Provisional restoration options in implant dentistry

234 Australian Dental Journal 2007;52:3.

Provisional restoration options in implant dentistry

RE Santosa*

AbstractUnlike their use in conventional crown and bridge,provisional restorations during implant therapy havebeen underutilized. Provisional restorations shouldbe used to evaluate aesthetic, phonetic and occlusalfunction prior to delivery of the final implantrestorations, while preserving and/or enhancing thecondition of the peri-implant and gingival tissues.Provisional restorations are useful as acommunication tool between members of thetreatment team which, in most cases, consists of therestorative clinician, implant surgeons, laboratorytechnicians, and the patient. This article describesand discusses the various options forprovisionalization in implant dentistry. Cliniciansshould be aware of the different types of provisionalrestorations and the indications for their use whenplanning implant retained restorations.

Key words: Provisional restorations, dental implant,custom impression.

(Accepted for publication 27 April 2007.)

healing period, patients may have to wear a removableprovisional prosthesis prior to delivery of the finalprosthesis, especially in the aesthetic zone. In the non-aesthetic zone, clinicians may decide not to constructprovisional restorations.

In some cases, patients are able to have a provisionalrestoration constructed after the treatment planningphase and delivered as early as the day of implantplacement.4 However, in restorative driven implantplacement,5,6 hard and soft tissue augmentation isroutinely performed to optimize the implant site priorto surgery, effectively extending the treatment time.Any provisional prostheses would then need to bestrong, durable and aesthetic to last throughout theduration of the treatment. A traditional provisionalprosthesis may consist of an existing or newlyconstructed removable provisional denture which canbe utilized until delivery of the final prosthesis.However, removable provisional prostheses may placeundesirable pressure upon these graft sites, hamperingthe healing process.4,7,8 Therefore, provisionalrestorations that are fixed to the adjacent teeth or thatcompletely eliminate the possibility for soft tissuecontact may be more beneficial for implant integrationand soft tissue maintenance. Tooth borne or fixedprovisional restorations may also satisfy patients’aesthetic, functional and psychological demands. Oneof our roles as clinicians is to provide functional andaesthetic provisional restorations that allow for thesmooth transition of patients from natural dentition toimplant based restorations.8,9

Function of provisional restorationsAccording to The Glossary of Prosthodontic Terms,10

a provisional prosthesis is a prosthesis designed toenhance aesthetics, provide stabilization and/or functionfor a limited period of time, and should be replaced bya definitive prosthesis after a period of time.

In restoration-driven implant placement,5,6 implantsare positioned in relation to anticipated requisites ofthe restorative phase rather than the availability ofbone. Provisional restorations can be used as adiagnostic restoration to evaluate the position andcontours of the planned definitive restoration prior tosurgical implant placement and during the healing

INTRODUCTIONImplant supported restorations for partially and fully

edentulous patients are a well-accepted and predictabletreatment modality. Success rate of implant retainedprostheses for complete and partial edentulism hasbeen shown to be over 90 per cent.1-3 With the increasein treatment acceptance for dental implants, bothpatients and clinicians have greater expectationstowards implant therapy. Patients facing loss of theirteeth may experience apprehension towards losing theirsocial image or daily function. Hence, patients oftenexpect to have their implants loaded with some type offixed prosthesis similar to their natural dentition muchearlier. Clinicians also expect their restorations to befunctional, aesthetic, and in harmony with thesurrounding hard and soft tissues. Today, implantintegration is given with the greater knowledge of thebiological basis for treatment and improvementsprimarily associated with implant morphology.Traditionally, for conventional loading protocols, theimplants are left unloaded for 3 to 6 months to allowthe osseointegration process to take place.1 During this

*Private Specialist Prosthodontist, formerly ITI Scholar, Centre forImplant Dentistry, University of Florida, Gainesville, Florida, USA.

Australian Dental Journal 2007;52:(3):234-242C L I N I C A L R E P O R T

phase. A provisional restoration immediately placedwith ovate pontics extending into the extractionsockets can also be used to preserve the pre-extractionsoft tissue morphology.11 They can guide the healing ofthe peri-implant tissue and allow the clinician todetermine any necessary phonetic or aesthetic adjust-ments. The clinicians may use information such asshade, crown and soft tissue contours from theprovisional restoration as a communication tool to thelaboratory. Provisional implant restorations also allowthe patient to visualize and evaluate the end restorativeresult, thus assisting in acceptance and/or guiding ofmodifications required for the definitive restoration.

Types of provisional restorationsProvisional restorations in implant therapy can be in

the form of removable or fixed prostheses. Removableprovisional prostheses are generally tooth and/or softtissue borne. Fixed provisional restorations can besupported by adjacent teeth or implant retained. Theycan be fabricated chairside, using similar techniques asin conventional prosthodontics; or in the laboratory onworking casts; or as a combination of indirect-directtechnique, where a provisional shell is fabricated beforethe patient’s appointment, reducing chairside time.Provisional restorations may be constructed prior totooth extraction, during socket healing, prior toimplant placement, or during osseointegration period(Table 1). Provisional restoration could also beconstructed after implant loading, allowing maturationof peri-implant soft tissue, and during construction ofthe final prostheses.

Provisionalization prior to implant loadingRemovable prosthesis

Removable partial acrylic dentures have commonlybeen used during post-extraction and throughout theimplant therapy. They are simple to construct,relatively inexpensive, and easy for the surgeon orrestorative clinician to adjust and fit. Patients thatrequire staged treatment with serial extractions mayhave teeth added to their existing removable dentureswith minimal cost. However, they may reduce theeffectiveness of any additional surgical bone andgingival augmentation procedure used to optimize theimplant site. Care must be taken to prevent the gingivalportion of the provisional partial denture fromcontacting the healing soft tissue or an exposed healingabutment. Soft tissue borne prostheses used duringhealing may cause uncontrolled implant loading

leading to implant exposure, marginal bone loss,and/or failed integration. Often provisional denturesare adjusted to minimize contact with the healingimplants (Fig 1).

There are alternatives to tissue borne provisionalrestorations. An Essix appliance12,13 (Fig 2) may be usedas a removable prosthesis in these cases, as well as inlimited interocclusal space or deep anterior overbite.This prosthesis is made from an acrylic tooth bonded toa clear vacuform material on a cast of the diagnosticwax up. The prosthesis provides protection to theunderlying soft tissue and implant during the healingphase. Limitations of this provisional restorationinclude its inability to mould the surrounding softtissue, and lack of patient’s compliance can cause rapidocclusal wear through the vacuform material. However,some patients may not like to wear, or are unable totolerate, a removable provisional prosthesis, thus fixedprovisional prosthesis are sometimes necessary.

Tooth supported provisional restorationsFixed tooth supported provisional restorations in the

upper anterior region include the use of orthodonticbrackets and archwire on several teeth adjacent to the

Australian Dental Journal 2007;52:3. 235

Table 1. Provisionalization prior to implant loadingType of support Prosthesis type

Removable Partial acrylic denturesEssix appliance

Fixed tooth supported Archwire supported ponticResin bonded ponticResin bonded, cast metal frameworkbridge

Fixed implant supported Transitional implants

Fig 1. Modified removable partial provisional denture. The denturewas modified during implant placement to allow proper healing of

the underlying implants. The patient had low smile line.

Fig 2. An Essix appliance replacing upper central incisors. The teethwere spot cured to the clear vacuform template material.


implant site with an attached pontic. An alternativemethod is the use of resin bonded provisional pontic,which are tooth supported and retained by acid etchingthe neighbouring teeth. Sometimes small retentivegrooves within enamel on the adjacent teeth can beused to increase retention of the pontic. The pontic canbe in the form of an acrylic tooth, porcelain, ordecoronated extracted tooth. The resin bonded acrylicor natural tooth may be reinforced with composite

resin and/or ultra high molecular weight polyethyleneribbon (Ribbond Bondable Reinforcement, Ribbon;Ribbond Inc, Seattle, Wash., USA).8,14 These prosthesesmay continue to be reused as provisionals after anappropriate implant healing period. The archwire/resinretainer can be removed and reattached between thedifferent surgical and prosthetic stages. They can alsobe used to guide the surgeon during grafting proceduresand as a template for the final restoration.

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Fig 3a. Pre-operative radiograph. The patient had generalized refractory periodontitis, especially in the maxillary arch.Fig 3b. Pre-operative facial view. One of the patient’s chief complaint was the anterior crowding and the vertical drifting of maxillary

anterior teeth.Fig 3c. Diagnostic wax up of the planned restoration illustrating anticipated contours of the final restoration. The alignment of anterior

teeth was altered to provide straighter, more aesthetically pleasing teeth. The incisal lengths of maxillary incisors were reduced, decreasingthe horizontal and vertical relationship of the anterior teeth.

Fig 3d. Facial view of prepared teeth immediately after extraction. Strategic teeth were maintained to retain the provisional prosthesis.The implant sites were previously selected and the non-strategic teeth were removed according to the diagnostic wax up.

Fig 3e. Provisional acrylic restoration prior to insertion. The provisional restoration is relined with compatible self cure resin to fit overthe prepared abutment teeth.

Fig 3f. Fixed provisional restorations cemented on strategic natural abutments. The molars have been retained temporarily to maintain thevertical dimension of occlusion.

A resin bonded, cast metal framework prosthesissuch as Maryland Bridge is suitable for long-termprovisionalization in the anterior region, especially inyoung patients.8 This type of provisional is difficult toreuse throughout the implant procedure as the bondstrength between the metal retainer and the enamel canbe unpredictable during removal and reattachmentbetween procedures. Furthermore, the laboratory costsare relatively high.

In some cases, a staged extraction and implantplacement approach can be adopted.8,15 In thistechnique, the implant sites are selected, and teeth thatoccupy these sites are extracted while the remainingteeth are used to support a fixed provisional restoration.Usually, natural abutments with poor prognoses areused as interim abutments and can be extracted whenthe implants have integrated. The teeth supportedprovisional restoration is then converted into animplant supported provisional restoration. Thisindirect–direct technique is often used in a full archsituation, where the patient’s dentition is failing due toperiodontal disease (Figs 3a–3f) or when the adjacentnatural teeth require fixed prosthesis at the same time.8

Transitional implant provisional restorationsIn extended partial edentulous areas where there are

no or limited natural abutments to support aprovisional restoration, one or more transitionalimplants may be used.16 These transitional implants areloaded immediately to support the provisionalrestoration. They can be used to support fixedrestorations or to retain complete mandibular dentures.Care should be taken in planning the position of theseimplants and with their maintenance post-loading.They should not interfere with potential implant sites,or be placed in poor quality bone. When the depth ofavailable bone is less than 14mm or the amount ofcortical bone is insufficient to provide stabilization, theimmediate provisional implant may be contraindicated.16

Once the implants integrate, the supporting provisionalrestoration will be converted into implant supported

provisional restoration, and the transitional implantsare backed out of position using a ratchet arm andinsertion tool used in the reverse mode (Fig 4).

Post-implant placementImplant retained provisional restorations

Provisional restorations may be used at the time ofimplant placement or after an appropriate healingperiod. The term “immediate restoration” is used whena prosthesis is fixed to the implants within 48 hourswithout achieving full occlusal contact with theopposing dentition, whereas “immediate loading” iswhen the prosthesis is fixed to the implants in occlusionwithin 48 hours.17

There are several benefits to members of thetreatment team and patient in using an immediateprovisionalization technique. Immediate provisional-ization offers the patient improved comfort andfunction during the implant healing period comparedwith a conventional denture.4 There are also fewerdenture adjustments postoperatively with no need fortissue conditioning or relining.

The decision to immediately restore or load dentalimplants is usually made during the treatment planningphase. The treatment can only be confirmed clinicallyat the time of implant placement with appropriateassessment of implant stability, bone quality, andgeneral site health. In a recent consensus review,18 fourimplants in an edentulous mandible, rigidly splintedwith a fixed restoration on a framework (acrylic and/ormetal) or hybrid prosthesis, can provide patients with areasonable degree of confidence for evidence-basedtreatment. Primary stability of these implants is crucialin the decision for immediate provisionalization.9,19 Theimplants need to be well distributed across themandibular arch to provide cross-arch stabilization.The final implant positions are based on the proposedrestoration through the use of templates/surgical guide.

In immediate loading of edentulous mandible, thepatient’s existing denture can be converted into screwretained provisional fixed hybrid prosthesis. Thetechnique involves the placement of temporarycylinders onto the implants and the modification ofpatient’s existing mandibular denture. These cylindersare luted to the rest of the denture using self cure resin.The denture is then converted into an immediate load,screw retained provisional hybrid fixed prosthesis withminimal cantilever and occlusal contacts (Figs 5a–5c).A lingual wire may be used within the acrylicframework to provide reinforcement. The provisionalhybrid restoration will need to remain during therecommended period of implant healing to allow theimplants to fully osseointegrate.17

This technique may also be used in early or delayedloading implant protocols. The provisional hybridrestoration may have multifunctional uses. It can beused as a verification jig (Fig 5d) to determine thepassivity and accuracy of the master impression,providing all the implants are relatively placed parallel


Fig 4. Immediate provisional implants were placed and strategicteeth were maintained to support long-term telescopic provisionalrestoration. The 14-year-old patient requested a long-term fixedprovisional restoration until the definitive implants are placed.


to each other. It can also be used to articulate theimplant master cast to the opposing study cast (Fig 5e),and records the laterotrusive functional envelope viacustomized incisal pin guidance.

Cement retained provisionalsClinicians have the option to either cement or screw

retain their final implant restorations.20,21 There areadvantages, disadvantages and limitations for eachoption and it is important to understand their influence

on the final prosthesis. The decision whether to cementor screw retain a provisional or final implantrestoration would be dependent on the clinicalsituations and clinicians’ preference towards themethod of fixation.

Most implant companies have prefabricatedabutments for cement retained restorations. Theseabutments come in various heights to allow enoughspace for the metal and porcelain in crown construction.They also have a slight taper and an indexingcomponent providing resistance form for the overlyingrestorations. The abutments are torqued onto theimplants, left in situ and a complementing pick-upcoping component may be used for impression andtransfer of the abutment position to the master cast.

A plastic protection cap, usually cylindrical in shape,may be cemented on the prefabricated abutment untilthe delivery of the final prosthesis. This technique isoften used by clinicians in non-aesthetic regions of themouth.

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Fig 5a. Patient’s existing complete mandibular denture was modifiedto accommodate temporary cylinders on the implants. A duplicateof the denture was used as radiographic and surgical guide for the

planning and surgical phase of the treatment. The three dimensionalpositions of the implants were determined from the diagnostic wax

up and clinical and radiographic examination. Fig 5b. Try in of the mandibular denture over the temporary

cylinders. Fig 5c. Self cure resin was used to attach the denture and the

temporary cylinders. The denture flange was then trimmed and thefitting surface was adjusted to allow proper hygiene.

Fig 5d. The provisional hybrid was used as verification jig over themaster cast. The soft tissue moulage was removed to verify the fit of

the provisional on the subgingival implant restorative margins.Fig 5e. The same provisional hybrid was articulated with a bite

registration material, against the previously articulated study cast.

Aesthetic provisional restorations can be constructedfor such abutments during the period between impres-sion and prosthesis delivery.8 The provisionalrestorations are usually made from a prefabricatedcustom shell (prefabricated preformed acrylic crowns;vacuform template from the diagnostic wax up;hollowed out denture tooth; or even a hollowed outdecoronated clinical crown) relined using self or lightcured resins intra-orally to capture the indexingcomponent of the abutment, and then completed extra-orally to fit the implant restorative margins (Figs 6a–6f).To facilitate treatment, the crown form can be waxedup, or selected, sized, and trimmed ahead of time to fitthe edentulous site on the study cast.

Care should be taken during the cementationprocedure where the crown margin is placed deep

subgingivally, especially in the anterior aesthetic regionof the mouth. Access to the deeply placed implantshoulder can be difficult, and excess residual cements aredifficult to clean and may cause peri-implantinflammation.22 Alternatively, a temporary mesoabutment would allow a machined connection atimplant shoulder, and customized cement margin thatcan be modified to allow a slightly subgingivalrestorative margin for ease of cement removal. Thisabutment can be modified intra- or extra-orally,prepared using diamond bur with accessible cement levelplaced just below the gingival margin, and correction ofany angulation problems to retain the provisional crowncan be made. A cementable provisional crown is thenconstructed using conventional crown and bridgetechnique (Figs 7a and 7b).


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Fig 6a. A cement on, prefabricated abutment was torqued to the recommended value, six weeks post-placement. The abutment waschosen to allow adequate space for crown construction within the available interocclusal space.

Fig 6b. A denture tooth with appropriate shade and shape was selected to fit the edentulous space. The acrylic tooth was then hollowedout to fit over a practice implant analog and abutment extra-orally.

Fig 6c. The denture tooth was relined intra-orally using self cured acrylic resin to capture the indexing component of the abutment.Fig 6d. The relined denture tooth was fitted over the practice implant extra-orally. Note on the deficiency from the implant margin to the

acrylic tooth due to tissue impingement.Fig 6e. The deficiency was filled in and the excess material trimmed to the appropriate emergence profile.

Fig 6f. The provisional crown was cemented with provisional cement.


Screw retained provisional prosthesesScrew retained provisional restorations would

eliminate the possibility of having any temporarycement present in the peri-implant tissue. This can beachieved using temporary cylinders directly placed onthe implant level. The provisional crown can then bebuilt up in the laboratory on the master cast orchairside by using self or light cure resin or compositeresin according to the diagnostic wax up. Thetemporary cylinder often has to be adjusted to fit intothe occlusion (Figs 8a and 8b).

The most important advantage of provisionalrestorations at the start of the restorative procedure isin shaping of the peri-implant tissues.8,23 This processwill establish a natural and aesthetic soft tissue formthat will help the laboratory fabrication with ananatomically appropriate soft tissue model.24-26 A well-shaped peri-implant tissue including interdentalpapillae will facilitate seating of the final prosthesis.The provisional restoration can be modified overseveral appointments to achieve the desired emergenceprofile (Fig 9).

Communication with laboratory using provisionalsOne of the challenges faced by the restorative

clinician is the circular shape and small diameter of theimplant compared to the root of a natural tooth. The

final prosthesis must be able to imitate the naturaltooth crown form when emerging from the gingivaltissues with narrow margins to fit the implant head.This transition zone between the implant shoulder tothe gingival crest, often up to the contact points isshaped by the subgingival part of the provisionalrestorations. The transition zone can be up to 5mmdeep, especially in the palatal and interproximal tissuesof teeth in the aesthetic zone. The peri-implant tissues

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Fig 7a. A temporary meso abutment, one piece temporary abutmentfits directly into the implant body. The abutment is made of PEEK

(Polyetheretherketone) plastic and titanium inlay.Fig 7b. Unaltered temporary meso abutment on the soft tissue

working cast. The abutment can be prepared in the laboratory orchairside with altered cement margin and corrections of any

angulation problems.

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Fig 8a. A screw retained provisional crown was made at chairsidefrom the patient’s existing partial denture, attached to the

temporary cylinder using additional self cure resin. The excesstemporary cylinder is reduced to follow the palatal contour of the

existing partial denture and patient’s occlusion. Fig 8b. Facial view of screw retained provisional restoration ontooth 11 site. The provisional restoration was hand tightened.

Fig 9. Moulded soft tissue from screw retained, 3 unit fixed acrylicprovisional bridge. Peri-implant tissue was shaped with screw

retained provisional restoration for 4 weeks prior. The pontic shapewas moulded using additional resin during the healing period.

must be permitted to adapt to the dimensions of theprovisional restoration.

Following the shaping and maturation of the peri-implant tissue, the clinician needs to transfer thisinformation to the working cast.27,28 This may beaccomplished with a custom impression coping or byretrofitting the provisional restoration to the workingcast (Figs 10a and 10b). The customized impressioncoping allows the clinician to capture the moulded softtissue with the appropriate emergence profile onto themaster cast.

In aesthetic cases, the shade and surfacecharacterization of the provisional restorations can bealtered using composite modifiers (Figs 11a–11d).Shades and surface characterization on the provisionalrestoration can be used by the treatment team,including the patient to evaluate the desired shade ofthe final restoration.

CONCLUSIONThis article discussed the role of provisionalization in

implant therapy from the removal of teeth, throughimplant placement to the final implant restoration.


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Fig 10a. Resultant emergence profile shaped by the provisionalrestoration in Fig 8, after approximately 4 weeks of

provisionalization. The mature peri-implant tissue has an oblongshape compared to the circular implant restorative collar.

Fig 10b. A custom impression coping with screw on impressioncoping replicated from the provisional restoration was placed over

the implant prior to final impression.

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Fig 11a. Screw retained, 3 unit fixed acrylic provisional bridgeconstructed to replace the modified removable partial denture from

Fig 1. The provisional restoration had a monochromatic shadesimilar to the pre-existing denture teeth.

Fig 11b. Colour modifiers for tooth shading characterizations. Themodifiers can be mixed together and incorporated into the

provisional acrylic/composite resin crown to mask discolourationand/or create surface characterizations.

Fig 11c. Aesthetic provisional restoration with customized shadecharacterization.

Fig 11d. Laboratory shade prescription for the final ceramicrestoration, incorporating the custom shade characterization.


Various provisionalization options were discussed withsome examples presented. Provisionalization ofimplants is often overlooked, as the time betweenimpression and delivery of the final prosthesis can beshort. Fixed provisionals would also help those patientsthat have not had removable prostheses before,providing a restoration which has superior comfort andaesthetics. Clinicians need to be aware of the range oftechniques, materials and temporary implantcomponents for short, medium and long-termprovisionalization.

The need for provisionalization should be consideredduring the treatment planning stage, and reassessedcontinually throughout the implant therapy. Cliniciansalso need to be able to transfer the informationgathered from the provisional restoration to thelaboratory. Construction of provisional restorationmay take up more chairside time but they may savetime and expense at subsequent appointments, henceproducing better restorations. There may be addedcosts associated with increased chairside time andadditional components, however these will be offset bythe improvement in overall patients’ treatment andtheir acceptance towards the treatment.

ACKNOWLEDGEMENTThe authors would like to acknowledge the

assistance of Dr James Mumme and Dr DebraMcAuslan in the preparation of this document.

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Address for correspondence/reprints:Dr Robert Santosa

Suite 44, Level 4183 Macquarie Street

Sydney, New South Wales 2000Email: [email protected]

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Provisional restoration options in implant dentistry