While implant treatment has become an increasingly predictable treatment for edentulism in patients with all bone types,[i] several key principles are essential in preventing complications. These include careful patient selection, the management of environmental and systemic factors, and the formulation of a precise surgical strategy. Prosthetic planning is also increasingly recognised as a fundamental component.
[ii]The prosthetically driven implant restoration treatment plan incorporates several advancements in implantology, including digital technology, bone grafting materials, guided bone regeneration (GBR), all aimed at prioritising the desired prosthetic outcome.[iii] The determination of the final functional and aesthetic results informs implant planning in terms of length, position, angle, and depth, as well as decisions about bone and soft tissue augmentation and management.[iv]
Within this plan, the provisional implant restoration provides clinicians with greater control in designing gingival contours around the final restoration. A precise approach to
soft tissue planning and management afforded by provisionals offers both aesthetic and clinical benefits, enhancing the overall outcome of treatment.[v]
Soft tissue management and provisional restorations
Provisional restorations have a variety of purposes in implant dentistry. They act as a temporary, functional replica of the final restoration. They can improve patient comfort, aesthetics and function during the treatment process, while maintaining the position of adjacent or opposing teeth.[vi] They are also an important tool to shape and condition the soft tissue around the newly placed implant, allowing the dentist to encourage the desired emergence profile before placing the final restoration.[vii]
A properly shaped emergence profile is important in implant treatment. It protects the implant-restoration complex from peri-implant infections, enables the patient to perform optimal dental hygiene and is a key element in the aesthetic outcome of the procedure.[viii]
If the contours are not as expected after initial soft tissue healing, strategic modifications can be made with the incremental addition of composite or acrylic resin. Excessive pressure on the mucosa can lead to tissue inflammation or necrosis, so it is advisable to undertake this process in stages for the most effective results.[ix]
Once optimal contours have been achieved, these must be transferred to the final restorations. Ensuring the established contours are accurately maintained promotes tissue stability and health as well as more successful long-term aesthetics.[x]
Provisional restoration design options
Provisionalisation is an important step to achieve aesthetic results in implant cases, and many different options are available when planning the fabrication of provisional restorations. Depending on the clinical need, different approaches and timescales will be considered. As micromovements can have negative biological consequences to the osseointegration process as well as the soft tissue connection, the treatment plan should involve as few disconnections of the prosthetic as possible.[xi]
The prosthesis design is contingent on the goal to be reached, i.e. to maintain the gingival structure. In the case of delayed implants, provisional restorations might need to recreate lost gingival contours.[xii] To achieve the latter, concave or flat subcritical contour can be effective, while the critical contour may be positioned at the zenith level of the tooth.[xiii]
When used with immediate implants the design of the provisional restoration should follow the natural margins of the gingiva at the critical contour to support soft tissue structure. This helps in maintaining the shape of the gingiva during the healing process, resulting in more successful soft-tissue integration with the final prosthesis. A concave subcritical contour in the buccal area may be considered to create a space for a stable blood clot to form.[xiv]
Retention of the provisional implant will be assessed on a case-by-case basis. A screw-retained provisional restoration allows for easy retrievability, and eliminates the risk of soft tissue irritation that can occur in the subgingival areas due to residual cement.[xv] In addition, the fastening screws provide a solid joint between the restoration and the abutment.[xvi] In some cases where implants are well-positioned, screw-retained provisionals can be fabricated intraorally using acrylic or composite resin.[xvii]
Hands on learning
The ICE Postgraduate Dental Institute and Hospital, under the guidance of renowned specialist oral surgeon Professor Cemal Ucer, presents a host of comprehensive hands-on courses for dentists wishing to add advanced implantology techniques to their practice. In a hands-on, one-day course: ‘The art and science of provisional and interim implant restoration’, participants can explore various options for provisional restorations and their specific indications. Additionally, the course will cover fabrication techniques, and methods for customising impression copings and accurately recording soft tissue contours.
Provisional restorations have become an essential element of successful prosthetically driven implant placement therapy, in successfully managing the aesthetic and healthy contouring of soft tissue around implants.[xviii] Gaining a high level of surgical skill along with advanced knowledge of prosthetic design and soft tissue management offers patients the best chance of success.[xix]
Please contact Professor Ucer at ucer@icedental.institute or Mel Hay at mel@mdic.co
01612 371842
Prof. Cemal Ucer, BDS, MSc, PhD, FDTFEd., ITI Fellow, Specialist Oral Surgeon
Cemal Ucer first established an implant referral centre in 1995. He was awarded an MSc in Implantology at Manchester Dental Hospital following his research into guided bone regeneration and osteopromotion. He later gained a PhD for his clinical and laboratory studies into the factors affecting the success of implant treatment in iliac grafts and the investigation of the effect of skeletal bone density on implant survival. He has personally trained and mentored more than 1,000 dentists in implant dentistry as one of the main providers of implant education in the UK.
Cemal’s current clinical research interests include immediate implant placement, reconstructive bone surgery, nerve damage and the effect of bone density on the success of implant treatment. Academically, he has gained European recognition for his work on the development of a new framework for teaching and assessment of clinical competence in implantology. He is a co-author of the consensus paper produced by the Association for Dental Education in Europe (ADEE) following the first pan-European collaboration between EU universities to establish common training and assessment standards in dental implantology. He is an invited member of the working group convened by the FGDP (UK) and the General Dental Council (GDC) to update the Training Standards in Implant Dentistry (TSID) guidelines in 2012 and 2016.
Cemal is a Fellow of the Dental Trainers Faculty of the Royal College of Surgeons of Edinburgh (RCSEd) and a Fellow of the International Team for Implantology (ITI) and a member of Megagen’s MINTEC UK & I Board for education and clinical research. He is a member of the editorial board of JOMR (Journal of Oral & Maxillofacial Research) and the chair of the editorial advisory board of Implant Dentistry Today. Cemal is Professor and Clinical Lead of the MSc programme in Dental Implantology and a member of the Faculty of Examiners of the Royal College of Surgeons of Edinburgh’s Diploma in Implant Dentistry. He is a past president of The Association of Dental Implantology (ADI) (2011-2013).
Cemal has been appointed by FGDP (UK) to lead the working group to develop the “national standards in implant dentistry” which is due to be published later in 2018 following the completion of an external consultation process.
[i] Gupta R, Gupta N, Weber, DDS KK. Dental Implants. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470448/
[ii] Romanos GE, Delgado-Ruiz R, Sculean A. Concepts for prevention of complications in implant therapy. Periodontol 2000. 2019 Oct;81(1):7-17. doi: 10.1111/prd.12278. PMID: 31407435.
[iii] Treatment Goals and Planning For Dental Implants ADI [Internet]. ND. Available at: https://www.adi.org.uk/resources/before_surgery_implant_planning/ Accessed December 2024
[iv] Treatment Goals and Planning For Dental Implants ADI [Internet]. ND. Available at: https://www.adi.org.uk/resources/before_surgery_implant_planning/ Accessed December 2024
[v] Ruales-Carrera. ITI. [Internet] May 2021. Available at: https://blog.iti.org/clinical-insights/soft-tissue-management-implant-supported-restorations/ Accessed December 2024.
[vi] https://pocketdentistry.com/implant-provisionalisation/
[vii] Son MK, Jang HS. Gingival recontouring by provisional implant restoration for optimal emergence profile: report of two cases. J Periodontal Implant Sci. 2011 Dec;41(6):302-8. doi: 10.5051/jpis.2011.41.6.302. Epub 2011 Dec 31. PMID: 22324008; PMCID: PMC3259239.
[viii] Kouveliotis G, Karoussis I, Papamanoli E, Tasopoulos T, Kourtis S, Rocha M, Oliveira D, Hosney S, Zoidis P. Customizing implant emergence profile and provisional prostheses. Combination of the digital and the analog protocol. A Case Report. J Clin Exp Dent. 2024 Jun 1;16(6):e789-e794. doi: 10.4317/jced.61633. PMID: 39183994; PMCID: PMC11345084.
[ix] Wittneben JG, Buser D, Belser UC, Brägger U (2013). Peri-implant soft tissue conditioning with provisional restorations in the esthetic zone: the dynamic compression technique. Int J Periodontics Restorative Dent 33(4): 447–455.
[x] Hinds KF (1997). Custom impression coping for an exact registration of the healed tissue in the esthetic implant restoration. International Journal of Periodontics & Restorative Dentistry 17(6).
[xi] Fabbri G, Staas T, Linkevicius T, Valantiejiene V, González-Martin O, Rompen E. Clinical Performance of a Novel Two-Piece Abutment Concept: Results from a Prospective Study with a 1-Year Follow-Up. J Clin Med. 2021 Apr 9;10(8):1594. doi: 10.3390/jcm10081594. PMID: 33918898; PMCID: PMC8070442.
[xii] Ruales-Carrera. ITI. [Internet] May 2021. Available at: https://blog.iti.org/clinical-insights/soft-tissue-management-implant-supported-restorations/ Accessed December 2024.
[xiii] González-Martín O, Lee E, Weisgold A, Veltri M, Su H. Contour Management of Implant Restorations for Optimal Emergence Profiles: Guidelines for Immediate and Delayed Provisional Restorations. Int J Periodontics Restorative Dent. 2020 Jan/Feb;40(1):61-70. doi: 10.11607/prd.4422. PMID: 31815974.
[xiv] Sun TC, Chang TK. Soft tissue management around dental implant in esthetic zone – the current concepts and novel techniques. J Dent Sci. 2024 Jul;19(3):1348-1358. doi: 10.1016/j.jds.2024.03.003. Epub 2024 Mar 28. PMID: 39035283; PMCID: PMC11259688.
[xv] Son MK, Jang HS. Gingival recontouring by provisional implant restoration for optimal emergence profile: report of two cases. J Periodontal Implant Sci. 2011 Dec;41(6):302-8. doi: 10.5051/jpis.2011.41.6.302. Epub 2011 Dec 31. PMID: 22324008; PMCID: PMC3259239.
[xvi] Manawar A, Dhanasekar B, Aparna I.N, Naim H. Factors influencing success of cement versus
screw-retained implant restorations: a clinical review. J Osseointegr 2012;3(4):43-47.
[xvii] Son MK, Jang HS. Gingival recontouring by provisional implant restoration for optimal emergence profile: report of two cases. J Periodontal Implant Sci. 2011 Dec;41(6):302-8. doi: 10.5051/jpis.2011.41.6.302. Epub 2011 Dec 31. PMID: 22324008; PMCID: PMC3259239.
[xviii] Son MK, Jang HS. Gingival recontouring by provisional implant restoration for optimal emergence profile: report of two cases. J Periodontal Implant Sci. 2011 Dec;41(6):302-8. doi: 10.5051/jpis.2011.41.6.302. Epub 2011 Dec 31. PMID: 22324008; PMCID: PMC3259239.
[xix] Sun TC, Chang TK. Soft tissue management around dental implant in esthetic zone – the current concepts and novel techniques. J Dent Sci. 2024 Jul;19(3):1348-1358. doi: 10.1016/j.jds.2024.03.003. Epub 2024 Mar 28. PMID: 39035283; PMCID: PMC11259688.
