Indirect Implant-Supported Fixed ProvisionalRestoration in the Esthetic Zone: FabricationTechnique and Treatment Workflow

ALEXANDER SHOR, DMD, MSD*

RALF SCHULER, DDS, PhD†

YOSHIHIRO GOTO, DDS, MSD‡

ABSTRACTTreatment objectives of an implant-supported fixed provisional restoration include shaping/preservation of the gingival soft tissue contour, functional and esthetic substitution of themissing dentition during postsurgical healing, and definitive prosthesis fabrication stages. Fixedprovisional restoration can also serve as an esthetic and functional blueprint in the fabricationof the definitive restoration. Despite its common use and important indications, limited infor-mation is available on the various aspects of the provisional fabrication and treatment. Thisarticle presents a production technique and treatment workflow of a laboratory-fabricated,screw-retained fixed provisional restoration. Provisional restoration is fabricated using layeringtechnique and internal stain characterization. The soft tissue profile of the working castis modified according to the coronal contour of the diagnostic wax-up. Upon delivery, the pro-visional contour is reevaluated and modified as necessary. The developed emergence profile ofthe provisional restoration is transferred to the master cast via customized impression copings.

CLINICAL SIGNIFICANCELaboratory-fabricated implant-supported provisional restorations allow the esthetic and func-tional substitution of the missing dentition and the shaping of the soft tissue profile, and canact as a blueprint in the fabrication of definitive restorations.

(J Esthet Restor Dent 20:82–97, 2008)

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

Dental implants are routinelyutilized for the support of

fixed restorations in the replace-ment of missing and hopelesssingle and multiple teeth.1–8 It is

evident that this treatmentapproach allows restoration ofthe integrity of the dental arch,occlusal stability for the opposingarch, restoration of masticatoryfunction, speech and esthetic sub-stitution of the missing dentition.

Widespread acceptance of implant-supported restorations is based ontheir excellent success rate andseveral principal advantages overthe tooth-borne fixed and remov-able treatment alternatives.1–8

These advantages include

*Affiliate assistant professor, Department of Restorative Dentistry, University of Washington, Seattle,WA, and private practice, Seattle, WA

†Affiliate assistant professor, Department of Periodontics, University of Washington, Seattle, WA,and private practice, Seattle, WA

‡Clinical assistant professor, University of Southern California, Los Angeles, CA, and private practice,Los Angeles, CA

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preservation of the integrityof the adjacent teeth, long-term stability of the remainingalveolar bone and overlyingsoft tissues, and excellentpatient compliance.3,4,6–10

Replacement of missing and hope-less teeth with implant-supportedfixed restorations in the estheticzone is a complex treatment.11–13

It consists of a number ofcommon treatment steps thatinclude implant site development,implant placement surgery, provi-sionalization, and fabrication andmaintenance of the definitive res-toration.12,14 Despite excellentsuccess rates, implant treatmentpresents with some obvious chal-lenges in the esthetic zone. Thecommon sequelae of tooth loss,which include resorption of thealveolar bone and apical migra-tion of the gingival tissues,present a considerable challengefor the attainment of the idealsoft tissue esthetics.12,13,15 Potentialdeficiencies of the soft tissues canrange from minor discrepancies tosevere defects. Numerous treat-ment protocols and techniqueshave been developed to counteractthis problem and may includeimmediate placement andprovisionalization of the dentalimplants, soft and hardtissue augmentation of theedentulous ridge and extractionsites, and orthodonticsite development.16–22

Provisionalization is an integralpart of implant treatment in theesthetic zone, and several types ofprovisional restorations have beendescribed.12,14,23 These are softtissue and/or tooth-supportedremovable prosthesis, tooth-supported fixed prosthesis, andimplant-supported fixed prosthesis.The obvious goals of provisional-ization include the esthetic andfunctional substitution of themissing dentition during treat-ment.12,23 Provisional restorationscan also be utilized for theshaping/preservation of the softtissues in the coronal portion ofthe peri-implant mucosa.14,23–27

Finally, the provisional restorationcan also serve the important func-tions of esthetic and functionalprototyping, thus acting as ablueprint in the fabrication ofthe definitive restoration.23,28,29

Selection of a specific type ofprovisional restoration is based onindividual case requirements andchosen treatment plan. It is alsoobvious that some cases mayrequire several different typesof provisional restorationsduring the course ofthe treatment.30

Fixed implant-supported provi-sional restoration is commonlyutilized in the esthetic zone.14,23,31

In comparison with the otherdesigns, it can fulfill all aforemen-tioned goals of provisionalization.Because of its fixed nature and

implant support, it is an ideal res-toration for the shaping of the softtissue profile and prototyping ofthe definitive prosthesis. From atreatment sequence point of view, afixed implant provisional restora-tion can be placed immediatelyfollowing implant surgery or in adelayed protocol following appro-priate healing time. Implant-supported fixed provisionals canbe fabricated in a number ofdifferent ways, and several designsand production techniqueshave been presented in thedental literature.23,32–37

The goal of this article is topresent a clinical and laboratorytechnique for provisional fabrica-tion (Table 1). A screw-retainedprovisional restoration is fabricatedin the laboratory using enamel anddentin layering and internal char-acterization. The soft tissue profileof the working cast is modifiedaccording to the coronal contourof the diagnostic wax-up. Upondelivery, the provisional contour isreevaluated and modified as neces-sary. The developed emergenceprofile of the provisionalrestoration is transferred tothe master cast via customizedimpression copings.

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

A 52-year-old female presented fora prosthodontic rehabilitation ofher failing maxillary central inci-sors (Figures 1 and 21). These

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teeth have been previously treatedwith root canal fillings, full-coverage ceramometal restorations,and post restoration on the leftcentral incisor. Clinical examina-tion revealed adhesive cementfailure between the restorationsand the teeth, and root caries atthe margins of the restorations.Radiographic evaluation revealed

short roots, periapical pathosis onright central incisor, and uncom-promised bone levels. Final treat-ment plan was prepared followingthe assessment of the diagnosticinformation, treatment alternatives,cost considerations, and patient’sdesires. It included implant replace-ment of the maxillary central inci-sors. In regard to the potential

risks associated with the proposedtreatment plan, existing clinicalpresentation was judged as favor-able because of the presence ofuncompromised gingival and bonytopography, thick flat periodontalbiotype, and low lip line duringmaximum smile (Figure 2).

The planned prosthetic designincluded single screw-retainedceramometal restorations. Theproposed treatment sequenceincluded immediate implant place-ment protocol. For the provision-alization and loading of theimplants, it was decided to utilizea delayed treatment protocol.In preparation for the implantsurgery, an interim acrylicremovable appliance and aclear vacuum-formed surgicaltemplate were fabricated onthe maxillary diagnostic cast.

Care was taken to ensure atrau-matic extractions of the incisorsat the time of implant surgery.Standard 4-mm-diameter, internalconnection-type implants wereplaced immediately following teethextractions. Implant placement wasfacilitated with the help of a surgi-cal template, and good primarystability of the implants wasachieved. For the preservation ofthe soft tissue profile and sealingof the sockets, custom healingabutments were fabricated in thefollowing manner. Engaging,two-piece titanium temporary

TA B L E 1 . L A B O R AT O R Y S T E P S I N P R O V I S I O N A L FA B R I C AT I O N .

1. Diagnostic wax-up on the working cast1.1 Scoring of the gingival outline around the margins of the wax-up

2. Duplication of the working cast2.1 Fabrication of the clear vacuum- and pressure-formed matrix on the

duplicate cast2.2 Fabrication of the silicone putty matrices on the duplicate cast

3. Carving of the subgingival soft tissue contour on the working cast4. Preparation of the temporary abutments and seating on the working cast

with guide pins.5. Seating of the clear matrix6. Injection of the dentin layer, vacuum, and pressure polymerization7. Dentin cutback and application of the internal stains8. Pressing of the enamel layer with the silicone matrix, vacuum, and pressure

polymerization9. Finishing and polishing

Figure 1. Initial presentation, intraoral view.

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abutments were seated on theimplants, and a flowable-type com-posite was injected into the socketto fill the space between the abut-ments and the soft tissue. Follow-ing light-polymerization, thehealing abutments were removedfor finishing and polishing. Theheight of abutments was adjustedso their occlusal surface was flushwith the tissues. Upon abutmentseating, an interim denture wasdelivered to the patient. The inta-glio surface of the denture wasrelieved in the area of the healingabutments. This portion of thedenture was relined with a softtissue conditioning material. Nocomplications were encounteredduring the surgical stage of thetreatment. Three months followingimplant surgery, and upon success-ful confirmation of the osseointe-gration, the patient presented forthe fabrication of the provisionalrestorations (Figure 3).

F I X E D P R O V I S I O N A L

R E S T O R AT I O N

Pickup-type impression copingswere attached to the implants,and complete seating of thecopings was verified with a peri-apical radiograph. Implant-levelimpression was taken with acombination of a high-viscositypolyvinylsiloxane placed into thestock tray and a light-body poly-vinylsiloxane injected around theteeth and impression copings. Theseries of intraoral and smile pho-tographs was taken with theselected shade tabs. In the labora-tory, implant analogues were con-nected to the impression copings.To prevent stone chipping at thetime of model separation, a thinfilm of modeling wax was placedon the subgingival portion ofthe impression copings. Theworking cast was poured in typeIV dental stone. Mounting andarticulation of the casts on a

semiadjustable articulator wascarried out using standard prosth-odontic protocols.

For the stability of the diagnosticwax-up, an armature-like supportwas created on the working cast inthe area of the missing teeth.Wooden pegs were placed on theimplant analogues. They wereconnected to each other with abraided wire and self-cured acrylic.The stone cast was covered with alayer of wax separator in the areaof the missing teeth. The modelingwax was flown into the socketarea of the missing teeth (Figure 4).Upon completion of this step, adiagnostic wax-up of the centralincisors was completed usingstandard laboratory protocols.Morphology of the central incisorswas developed to complement thetooth form of the adjacent intactanterior teeth. The stone castin the areas of the facial and

Figure 2. Initial presentation, smile view. Figure 3. Patient presentation following postsurgicalhealing.

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lingual gingival marginswas scored with a sharpinstrument (Figure 5).

The working cast with the com-pleted wax-up was duplicated withthe irreversible hydrocolloidimpression material. Three matri-ces were fabricated on the dupli-cate cast. The first matrix of thewhole arch was made from a clearvacuum and pressure-molded mate-rial (Copyplast, Scheu-DentalGmbH, Iserlohn, Germany).The other two matrices of themaxillary anterior teeth weremade from a combination oflow-viscosity polyvinylsiloxaneimpression material andlaboratory putty.

The diagnostic wax-up wasremoved from the working cast,and stone extensions of the castabove the gingival scoring marks

were trimmed away in order tocreate a gradual emergence profileof the crowns. Engaging plastictemporary abutments were utilizedin the fabrication of the provision-als. The height of the abutmentswas shortened so they extend justabove the level gingival margins onthe stone cast. Temporary abut-ments were secured on the working

cast with the impression guidepins. The clear matrix was seatedover the guide pins on the workingcast (Figure 6). The clear matrixwas then removed from the cast,and two access holes 1.5 mm indiameter were created in thelingual area of the matrix, one foreach missing tooth. The stone castin the area of the anterior teeth

Figure 6. The clear matrix is seated over the guide pins.

Figure 4. Armature-like support is constructed for thediagnostic wax-up; modeling wax is flown into the socketarea of the missing teeth.

Figure 5. The stone cast is scored in the area of thegingival margins.

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and guide pins were lubricatedwith petroleum jelly. The acrylicdentin power and monomer liquid(New Outline, Anaxdent GmbH,Stuttgart, Germany) were mixedtogether in a mixing cup andloaded into a delivery syringe. Thedentin material was injected intothe socket areas of the incisors.The clear matrix was immediatelyseated on the master cast, andresin was injected into the selectedaccess hole of the matrix untilit completely filled the areas ofthe missing incisors. The materialwas allowed to bench set until itreached a doughy stage. The wholeassembly was placed into thechamber of the pressure pot,where it was polymerizedfollowing the manufacturer’srecommended guidelines.

Upon removal of the clear matrix,the excess dentin material wastrimmed away from the provisional

crowns (Figure 7). The outer facialsurface of the crowns was cut backby approximately 0.5 to 1.00 mm.A silicone matrix was utilized inorder to assure a uniform facialreduction. No incisal cutback wascarried out in order to preventexcessive translucency at the incisalaspect of the crowns. Light-polymerized chromatic stains(Creactive, Heraeus Kulzer Inc.,Armonk, NY, USA) were appliedin the desired facial areas of thecrowns (Figure 8). The screwaccess holes were closed with ablock-out wax material. Thesecond silicone matrix was short-ened up to the incisal one-third onits lingual aspect in order to allowfor the escape of the resin excess.A desired enamel combination(New Outline) was mixed with amonomer liquid until it reached acreamy consistency. The mix wasthen placed into the silicone matrixin the facial areas of the central

incisors (Figure 9). The siliconematrix with the enamel mixwas seated onto the working castand secured to it with thehelp of rubber bands. The excessacrylic material, which escapedunderneath the matrix on thelingual aspect of the provisional,was removed with a brush. Poly-merization was completed in thepressure pot under controlled con-ditions. The provisional restora-tions were removed from the cast,and excess acrylic was trimmedaway. The provisional crowns weresectioned from each other in thearea of the interproximal contactusing an ultrathin separatingdisk. The surface of the crownswas finished and polished(Figure 10).

Provisional restorations wereseated intraorally, and soft tissueresponse was evaluated. Initial softtissue response included blanching

Figure 7. Provisional restoration before the dentin cutback. Figure 8. Internal characterization of the dentin.

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of the gingival tissues (Figure 11).Upon continuous observation, itwas noted that the blanching ofthe tissues was not subsiding. Thesubgingival contour of the provi-sional restorations was reducedincrementally until no blanchingwas further observed. Access holeswere closed with a temporaryfilling material. The patient did notreport any complaints at the

24-hour recall appointment, andclinical examination revealed anuneventful soft-tissue healing. Thedesired emergence profile of theimplant crowns was completed atthe subsequent recall appointment.Recall appointments were estab-lished on a monthly basis, andgood soft-tissue maturation wasobserved around the provisionalrestorations (Figures 12–14).

Three months from the provisionaldelivery date, the patientpresented for the finalimpression procedure.

F I N A L I M P R E S S I O N A N D

D E F I N I T I V E R E S T O R AT I O N S

Pickup-type impression copingswere customized in order to dupli-cate the gingival emergence profile

Figure 9. Enamel mix inside the silicone matrix. Figure 10. Completed provisional restorations on theworking cast.

Figure 11. Provisional restoration immediately followingseating.

Figure 12. Smile view with the provisional restorations.

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of the provisional. Implant ana-logues were set into a fast-set stoneputty placed inside the medicinalcup. Several millimeters of thecoronal portion of the analogueswere left uncovered by the stone.The provisional restorations wereremoved from the mouth andseated on the implant analogues(Figure 15). In order to preventsoft tissue collapse, previouslyutilized healing abutments wereseated intraorally. Low-viscositypolyvinylsiloxane impression mate-rial was injected up to the gingivalone-third of the provisionals(Figure 16). The provisionalcrowns were removed and theimpression copings were seated onthe analogues. Flowable light-polymerized composite was incre-mentally injected and cured in thespace developed by the provisionalrestorations (Figure 17). Completeseating of the impression copingswas verified with a periapical

radiograph (Figure 18). Finalimpression was taken with a com-bination of high-viscosity polyvi-nylsiloxane placed into the stocktray and light-body polyvinylsilox-ane injected around the teeth andimpression copings. Diagnosticcast of the provisional and smilephotographs were also sent tothe laboratory.

In the laboratory, the implantanalogues were attached to theimpression copings and a polyvi-nylsiloxane soft tissue model wascreated around the implant ana-logues. Master cast fabrication andmounting of the models to thesemiadjustable articulator werecarried out using standard labora-tory protocols. Standard laboratory

Figure 15. Provisional restorations seated on the implantanalogues.

Figure 13. Soft tissue maturation around provisionalrestorations.

Figure 14. Soft tissue maturation around provisionalrestorations.

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protocols were utilized in the fabri-cation of individual ceramometalone-piece screw-retained restora-tions (Figures 19 and 20).

At the delivery appointment, inter-proximal contacts and occlusionwere adjusted as necessary. Com-plete seating of the restorationswas verified with a periapicalradiograph (Figure 21). Retaining

screws were tightened to the manu-facturer’s recommended value, andaccess holes were closed withrestorative composite. Definitiverestorations are depicted inFigures 22 and 23.

D I S C U S S I O N

The presented provisional fabrica-tion technique is best applicableto situations of delayed implant

loading. It can be equally utilizedfor the production of singleand multiple splinted orunsplinted units.

Important considerations in theproduction of the implant-supported fixed provisional includeprosthetic design, restorative mate-rial choice, and fabrication tech-nique. From the design point of

Figure 18. Impression copings are seated intraorally. Figure 19. Definitive ceramometal restorations.

Figure 16. Polyvinylsiloxane material is injected aroundthe provisional restorations.

Figure 17. Flowable composite is injected and polymerizedin the space developed by the provisional restorations.

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view, the most common optionsinclude a one-piece screw-retainedprovisional and a two-piece provi-sional, which consists of a screw-retained temporary abutment anda cemented temporary crown.25,32–37

It appears that both types of

designs can be successfully utilizedin the esthetic zone. However,advantages of the one-piecescrew-retained provisional includea more simplified design, ease ofadjustments, and ease of deliveryand retrieval. In addition,

complications of the cemented pro-visional restoration, such as incom-plete removal of the temporarycement and loss of retention of theprovisional, are avoided with ascrew-retained provisional design.One potential critique of thescrew-retained provisional restora-tion relates to the fact that theretaining screw access hole cancompromise the esthetics of theprovisional when it emergesthrough the facial or incisal aspectof the provisional. However, thescrew access hole can be easilymasked with restorative composite,and the esthetics of the provisionalrestoration should not besignificantly compromised.

The two most common types ofmaterials utilized for the fabrica-tion of a provisional restorationinclude acrylic and compositeresins.25,32–37 Both types of materi-als can be successfully utilized forthe provisional fabrication, and thedental literature does not indicateclear clinical superiority of oneclass of material over the other. Itis obvious that a large number ofprovisional material brands exist inthe dental market. However,between the group and within thegroup, clinical performance data isnot available, and it appears thatchoice of the specific material isempirically based. It should also benoted that enamel and dentinmaterials for the layering techniqueare available only with selected

Figure 20. Definitive ceramometal restorations.

Figure 21. Periapical radiographs before and after completion of thetreatment.

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brands of provisional materials.The advantages of the NewOutline provisional system includeavailability of the enamel anddentin shades as well as the factthat the layering technique withthis material has been presented inthe dental literature.38

Fabrication of an implant-supported fixed provisional resto-ration can be carried out directlyin the mouth or in the dentallaboratory in a so-called indirectapproach.32,34,36,37 Most commonly,for the direct approach, a clearvacuum-formed matrix, siliconmatrix, or prefabricated resin shellis filled with a provisional materialand relined over the prepared tem-porary abutment. The main advan-tage of this approach includesreduced number of clinical andlaboratory steps. This approachcan also be advantageous in casesof immediate provisionalization

following implant surgery becauseof the reduced patient-waitingtime. Conversely, in the indirectapproach, provisional fabricationis outsourced to the dental labora-tory. Its obvious disadvantagesinclude additional clinical andlaboratory steps and associatedlaboratory cost. On the otherhand, its advantages include amore controlled environment forprosthesis fabrication as well asreduced chair time. The advantagesof the indirect approach are espe-cially appreciated in cases wherea provisional is fabricated formultiple missing teeth and/orthere is a need to create a restora-tion that closely mimics naturaltooth structure.

In the presented approach, enameland dentin layering in combinationwith internal stain characterizationwere utilized in provisionalfabrication. The advantages of the

layering technique include detailedreproduction of the tooth shadeand tooth characterization.38–40 Itis especially advantageous in theesthetic zone where adjacent teethmay present with complex charac-terization. However, for its success,the layering approach requiresa detailed understanding of theoptical behavior of the utilizedmaterials and is somewhattechnique-sensitive.

Optimizations that have been madein order to adapt the layering tech-nique to the implant provisionalsinclude the sequential use of theclear vacuum-formed and siliconematrices. The clear matrix allowsfor complete and easy seating overthe guide pins. In this manner,the provisional restoration can beeasily retrieved from the model.The use of a second silicone matrixallows for the precise positioningof the enamel layer. In addition,

Figure 22. Intraoral view of the definitiverestorations.

Figure 23. Smile view of the definitive restorations.

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this type of matrix can be easilycompressed against the stonemodel in order to prevent overcon-touring of the provisional. Theaccess hole channel that emergesthrough the incisal or the facialaspect of the provisional must beclosed with a block-out wax fol-lowing the completion of dentincutback and internal staining.Upon completion of the enamellayering, the screw access hole isdrilled in the provisional and thelocation of the access channel isfacilitated with a clear matrix. Itshould also be noted that the pre-sented technique is designed for anautopolymerized acrylic resin mate-rial and may not be suitable forother provisional materials.

From the material performancepoint of view, special consider-ations should be given to the clini-cal scenarios where there is a riskof provisional fracture. Potentialrisk factors may include long-spanprovisional with several pontics,presence of cantilevers, unfavorableocclusion, among others. If such arisk is identified, reinforcingpolymer fibers or metal frameworkcan be incorporated into theprovisional restoration.41,42

Standard impression coping, whichis circular in its diameter, does notmimic the ovoid root of thenatural tooth. In addition, impres-sion coping size in its horizontalcross section is usually smaller in

comparison with the natural tooth.Upon placement of the impressioncoping in the mouth, soft tissuequickly adapts to its contours.When transferred to the laboratory,the resultant soft tissue profile doesnot correspond to the desiredemergence profile of the provi-sional restoration. Therefore, it isdeveloped via modification of theworking cast, as described in thearticle. For the fabrication ofthe definitive restoration, the devel-oped emergence profile of theprovisional is transferred to thelaboratory via customization of thestandard impression coping. Thisapproach has been well presentedin the dental literature, and thedescribed technique yields an accu-rate duplication of the subgingivalemergence profile on themaster cast.25,37

C O N C L U S I O N

A fabrication technique and treat-ment workflow of a laboratory-fabricated implant-supported fixedprovisional restoration is presentedin the article. Provisional design iscarried out as a one-piece screw-retained prosthesis. The provisionalis fabricated using enamel anddentin layering in conjunctionwith an internal stain characteriza-tion. The soft tissue profile of theworking cast is modified accordingto the coronal contour of the diag-nostic wax-up. The developedemergence profile of the provi-sional restoration is transferred to

the master cast via customizedimpression copings.

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

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

The authors do not have anyfinancial interest in the companieswhose materials are included inthis article.

The provisional restorations werefabricated by Dr. Alexander Shor.The authors extend their gratitudeto Mr. Harald Heindl and Ms.Daniela Heindl for the fabricationof the definitive restorations.

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