The International Journal of Periodontios & Restorative Dentistry

21

Restoring the Gingival Contour by

Means of Provisional Resin Crowns
After Singie-Implant Treatment

Torsten Jemt. DDS. PhD' Loss of gingivai papillae is a fre-

quent problem associated with
single-implant rehabilitation.'
Current clinical research has
focused on different surgical
procedures for restoring the
A consecutivo group of 55 patiQrtts was treoted with 63 single-Implant alveolar crest and managing
restorotions. The soft tissue was allowed to heat to either provlslor>al resin the soft tissue contour adjacent
orowns (n = 25) that were piaced at ttie time of second-stoge surgery, or to fo restorations,'-^ Most of the
tiealing abutments (n = 38) before final crown ir^sertion. An index that
new techniques have shown
assessed the size of the interproximal mucosa adjaoent to the single-
good esthetic results for the soft
implant restorations was used to evaluate the volume of the papillae 2
years aftercrown insertian. The results Indicated that the use of provisional
tissue margin, but the lack of
crowns may restore soft tissue contour faster than healing abutments ciinicai controls has been an
alone, but the papillae adjaceht to single-Implant restorations presented obvious shortcoming,^ in a
similar volume In bcth groups otter 2 years In function. Furthermore, the recent artioie by the outhor, a
mean marginal bone loss at the Implants was 0.9 mm after / year, and no soff tissue index wos proposed
differences were observed between the 2 groups. The present data focus to allow a more controlled eval-
on the heed for more scientific data to evaluate different clinical proce- uation of the volume of inter-
dures tor cptimizing esthetic results in implant dentistry (Int J Periodonfics proximai soft tissue papillae,'
Restorative Dent 1999:19:21-29,) That paper aiso indicated fhat
the papulae that were missing
after single-impiant treatment
spontaneousiy regenerated
aimost compietely after a few
years in function in most cases.'
The mechanism behind this
spontaneous regeneration is still
unclear, but gingival hyperplasia
•Head ot Prosthetic Division, The Brônemark Clinic, Göteborg, Sweden. in response to plaque accumu-
lation was suggested to be a
Reprint requests: Dr Torsten Jemt, The Bränemork Clinio, Public
Dental Health, Medicinaregotan 12 C, S-413 90 Göteborg, Sweden, possible contributing factor. If

Voiume 19, Number 1,1999

22
Fig 1 Single implant in the position of
¡he right lateral inoisor at the time of
seoonä-stage surgery. A temporary
piastic cylinder is connected to fii©
standard abutment and the cylinder is
then cut to appropriate oiinlcat length.
this is the case, soft tissue infiam-
mation adjacent to single im-
plants may play an important
role in the early reformation ot
soft tissue contour after crown
insertion.
The objective oi the present
study was to propose a clinicai
technique to create gingivai
papillae by means of guiding
the tissue during the posfsurgicai
swelling period, and to evaiuate
the results in a study of retro-
spective consecutive patients
by means of the previously pre-
sented papula index.
The Internofionol Journal of Periodontics & Resforative Dentistry
Method and moteriais
The present paper was de-
signed OS a retrospective study
in which a consecutive group ot
55 patients who were treated
with single-impiant restorations
wos included. The pafienfs were
randomly treated with singie
implonfs following fhe standard
ciinicol protocol with heoling
abutments and finai soft tissue
heaiing before finai impression
(control group), ^^ or with provi-
sional resin crowns that were
placed at the time of second-
stoge surgery (test group).
Test group
The test group consisted of 21
patients (8 female), who re-
ceived 25 single crowns. The
mean age of the group was
30.2 years (SD 14,7 years) at the
time of implant surgery, and the
age ranged from 17 to 72 years.
Of the 21 patients, 4 received 2
single impiants each, while the
remaining 17 patients eoch re-
ceived 1 implant. The crowns
consisted ot 12 central incisors,
11 lateral inoisors, 1 canine, and
1 premolar. Ail 25 crowns were
placed in the maxiüa.
The patients were provided
with Brônemark impiants (Nobel
Biocare) according to a stan-
dard surgical protocol.* At the
time of second-stage surgery.
the patients had standard
Bronemark abutments con-
nected, and they received a
provisionol resin crown at the
same appointment. Radio-
graphs were taken to controi
correct seating of the abutment
cylinder. The provisionoi resin
crowns were made using a pias-
tic cylinder (DCA 159, Nobel
Biocare). which was connected
to fhe standard abutment (Eig
1) with a standard gold screw
(DOA 075). A prefabricated prc-
visionoi crown was cured fo the
piastic cylinder by means of
resin (Eig 2a). An access hole
was made on the palatal side
of the crown. The crown was
overcontoured, ieaving oniy
smail spaces odjacent to the
permanent teeth. When com-
pieted, the crowns were se-
cured fo the impiants and the
access hole was temporofiiy
seaied with gutta percha. The
patients were sent home with
no special emphasis with regard
to oral maintenance. The only
instruction was to use a normai
toothbrush and possibly perform
gentle proximal cleaning with
dental tioss,'
All patients were recalied
once a week tor the toilowing 4
to ó weeks. At these appoint-
ments, fhe provisionai crowns
were removed and the spaces
were genfiy opened by reduc-
ing fhe resin crowns in the proxi-
mal areas (Figs 2b to 3). Atter
soff tissue healing, a final impres-
sion for a permanent singie-
impiant restoration was per-
formed by means cf either an
original implant transter coping
technique (DCA 099, Nobei
 23

Fig 2a (ieft) Provisional resin crown

cured fo fhe temporary plastic cyiinder
in ttie position of the iaterai incisor at
the time of second-stage surgery.

Fig2b(right) Ciinical situation of pro-

visional crown after 4 weeifS of soft tis-
sue heaiing. Defects created by sutures
can stiii be observed in ttie soft tissue
The tissue hos started to recover on the
mesial side.

fig 2c (left) Clinicai situation after Ô

weeliS of son tissue i-¡eaiing The provi-
sional crown has just been shortened
on the distal side in an effort to Increase
the soft tissue volume in relation to the
distal popilla.

Fig 2d (rigtit) Clinical situation at ttie

time of insertion otthe fihaicfown.8
weeks atter second-stage surgery.

Fig 3 Soft tissue situation after removal

of the provisional crown. 8 weeks after
second-stage surgery. After cleaning of
the adjacent teeth, the temporary aPut-
ment is repiaced by the final crawn
restoration.

VoiumG 19, Number 1,1999

 24
Biooare) or a piastic transfer
coping for fhe CeraOne tech-
nique (DCB 119, Nabel Biocare).
The impression was made an
average of 51.5 days (SD 23.5
days) after second-stage sur-
gery. The permanent crowns
were fabricated either by bak-
ing porceiain directiy onto cus-
tomized titanium abutment cy-
linders or by cementation to
CeraOne abutments, according
to restorative protocols pre-
sented elsewhere.'-^ The pa-
tients were followed up accord-
ing to routine protocois, with
clinical and rodiographic exami-
nation at about 4 weeks after
final crown insertion and again
after 1 year. A clinical checkup
was also performed after 2 years
in function (Figs 4 and 5). At fhis
second annual appointment, or
The Internafionol Journal ot Periodonfics & Restoroflve Dentistry
at an extra, iater appointment, a
olinioal photograph was taken
of fhe single-implant crowns and
the adjacent teeth (Fig 4b).
These clinical photographs were
obtained an average of 22.5
months (SD 7.5 months) after
abutment surgery Two patients
(2 crowns) did not attend the
clinical central appointment
and photographing cf fhe single
crowns and their soft tissue.
Besides the photographs
token after 2 years in function
(Fig 5b), clinical photographs of
the single crowns that were
takeh at the time of orown inser-
tion were retrospectively avaii-
abie for 13 patients (15 crowns).
These pairs of phofcgraphs (n =
15) were used to assess the
change in the soft fissue over
time.
Fig 4a (left) Clinical situation after final
crown insertion. The soft tissue Is healing
on Ihe distal side. Note that The final
crown has been made with a wider
spaoe on the distal side, leaving a smail
gap between the crown and the soft
tissue.
Fig 4jb (right) Clinical situation after 2
years in function. The soft tissue has
recovered and matured in the lateral
incisor area.
Fig 5a (leff) Left first premolar restored
with singie-implonf restoration. At final
crown insertion 4 weeks after second-
stage surgery, fhe soft tissue has heated
Without a provisional crowa ond the
papiiiae are missing.
Fig 5b (right) ieft first premolar crown
after 2 years of function. Complete
recovery of the son tissue has sponta-
neously taiien piace.
Control group
The controi group consisted of
34 patienfs who were provided
wifh 38 single-crcwn restora-
ticns. In this grcup, 14 of the
patients were female, and the
mean age of the group was
28.8 years (SD 9.5 years) at the
time of impiant insertion. The
age ranged from 16 to 4ó
years. Of the 34 patients, 4 re-
ceived 2 single impiants each,
while the remaining 30 patients
had 1 implant eaoh. The crowns
consisted of 17 centrai inoisors,
11 iaterai incisors, ó canines,
and 3 premolars. Oniy 1 premc-
iar crcwn was piaced in the
mandible, and the remaining 37
were placed in the maxilla.
Standard Brânemark im-
plants were inserted foiiowing

fhe previously mentioned rou-
tine surgicai profocoi.* Ali im-
plants were provided with
standard or heaiing abuf-
menfs affer healing. The fops
of fhe abutmenfs were placed
above the soft tissue morgin to
oilow proper heaiing of the
mucosa.* Radiogrophs were
taken fo control correct seat-
ing ot fhe abutment cylinder.
Affer on overoge of 34.9 days
(SD 29.9 days) of sott tissue
healing, o finai impression was
made using eifher an implant
franster coping (DCA 099) or a
plastic transfer coping (DCB
119). This was foliowed by fabri-
cation of the permanent
crowns foiiowing the same
profoooi OS fhaf used for fhe
tesf group.^'^ No speciai em-
phasis wifh regard to oral
maintenance was given in
connection fo the placement
of fhe finaf crowns, ie, normal
foofhbrushing and possibly
genfle proximai cleaning with
dental floss wos suggested.'
The pafients were followed
up with clinioal and radio-
graphic examinotions foiiowing
the same protocol os that used
for fhe fesf group. Of the origi-
nal 34 patients, 7 did not
attend fhe recall fhat included
fotlow-up photographs. The
remaining 27 patients (30
crowns) were considered fhe
oonfrol group. The appoint-
ment tor fhe ciinical phofo-
graph took place an average
of 21.9 months (SD 7.0 months)
after abutment surgery
PapiHa contour measurements
The contour of the proximal
papillae was assessed from the
photographs by means ot on
index, which is described in
more detaii in onother paper by
the author.! in brief, fhe index
wos designed for 5 difl^erent iev-
eis. The assessment was reiafed
fo fhe space befween refer-
ence lines fhrough the highest
gingival curvature of the crown-
tooth margin and the contact
point.
A score of 0 indicotes thot
no popilla is present, and there
is no indicotion of ourvature of
fhe soft tissue contour odja-
cent to the singie-implant re-
storation,
A score of ! indioofes thot
iess than half of the height of
the pcpiila is present. A convex
curvature ot the soft tissue con-
tour adjacent to the singie-
implont crown and the odja-
cent tooth is observed.
A score of 2 indicates that
haif or more of fhe heighf of
fhe popillo is presenf, but it
does not extend all the way up
fo the contoct point between
the teeth. The papilla is not
complefely in hormony with
the adjacent papillae be-
tween fhe permanenf teeth.
Accepfabie soft tissue contour
is in hormony wifh adjacent
feefh.
A score of 3 indicates fhaf
the papiiia fills up the entire
proximal space and is in good
hormony wifh the adjacent
25
popiiiae. There is optimai soft tis-
sue contour.
A score of 4 indicotes thot
fhe popilla is hyperplasfic and
covers the singie-impiont re-
storation and/or the adjacent
foofh foo much. The soft tissue
contour is more or iess irreguior,
in addition to indexing,
mechonical problems such as
ioose crowns/abutmenf screws,
as weii as signs of severe inflam-
mation or tisfuios, were noted
for the 2-year tollow-up period.
Marginal bone level
Infraorai apical radiogrophs
were taken on a routine basis of
fhe time of second-stage sur-
gery ot fhe insertion of fhe per-
monent crown, and after 1 year.
The marginoi bone levei wos
meosured in relation to the im-
plant radiographie reference
point^'!" ot fhe mesioi and disfal
sides of fhe impiant head.
Stotisticai analysis
Descriptive statistics were used
to present the changes in the
soft tissue and the marginal
bone of the impionts. Loss of
morginol bone was based on
intraindividual calculations. The
sign test for paired compari-
sons" was used to stofisfically
test chonges in the papilla con-
tour index score from the time
ot piacemenf fo the foilow-up
on fhe mesial and distal sides ot
Volume 19, Number 1.1999
26

Distribution of papilla index in Distribution of papilla index in test

prospective subgroup and control groups

Mesial papillae" Distal papillae

Papilla Crown 2-year Crown 2-year
index insertion follow-up insertion follow-up
(n = 15) (n = (n =

MeaniSD) 2,58(0,65) 2,43(0,73) 2,17(0,70] 2,17(0,70)

n = number of crowns.
"There was a significant increase in uoiume on tiie mesial (P < 0.01), but not n = nLimber of Clowns.
on the distai side (P > 0,05), •There were no iignificani differences in Index distirbution between the 2
groups.

the single-implant restoration. Results distai sides, respectively. The dif-

The chi square test was used for
comparing the soft tissue index
of the test and control groups
after 2 years in function, and the
Student's / test was used for
comparing bone loss between
the groups, A P value of > 0.05
was not considered signifcanf.
The results are presented as an
infraindividual comparison ot
the soft tissue situation at final
crown insertion and after 2
years for 15 patients in the test
group (Tabie 1), and as an
interindividuai comparison
between the test group and
the control group after 2 years
in function G'oble 2), The distrib-
ution of the papiiia size index at
the time of final crown insertion
and after 2 years is presented
in Table 1, The ddta indicate
that the papulae recovered in
volume over time and the
mean papiiia index increased
from 2.1 (SD 0.35) to 2,6 (SD
0,63) and from 1,9 (SD 0,83) to
2,1 (SD 0,04) on the mesial and
ference between the distribu-
tion of the index (Table 1) at
finai crown insertion and 2-year
follow-up reached a significant
level on the mesial (P < 0,01),
but not on the distal side (P >
0,05), The papillo size index
ranged from 1 to 4 in both the
test and control groups at the
time of the 2-year photo-
graphic checkup appointment
(Table 2), The distribution of the
index did not show any signifi-
cant differences between the 2
groups (P > 0,05), and bofh
groups aiso showed similar
mean index values for the
mesial and distal sides ot the
single-impianf crowns (Table 2),
In the test group, 3 of the
crowns became loose during

The Internotionai Journal cf Periodontics & Restorative Dentistry

 27

Mean marginai bone ieveis after sec- Mean marginai bone ioss after final
ond-stage surgery (abutment),finai crown insertion and 1 year in function
crown insertion,and 1 year in function

Mean (SD) marginal bone level (mm) Mean (SD) marginal bone loss (mm)
Abutment Final crown 1 year Period Test Control

Test 0.0 (0.09) 0.7 (0.S2) 0.8 (0.63) Abutment- 0.7 (0.56) 0.5 (0.52)
n = 25 n = 22 n = 23 final crown n = 22 n^36
Control 0.1(0.42) 0.6(0.60) 1.1(0.67) Final crown- 0.1 (0.42) 0.3 (0.59)
n = 31 1 year n = 20
Abutment- 0.8 (0.63) 0.9 (0.63)
n = number of impiants.
1 year n = 30
n = nufnhe'of innaindividual pans of meaîuremenisror each period.

the tirst year. Of these 3 crowns,
2 were ioose twice. Cnly 1
crown was found fo be loose in
the control group before the first
annual checkup. No crowns
loosened during the second
year. Of the 3 loose crowns in
the test group during the first
year, 2 were associated with fis-
tulös. Anofher 2 crowns pre-
sented fistulas during fhe firsf
year in the test group, while
there were no fistuias in the con-
frol group.
The mean marginal bone
levei for fhe fest group was 0,7
mm (SD 0.52 mm) after finai
crown insertion, and 0.8 mm (SD
0.63 mm) after 1 year in func-
tion. The corresponding mean
marginai bone ieveis were 0.6
mm (SD 0.60 mm) and 1,1 mm
(SD 0.67 mm) for fhe controi
groups (Tabie 3). Mean marginal
bone loss from abutment con-
nection to 1 year in function
was 0.8 mm (SD 0.63 mm) and
0,9 mm (SD 0.63 mm) tor the test
and control groups, respectively
(Table 4). No signficant differ-
ences in bone ieveis or bone
ioss were found between the
groups (P> 0,05).
Discussion
The present results indicate that
regardless of whether a provi-
sional crown was placed at the
time ot abutment connection
or the soff tissue was first ai-
lawed to heal around a tempo-
rary abutment there was a
similar volume o1 soft tissue
adjacent to single-implant
restorations after an average of
2 years (Table 2). The mean
papiiia index score after 2 years
(Table 2) was comparable to
the 1 - fo 3-yeor foilow-up resuits
previously presented by the
author 1 On the other hand, fhe
mean index of the present
prospective subgroup was
higher at the time of tinai crown
insertion thon the comparoble
mean index of fhe eariier pre-
sented group.' The reason tor
this difference is probably that in
the present cases the tinal
crowns were inserted later after
second-stage surgery, and con-
sequentiy the soft tissue had
more time to recover before the
final crowns were placed (Figs 4

Voiume 19, Number 1,1

28
and 5), In the present study
there were also indications of
spantaneous soft tissue regener-
ation, not only during the eariy
period, but aiso from tinai crown
insertion to the 2-year tollow-up
(Table 1). This is aiso in accor-
dance with eariier findings^ The
tact that the tinai crowns in the
present study were placed later
couid expiain the weaker trend
of spontaneous soft tissue re-
generation on the distai side, as
compared to the eariier soft tis-
sue follow-up study.' Provisional
crowns at the time of abutment
cannecticn surgery may guide
fhe healing of the soft tisssue
and restore the gingivai contour
in eariier stages af heaiing, but
fhe iong-term effect of this
treatment seems to be the
same (Figs 4b and 5b) as aiiow-
ing the sott tissue to heai
around temporary abutments
before finai crown insertion
CTabie 2).
Soft tissue aiways reacts with
swelling ond inflammation after
surgicai interventions. Provisionai
crowns in this study were used in
connection with secand-stage
surgery to guide the saft tissue
inta the spaces during this
phase of posfsurgicai soft tissue
swelling. Theoretically, the more
sweiiing thot is achieved, the
more soft tissue wiii fiii up the
praximai areas; overcontoured
provisianai crowns with smaii
spaces wiii ailaw better fiii with
soft tissue. The step-by-step
increase of the spaces, com-
bined with o slight neglect of
m e internotionai Journal of Periodontics & Restorative Dentistry
the cleoning in an eariy stage,
may aiiow the hyperplastic soft
tissue to reorganize ond mature
into the shape of a naturoi
papilia (Figs 1 to 4),The protocol
of using the phase of postsurgi-
cai soft tissue sweiiing, overcan-
tcured provisional crowns, and
slight negiect ot oral mainte-
nanace in on early stage atter
treatment are certainiy chai-
ienges to the present dental
paradigm of optimai heaith
and cleaning around teeth. It is
naturai to aim for a restorative
procedure that aiiaws for opti-
mai heaith of the soft tissue sur-
rounding the impiant restora-
tion, ond any adverse ciinical
effects of the present suggested
protocol must be scrutinized.
The eariy probiems with 4 fistulas
in the test group—compared to
no reported mucosai probiems
in the controi group—couid be
taken as a sign ot adverse scft
tissue reaction to the temporary
crown protocoi.
iHawever, no further soft tis-
sue probiems were observed in
either group during the second
year. In connection with the simi-
lar levels of bone ioss in both
groups after 1 year in function
(Table 4), this finding con be
taken as an indication that the
suggested temporary crown
protocoi does not induce any
severe prcbiems that may jeop-
ardize the medium-range prog-
nosis at the singie-impiant treat-
ment. Although the provisionai
crown protocol is based on soft
tissue swelling after surgery, there
are no indications that this af-
fects the more deepiy placed
marginal bone. Simiiar findings
have been observed in clinical
procedures using temporary
abutments and manipulation of
finai titanium abutment compo-
nents in the laboratory,^ These
protocols may theoretically
cause inflammation and mar-
ginal bcne loss, but they have
shown bone levels comparable
to those observed in other sin-
gle-impiant procedures, in which
the permanent singie abutment
was left undisturbed after sec-
and-stage surgery,^-'^""
The present study indicates
that the papiiioe odjocent to
single-implant restorations pre-
sent simiiar volume after 2
years, regardiess ot whether
the sott tissue was ailowed to
heal Pefare final insertion or a
temparory resin crown wos
placed immedioteiy after
abutment surgery. The present
data indicate that the provi-
sionai crown may restare the
soft tissue contour taster than
heaiing abutments olone. The
provisionai crown technique is
based on postsurgicai infiam-
mation, which does not seem
to induce any more bane loss
at the head of the implant
after 1 year ot tunction.

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Volume 19, Number 1,1999