients who receive implants may be candidates forimmediate provisionalization at the time of implantplacement. The restorative dentist can fabricate theprovisional restoration at chairside or before implantplacement. Chairtime for the dentist and patient is

less when the provisional restoration is fabricatedbefore implant placement. The provisional crown

provides a reliable method for developing the soft

tissue site of single tooth restorations. This report

documents a reliable and simple method for fabricat-

ing a provisional restoration before surgical place-

ment of the implant, used in consecutive cases that

have been prospectively followed.

Review of the literature reveals multiple reports on

successful fabrication of provisional restorations at

the time of implant placements, using chairside tech-

niques.1-10 The techniques use a modified or standard

abutment that is adjusted at chairside with a provi-

sional crown relined and left out of occlusion. Theauthors indicate their use of insertion torque as the

method to use to decide if immediate provisionaliza-

tion can be performed.5,9 The disadvantages of chair-

side techniques are increased chairside time for both

the dentist and patient and increased manipulation of

the implant by removing and replacing the abutment.

Gomes et al11 reported 1 case using a preoperative

model to fabricate a provisional implant restoration

out of occlusion. They placed an abutment into an

analog on a model and fabricated a provisional crown

similar to the technique described in this article. How-

Received from Louisiana State University, School of Dentistry, New

Orleans, LA.

*Professor, Department of Oral and Maxillofacial Surgery.

Professor and Director of Residency Training, Department of

Prosthodontics.

Assistant Professor, Department of Prosthodontics.

Research Associate, Department of Oral and Maxillofacial Sur-

gery.

Address correspon dence and reprint request s to Dr Block:

Department of Oral and Maxillofacial Surgery, LSU School of

Dentistry, 1100 Florida Ave, New Orleans, LA 70119; e-mail:

[email protected]

2004 American Association of Oral and Maxillofacial Surgeons

0278-2391/04/6209-0016$30.00/0

doi:10.1016/j.joms.2004.05.115

1131

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ever, details on additional cases and site-specific mod-ifications were not included.

Rocci et al12 reported a technique using tissuethickness mapping to determine the location of theunderlying bone. This information was transferred toa model and the tissue was replicated in silicone.Implant analogs were placed into the model and then

the provisional restoration fabricated out of occlu-sion. Ninety-seven implants were placed in 46 pa-tients with a 91% success rate.

Petrungaro13 reported a larger, diverse series ofimplants immediately provisionalized out of occlu-sion. The cases included single edentulous sites, ex-traction sites, multiple implant restorations, and im-mediate provisionalization of implants immediatelyplaced into sinus grafts. He reported a success rate of

97.8% with minimal details on follow-up methods.This team has followed 74 implants for 6 months to

2 years using the technique described later. The ex-

periences indicate that with careful planning and anunderstanding of potential need for modification ofthe provisional crown at the time of surgery, preop-erative fabrication of the provisional restoration canresult in efficient treatment of the patient.14

Based on these experiences, our team has estab-

lished diagnostic criteria for selecting immediate pro-visionalization for the patient, which include:

1. Sufficient bone height, width, and density forstability of the implant at time of placement. Thechoices of implant length and width are similar

to those considerations that would be used if theimplant was used in a 2-stage method. This teamuses 20 N-Cm implant insertion torque as the

deciding factor for choice of using the implantfor immediate provisionalization or using a2-stage approach.

2. Sufficient mesial-distal, buccal-lingual, and in-terocclusal space for placement of an anatomicrestoration. If the space is less than 6 mm or ifthe opposing occlusion interferes with the pro-

visional restoration, then a 2-stage technique isused rather than the immediate provisionaliza-

tion method.

3. The patient should have the expected compli-ance with the understanding to limiting chew-ing to only the softest foods, preferably liquids,for up to 8 weeks. In addition, patients withexcessive parafunctional habits are not provi-sionally reconstructed.

Once the patient has been confirmed to be a can-

didate for immediate provisionalization, mandibularand maxillary impressions are made and a periapicalradiograph is obtained at the implant site. The preop-erative laboratory phase is completed and the patient

is scheduled for surgery. At the time of implant place-ment surgery, the surgeon should have the abutment,retaining screw, provisional crown, and models withthe analog in place.

Our hypothesis is that preoperative fabrication ofthe abutment and provisional restoration can providesuccessful immediate temporary restoration of im-

plants. This hypothesis is evaluated by prospectivelyfollowing 74 implants thus treated for 6 months to 2

years. Literature review indicates that single toothrestorations, with a delayed approach allowing forintegration of the implant before placing the finalrestoration, have success rates between 94% and100%, depending on specific implant protocols andthe nature of the implant site.15-18

Report of a Case

Our patient is a candidate for an immediate provi-sionalization of a second premolar restoration (Fig 1).Impressions were made of the maxilla and mandible,

and a stone cast was poured. A wax-up of the missing

tooth was made, and the cast was duplicated. A vac-uum formed stent was made over the duplicated cast,and the missing tooth site was filled with resin andthen returned to the master cast. The position of theimplant to be placed was marked, and a hole wasdrilled through the stent and into the stone cast. Thestone above the analog is shaped to allow for anemergence profile of the provisional restoration.

Delineation of the crestal level of the alveolar ridgein relation to the cementoenamel junction of theadjacent teeth was established from a periapical ra-diograph. The vertical position of the implant analog

FIGURE 1. Edentulous mandibular right second premolar site withwide band of keratinized gingiva on crest.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

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in the model was then marked on the cast, anticipat-ing approximately 1 to 2 mm of gingival thickness.

An analog of the implant to be placed is positionedin the hole, with its vertical position placing the topof the implant at the anticipated level of the bone (Fig2). The analog is cemented with cyanoacrylate glue orcan be secured to the model with stone or plaster.The analog should be positioned with its internal orexternal retentive feature, such as the flat surface of ahex, facing the labial. When the implant team main-tains consistent orientation of the analog, there willbe less variability of implant orientation, better posi-

tioning of the prepared abutment and temporarycrown, and better communication between membersof the implant team.

A prepable abutment is placed in the analog andprepared in the laboratory to allow for placement of aprovisional crown. The abutment margins should beat the level of the gingiva to avoid deep subgingivalmargins and to allow for ease of cleaning after the

implant and provisional crown are placed. In addi-tion, a small groove or dot should be placed on thelabial surface of the abutment to allow for accurateorientation of the abutment at the time of surgery.

The labial groove will also provide additional reten-tion of the provisional crown. The prepared fixedabutment should be left with a rough surface to allowfor retention of the temporary cement to the provi-sional crown. The abutment preparation will result ina shorter abutment than the final abutment, to allowfor 1 to 2 mm of interocclusal space between theprovisional crown and the opposing restoration (Fig3). This is important to avoid loading of the implant

during the immediate healing period. These crownsare provisional and are not placed in occlusion.

After the abutment has been prepared, either ahollow denture tooth or a hollow shell crown isrelined over the abutment with the use of the oppos-ing model (Fig 4). The provisional crown is adjustedto avoid occlusion. It is useful to leave 0.5-mm to1-mm space at the mesial and distal marginal ridges to

FIGURE 3. Abutment prepared on model with margins at level ofgingiva. Note small labial groove for orientation and rough surface ofabutment to aid in crown retention.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

FIGURE 5. Occlusal view of provisional crown with occlusal accessto abutment retaining screw.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

FIGURE 2. Analog of implant placed into model with top of implantat level of bone approximately 1 mm inferior to adjacent teeth cemen-toenamel junction.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

FIGURE 4. Provisional crown made from hollow shell crown relinedwith acrylic. Note margin smoothed and polished and 1-mm space atmarginal ridges.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

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allow for surgical flexibility at the time of the place-ment and to prevent micromotion on the implant dueto movement of the adjacent teeth. The provisional

crown margins are smoothed and polished to opti-mize the soft tissue response.A hole is made in the occlusal aspect of the provi-

sional crown to allow for access to the retaining

screw, which secures the abutment to the implant,and to allow for excess cement to vent (Fig 5). Thisprovides the restorative dentist the option of takingan impression of the provisional crown to avoid theuse of transfer copings. The abutment retaining screwis removed, and the abutment and provisional crownare removed as 1 piece. The abutment and crown as1 unit are placed onto an analog of the appropriateimplant system. This is then placed in the impression,

which is poured into stone. The transfer of the im-plant and the subgingival sulcus is very accurate andavoids the use of a transfer coping and resin placedinto the gingival sulcus. Traditional techniques using

transfer copings can also be used but lose 1 to 1.5 mm

of buccal-lingual width.14

At the time of implant placement, the surgeon willhave the prepared provisional abutment, provisionalcrown, and the screw to retain the abutment into theimplant (Fig 6). In addition, the surgeon will receive astent that will have full arch coverage to guide thesurgeon at the time of placement (Fig 7). It is useful

for the surgeon to also have the model of the analog

FIGURE 6. Retaining screw, prepared abutment, and provisionalcrown as delivered to surgeon on day of implant placement.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

FIGURE 7. Surgical guide stent with full arch coverage.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

FIGURE 8. Surgical guide pin placed into implant preparation site to

confirm accurate implant placement.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

FIGURE 9. The implant has been placed flush to the bone.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.


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in place to help guide implant placement and orien-tation.

The design of the incision takes into considerationthe need to transpose keratinized gingiva to the labialsurface of the implant restoration. In sites with anexcess of 6 mm of keratinized gingival present, atissue punch can be used to place the implant and

provisional restoration. In most molar sites or in sitesthat have had prior surgery with loss of some keratin-ized gingiva, the incision is made across the crestcombined with anterior and posterior releasing inci-

sions (Fig 8). A full-thickness mucoperiosteal reflec-

tion is made. The tissue punch technique is useful foranterior sites.

The stent is placed and the initial preparation drillsare used. A guide pin is placed through the guidestent to indicate an accurate implant position (Figure8). The implant preparation is completed, and theimplant is placed with the orientation of the internalor external retentive features matching the orienta-tion of the analog in the model. The implant should

be flush or slightly supracrestal (Fig 9). The abutmentshould be placed passively without interference withsoft or hard tissue (Fig 10). If present, bony interfer-

ences will need to be removed from the platform ofthe implant to allow for the passive placement of theabutment into the implant. If the abutment is notplaced passively, excessive pressure can be trans-ferred to the threads, increasing the chance of im-

FIGURE 10. The previously prepared abutment is placed passively.After the occlusal space is confirmed, a small piece of cotton is placedbefore cementation of the crown.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

FIGURE 11. After the crown has been tried in place and the lack ofocclusion has been confirmed, the crown is cemented with temporarycement.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

FIGURE 12. The gingiva is sutured to transpose the keratinizedgingiva to the labial surface of the provisional restoration.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

FIGURE 13. This photograph shows the excellent soft tissue responsewithin 2 weeks of implant placement.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

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plant failure. The interocclusal distance is confirmed

at this time. If the abutment has not been shortenedsufficiently on the model or if the implant is placedmore superficially than planned, the abutment mayhave to be adjusted with a high-speed drill out of themouth. Then the corresponding provisional crownmay need a reline at time of insertion. With accuratemodel preparation, the incidence is less than 10%.

The abutment screw is hand tightened rather than

torqued because it is difficult to place countertorquepressure on the abutments while a torque procedureis performed. The provisional crown is tried in posi-tion (Fig 11), and after the margins are confirmed to

be acceptable, the crown is cemented after place-ment of a small piece of cotton into the abutment toprotect the screw from being clogged with temporarycement. After the provisional crown is cemented andthe cement is cleaned from the margins, the gingiva issutured (Fig 12). The keratinized gingival tissue that

was previously on the crest is against the labial sur-

face of the provisional crown. Resorbable sutures areused both interproximally and along the vertical inci-sions.

POSTOPERATIVE MANAGEMENT

Patients are instructed to avoid chewing solid, tex-tured food for 8 weeks. They are advised to chew onthe opposite side of the mouth and avoid loading ofthe implant restoration. Postoperative antibiotics and

pain medication are prescribed. Diluted chlorhexi-dine solution is started 1 week after implant place-ment.

The gingiva heals quickly and facilitates the effi-cient restoration of the patient (Figs 13, 14). After anappropriate time for integration of the implant, thefinal impression is taken using either the provisionalcrown or transfer coping method. The final abutmentis prepared to place the final crown margins to within

1 to 0.5 mm of the gingival margin (Fig 15). At thispoint, the final crown is fabricated and cemented (Fig16).

Patients and Methods

Using the diagnostic criteria given earlier, 63 pa-tients have had the described provisionalization pro-tocol used for 74 implants placed in locations de-

scribed in Table 1. Three implant systems were usedin this prospectively followed series of patients:Centerpulse (Carlsbad, CA)Spline (hydroxyapatite-

FIGURE 14. At the time of impression, the abutment-crown complexis removed, and the formation of a well-defined sulcus is visible.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

FIGURE 15. In the laboratory, a new abutment is prepared to finalform.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.


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coated threaded) and Tapered Screw Vent; and Im-plant Innovations (Palm Beach Gardens, FL)internalconnection Osseotite surface. All data for the 3 sys-tems are summed.

All restorations were fabricated under the supervi-sion of the prosthodontic authors, and all surgicalprocedures were supervised by the surgical author.

All patients were prospectively followed every 4weeks after implant placement until the final impres-sion was taken, and then every 6 months after deliv-ery of the final restoration, with standardized radio-graphs taken serially. Bone level data will be reportedin a separate study. For this report, success isachieved if the implant received a functional restora-tion, with crestal bone loss less than 2 mm beyond thefirst thread of the implant, and no evidence of pain

during function.

Results

Four implants (3.1%) failed before placement of thefinal restoration. One central incisor was not left outof occlusion and the patient did not comply by wear-ing her bite opening device; thus she occluded on thecentral incisor provisional restoration. The implant

loosened within 1 week and was eventually removed.One lateral incisor implant was placed immediatelyafter extraction of a tooth, became infected, and wasremoved 10 days after placement. The lateral incisorimplant was replaced with another implant after theinfection resolved. One molar implant did not inte-

grate, and one molar implant became infected andwas removed. The site with the previous infectionhad a second implant successfully placed using a

2-stage protocol. No implants failed after final resto-ration. Follow-up ranges from 1 to 5 years postprovi-sionalization with no cases lost to follow-up throughthe present time period. Because of the small sample

size, a cumulative survival table analysis was not per-formed since the sample size was not sufficient to

achieve 95% power and no concurrent controls (2-

stage protocol) were included in this series of pa-

tients.

At the time of implant placement, several situations

were encountered.

1. The implant was placed with a different labial

flare than anticipated because of variations of

bone morphology (5 of 74, or 6.67%). The pro-

visional restoration required revision at chair-side by adjusting the contour and resulted in an

adequate restoration.

2. The abutment was too close to the opposing

occlusion, requiring adjustment of the abutment

(2 of 74, or 2.7%). This occurred if the implant

analog was placed too deep into the model, and

the implant was then placed flush with the

bone, resulting in the abutment needing adjust-

ment. This was accomplished at chairside after

removing the abutment from the implant.

3. The provisional crown needed occlusal adjust-

ment to keep it out of occlusion (21 of 74, or28.3%).

4. The provisional crown needed removal of a con-

tact to allow for passive placement (15 of 74, or

20.2%).

5. The provisional crown became loosened and

required recementation (15 of 74, or 20.2%).

This occurred because of the lack of ideal reten-

tion by an abutment, which often was shorter

than the final restoration. By placing a labial

groove and leaving the abutment surface rough,

cement retention was improved.

FIGURE 16. The final crown cemented in place approximately1 month after the final impressions were taken.Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

Table 1. LOCATION OF IMPLANTS IMMEDIATELYPROVISIONALIZED AND FAILURES

Location

No.Immediately

Provisionalized

No.Failed andRemoved

Mandible 40 Total 2Anterior incisors/canines 6 0Premolars 9 0Molars 25 2

Maxilla 34 Total 2Central incisors 5 1Lateral incisors 6 1Canines 3 0Premolars 16 0Molars 4 0

Block et al. Single Tooth Provisional Restorations. J Oral Maxil-lofac Surg 2004.

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Discussion

The decision to immediately provisionalize a dental

implant involves excellent cooperation of the surgeonand restorative dentist. Using the described tech-

nique, the team should communicate to ensure

proper patient selection, proper placement of the

analog in the model, and delivery of a modified abut-ment and provisional that can be efficiently placed by

the surgeon.For many cases, the surgeon may need to drill the

hole into the diagnostic model until the method has

been well experienced by the team. If the implant is

placed at the wrong depth, interference with theopposing occlusion can occur or the implant restora-

tion may be extremely short. If the restoration is too

short and is an aesthetic problem, the provisional willneed a reline at the time of abutment insertion.

The restorative dentist or laboratory technician

may provide a refined, ideal type of preparation.The ideal abutment preparation, especially if highlypolished, will limit flexibility if the implant is angled

slightly different than planned. Angulation alterations

by the surgeon may occur to avoid exposing theimplant through bony undercuts or unknown angula-

tions of the cortical plates. To avoid the problem of

lack of flexibility, this team suggests that the abut-

ment be slightly overprepared with labial grooves andthe surface of the abutment left in a roughened state.

The presence of the grooves and roughened surface

will enhance retention of the provisional crown.If the implant angulation results in an unaesthetic

situation, the provisional crown may need to be

adjusted by the restorative dentist by selective

grinding, polishing, and, in rare cases, relining ofthe provisional restoration. To anticipate the need

to have access to the margins of the abutment, it is

suggested to have the margins of the provisional

within 0.5 mm of the gingival margin, avoidingdeep margins.

The surgeon should be prepared to adjust the me-

sial and distal contact of the provisional crown ifnecessary to avoid direct contact and inadvertent

loading of the implant from the adjacent teeth. The

surgeon should always check the occlusion of therestoration and as necessary reduce the occlusal sur-face to keep the provisional restoration free from

occlusal load from the opposing dentition.

One advantage of using this provisional restorationtechnique is the development of the gingival sulcus.

The provisional restoration will shape the gingival

sulcus, providing the restorative dentist with less

needed manipulation of the implant sites soft tissuemorphology. The maturation of the soft tissue allows

for immediate placement of the final restoration afterthe implant has integrated. The soft tissues have ap-peared stable in form after they have healed from theimplant surgery.

References

1. Kupeyan HK, May KB: Implant and provisional crown place-ment: A one stage protocol. Implant Dent 7:213, 19982. Kan JY, Rungcharassaeng K: Immediate placement and provi-

sionalization of maxillary anterior single implants: A surgicaland prosthodontic rationale. Pract Periodontics Aesthet Dent12:81, 2000

3. Locante WM: The nonfunctional immediate provisional in im-mediate extraction sites: A technique to maximize esthetics.Implant Dent 10:254, 2001

4. Proussaefs P, Lozada J: Immediate loading of single root formimplants with the use of a custom acrylic stent. J Prosthet Dent85:382, 2001

5. Hui E, Chow J, Li D, et al: Immediate provisional for single-tooth implant replacement with Branemark system: Prelimi-nary report. Clin Implant Dent Relat Res 3:79, 2001

6. Andersen E, Haanes HR, Knutsen BM: Immediate loading ofsingle tooth ITI implants in the anterior maxilla: A prospective

5-year pilot study. Clin Oral Implants Res 13:281, 20027. Schiroli G: Immediate tooth extraction, placement of a tapered

screw-vent implant, and provisionalization in the esthetic zone:A case report. Implant Dent 12:123, 2003

8. Groisman M, Frossard WM, Ferreira HMB, et al: Single-toothimplants in the maxillary incisor region with immediate provi-sionalization: 2 Year prospective study. Pract Proced AesthetDent 15:115, 2003

9. Malo P, Friberg B, Polizzi G, et al: Immediate and early functionof Branemark system implants placed in the esthetic zone: A1-year prospective clinical multicenter study. Clin ImplantDent Relat Res 5:37, 2003 (suppl 1)

10. Calandriello R, Tomatis M, Vallone R, et al: Immediate occlusalloading of single lower molars using Branemark system wide-platform TiUnite implants: An interim report of a prospectiveopen-ended clinical multicenter study. Clin Implant Dent Relat

Res 5:74, 2003 (suppl 1)11. Gomes A, Lozada JL, Caplanis N, et al: Immediate loading of asingle hydroxyapatite coated threaded root from implant: Aclinical report. J Oral Implantol 24:159, 1998

12. Rocci A, Mertignoni M, Gottlow J: Immediate loading in themaxilla using flapless surgery, implants placed in predeter-mined positions and prefabricated provisional restorations: Aretrospective 3-year clinical study. Clin Implant Dent Relat Res5:29, 2003 (suppl 1)

13. Petrungaro PS: Immediate implant placement and provisional-ization in edentulous, extraction, and sinus grafted sites. Com-pendium 24:95, 2003

14. Potiket N, Finger I, Block MS: Use of provisional restoration forfinal impression technique. J Prosthet Dent (submitted forpublication)

15. Anderson B, Odman P, Lindvall AM, et al: Cemented singlecrowns on osseointegrated implants after 5 years: Results from

a prospective study on CeraOne. Int J Prosthodont 11:212,1998

16. Jemt T, Laney WR, Harris D, et al: Osseointegrated implantsfor single tooth replacement: A 1-year report from a multi-center prospective study. Int J Oral Maxillofac Implants6:29, 1991

17. Schmitt A, Zarb GA: The longitudinal clinical effectiveness ofosseointegrated dental implants for single-tooth replacement.Int J Prosthodont 6:197, 1993

18. Ekfeldt A, Carlsson GE, Borjesson G: Clinical evaluation ofsingle tooth restorations supported by osseointegrated im-plants: A retrospective study. Int J Oral Maxillofac Implants9:179, 1994


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