CLINICAL REPORT

Australian Dental Journal 2007;52:(3):234-242

Provisional restoration options in implant dentistry

RE Santosa*

Abstract
Unlike their use in conventional crown and bridge,
provisional restorations during implant therapy have
been underutilized. Provisional restorations should
be used to evaluate aesthetic, phonetic and occlusal
function prior to delivery of the final implant
restorations, while preserving and/or enhancing the
condition of the peri-implant and gingival tissues.
Provisional restorations are useful as a
communication tool between members of the
treatment team which, in most cases, consists of the
restorative clinician, implant surgeons, laboratory
technicians, and the patient. This article describes
and
discusses
the
various
options
for
provisionalization in implant dentistry. Clinicians
should be aware of the different types of provisional
restorations and the indications for their use when
planning implant retained restorations.
Key words: Provisional restorations, dental implant,
custom impression.
(Accepted for publication 27 April 2007.)

INTRODUCTION
Implant supported restorations for partially and fully
edentulous patients are a well-accepted and predictable
treatment modality. Success rate of implant retained
prostheses for complete and partial edentulism has
been shown to be over 90 per cent.1-3 With the increase
in treatment acceptance for dental implants, both
patients and clinicians have greater expectations
towards implant therapy. Patients facing loss of their
teeth may experience apprehension towards losing their
social image or daily function. Hence, patients often
expect to have their implants loaded with some type of
fixed prosthesis similar to their natural dentition much
earlier. Clinicians also expect their restorations to be
functional, aesthetic, and in harmony with the
surrounding hard and soft tissues. Today, implant
integration is given with the greater knowledge of the
biological basis for treatment and improvements
primarily associated with implant morphology.
Traditionally, for conventional loading protocols, the
implants are left unloaded for 3 to 6 months to allow
the osseointegration process to take place.1 During this
*Private Specialist Prosthodontist, formerly ITI Scholar, Centre for
Implant Dentistry, University of Florida, Gainesville, Florida, USA.
234

healing period, patients may have to wear a removable

provisional prosthesis prior to delivery of the final
prosthesis, especially in the aesthetic zone. In the nonaesthetic zone, clinicians may decide not to construct
provisional restorations.
In some cases, patients are able to have a provisional
restoration constructed after the treatment planning
phase and delivered as early as the day of implant
placement.4 However, in restorative driven implant
placement,5,6 hard and soft tissue augmentation is
routinely performed to optimize the implant site prior
to surgery, effectively extending the treatment time.
Any provisional prostheses would then need to be
strong, durable and aesthetic to last throughout the
duration of the treatment. A traditional provisional
prosthesis may consist of an existing or newly
constructed removable provisional denture which can
be utilized until delivery of the final prosthesis.
However, removable provisional prostheses may place
undesirable pressure upon these graft sites, hampering
the healing process.4,7,8 Therefore, provisional
restorations that are fixed to the adjacent teeth or that
completely eliminate the possibility for soft tissue
contact may be more beneficial for implant integration
and soft tissue maintenance. Tooth borne or fixed
provisional restorations may also satisfy patients
aesthetic, functional and psychological demands. One
of our roles as clinicians is to provide functional and
aesthetic provisional restorations that allow for the
smooth transition of patients from natural dentition to
implant based restorations.8,9
Function of provisional restorations
According to The Glossary of Prosthodontic Terms,10
a provisional prosthesis is a prosthesis designed to
enhance aesthetics, provide stabilization and/or function
for a limited period of time, and should be replaced by
a definitive prosthesis after a period of time.
In restoration-driven implant placement,5,6 implants
are positioned in relation to anticipated requisites of
the restorative phase rather than the availability of
bone. Provisional restorations can be used as a
diagnostic restoration to evaluate the position and
contours of the planned definitive restoration prior to
surgical implant placement and during the healing
Australian Dental Journal 2007;52:3.

Table 1. Provisionalization prior to implant loading

Type of support

Prosthesis type

Removable

Partial acrylic dentures

Essix appliance
Archwire supported pontic
Resin bonded pontic
Resin bonded, cast metal framework
bridge
Transitional implants

Fixed tooth supported

Fixed implant supported

phase. A provisional restoration immediately placed

with ovate pontics extending into the extraction
sockets can also be used to preserve the pre-extraction
soft tissue morphology.11 They can guide the healing of
the peri-implant tissue and allow the clinician to
determine any necessary phonetic or aesthetic adjustments. The clinicians may use information such as
shade, crown and soft tissue contours from the
provisional restoration as a communication tool to the
laboratory. Provisional implant restorations also allow
the patient to visualize and evaluate the end restorative
result, thus assisting in acceptance and/or guiding of
modifications required for the definitive restoration.
Types of provisional restorations
Provisional restorations in implant therapy can be in
the form of removable or fixed prostheses. Removable
provisional prostheses are generally tooth and/or soft
tissue borne. Fixed provisional restorations can be
supported by adjacent teeth or implant retained. They
can be fabricated chairside, using similar techniques as
in conventional prosthodontics; or in the laboratory on
working casts; or as a combination of indirect-direct
technique, where a provisional shell is fabricated before
the patients appointment, reducing chairside time.
Provisional restorations may be constructed prior to
tooth extraction, during socket healing, prior to
implant placement, or during osseointegration period
(Table 1). Provisional restoration could also be
constructed after implant loading, allowing maturation
of peri-implant soft tissue, and during construction of
the final prostheses.
Provisionalization prior to implant loading
Removable prosthesis
Removable partial acrylic dentures have commonly
been used during post-extraction and throughout the
implant therapy. They are simple to construct,
relatively inexpensive, and easy for the surgeon or
restorative clinician to adjust and fit. Patients that
require staged treatment with serial extractions may
have teeth added to their existing removable dentures
with minimal cost. However, they may reduce the
effectiveness of any additional surgical bone and
gingival augmentation procedure used to optimize the
implant site. Care must be taken to prevent the gingival
portion of the provisional partial denture from
contacting the healing soft tissue or an exposed healing
abutment. Soft tissue borne prostheses used during
healing may cause uncontrolled implant loading
Australian Dental Journal 2007;52:3.

Fig 1. Modified removable partial provisional denture. The denture

was modified during implant placement to allow proper healing of
the underlying implants. The patient had low smile line.

leading to implant exposure, marginal bone loss,

and/or failed integration. Often provisional dentures
are adjusted to minimize contact with the healing
implants (Fig 1).
There are alternatives to tissue borne provisional
restorations. An Essix appliance12,13 (Fig 2) may be used
as a removable prosthesis in these cases, as well as in
limited interocclusal space or deep anterior overbite.
This prosthesis is made from an acrylic tooth bonded to
a clear vacuform material on a cast of the diagnostic
wax up. The prosthesis provides protection to the
underlying soft tissue and implant during the healing
phase. Limitations of this provisional restoration
include its inability to mould the surrounding soft
tissue, and lack of patients compliance can cause rapid
occlusal wear through the vacuform material. However,
some patients may not like to wear, or are unable to
tolerate, a removable provisional prosthesis, thus fixed
provisional prosthesis are sometimes necessary.
Tooth supported provisional restorations
Fixed tooth supported provisional restorations in the
upper anterior region include the use of orthodontic
brackets and archwire on several teeth adjacent to the

Fig 2. An Essix appliance replacing upper central incisors. The teeth

were spot cured to the clear vacuform template material.
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a
b

e
f
Fig 3a. Pre-operative radiograph. The patient had generalized refractory periodontitis, especially in the maxillary arch.
Fig 3b. Pre-operative facial view. One of the patients chief complaint was the anterior crowding and the vertical drifting of maxillary
anterior teeth.
Fig 3c. Diagnostic wax up of the planned restoration illustrating anticipated contours of the final restoration. The alignment of anterior
teeth was altered to provide straighter, more aesthetically pleasing teeth. The incisal lengths of maxillary incisors were reduced, decreasing
the horizontal and vertical relationship of the anterior teeth.
Fig 3d. Facial view of prepared teeth immediately after extraction. Strategic teeth were maintained to retain the provisional prosthesis.
The implant sites were previously selected and the non-strategic teeth were removed according to the diagnostic wax up.
Fig 3e. Provisional acrylic restoration prior to insertion. The provisional restoration is relined with compatible self cure resin to fit over
the prepared abutment teeth.
Fig 3f. Fixed provisional restorations cemented on strategic natural abutments. The molars have been retained temporarily to maintain the
vertical dimension of occlusion.

implant site with an attached pontic. An alternative

method is the use of resin bonded provisional pontic,
which are tooth supported and retained by acid etching
the neighbouring teeth. Sometimes small retentive
grooves within enamel on the adjacent teeth can be
used to increase retention of the pontic. The pontic can
be in the form of an acrylic tooth, porcelain, or
decoronated extracted tooth. The resin bonded acrylic
or natural tooth may be reinforced with composite
236

resin and/or ultra high molecular weight polyethylene

ribbon (Ribbond Bondable Reinforcement, Ribbon;
Ribbond Inc, Seattle, Wash., USA).8,14 These prostheses
may continue to be reused as provisionals after an
appropriate implant healing period. The archwire/resin
retainer can be removed and reattached between the
different surgical and prosthetic stages. They can also
be used to guide the surgeon during grafting procedures
and as a template for the final restoration.
Australian Dental Journal 2007;52:3.

provisional restoration, and the transitional implants

are backed out of position using a ratchet arm and
insertion tool used in the reverse mode (Fig 4).

Fig 4. Immediate provisional implants were placed and strategic

teeth were maintained to support long-term telescopic provisional
restoration. The 14-year-old patient requested a long-term fixed
provisional restoration until the definitive implants are placed.

A resin bonded, cast metal framework prosthesis

such as Maryland Bridge is suitable for long-term
provisionalization in the anterior region, especially in
young patients.8 This type of provisional is difficult to
reuse throughout the implant procedure as the bond
strength between the metal retainer and the enamel can
be unpredictable during removal and reattachment
between procedures. Furthermore, the laboratory costs
are relatively high.
In some cases, a staged extraction and implant
placement approach can be adopted.8,15 In this
technique, the implant sites are selected, and teeth that
occupy these sites are extracted while the remaining
teeth are used to support a fixed provisional restoration.
Usually, natural abutments with poor prognoses are
used as interim abutments and can be extracted when
the implants have integrated. The teeth supported
provisional restoration is then converted into an
implant supported provisional restoration. This
indirectdirect technique is often used in a full arch
situation, where the patients dentition is failing due to
periodontal disease (Figs 3a3f) or when the adjacent
natural teeth require fixed prosthesis at the same time.8
Transitional implant provisional restorations
In extended partial edentulous areas where there are
no or limited natural abutments to support a
provisional restoration, one or more transitional
implants may be used.16 These transitional implants are
loaded immediately to support the provisional
restoration. They can be used to support fixed
restorations or to retain complete mandibular dentures.
Care should be taken in planning the position of these
implants and with their maintenance post-loading.
They should not interfere with potential implant sites,
or be placed in poor quality bone. When the depth of
available bone is less than 14mm or the amount of
cortical bone is insufficient to provide stabilization, the
immediate provisional implant may be contraindicated.16
Once the implants integrate, the supporting provisional
restoration will be converted into implant supported
Australian Dental Journal 2007;52:3.

Post-implant placement
Implant retained provisional restorations
Provisional restorations may be used at the time of
implant placement or after an appropriate healing
period. The term immediate restoration is used when
a prosthesis is fixed to the implants within 48 hours
without achieving full occlusal contact with the
opposing dentition, whereas immediate loading is
when the prosthesis is fixed to the implants in occlusion
within 48 hours.17
There are several benefits to members of the
treatment team and patient in using an immediate
provisionalization technique. Immediate provisionalization offers the patient improved comfort and
function during the implant healing period compared
with a conventional denture.4 There are also fewer
denture adjustments postoperatively with no need for
tissue conditioning or relining.
The decision to immediately restore or load dental
implants is usually made during the treatment planning
phase. The treatment can only be confirmed clinically
at the time of implant placement with appropriate
assessment of implant stability, bone quality, and
general site health. In a recent consensus review,18 four
implants in an edentulous mandible, rigidly splinted
with a fixed restoration on a framework (acrylic and/or
metal) or hybrid prosthesis, can provide patients with a
reasonable degree of confidence for evidence-based
treatment. Primary stability of these implants is crucial
in the decision for immediate provisionalization.9,19 The
implants need to be well distributed across the
mandibular arch to provide cross-arch stabilization.
The final implant positions are based on the proposed
restoration through the use of templates/surgical guide.
In immediate loading of edentulous mandible, the
patients existing denture can be converted into screw
retained provisional fixed hybrid prosthesis. The
technique involves the placement of temporary
cylinders onto the implants and the modification of
patients existing mandibular denture. These cylinders
are luted to the rest of the denture using self cure resin.
The denture is then converted into an immediate load,
screw retained provisional hybrid fixed prosthesis with
minimal cantilever and occlusal contacts (Figs 5a5c).
A lingual wire may be used within the acrylic
framework to provide reinforcement. The provisional
hybrid restoration will need to remain during the
recommended period of implant healing to allow the
implants to fully osseointegrate.17
This technique may also be used in early or delayed
loading implant protocols. The provisional hybrid
restoration may have multifunctional uses. It can be
used as a verification jig (Fig 5d) to determine the
passivity and accuracy of the master impression,
providing all the implants are relatively placed parallel
237

a
b

c
d
Fig 5a. Patients existing complete mandibular denture was modified
to accommodate temporary cylinders on the implants. A duplicate
of the denture was used as radiographic and surgical guide for the
planning and surgical phase of the treatment. The three dimensional
positions of the implants were determined from the diagnostic wax
up and clinical and radiographic examination.
Fig 5b. Try in of the mandibular denture over the temporary
cylinders.
Fig 5c. Self cure resin was used to attach the denture and the
temporary cylinders. The denture flange was then trimmed and the
fitting surface was adjusted to allow proper hygiene.
Fig 5d. The provisional hybrid was used as verification jig over the
master cast. The soft tissue moulage was removed to verify the fit of
the provisional on the subgingival implant restorative margins.
Fig 5e. The same provisional hybrid was articulated with a bite
registration material, against the previously articulated study cast.

to each other. It can also be used to articulate the

implant master cast to the opposing study cast (Fig 5e),
and records the laterotrusive functional envelope via
customized incisal pin guidance.
Cement retained provisionals
Clinicians have the option to either cement or screw
retain their final implant restorations.20,21 There are
advantages, disadvantages and limitations for each
option and it is important to understand their influence
238

on the final prosthesis. The decision whether to cement

or screw retain a provisional or final implant
restoration would be dependent on the clinical
situations and clinicians preference towards the
method of fixation.
Most implant companies have prefabricated
abutments for cement retained restorations. These
abutments come in various heights to allow enough
space for the metal and porcelain in crown construction.
They also have a slight taper and an indexing
component providing resistance form for the overlying
restorations. The abutments are torqued onto the
implants, left in situ and a complementing pick-up
coping component may be used for impression and
transfer of the abutment position to the master cast.
A plastic protection cap, usually cylindrical in shape,
may be cemented on the prefabricated abutment until
the delivery of the final prosthesis. This technique is
often used by clinicians in non-aesthetic regions of the
mouth.
Australian Dental Journal 2007;52:3.

b
a

Fig 6a. A cement on, prefabricated abutment was torqued to the recommended value, six weeks post-placement. The abutment was
chosen to allow adequate space for crown construction within the available interocclusal space.
Fig 6b. A denture tooth with appropriate shade and shape was selected to fit the edentulous space. The acrylic tooth was then hollowed
out to fit over a practice implant analog and abutment extra-orally.
Fig 6c. The denture tooth was relined intra-orally using self cured acrylic resin to capture the indexing component of the abutment.
Fig 6d. The relined denture tooth was fitted over the practice implant extra-orally. Note on the deficiency from the implant margin to the
acrylic tooth due to tissue impingement.
Fig 6e. The deficiency was filled in and the excess material trimmed to the appropriate emergence profile.
Fig 6f. The provisional crown was cemented with provisional cement.

Aesthetic provisional restorations can be constructed

for such abutments during the period between impression and prosthesis delivery.8 The provisional
restorations are usually made from a prefabricated
custom shell (prefabricated preformed acrylic crowns;
vacuform template from the diagnostic wax up;
hollowed out denture tooth; or even a hollowed out
decoronated clinical crown) relined using self or light
cured resins intra-orally to capture the indexing
component of the abutment, and then completed extraorally to fit the implant restorative margins (Figs 6a6f).
To facilitate treatment, the crown form can be waxed
up, or selected, sized, and trimmed ahead of time to fit
the edentulous site on the study cast.
Care should be taken during the cementation
procedure where the crown margin is placed deep
Australian Dental Journal 2007;52:3.

subgingivally, especially in the anterior aesthetic region

of the mouth. Access to the deeply placed implant
shoulder can be difficult, and excess residual cements are
difficult to clean and may cause peri-implant
inflammation.22 Alternatively, a temporary meso
abutment would allow a machined connection at
implant shoulder, and customized cement margin that
can be modified to allow a slightly subgingival
restorative margin for ease of cement removal. This
abutment can be modified intra- or extra-orally,
prepared using diamond bur with accessible cement level
placed just below the gingival margin, and correction of
any angulation problems to retain the provisional crown
can be made. A cementable provisional crown is then
constructed using conventional crown and bridge
technique (Figs 7a and 7b).
239

Fig 7a. A temporary meso abutment, one piece temporary abutment

fits directly into the implant body. The abutment is made of PEEK
(Polyetheretherketone) plastic and titanium inlay.
Fig 7b. Unaltered temporary meso abutment on the soft tissue
working cast. The abutment can be prepared in the laboratory or
chairside with altered cement margin and corrections of any
angulation problems.

Fig 8a. A screw retained provisional crown was made at chairside

from the patients existing partial denture, attached to the
temporary cylinder using additional self cure resin. The excess
temporary cylinder is reduced to follow the palatal contour of the
existing partial denture and patients occlusion.
Fig 8b. Facial view of screw retained provisional restoration on
tooth 11 site. The provisional restoration was hand tightened.

Screw retained provisional prostheses

Screw retained provisional restorations would
eliminate the possibility of having any temporary
cement present in the peri-implant tissue. This can be
achieved using temporary cylinders directly placed on
the implant level. The provisional crown can then be
built up in the laboratory on the master cast or
chairside by using self or light cure resin or composite
resin according to the diagnostic wax up. The
temporary cylinder often has to be adjusted to fit into
the occlusion (Figs 8a and 8b).
The most important advantage of provisional
restorations at the start of the restorative procedure is
in shaping of the peri-implant tissues.8,23 This process
will establish a natural and aesthetic soft tissue form
that will help the laboratory fabrication with an
anatomically appropriate soft tissue model.24-26 A wellshaped peri-implant tissue including interdental
papillae will facilitate seating of the final prosthesis.
The provisional restoration can be modified over
several appointments to achieve the desired emergence
profile (Fig 9).

final prosthesis must be able to imitate the natural

tooth crown form when emerging from the gingival
tissues with narrow margins to fit the implant head.
This transition zone between the implant shoulder to
the gingival crest, often up to the contact points is
shaped by the subgingival part of the provisional
restorations. The transition zone can be up to 5mm
deep, especially in the palatal and interproximal tissues
of teeth in the aesthetic zone. The peri-implant tissues

Communication with laboratory using provisionals

One of the challenges faced by the restorative
clinician is the circular shape and small diameter of the
implant compared to the root of a natural tooth. The
240

Fig 9. Moulded soft tissue from screw retained, 3 unit fixed acrylic
provisional bridge. Peri-implant tissue was shaped with screw
retained provisional restoration for 4 weeks prior. The pontic shape
was moulded using additional resin during the healing period.
Australian Dental Journal 2007;52:3.

b
Fig 10a. Resultant emergence profile shaped by the provisional
restoration in Fig 8, after approximately 4 weeks of
provisionalization. The mature peri-implant tissue has an oblong
shape compared to the circular implant restorative collar.
Fig 10b. A custom impression coping with screw on impression
coping replicated from the provisional restoration was placed over
the implant prior to final impression.

must be permitted to adapt to the dimensions of the

provisional restoration.
Following the shaping and maturation of the periimplant tissue, the clinician needs to transfer this
information to the working cast.27,28 This may be
accomplished with a custom impression coping or by
retrofitting the provisional restoration to the working
cast (Figs 10a and 10b). The customized impression
coping allows the clinician to capture the moulded soft
tissue with the appropriate emergence profile onto the
master cast.
In aesthetic cases, the shade and surface
characterization of the provisional restorations can be
altered using composite modifiers (Figs 11a11d).
Shades and surface characterization on the provisional
restoration can be used by the treatment team,
including the patient to evaluate the desired shade of
the final restoration.
CONCLUSION
This article discussed the role of provisionalization in
implant therapy from the removal of teeth, through
implant placement to the final implant restoration.
Australian Dental Journal 2007;52:3.

d
Fig 11a. Screw retained, 3 unit fixed acrylic provisional bridge
constructed to replace the modified removable partial denture from
Fig 1. The provisional restoration had a monochromatic shade
similar to the pre-existing denture teeth.
Fig 11b. Colour modifiers for tooth shading characterizations. The
modifiers can be mixed together and incorporated into the
provisional acrylic/composite resin crown to mask discolouration
and/or create surface characterizations.
Fig 11c. Aesthetic provisional restoration with customized shade
characterization.
Fig 11d. Laboratory shade prescription for the final ceramic
restoration, incorporating the custom shade characterization.
241

Various provisionalization options were discussed with

some examples presented. Provisionalization of
implants is often overlooked, as the time between
impression and delivery of the final prosthesis can be
short. Fixed provisionals would also help those patients
that have not had removable prostheses before,
providing a restoration which has superior comfort and
aesthetics. Clinicians need to be aware of the range of
techniques, materials and temporary implant
components for short, medium and long-term
provisionalization.
The need for provisionalization should be considered
during the treatment planning stage, and reassessed
continually throughout the implant therapy. Clinicians
also need to be able to transfer the information
gathered from the provisional restoration to the
laboratory. Construction of provisional restoration
may take up more chairside time but they may save
time and expense at subsequent appointments, hence
producing better restorations. There may be added
costs associated with increased chairside time and
additional components, however these will be offset by
the improvement in overall patients treatment and
their acceptance towards the treatment.
ACKNOWLEDGEMENT
The authors would like to acknowledge the
assistance of Dr James Mumme and Dr Debra
McAuslan in the preparation of this document.
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242

Address for correspondence/reprints:

Dr Robert Santosa
Suite 44, Level 4
183 Macquarie Street
Sydney, New South Wales 2000
Email: r_santosa@hotmail.com

Australian Dental Journal 2007;52:3.