Provisional Restorations for Optimizing Esthetics in Anterior Maxillary Implants[1]. a Case Report

6© 2 0 0 7 , C O P Y R I G H T T H E A U T H O R SJ O U R N A L C O M P I L A T I O N © 2 0 0 7 , B L A C K W E L L M U N K S G A A R D

*Assistant professor, Department of Prosthodontics, University of Athens, Athens, Greece†Former postgraduate student, Department of Prosthodontics, University of Athens, Athens, Greece‡Clinical instructor, Department of Prosthodontics, University of Athens, Athens, Greece§Professor and chairman, Department of Prosthodontics, University of Athens, Athens, Greece

Provisional Restorations for Optimizing Esthetics inAnterior Maxillary Implants: A Case Report

STEFANOS KOURTIS, DDS, D. ODONT.*

CHRISTINA PSARRI, DDS†

PANAGIOTIS ANDRITSAKIS, DDS, MSC ‡

ASTERIOS DOUKOUDAKIS, DDS, MSC, D. ODONT.§

ABSTRACTThe use of implants for the restoration of anterior missing teeth has been established and docu-mented during the past years. However, the use of dental implants in the anterior region is atechnique-sensitive procedure. The placement of implants in an ideal position is often not possi-ble because of the lack of sufficient bone. The clinical situation can be further complicated if theteeth were lost as a result of trauma and there is possible damage to the surrounding soft andhard tissues. The restoration of lost anterior teeth and maintenance of the surrounding soft tis-sues with adequate surgical and prosthetic techniques are a real challenge for the clinician. Theaim of this article was to report the laboratory and clinical stages in the restoration of anteriormaxillary teeth, which were lost as a result of trauma with implant-supported fixed partial den-ture. In this case, an intraoperative transfer of the impression posts allowed the construction ofprovisional restorations, which were inserted at implant uncoverage surgery and contributed sig-nificantly to the creation of a better emergence profile and to the final esthetic result.

CLINICAL SIGNIFICANCEProvisional restorations are an important stage in anterior maxillary implants, allowing guidedsoft tissue management and creating an esthetic emergence profile.

(J Esthet Restor Dent 19:6–18, 2007)

I N T R O D U C T I O N

The use of implants for therestoration of anterior missing

teeth has been established and doc-umented during the last years.1–5

Implant restorations are a challeng-ing option for the dentist and thepatient because the preparation ofadjacent teeth can be avoided.However, the use of dental implants

in the anterior region is a tech-nique-sensitive procedure.

The placement of implants in aprosthetically ideal position is oftennot possible because of the lack ofsufficient bone. The clinical situa-tion can be further complicated ifthe teeth were lost as a result oftrauma and there is possible

damage to the surrounding soft andhard tissues. An esthetic result mustbe achieved for the teeth and thesoft tissues in order to fulfill theesthetic demands of the patient.6–8

The restoration of lost anteriorteeth and maintenance of the sur-rounding soft tissues with adequatesurgical and prosthetic techniques

DOI 10.1111/j.1708-8240.2006.00056.x

K O U R T I S E T A L

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are a real challenge for the clini-cian.9–12 Besides the postextractionimplant placement and the propermanagement of the soft tissues, theuse of tooth- or implant-supportedprovisional restorations contributessignificantly to the overall successof the therapy.13–16

A I M

The aim of this clinical article wasto report the laboratory and clinicalstages in the restoration of anteriormaxillary teeth, which were lost asa result of trauma, with an implant-supported fixed partial denture(FPD).

C A S E P R E S E N T A T I O N

Initial Clinical Examination andImmediate Provisional RestorationA 50-year-old male Caucasian presented for treatment in theGraduate Prosthodontic Clinic ofthe University of Athens. As a result

of trauma from an accident, theupper right central and lateralincisor (teeth #7 and 8) were com-pletely luxated. The upper left cen-tral incisor (tooth #9) was partiallyluxated, but the root remained inthe socket (Figures 1–3). As animmediate provisional restoration,the fractured teeth were bonded tothe adjacent teeth with photopoly-

merizing resin to restore the esthet-ics and phonetics of the patient. Aweek later a removable partial den-ture was fabricated as an interimrestortion.

Besides the restoration of the lostanterior teeth, the patient consentedfor a complete prosthetic treatmentin the maxilla, as he was not

Figure 1. Initial clinical situation immediately after trauma.Labial view.

Figure 2. Initial clinical situation. Palatal view. Figure 3. Radiographic examination after trauma.The apex of the upper left central incisor is left inthe alveolar socket.

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P R O V I S I O N A L R E S T O R A T I O N S F O R A N T E R I O R I M P L A N T S

© 2 0 0 7 , C O P Y R I G H T T H E A U T H O R SJ O U R N A L C O M P I L A T I O N © 2 0 0 7 , B L A C K W E L L M U N K S G A A R D

Figure 4. Clinical situation 1 month after trauma. Palatalview.

satisfied with the esthetic appear-ance of his anterior maxillary teeth.The existing restorations (splintedmetal-ceramic crowns on the upperleft first premolar [#12] with thesecond upper left premolar [#13] asa cantilever, FPD on teeth #2–6)showed marginal gaps and shouldbe replaced. The upper left lateralincisor (#10) and the adjacentcanine (#11) showed cervicalabfractions that had been repeatedly restored (Figures 3–6).

Initial Clinical StepsThirty days after the trauma, thesoft tissues appeared healthy with-out any sign of inflammation. Ini-tial alginate impressions were madefor the construction of study casts.Face-bow registration transfer wasobtained for the mounting of themaxillary cast. A centric relationregistration was used for themounting of the mandibular cast.The centric relation record wastaken with an anterior deprogram-mer made of acrylic resin (Pattern

Resin, GC Co., Tokyo, Japan) andbite registration material (BlueMousse, Parkell Co., Edgewood,NY, USA).

The casts were mounted on a semi-adjustable articulator (Hanau H2,Teledyne Co., Fort Collins, CO,USA) and a full diagnostic wax-upwas done for all maxillary teeth(Figure 7).

Radiographic ExaminationBesides the initial dental radiogra-phy, a complete radiographic exam-

Figure 5. Existing restorations. Buccal view.

Figure 6. Existing restorations. Buccal view. Figure 7. Diagnostic wax-up of all maxillary teeth.


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ination was performed. From thediagnostic wax-up a provisionalrestoration was fabricated fromautopolymerizing acrylic resin(Dentalon Plus, Kulzer Co., Werheim, Germany), and gutta-percha points were inserted alongthe teeth axes. This restoration wasused as a radiolographic splint forpresurgical panoramic and computer tomography (CT) scanradiographies.

Treatment PlanningPresurgical Steps1. preparation of all existing

maxillary teeth (#3, 6, 10, 11,14) and placement of a provi-sional restoration (FPD) madeof acrylic resin

2. placement of two implants inthe regions of the upper rightlateral incisor and the upperleft central incisor (teeth #7, 9)

3. intraoperative transfer of theimpression posts

During the Osseointegration Period1. application of guided pressure

on soft tissues during theosseointegration period

2. fabrication of provisionalimplant abutments andimplant-supported FPD (#7–9)

Implant Uncoverage and Soft TissueHealing Period1. implant uncoverage and imme-

diate placement of implant-supported provisionalrestoration; soft tissue graft inthe pontic area (#8)

2. soft tissue contouring duringthe healing period with guidedpressure from the provisionalrestorations

3. correction/replacement of pro-visional abutments and restora-tions with adequate guided softtissue management

Final Steps1. construction of the final

restorations on teeth andimplants

Treatment StepsTeeth PreparationAll maxillary teeth were preparedat the same session with a circum-ferential chamfer. Provisionalrestorations were fabricated fromautopolymerizing resin (DentalonPlus, Kulzer Co.) with the directtechnique using a thermoplasticsheet (Omnivac Sheet, EssixMachine, Essix Raintree Co., NewOrleans, LA, USA) from the diag-nostic wax-up (Figure 8). The root

apex of the maxillary left centralincisor (#9) was left in place to beextracted during implant placement.

Fabrication of Surgical Guide andTransfer Splint

After the preparation of the maxil-lary teeth, an alginate impressionwas made and a gypsum cast waspoured. On this cast a vacuum-formed polypropylene matrix(Omnivac sheet) was applied,which was made as a duplicate ofthe wax-up. Into the matrix, tooth-colored autopolymerizing resin waspoured and the matrix was pressedon the cast of the prepared teeth inorder to fabricate a surgical guide(splint). This way the exact fit ofthe surgical splint on the preparedteeth was ensured. The matrix wascut to fit on the prepared teeth andguiding grooves were opened on thepalatal surfaces of teeth #12 and21.

Figure 8. Provisional restorations on all maxillary teeth.

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As an intraoperative transfer of theimpression posts was planned, atransfer splint from autopolymeriz-ing resin (Pattern Resin) was alsofabricated on the cast of the pre-pared teeth, to allow the transfer of the implant position and inclination immediately afterimplant placement with open flaps. The transfer splint should fitprecisely on the adjacent teeth andtwo sufficient openings were leftabove the intended implant sites(Figure 9).

Implant PlacementTwo weeks after teeth preparation, two implants (Frialit2, Denstply–Friadent Co.,Mannheim, Germany) wereinserted at the extraction sockets ofteeth #7 (diameter = 3.8mm/ length= 15mm) and #9 (diameter = 5.5mm/ length = 15mm) after rais-ing the full thickness flap and care-ful atraumatic extraction of root

apex #8. The implant positions and inclinations were guided by the surgical splint. The initial stabilityof the implants was verified with atorque-control device (Friadent surgical unit, Dentsply–FriadentCo.) and exceeded 35Ncm.

Two impression posts of the corre-sponding diameter were mountedon the implants with long fixingscrews. The impression posts wereattached on the transfer splint withautopolymerizing resin (PatternResin), avoiding contact of the resinwith the implant surface (Figure10). Alternatively, a photopolymer-izing flowable composite materialcould have been used. The fixingscrews were loosened and the trans-fer splint was removed from theimplants, with the impression postsretained on it. The implants werecovered with the correspondingcover screws and the flap wassutured.

Fabrication of Implant-SupportedProvisional RestorationsAfter implant placement and duringthe osseointegration period the lab-oratory steps for the fabrication ofthe provisional restorations wereaccomplished. The transfer splintwith the impression posts was fittedon the cast of the prepared teethafter removing gypsum at theimplant sites.

Two laboratory analogs of the cor-responding diameter were fixed onthe impression posts with the longscrews and gypsum was addedaround the implant analogs. Thelabial side of the cast around theimplants was formed according tothe ideally desired emergence pro-file, and a new wax-up was per-formed (Figure 11).

Two provisional abutments (Protectabutments, Dentsply–Friadent Co.,Mannheim, Germany) were fitted

Figure 9. The transfer splint made from autopolymerizingresin.

Figure 10. The impression posts attached on the transfer splint immediately after implantinsertion.


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on the implant analogs and weremodified according to the desiredrestoration contour with siliconepartial impressions (silicone keys)from the wax-up (Figure 12). Onthe provisional implant abutmentsa cement-retained provisionalrestoration (FPD) was fabricated.

In order to improve the estheticappearance and minimize plaqueaccumulation, the labial side of the restoration was formed by

using veneers from acrylic dentureteeth. The veneers were attached on a silicone partial impression (silicone index) from the wax-upand the restoration was completedwith heat-polymerizing acrylic resin(Figure 13).

The use of prefabricated acrylicveneers for the construction of pro-visional restorations is definitely atechnique-sensitive and time-con-suming procedure, but improved

esthetic performance can be thusachieved, compared with the use ofonly heat-polymerizing resin. Newprovisional restorations were alsoconstructed in the laboratory forthe rest of the maxillary teeth.

Osseointegration Period andImplant UncoverageDuring the osseointegration period,guided pressure was applied on thesoft tissues above the implants inorder to enhance the formation of

Figure 11. The new diagnostic wax-up made with prefabri-cated veneers from acrylic denture teeth.

Figure 12. The working cast with the provisionalplastic abutments and a silicone index from thenew diagnostic wax-up.

Figure 13. The acrylic veneers fixed on a silicone indexfrom the wax-up. The provisional implant-supportedrestoration will be fabricated from heat polymerized resinwith this silicone index.

Figure 14. The soft tissue condition after guided pressureduring the osseointegration period.

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interdental papillae (Figure 14).The patient was examined atweekly recalls. The provisionalrestoration was removed andacrylic resin was added under thepontic and on the interdental areas.The restoration was fitted on theprepared teeth, and slight ischemiawas caused on the soft tissues. Theamount of added resin was consid-ered adequate if the color of softtissues returned to normal after 5minutes of guided pressure.

The implant uncoverage procedurewas initially planned to be accom-plished with the use of a tissuepunch, without raising a flap, thusavoiding the distraction or defor-mation of regenerated soft tissues.

Four months after implant inser-tion, the interdental papillae wereformed successfully, but a horizon-tal soft tissue deficiency was notedat the pontic area (tooth #8). Forthis reason a partial thickness flapwas raised for implant uncoverage.A free gingival connective tissuegraft harvested from the palate was

inserted in region #8 to increase tis-sue volume.

The provisional abutments werefixed on the implants with fixationscrews, and the provisional restora-tion was cemented on the implantabutments with temporary cement(Temp-Bond, Kerr Hawe Co., Bioggio, Switzerland) (Figure 15).The excess cement was removedbefore suturing to avoid any possi-ble tissue irritation. The flap was

adapted on the provisional restora-tion and sutured (Figure 16).

Soft Tissue HealingThe healing of soft tissues wasuneventful, but tissue shrinkagewas obvious 4 weeks after second-stage surgery (Figure 17). In orderto stabilize the soft tissue contouron the existing clinical situation, anew provisional restoration on newabutments was considered as neces-sary. An impression of the implants

Figure 15. The provisional abutments fixed on the implantsat the uncoverage surgery.

Figure 16. The provisional restoration on the provisionalabutments after soft tissue grafting and suturing.

Figure 17. Soft tissue condition 4 weeksafter implant uncoverage.


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was made with an addition-typevinyl-polysiloxane impression mate-rial (Relay, Tissy Dental Co., Milan,Italy) using the impression posts(De Trey/Friadent Co., Mannheim,Germany) of the correspondingdiameter (Figure 18).

A working cast was poured fromextra-hard stone material with agingival mask (soft tissue mask),reproducing the exact soft tissuecondition. The gingival mask was

modified by trimming to the desiredshape according to the intendedemergence profile (Figure 19).

The new provisional abutments(Tempbase abutment made of tita-nium, provided by the manufac-turer for the implant insertion)were used instead of the previouslyused plastic abutments and weremodified with photopolymerizingresin in order to support the peri-implant tissues with guided

pressure (Figure 20). A new cement-retained provisional FPD was fabri-cated on the modified temporaryimplant abutments (Figure 21).

The new provisional restorationwas placed on the implants andguided pressure was applied in theinterdental areas in order toenhance the regeneration of thepapillae (Figure 22). The patientwas examined at weekly recalls fora period of 6 weeks. In each recall

Figure 18. An impression is made for the fabrication ofnew provisional restoration.

Figure 19. The soft tissue masque is trimmed to the desiredshape.

Figure 20. The metal-reinforced provisional abutments aremodified in the cervical area with flowable photopolymeriz-ing resin.

Figure 21. The new modified provisional abut-ments fixed on the implants.

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session, photopolymerizing resinwas added in the interdental and in the pontic areas in order toreform the papillae with guidedpressure.

Construction of the Final RestorationAfter stabilization of the soft tissues(Figure 23), a final impression wasmade with an addition-type

polyvinyl-siloxane impression mate-rial and the final metal-ceramicrestorations were fabricated (Fig-ures 24–26). The final restorationincluded independent cement-retained FPDs on the implants andon the remaining teeth. The totaltreatment time was 9 months, andthe final result fulfilled the patient’sfunctional requirements andesthetic expectations and

remained stable, as verified at theregular 6-month recalls (Figures27–29).

D I S C U S S I O N

The restoration of anterior maxil-lary implants often requires soft tis-sue management in order toimprove the esthetic result.17,18

Prosthetic ally-driven implantplacement facilitates the integration

Figure 22. The new provisional restoration immediatelyafter insertion. Note the difference of the soft tissue contouras it was created with the former restoration.

Figure 23. Soft tissue condition after healing period of 4weeks and before the final impression.

Figure 24. The metal framework try-in. Figure 25. The final restoration after insertion in the mouth.


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and harmonization of the restora-tion with the adjacent teeth.19

The placement of implants 6 weeksafter tooth extraction (or traumaticloss, as in this case) preventsresorption of the alveolar bone withadequate soft tissue coverage overthe extraction sockets.20,21 In thiscase, the extraction of the root apexof tooth #9 was performed at thesame time of implant placement in

this site in order to minimize surgi-cal sessions and avoid any furthertrauma in this area.

The intraoperative transfer of theimpression posts offers the possibil-ity of immediate placement of theimplant-supported provisionalrestoration at implant uncoverage,allowing better tissue adaptationduring the healing period. A betteremergence profile can thus be

achieved.22,23 For the same reason,guided pressure was applied bothduring osseointegration and soft tis-sue healing periods, aiming at thecorrection of the soft tissuecontour.24,25

Further tissue corrections could beachieved by the modification of theimplant abutments and the place-ment of a new provisional restora-tion.26–29 The use of a free gingival

Figure 26. The final restoration after insertion in themouth.

Figure 27. The final restoration and the soft tissue condi-tion at the first-year recall. A stable clinical result.

Figure 28. The final restoration and the soft tissue condi-tion at the first-year recall. A stable clinical result.

Figure 29. The final restoration and the soft tissue condition atthe first-year recall. A stable clinical result.

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graft at the second-stage surgeryfacilitates the formation of anattached gingival zone andenhances the creation of the desiredemergence profile.24,30–32 The inter-dental contact points, however,must extend apically both in theprovisional and the final restorationin order to support the regenerationof the papillae.12,24,33,34

Immediate loading of the implantscould have been considered as nec-essary if the adjacent teeth wereintact, and a removable provisionalrestoration might have causedincreased pressure on the peri-implant soft tissues.35–37 In the pre-sent case, however, the delayedloading was considered as the safestapproach. The implant uncoveragesurgery was also preferred in orderto allow proper soft tissue handling.

A C K N O W L E D G M E N T S

The authors would like to thankDr. I. Fourmouzis (Lecturer,Department of Periodontics, Uni-versity of Athens, Greece) and Dr. I.Lignos (former postgraduate stu-dent, Department of Periodontics,University of Athens, Greece) fortheir contribution at the surgicalstages of the therapy. They also sin-cerely thank Mr. V. Mavromatis(Certified Dental Technician) forthe accomplishment of the labora-tory stages.

D I S C L O S U R E S T A T E M E N T

The authors do not have any finan-cial interest in any of the manufac-

turers whose products are men-tioned in this article.

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Reprint requests: Dr. Stefanos Kourtis,Assistant Professor, Department of Prostho-dontics, University of Athens, PlazaChrysostomou Smyrnis 14 17121 Athens,Greece. Tel.: 30-210-9357306; Fax: 30-210-9310637; e-mail: [email protected]

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Provisional Restorations for Optimizing Esthetics in Anterior Maxillary Implants[1]. a Case Report

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