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Patients’ esthetic demands andexpectations are becoming

greater every day. The clinicianmust be able to deliver uncompro-mised esthetics along with idealfunction following implant surgery.

An implant that is osseointegrateddoes not always have esthetic suc-cess.1 To be considered successful,an implant-supported restorationmust achieve a harmonious bal-ance between functional, esthetic,and biologic imperatives. This concept has resulted in the devel-opment of “restoration-drivenimplant placement,” in whichimplants are positioned in relation

to anticipated requisites of therestorative phase rather than theavailability of bone.2

If there is not adequate bone avail-able where the implant must beplaced, alternative procedures suchas bone augmentation must be per-formed. Since the implant replacesthe root of the missing tooth, thetransition between the properly sizedimplant and the anatomic crownmust be harmonious to establish anesthetic emergence profile.3

To achieve natural soft tissueesthetics, the contour, height, andwidth of the gingiva at the implant

site must correspond to the softtissues that surround the adjacentteeth. Adequate bone must existfor placement of the implant,along with proper soft tissue fram-ing that consists of interproximalpapillae and an adequate zone ofattached gingiva.3

A patient’s goal is not just success-ful integration but being able tofunction and have an estheticrestoration. Since esthetics in theanterior region is critical, the use ofthe patient’s natural tooth as a pro-visional allows the tissue to heal inthe exact cervical contour andemergence profile of the definitive

*Adjunct professor, Department of Operative Dentistry, University of Iowa College of Dentistry, Iowa City,and private practice, Des Moines, IA, USA

Predictable Periimplant Gingival Esthetics: Use of the Natural Tooth as a Provisional following Implant Placement

ROBERT C. MARGEAS, DDS*

ABSTRACT

Maintaining the interdental papilla and bone height following implant placement has been achallenge for the restorative dentist. Bone resorption following anterior tooth extraction is com-mon and often compromises the esthetics of the final restoration. The tissue must be maintainedduring the surgical and healing phases to achieve an esthetic outcome. Using the patient’s naturaltooth as a provisional can help maintain the volume and support the papilla. This articledescribes a technique to achieve maximum esthetics and preservation of tissue following toothextraction and implant placement.

CLINICAL SIGNIFICANCE

By using the patient’s extracted natural tooth, the tissue should maintain itself with minimalrecession. This will allow for a more esthetic outcome.

(J Esthet Restor Dent 18:5–12, 2006)

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prosthesis. Immediate placement ofthe extracted natural tooth crownfollowing implant placement willmaintain the volume and profile ofthe soft tissue contour.4

Clearly, immediate implantation inextraction sites can no longer beconsidered an experimental tech-nique. Numerous studies haveshown short- and medium-term sur-vival rates that are comparable tothose with conventional techniquesinvolving delayed implantation.5,6

Defining a strict protocol is impera-tive to produce consistent results.As outlined in his report of14 cases, Wohrle immediatelyloaded only those implants thattorqued to 45 Ncm or more.7 Simi-larly, Malo and colleagues, usingmachined-surface implants,required an insertion torque of40 Ncm.8 Although 40 Ncm is nec-essary during immediate loading, itis not sufficient to establish a per-fect diagnosis of stability. The suc-cess of the immediate implantplacement procedure depends onthe primary stability of the implant,attained by drilling the bonebeyond the extraction site. It is notearly loading that creates the effectof fibrosis encapsulation but,rather, micromovements at thebone-implant interface resultingfrom inadequate primary stability.9

In both studies the occlusion wasprotected by adjacent teeth. All

occlusal, working, and non-working contacts were eliminated.

Recession following tooth removalpresents a unique restorative chal-lenge. The most difficult area topreserve is the papilla. We must doeverything possible to maintain thevolume of tissue and preventshrinkage. The most effective wayof maintaining papilla and soft tis-sue height is to prevent its loss atthe time of extraction. The gingivalarchitecture must be maintainedand supported immediately follow-ing extraction. This requires a pre-cise surgical technique that does notremove interproximal or facialbone. The extraction must be asatraumatic to the tissue as possible.In the ideal situation, incising of thepapilla should not occur.

Flapless surgery is more difficultbecause of the lack of visibility ofthe bone level. Sometimes theimplant can be placed deeper than isideal owing to limited visual access.

Critical to the preservation of tis-sue height is control of the gingivalembrasure at the time of extrac-tion. If the embrasure space is notfilled with a provisional that isequal in volume to that of theextracted tooth, the papilla andsurrounding tissue will lack sup-port, causing the gingival scallop toflatten and the interproximalpapilla to recede.10

Before extraction of the tooth, thegingival form and bony architecturemust be evaluated. If the tissue andbone are acceptable, then the objec-tive is to preserve as much of theoriginal form as possible. If there isfacial bone loss, a degree of reces-sion can be expected. The bone isneeded to maintain and support theoverlying tissues. The predictabilityof treatment is also influenced bythe thickness of the periodontiumas thicker tissues have a reducedtendency to recede.

This article presents a technique tominimize the duration of treatmenttime and preserve the hard and softtissue contours. This procedure alsoeliminates the necessity of a remov-able provisional prosthesis as itinvolves immediate placement andthe provisionalization of a single-stage implant using the patient’sextracted tooth. Although a remov-able partial denture could be usedas a provisional restoration, there isa greater risk of effecting tissuechanges owing to the movement ofthe prosthesis. When incorporatingthis current procedure, the patientmust be compliant and understandthat no occlusal force can beapplied on the provisional.

CASE REPORT

A 50-year-old male presented withapical resorption and discomfort ofhis lower right cuspid. The patientreported a history of trauma to the

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area several years earlier. Upon con-sultation with an endodontist, itwas determined that the tooth hada questionable prognosis for long-term success. The patient was givenseveral treatment options, includinga fixed partial denture, removableappliance, or single-tooth implantrestoration. The patient opted for asingle-tooth implant with acemented restoration.

Both clinical and radiographicexaminations revealed no signs ofactive infection. Probing depthswere within normal limits. Thepatient was informed that possiblemodifications to the tissue might benecessary if there were significantgingival changes following surgery.The patient presented with an idealtissue type—thick with excellentbony support. Approximately 85%of the population present withthick, flat periodontal forms,whereas the periodontal architec-ture of the remaining population is

thin and scalloped.11 Although theamount of postoperative soft tissuemodification is generally minimalfor patients with thick and flat gin-giva, significant changes have beenobserved in those with the thin andscalloped type.12

The projected interproximal tissueheight depends on the interproxi-mal bone height of the adjacentteeth. Bone sounding of the teethadjacent to the failing tooth canascertain predictable interproximaltissue height.

Maintenance of gingival tissues andpapillae can be a demanding taskwhen using a full periosteal flapreflection. Several reports have pro-posed implant placement withoutflap elevation to minimize boneloss.13,14 Although initial resultsappear promising, the lack of directvisibility in flapless surgery maypresent limitations that requirecareful evaluation of the osseous

topography as well as meticuloussurgical execution.15

Prior to the extraction of the tooth,stone models were made and aputty index was formed over theteeth (Figure 1). This was later usedto help guide the tooth onto theimplant abutment in the proper ori-entation following surgery.

Local anesthetic was administered,and periotomes were used to loosenthe periodontal ligament. The toothwas removed atraumatically with-out reflecting a flap.

A 13 mm Straumann (Straumann,Basel, Switzerland) standard-diameter 4.1 mm implant with a4.8 mm collar was inserted withthe top of the implant placed3 mm from the final proposed gingival margin. A 16 mm guide is shown in Figure 2. Ideally, the 1 mm polished collar should beabove the bone level. With a

Figure 1. Fabrication of a putty matrix prior to theextraction of the tooth.

Figure 2. A guide pin is used to measure the depth ofthe implant.

flapless surgery, this is sometimesdifficult to visualize.

A Straumann 7.0 mm solid abut-ment was placed and hand torqued,being careful not to turn theimplant (Figure 3). No preparationwas necessary as this is a stockcomponent and the occlusion didnot interfere.

The patient’s extracted tooth was toserve as the provisional restorationwhile healing occurred (Figure 4).

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The root was sectioned horizontallywith a diamond bur (Brasseler, USA,Savannah, GA, USA) 3 mm from thecementoenamel junction (Figure 5).The tooth was hollowed out to fitover the abutment (Figure 6). Afterconfirming an accurate fit, thetooth was etched for 30 seconds(Figure 7). A bonding agent (BiscoD/E resin, Bisco Inc., Schaumburg,IL, USA) was applied (Figure 8) andlight cured for 20 seconds (Figure 9).A bis-acryl material (Temptation,Clinician’s Choice, New Milford,

CT, USA) was injected into thetooth (Figure 10), which was thenplaced onto the abutment with theuse of the putty index (Figure 11).This was allowed to fully polymer-ize for 2 minutes. It is difficult toget an accurate margin when relin-ing a provisional, so it is necessaryto reline the margins out of themouth with a flowable resin. Thisresin adheres to the bis-acryl mater-ial well. A laboratory implant ana-log with an actual 7 mm solidabutment was later used to reline

Figure 3. A 7.0 mm solid abutment is hand tight-ened on the implant.

Figure 4. Patient’s extracted tooth.

Figure 5. The root is sectioned horizontally 3 mmfrom the cementoenamel junction.

Figure 6. The tooth is hollowed out to fit over theabutment.

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the final margins (Figure 12). Theprovisional did not fit the marginsaccurately, as is seen in Figure 13.The flowable resin was manipulatedaround the margins (Figure 14) andlight cured. Once the flowable resinhad polymerized, it was polishedwith finishing burs and disks. Thefinal reline is shown in Figure 15. A thin layer of Zone temporarycement (Dux Dental, Oxnard, California, USA) was placed in theprovisional (Figure 16), which wasthen put on the laboratory analog

to remove the excess cement prior toplacing it in the mouth (Figure 17).This procedure allows only a mini-mal amount of cement to engagethe abutment and prevents excesscement from irritating the tissue(Figure18).

It is important to have a fairly flatemergence profile on the facialaspect to help decrease tissue reces-sion. Interproximal support shouldbe carefully achieved. The toothwas out of occlusion and there were

no contacts in centric or excursivemovements. The tooth on the dayof surgery is shown in Figures 19and 20.

The patient was advised againstusing the surgical site and that careshould be taken when performingoral hygiene. After 2 months ofhealing, the patient returned for atissue check. The free gingival mar-gin had maintained itself withoutrecession (Figures 21 and 22). The2-month postoperative radiograph

Figure 7. The tooth is etched for 30 seconds. Figure 8. A bonding agent is applied and airdried.

Figure 9. The bonding agent is light cured for 20 seconds.

Figure 10. A bis-acryl is applied to the inside ofthe tooth.

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Figure 11. The tooth is placed on the abutmentand allowed to cure for 2 minutes.

Figure 12. An implant analog with cor-responding abutment is used later toreline the provisional because of inaccu-rate margins.

Figure 13. The provisional does not fitthe margins accurately.

Figure 14. A flowable resin is used toreline the margins.

Figure 15. Final reline of provisionalmargins.

Figure 16. Zone cement is injected intothe provisional.

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Figure 17. The provisional is placed on the implantanalog abutment, and excess cement is removedprior to placement of the provisional in the mouth(as first described by Frank Higginbottom, DDS).

Figure 18. The provisional is placed on the abut-ment with minimal excess cement.

Figure 19. Tooth cemented on the abutment onthe day of surgery.

Figure 20. Lingual view on the day of surgery.

Figure 21. Provisional at 2 months postoperative. Figure 22. Lingual view at 2 months postoperative.

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(Figure 23) reveals a perfect fit ofthe provisional restoration. Theplacement of the final restorationcould begin.

CONCLUSIONS

Immediate implantation in extrac-tion sites can no longer be consid-ered an experimental technique.When indicated, immediateimplant placement and provision-alization after extraction enablethe maintenance of esthetics andphonetics during the healingphase. The combined approach,with a single-stage implant andnon-loaded provisional, reducesthe number of surgeries, deliverssignificant comfort, and reduces

the healing time for the finalrestoration versus the two-stageapproach. More importantly, this approach achieves the preser-vation of the gingival architectureand papillae.

DISCLOSURE AND

ACKNOWLEDGMENTS

The author would like to acknowl-edge the expertise of oral surgeonJohn Maletta, DDS, MS.

The author does not have anyfinancial interest in the companieswhose materials are discussed inthis article.

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Figure 23. Radiograph at2 months postoperative.

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Reprint requests: Robert C. Margeas, DDS,1233 63rd Street, Des Moines, IA, USA50311; e-mail: rcmarge@aol.com©2006 BC Decker Inc