IMMEDIATE RESTORATION OF THE JAW

J Oral Maxillofac Surg

63:72-79, 2005, Suppl 2

Techniques to Facilitate
Provisionalization
of Implant Restorations
Paulino Castellon, DDS,* Michael Casadaban, DDS, MD,†
and Michael S. Block, DMD‡

Purpose: The aim of this article was to review current methods for immediate provisionalization of
single unit implant restorations.
Methods: Four methods are discussed and illustrated in detail, including: preoperative preparation of
an abutment and provisional crown using diagnostic models; abutment placement and modification at
the time of implant placement; the use of 1-piece or non-prepable abutments; and methods of indexing.
Material characteristics for indexing are presented to provide the clinician with an understanding of
material handling in relation to accuracy of indexing.
Conclusion: Depending on clinician and patient case specific criteria, immediate provisionalization of
implant restorations can be performed in an efficient manner.
© 2005 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 63:72-79, 2005, Suppl 2

Immediate provisionalization of endosseous implants
for single and multiple unit restorations has been
reported with high success rates.1-3 After implant
placement, traditional techniques recommend a heal-
ing time of 4 to 6 months before restoration of the
implant.4-8 However the extended interval of time
between implant placement and restoration is not
optimal to return the patient to function and esthet-
ics. Immediate provisionalization of an implant pro-
vides the patient with tooth-like structures that satisfy
the patient’s desire to replace missing teeth. The goals
for immediate or early provisionalization of implants
include: maintenance of interdental space, develop-
ing the gingival sulcus and contours to minimize delay
to the final restoration, patient comfort by eliminating
a removable provisional restoration, and elimination
of second stage surgery.
Received from the Louisiana State University School of Dentistry,
New Orleans, LA.
*Assistant Professor, Department of Prosthodontics.
†Resident, Department of Oral and Maxillofacial Surgery.
‡Professor, Department of Oral and Maxillofacial Surgery.
Address correspondence to Dr Block: LSU School of Dentistry,
1100 Florida Ave, New Orleans, LA 70119.
© 2005 American Association of Oral and Maxillofacial Surgeons
0278-2391/05/6309-0208$30.00/0
doi:10.1016/j.joms.2005.05.152
The purpose of this article is to summarize and
describe various options available for the surgeon and
restorative dentist to facilitate provisionalization of an
implant. Different approaches of placing the implant
and preparing the immediate provisional have been
used. The approaches considered in this article refer
to the preoperative abutment preparation, intraoral
abutment preparation, and 1-piece implant systems.
Preoperative Preparation of Abutments
and Temporary Restorations
A proper treatment plan, including diagnostic
set-up and casts, should be performed by the restor-
ing dentist and surgeon (Tables 1-3). After determin-
ing the size and type of implant to be placed, the
appropriate implant analog is placed in the model in
the ideal location as determined by the planned pros-
thesis. The implant depth is dependent on the
planned gingival location, placing the shoulder of the
implant approximately 2 to 3 mm below the gingiva
(Fig 1).
The abutment is chosen to place the margins of the
temporary at the level of the gingiva, except for the
anterior maxilla where the margins can be 1 mm
subgingival. The abutment height and angulation is
modified as necessary. Because the provisional resto-
ration will not be in occlusion, the abutment height
may need to be shorter than the ideal final abutment.

72
CASTELLON, CASADABAN, AND BLOCK 73

Table 1. PREOPERATIVE ABUTMENT PREPARATION, ROLES OF CLINICIANS

Preop Intraop Postop Postop 4 Mos

Surgeon Assessment of bone and Place implant, prepared

soft tissue abutment, and
provisional crown
Restorative Assessment, models, Adjust the abutment Transfer impression
dentist prescribe contour and for final
occlusion, deliver the abutment and
temporary crown crown
Lab Place implant analog in Fabricate final
model, prepare crown
abutment, fabricate
temporary crown and
drill guide
Castellon, Casadaban, and Block. Provisionalization of Implant Restorations. J Oral Maxillofac Surg 2005.

Table 2. INTRAORAL ABUTMENT PREPARATION, ROLES OF CLINICIANS

Preop Intraop Postop Postop 4 Mos

Surgeon Assessment of bone and Place the implant, and abutment,

soft tissue adjust the height and labial
contours of the abutment
Restorative Assessment, fabrication Re-line and deliver Final impression
dentist of temporary crown temporary crown
and drill guide
Lab Fabrication of temporary Fabricate final
crown and drill guide crown
Castellon, Casadaban, and Block. Provisionalization of Implant Restorations. J Oral Maxillofac Surg 2005.

Table 3. ONE-PIECE IMPLANT PREPARATION, ROLES OF CLINICIANS

Preop Intraop Postop Postop 4 Mos

Surgeon Assessment of bone Place the implant, minimally

and soft tissue adjust the height and
labial contours of the
abutment
Restoring Assessment, choose Re-line and deliver Adjust abutment
dentist shade and temporary crown margins, final
polycarbonate impression
crown. Fabricate
drill guide
Lab Fabricate final crown
Castellon, Casadaban, and Block. Provisionalization of Implant Restorations. J Oral Maxillofac Surg 2005.

It is important to create and preserve retentive ele-
ments on the abutment which may include a rough
surface, development of grooves, and minimal prep-
aration of the flat surface that is usually present on
many abutments. If the abutment is highly polished
and deprived of retentive elements the temporary
crown may become loose more often.
After the abutment is prepared and the clearance
confirmed on the casts, the provisional crown is pre-
pared. The margins are polished to optimize subgingival
health. The mesial and distal contacts are eliminated to
prevent excessive pressure upon placement. The occlu-
sal surface is modified to eliminate contacts in vertical
and lateral excursions. Depending on clinician prefer-
ence a vent hole can be made in the occlusal surface to
allow cement to escape after delivery.
A surgical guide is made from the model using the
analog as guidance for implant positioning. This guide
is useful to indicate the labial surface of the restora-
tion, location of embrasures, the gingival margin of
74 PROVISIONALIZATION OF IMPLANT RESTORATIONS

FIGURE 1. A, This occlusal photograph identifies a premolar tooth with a fracture. This tooth will be extracted and an implant immediately placed
in the extraction site. B, A model is made and the tooth is ground away on the model. An implant analog is placed into the model positioning the
implant ideally. The implant analog should be 2 to 3 mm apical to the gingival margin of the planned restoration, and as well, approximately 1
½ mm palatal to the labial emergence of the planned crown. The retentive feature of the implant should be consistently oriented along the labial
surface. In this case, for this internal connected implant, the flat of the internal hex is placed parallel to the labial plane. C, A fixed abutment is
modified to provide the appropriate provisionalization of the tooth. The gingival margin height of the abutment is chosen to place the gingival margin
just at the level of the gingiva. Flat surfaces and parallel walls are preserved to aid in the retentive aspects for the temporary crown. The vertical of
the abutment is trimmed appropriately to allow for appropriate occlusal clearance. D, A hollow shell crown is relined. The margins are finished to
allow for excellent gingival health. The abutment and crown are available to the surgeon at the time of implant placement so they may be placed
immediately after implant placement. E, This photo shows the abutment with appropriate occlusal clearance. Note the flat surface is directly labial.
F, The provisional crown is made and as can be seen, appropriate contours and esthetic concerns are met with the provisional crown. G, The
provisional crown is approximately 1 mm out of occlusion. If the implant is placed at the same depth as on the model, there will be minimal adjustment
of the temporary at the time of implant placement. Also, note that there is a 1 to ½ mm clearance at the medial and distal contacts to allow for small
flexibility and passage seating of the provisional at the time of implant placement. H, A sulcular incision was made around the teeth with a minimal
reflection. The implant was placed at the appropriate depth. The abutment was placed. I, The occlusal view shows the appropriate positioning of
the implant in the extraction site. Notice that the implant was placed in the ideal location regardless of the presence of bone. Small gaps between
the implant and the labial and palatal plates of bone will be grafted. J, Human mineralized bone particles are placed into these gaps and packed
firmly to graft these defects. K, The provisional crown is placed and the occlusion is checked. The provisional crown is cemented with temporary
cement to the abutment. The small incisions are sutured with resorbable materials using vertical mattress suture technique.
Castellon, Casadaban, and Block. Provisionalization of Implant Restorations. J Oral Maxillofac Surg 2005.
CASTELLON, CASADABAN, AND BLOCK 75
76 PROVISIONALIZATION OF IMPLANT RESTORATIONS

the planned restoration, and the incisal edge. This
critical information will ensure proper horizontal and
vertical implant placement as well as the correct an-
gulation.
At the time of implant placement, the surgeon may
elect to use a flapless approach or a small flap (Fig 2).
The implant should be placed flush with the bone, or
if countersunk because of esthetics, the crestal bone
may need to be contoured to allow for passive seating
of the abutment into the implant. The abutment is
placed and secured with a screw and torqued if re-
quired by the manufacturer without moving the im-
plant. The provisional crown is placed. Contact
points are adjusted as necessary and the occlusal
surface relieved to avoid occlusal loading. The provi-
sional crown is cemented with temporary cement.
After 4 months of tissue healing, the restoring dentist
makes a transfer impression, selects the final abut-
ment according to healed tissue levels and fabricates
the final crown.
Use of Stock Abutments Designed for
Minimal Preparation
There are a variety of abutments available that are
designed to be placed without the need for modifica-
tion. In these cases, abutment selection is made taking
into consideration the height necessary and the gin-
gival margin location. These abutments are made with
a complementing pick-up coping, which aids in the
transfer of the abutment position to the master cast.
These abutments typically have a dense structure and
a margin included on the abutment. The surgeon can
place the abutment at the time of surgery, or at
implant exposure, or the abutment can be placed by
the restorative dentist (Fig 3). To facilitate immediate
provisionalization, the surgeon can place the abut-
ment after the implant is placed. The surgeon should
torque the abutment to 20 N-cm as recommended by
the implant manufacturer. The abutment is chosen
based on 2 criteria. The first is to choose an abutment
with the correct gingival margin height, to place the
crown margins consistent with the esthetic needs of
the restoration. The second criterion is to choose the
abutment which should allow for sufficient clear-
ances from the opposing occlusion. After the abut-
ment is placed, the surgeon may snap on the impres-
sion coping, take an impression using the appropriate
materials, and place a comfort cap to prevent soft
tissue trauma from the sharp edges at the top of the
abutment. The impression is poured by the surgeon,
the lab, or the restorative dentist. The provisional
crown, made intentionally without occlusal contacts,
is then prepared in the laboratory and placed the next
day if possible. As with all provisional single crowns,
occlusal contacts should be avoided. If the surgeon is
delivering the temporary crown, a hollow shell can be
relined with conventional techniques. After the im-
plant has integrated, the restorative dentist will re-
move the temporary abutment and transfer the posi-
tion of the abutment using the “snap-on” coping and
the final crown is fabricated.
Abutment Placement and Modification
at the Time of Implant Placement
To minimize preoperative preparation time, the
abutment may be prepared at the time of implant
placement. Similar diagnostic planning is still neces-
sary to position the implant properly. After the im-
plant has been placed, the chosen abutment is deliv-
ered.
PREPABLE ABUTMENTS
The abutment is placed onto the implant. There are
2 options for the surgeon who places the abutment.

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FIGURE 2. A, This photograph shows a first premolar in need for extraction because of a root fracture. B, The fractured tooth was removed and
the extraction site grafted with human mineralized bone. A collagen resorbable material (Collaplug; Zimmer Dental, Carlsbad, CA) was used to hold
the graft in position. C, Four months after the tooth extraction, after graft, note the excellent ridge form. With excellent ridge form and maintenance
of bone, a flapless or minimized flap procedure can be performed at the time of implant placement. D, In a model, an implant analog is ideally
positioned. The internal flat of the hex is placed directly labial. E, An abutment is chosen to place the gingival approximately 2 to 3 mm coronal
to the implant interface. The abutment is prepared vertically with minimal change in the wall parallelism to insure retention of the provisional crown.
F, The modified fixed abutment has the flat is remaining to provide excellent retention for the provisional crown. G, The provisional crown on the
abutment has the margins finished to allow for optimal gingival health. H, This is the provisional crown on the model, before surgery. Notice the small
gap between the mesial and distal contact points to allow for a small amount of flexibility and passive seating of the crown. Notice the gingival
margin has been prepared to match the gingival margin of the tooth before extraction. I, After application of local anesthesia, a tissue punch is used
in the exact location where the crown is to be emerging. J, After the tissue punch has been made, a small incision is made across the crest and around
the adjacent teeth. A small well-defined elevation of tissue is made just to the superior crest. This is especially useful when the surgeon wants to palpate
the adjacent bone. The circle of tissue made with the tissue punch is removed and now the ridge is further examined before implant placement. K,
A round burr is used to create the entry for the first drill. This round burr sets the position of the implant and must be perfectly located. L, The implant
is properly positioned as per prescription from the model. Notice the internal flat of the hex is directly labial. Also, notice the excellent bone contour
over the area. M, The abutment that had been previously prepared in the laboratory is now passively seated and secured with a screw. After cotton
is placed, the provisional crown is tried in. N, The provisional crown is placed in position. After confirmation of occlusal clearance, it is cemented
in position with temporary cement. Vertical mattress sutures are used to place the gingival back in correct position.
Castellon, Casadaban, and Block. Provisionalization of Implant Restorations. J Oral Maxillofac Surg 2005.
CASTELLON, CASADABAN, AND BLOCK 77

FIGURE 3. A, This patient had an implant placed in the first premolar location using a tissue punch with a flapless technique. The implant was
placed in the appropriate vertical and horizontal location. After the implant was placed, the non-prepable abutment (E-Z abutment; Nobel Biocare,
Yorba Linda, CA) was placed, the clearance was checked, and the abutment then torqued to 20 N-cm. A transfer impression using the impression
coping was made, and the surgeon then placed a comfort cap, which is seen in this photograph. (Surgery courtesy of Dr Hisham Nasr, New
Orleans, LA). The impression was delivered to the restorative dentist’s office on the same day as implant surgery. A provisional crown was made
and the patient saw the restorative dentist 1 day after the implant was placed. B, On the day following surgery, the comfort cap was removed.
Appropriate clearance is observed to allow for the thickness of the temporary provisional crown as well as the final restoration. C, This is an occlusal
view of the abutment in place. Notice that the labial emergence of the implant is approximately 1.5 mm palatal to a line drawn from the emergence
of the adjacent teeth. The middle of the implant is also lined up in the middle of the fossas. D, Non-prepable abutments classically have an impression
coping that snaps over the non-prepable abutment. This facilitates the impression procedure and also allows a distinct identification of the margins
of the abutment. E, The transfer coping is snapped into position. This can be achieved with placement of the non-prepable abutment at the time of
implant surgery. The surgeon then places the impression coping on the abutment and a pick-up of the coping is obtained, using conventional
impression material. The impression coping can also be used as a final impression technique after the implant has integrated or at time of implant
exposure. For the impression, a small syringe is positioned in the aperture at the coronal area of the coping and impression material is pushed into
the coping to obtain an accurate transfer of the non-prepable abutment, as well as flowing the material to the adjacent teeth for the routine impression.
F, A hollow shell polycarbonate crown is chosen to match the adjacent teeth and is relined with resin. It is important to note that this provisional
restoration is out of occlusion, with at least ½ to 1 mm clearance in all the excursions of the patient’s mouth. G, After 4 months with wearing the
provisional restoration, the provisional crown is removed and you can note the excellent gingival sculpting that has occurred as the soft tissue matures
around the provisional restoration. The contours of the temporary allowed the gingival to conform appropriately. H, This is the final restoration at the
time of seating. The excessive cement has been removed and the occlusion is verified. It is recommended to use a retraction core during cementation
to prevent excessive cement from flowing beyond the margins of the crown. I, This is a final photograph of the patient. She had bilateral first premolars
restored in this manner.
Castellon, Casadaban, and Block. Provisionalization of Implant Restorations. J Oral Maxillofac Surg 2005.

The surgeon can shorten the abutment in the mouth
using a high speed handpiece and new burs. If angu-
lation modification is necessary the abutment can also
be modified while in the mouth with high speed
drills. The second option is for the surgeon to mark
the abutment and remove it from the mouth. The
abutment can then be trimmed as necessary. It is
useful to place the abutment onto an analog for ease
of handling. After the abutment has been modified it
is placed back onto the implant and the incisions
sutured. The restorative dentist can then reline a hol-
low shell crown out of occlusion using conventional
reline techniques. A healing period of 4 months is
allowed and the final impression is made by the re-
storing dentist. The final crown is then fabricated by
the laboratory.
One-Piece Systems
for Provisionalization
A 1-piece implant system has the implant and abut-
ment connected as 1 unit without an interface
78 PROVISIONALIZATION OF IMPLANT RESTORATIONS

FIGURE 4. A, This patient presents with a missing first premolar. She previously had a tooth removed and a graft placed in this site to prepare her
for the implant surgery. B, After an application of local anesthesia, a flapless surgical technique is used to place a 1-piece implant. The supragingival
aspect of this implant is directly connected as 1 piece to the implant body. The implant must be appropriately positioned both in the middle of the
crest matching the fossas of the adjacent teeth and also the planned emergence of the crown. After the implant is placed through a tissue punch,
small modifications may be necessary. C, A high-speed diamond burr is used to remove a small amount of implant structure as necessary. Most often,
a small amount of the labial aspect of the implant may be removed. After this has been performed, the provisional restoration is placed. D, A hollow
shell crown is tried in and the appropriate shade is determined. E, The hollow shell crown is then filled with resin to reline it in the mouth. After the
material sets, it will be trimmed out of the mouth and appropriate subgingival margins created. F, This is the patient immediately after completion
of the provisional crown. Notice the excellent gingival contours, which are present because of the flapless technique and appropriate position of
the implant. G, Four months after placement of the implant. Notice how the soft tissue has adapted beautifully to the provisional crown, which is well
proportioned. A final impression will be taken and the final crown fabricated.
Castellon, Casadaban, and Block. Provisionalization of Implant Restorations. J Oral Maxillofac Surg 2005.

Table 4. MATERIAL CHARACTERISTICS FOR INDEXING

Condensation Addition
Property Polysulfide Silicone Silicone Polyether

Working time Moderately long Short Short-moderate Short

Setting time Moderately long Short-moderate Short-moderate Short
Flexibility during removal High Moderate Low-moderate Low
Tear strength Moderate-high Low-Moderate Moderate Low
Detail reproduction Excellent Excellent Excellent Excellent
Data from Craig et al.13
Castellon, Casadaban, and Block. Provisionalization of Implant Restorations. J Oral Maxillofac Surg 2005.
CASTELLON, CASADABAN, AND BLOCK
(Fig 4).9 The implants are placed in the correct posi-
tion allowing for 2 mm of occlusal space. Correction
of angulation is often difficult with a 1-piece implant;
thus these implants should be reserved for clinical
situations where a straight emergence is easily
achieved, such as molars, premolars, and possible
anterior teeth. The implant is placed and the height
and contour is minimally adjusted by the surgeon.
Immediately postoperative, the patient sees the re-
storing dentist for positioning of the prefabricated
temporary crown. After 4 months of tissue healing
and implant integration, the margins of the abutment
are refined and a final impression is made by the
restoring dentist following conventional techniques.
The final crown is then fabricated by the laboratory.
Methods for Indexing and Facilitating
Implant Provisionalization
and Restoration
Indexing an implant at the time of surgery can
facilitate the placement of a provisional restoration
earlier in the healing period or after implant exposure
after implant integration, and can be useful when
using CAD CAM technology for abutment fabrication.
The clinician using indexing materials must have a
basic understanding of their characteristics to choose
which material would be best for the specific clinical
situation. There are a number of implant impression
techniques being used; some of the more common
techniques are direct, indirect, and direct-splinted.
Most of the literature supports the direct technique as
most accurate, followed by the direct-splinted and
then indirect.10-12
MATERIAL CONSIDERATIONS
Materials available for impression techniques in-
clude polyethers, silicones, and polysulfides.12 A du-
rable and sturdy material is preferred to avoid flexion
during removal resulting in positional distortion. Im-
plant impressions should be performed as accurately
as possible to avoid problems with crown occlusal
accuracy. Important factors such as material accu-
racy, working time, ease of handling, and clinician’s
experience with the material all contribute to optimal
indexing (Table 4).
Polysulfide rubber impression materials come in 3
types: light, regular, or heavy bodied, depending on
their viscosity and how easily they flow under load.
The base material consists of 80% low molecular
weight organic polymer, containing reactive mercap-
tan groups and 20% reinforcing agents such as tita-
nium dioxide, zinc sulfate, copper carbonate, or sil-
79
ica. The accelerator, or catalyst, is usually lead
dioxide.13
Two types of silicones are used as impression ma-
terials: condensation and addition types. The conden-
sation type is supplied as a base and a catalyst. The
base is a paste containing a moderately low molecular
weight silicone liquid called dimethylsiloxane. The
accelerator, a liquid, consists of a tin organic ester
suspension and an alkyl silicate such as ortho-ethyl
silicate. The addition type is a 2-putty or a 2-paste
system, with 1 containing low molecular weight sili-
cone having terminal vinyl groups, reinforcing filler,
and a chloroplatinic acid catalyst and the other con-
taining a low molecular weight silicone having saline
hydrogens and reinforcing filler.13
Polyether rubber impression materials are supplied
as a base and catalyst system. The base is a low
molecular weight polyether, containing ethylene
imine terminal groups. The terminal groups are re-
acted together by the action of an aromatic sulfonic
acid ester catalyst to form a cross-linked high molec-
ular weight rubber.13
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