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Achieving the Optimal Peri-implant Soft Tissue Profile bythe Selective Pressure Method via Provisional Restorationsin the Esthetic ZoneJUNG NAM, D.M.D., M.S., M.S.D.*, PRASIT ARANYARACHKUL, D.D.S., M.S.†

ABSTRACT

For the successful single-tooth implant therapy in the esthetics zone, achieving an ideal peri-implant soft tissue profile isparamount. It can achieve by the manipulation of the provisional restorations.This clinical report demonstrate theselective pressure method and concave transmucosal profile of the provisional restorations to achieve the ideal andstable gingival profile in esthetic single tooth implant restorations.

CLINICAL SIGNIFICANCE

The selective pressure method and the concave transmucosal profile in implant provisional restorations facilitate stableand harmonized peri-implant gingival tissue in the esthetic zone.

(J Esthet Restor Dent 27:136–144, 2015)

INTRODUCTION

In order to deliver a successful single-tooth implanttherapy in the esthetics zone, one of the critical andchallenging treatment objectives is achieving an idealperi-implant soft tissue profile.1–4 The margin, color,contour, texture, and thickness of the peri-implant softtissue, as well as the height of the interdental papillae,should be matched and harmonized with the existingadjacent dentition.5–8 In replacing a failing dentitionwith a dental implant in the esthetics zone, severalimportant factors should be considered. These include:timing of the implant placement, timing of theprovisional restoration placement, and the necessity ofthe hard and soft tissue grafts.9

Provisional restorations play a large role in creatingand/or preserving the soft tissue architecture when

achieving the ideal profile of the peri-implant gingivaltissue.10 The timing of the provisional restorationplacement is dictated by several factors, including theprimary stability of implant, the size of defects and/orgaps between implant and buccal plate, and the amountof hard and/or soft tissue grafts. While the main goal ofthe immediate implant provisional restoration is topreserve the existing dento-gingival tissue, especially atthe facial gingival level and at the interdental papilla,11,12

the utilization of the delayed restoration is to createperi-implant soft tissue architecture that harmonizeswith the soft tissue of the adjacent teeth.10 In mostcases, changing the emergence profile could beperformed restoratively by adding or subtracting therestorative provisional materials,10 and/or surgically bythe addition of the soft tissue graft, leading to thickertissue that could hide the shadow effects of abutmentsand facilitate more stable peri-implant soft tissue.13–15

*Adjunct Assistant Professor, †Private Practice, Department of Integrated Reconstructive Dental Sciences, Arthur A. Dugoni School of Dentistry, University of the Pacific,

Saratoga, San Francisco, CA, USA

CLINICAL ARTICLE

DOI 10.1111/jerd.12147 © 2015 Wiley Periodicals, Inc.Vol 27 • No 3 • 136–144 • 2015 Journal of Esthetic and Restorative Dentistry136

The following three clinical cases demonstrate thesuccessful harmonization of the peri-implant andadjacent soft tissue by utilizing the selective pressuremethod and a concave transmucosal profile via theimmediate or delayed implant-supported provisionalrestorations in three different scenarios.

CASE REPORTS

Case I

A 31-year-old Asian male was referred to the office dueto a failing maxillary right central incisor (Figure 1). Thetooth was not restorable due to the compromisedferrule and the vertical root fracture. Upon clinical andradiographic examination, the tooth did not present anyactive infections, and a good buccal bony architecturewas confirmed with a bone sounding (Figures 1 and 2).After the tooth was removed by a careful and minimallytraumatizing extraction, the intact buccal cortical platewas reconfirmed. With the guidance of the surgicalstent, the implant (Astra 4.5 × 15 mm; DentsplyImplants, MÖLNDAL, SWEDEN) was immediatelyplaced at approximately 3 mm below the free gingivalmargin. After filling the gap between the buccal plateand the implant fixture with a bone graft (EndobonZenograft Granules; Biomet 3i, Palm Beach Gardens,Florida, USA), the sub-epithelial connective graft wasplaced in the facial gingival pouch to thicken the softtissue profile (Figure 3). Due to the stability of the

implant, the nonfunctional screw-retained provisionalrestoration was immediately delivered (Figure 4).

To fabricate the provisional restoration,self-polymerized bis-acrylic material (Luxatemp;DMG, Hamburg, Germany) was injected around thetemporary abutment, with the guidance of the puttyindex placing on the adjacent teeth. To finalize theshape of the provisional restoration, the abutment wascarefully removed from the implant and added with theflowable composite resin (Filtek Supreme; 3M ESPE, St.Paul, MN, USA) (Figures 4 and 5). The provisionalrestoration was maintained with no function for 6months. The customized impression coping was

FIGURE 1. Initial clinical photo for case I.

FIGURE 2. Initial periapical radiograph.

FIGURE 3. Implant placement surgery with connective tissuegrafts and bone grafts.

PROVISIONAL RESTORATIONS IN THE ESTHETIC ZONE Nam and Aranyarachkul

© 2015 Wiley Periodicals, Inc. DOI 10.1111/jerd.12147 Journal of Esthetic and Restorative Dentistry Vol 27 • No 3 • 136–144 • 2015 137

fabricated to transfer the soft tissue contours from theprovisional restoration to the definitive prosthesis(Figure 6).16,17

An immediate nonfunctional implant provisionalrestoration was fabricated to preserve most of theexisting soft tissue architecture, except for the buccalgingival margin. With a selective pressure technique, arelatively lower pressure was applied through theunder-contoured buccal marginal area, resulting in abuccal-free gingival margin located slightly morecoronal than the free gingival margin of the maxillaryleft central incisor. In contrast, more pressure was

applied through the ideally contoured interproximalareas, leading to the fully supported interproximalpapillae.

The final zirconia customized abutment (Atlantisabutment; Dentsply Implants) was placed and torquedwith 25 Ncm. The zirconia-based crown (Procera;Nobel Biocare, Zürich, Switzerland) was then cementedwith the provisional cement (premier implant cement;Premier Dental, Plymouth Meeting, PA, USA). Theexisting crown of the maxillary left central incisor wasreplaced with the zirconia-based porcelain crown, andcemented with the resin cements (Rely-x ultimate; 3MESPE) (Figures 7–11).

FIGURE 4. Screw retained provisional restoration at thesurgery day.

FIGURE 5. Emergency profile of a screw retained provisionalrestoration.

FIGURE 6. Provisional restorations after 6 months ofsurgery. Note the gingival margin of implant provisionalrestoration is more coronal than that of right centralincisor.

FIGURE 7. Customized impression coping in situ prior tofinal impression.



Case II

A 40-year old Asian male presented to the office with afailing maxillary right central incisor with vertical rootfracture (Figure 12). Due to an existing active infection,the treatment was planned according to the earlyimplant placement protocol (6–8 weeks after the toothextraction).18,19 The extraction socket was allowed toheal for 6 weeks (Figure 13). The dental implant (Astra4.5 × 11 mm; Dentsply Implants) was placed inconjunction with the guided bone regeneration(Endobon Zenograft Granules; Biomet 3i) and thesub-epithelial connective tissue graft procedures. AnEssix retainer was delivered as an interim prosthesisduring the 5-month healing period.

After the implant was uncovered, an implant-levelimpression was made. To fabricate the provisionalrestoration creating the natural-looking soft tissue andthe emergence profile of the peri-implant tissue, thestone cast was carved according to the wax-up(Figure 14). The stone cast was under-carved at thebuccal area, hence the provisional restoration withthe slightly under-contoured buccal surface and theconcave transmucosal profile. The provisionalrestoration was cemented with interim cements (tempbond NE; Kerr, Orange, CA, USA) (Figure 15). With themanipulation by the provisional restoration for 4months, the buccal soft tissue margin locating slightlymore coronal than the free gingival margin of themaxillary left central incisor, and the mature

FIGURE 8. Peri-apical soft tissue contour prior to finalrestoration insertion.

FIGURE 9. Zirconia customized abutment in situ.

FIGURE 10. Final periapical radiograph.

FIGURE 11. Final clinical follow-up shows stable andharmonized soft tissue profile.



interproximal papillae was achieved. Then, the finalimpression was made utilizing customized impressioncoping. The zirconia abutment (Procera; Nobel Biocare)was torqued to 25 Ncm, and the alumina-based(Procera; Nobel Biocare) crown was delivered with thetemporary cement (premier implant cement; PremierDental) (Figures 16–18).

Case III

A 29-year-old Caucasian female patient was referred tothe office with an unsatisfactory maxillary right canineimplant supported crown (Figure 19). She expressedconcern with the gingival level of the implant crown,which was significantly more coronal than that of thecontralateral tooth.

FIGURE 12. Initial clinical photo for case II. FIGURE 13. Six weeks post-extraction prior to implantplacement.

FIGURE 14. Carving the cast to create emergency profile. FIGURE 15. Provisional restorations in situ. Note thegingival margin of implant provisional restoration of rightcentral incisor is more coronal than that of left central incisor.

FIGURE 16. Zirconia customized abutment in situ.



The selective pressure method was utilized tomanipulate and train the buccal soft tissue level aroundthe implant (Tri-CAM 3.5 mm × 10 mm; ACE SurgicalSupply Co., Brockton, MA, USA) with the provisionalrestoration. First, an impression was made, and thestone cast around the implant was carved to create anemergency profile according to the wax-up (Figure 20).The screw-retained provisional restoration was placed,and the buccal contour was modified by graduallyadding flowable composites for several times. Afterreaching the satisfactory tissue level, the buccalperi-implant tissue locating more apical than the initialbut slightly more coronal than the ideal level(Figures 21–23), it was maintained for 3 months. Thezirconia customized abutment (Procera; Nobel Biocare)was torqued down with 30 Ncm, and the zirconia-basedcrown (Katana; Kuraray Noritake Dental Inc, Tokyo,Japan) was cemented with the temporary cement(Figures 24–25).

DISCUSSION

To achieve successful treatment outcomes of estheticdental implants, both surgical and prostheticmanagement are of paramount significance. Theprosthetic-driven surgical implant placement and thesub-epithelial connective graft facilitate esthetic implantrestorations with pleasing peri-implant soft tissuearchitecture.20 Also, soft tissue management withprovisional restorations is essential.

FIGURE 17. Two-year follow-up clinical photo. Note thestable and harmonized gingival profile.

FIGURE 18. Two-year follow-up peri apical radiograph.

FIGURE 19. Initial clinical photo of case III.

FIGURE 20. Carving the cast to create the emergencyprofile.



In cases of proper implant position and angulation,screw-retained provisional restorations are preferred tocement retained ones due to their multiple advantages:fewer possible residual cement issues, easierretrievability, and increased ease of controlling pressurewhen manipulating the soft tissue.

To utilize the selective pressure method via provisionalrestorations, a relatively lower pressure was appliedthrough the under-contoured buccal marginal area,resulting in a buccal-free gingival margin locatedslightly more coronal than the prospective or ideal

gingival margin. In contrast, more pressure was appliedthrough the ideally contoured interproximal areas,leading to the fully supported interproximal papillae.After the removal of the provisional restorations duringseveral treatment procedures, including impressions, tryin, and delivery appointments, the abutment/implantinterface could be interrupted, and the peri-implanttissue could be traumatized. One possible consequencewould be buccal gingival margin recession, which couldbe offset by a low pressure applied through theunder-contoured buccal area of the provisionalrestorations.

FIGURE 21. Emergency profile of a screw retainedprovisional restoration.

FIGURE 22. Screw retained provisional restoration in situ atthe initial insertion.

FIGURE 23. Screw retained provisional restoration in situafter modification of the buccal contour by adding flowablecomposites. Note the gingival margin of maxillary right canineimplant provisional restoration is more apical than inFigure 22.

FIGURE 24. Final clinical photo. Note the harmonizedgingival margin of maxillary right canine compared to adjacentdentition.



The soft tissue response should be evaluated afterplacing the provisional restorations. After the pressureis applied, blanching of the tissue is expected, andshould disappear within 15 minutes.21 In most cases,restorative provisional materials need to be added orsubtracted depending on the tissue response, in orderto give more pressure to, or room for, the soft tissue,respectively.22–24

To achieve a thick and stable peri-implant soft tissue,the transmucosal portion of the provisional restorationsand the final abutments should be concave.25,26 Allprovisional restorations must be highly polished toreduce plaque accumulation, and promote a healthyperi-implant soft tissue.

CONCLUSION

In the anterior areas, achieving an esthetically pleasingand healthy soft tissue profile is one of the crucialfactors of the single tooth esthetic implant treatments.With the selective pressure technique and a concavetransmucosal profile of the provisional restorations,esthetically and functionally successfulimplant-supported restorations of the presented clinicalcases were delivered. The illustrated methods facilitatepreserving and/or creating the optimal emergencyprofile and peri-implant soft tissue architecture fordefinitive restorations.

DISCLOSURE AND ACKNOWLEDGEMENTS

The authors do not have any financial interest in thecompanies whose materials are included in this article.

The authors would like to thank Mr. Jungo Endo,R.D.T., in Case I, Mr. Yi-Yuan Chang, M.D.C., in CaseII, and Mr. Hiro Tokutomi, R.D.T., in Case III forfabricating definitive restorations and customizedabutments, as well as Dr. Dennis W. Calvert (San Jose,CA) for the implant surgery in Case III.

REFERENCES

1. Fürhauser R, Florescu D, Benesch T, et al. Evaluationof soft tissue around single-tooth implant crowns: thepink esthetic score. Clin Oral Implants Res 2005;16:639–44.

2. Kan JYK, Rungcharassaeng K. Immediate placement andprovisionalization of maxillary anterior single implants: asurgical and prosthodontics rationale. Pract PeriodonticsAesthet Dent 2000;12:817–24.

3. Funato A, Salama MA, Ishikawa T, et al. Timing,positioning, and sequential staging in esthetic implanttherapy: a four-dimensional perspective. Int JPeriodontics Restorative Dent 2007;27:313–23.

4. Kois JC. Predictable single-tooth peri-implant esthetics:five diagnostic keys. Compend Contin Educ Dent2004;25:895–6.

5. Steigmann M, Monje A, Chan HL, Wang HL. Emergencyprofile design based on implant position in the estheticzone. Int J Periodontics Restorative Dent 2014;34:559–63.

6. Chu SJ, Paravina RD. Periodontal-prosthodontics incontemporary practice. J Dent 2013;41(Suppl 3):e1–2.

7. Chu SJ, Tarnow DP, Tan JH, Stappert CF. Papillaproportions in the maxillary anterior dentition. Int JPeriodontics Restorative Dent 2009;29:385–93.

8. Chu SJ, Tan JH, Stappert CF, Tarnow DP. Gingival zenithpositions and levels of the maxillary anterior dentition.J Esthet Restor Dent 2009;21:113–20.

9. Cooper LF, Reside G, Raes F, et al. Immediateprovisionalization of dental implants in grafted alveolarridges in the esthetic zone: a 5-year evaluation. Int JPeriodontics Restorative Dent 2014;34:477–86.

10. Wittneben JG, Buser D, Belser UC, Brägger U.Peri-implant soft tissue conditioning with provisionalrestorations in the esthetic zone: the dynamiccompression technique. Int J Periodontics RestorativeDent 2013;33:447–55.

FIGURE 25. Final periapical radiograph.



11. Slagter KW, den Hartog L, Bakker NA, et al. Immediateplacement of dental implants in the esthetic zone: asystematic review and pooled analysis. J Periodontol2014;85:e241–50.

12. Kan JY, Rungcharassaeng K. Immediate placement andprovisionalization of maxillary anterior single implants: asurgical and prosthodontic rationale. Pract PeriodonticsAesthet Dent 2000;12:817–24.

13. Yoshino S, Kan JY, Rungcharassaeng K, et al. Effects ofconnective tissue grafting on the facial gingival levelfollowing single immediate implant placement andprovisionalization in the esthetic zone: a 1-yearrandomized controlled prospective study. Int J OralMaxillofac Implants 2014;29:432–40.

14. Tsuda H, Rungcharassaeng K, Kan JY, et al. Peri-implanttissue response following connective tissue and bonegrafting in conjunction with immediate single-toothreplacement in the esthetic zone: a case series. Int J OralMaxillofac Implants 2011;26:427–36.

15. Cosyn J, Eghbali A, De Bruyn H, et al. Immediatesingle-tooth implants in the anterior maxilla: 3-yearresults of a case series on hard and soft tissue responseand aesthetics. J Clin Periodontol 2011;38:746–53.

16. Ntounis A1, Petropoulou A. A technique for managingand accurate registration of periimplant soft tissues.J Prosthet Dent 2010;104:276–9.

17. Hinds KF. Custom impression coping for an exactregistration of the healed tissue in the esthetic implantrestoration. Int J Periodontics Restorative Dent1997;17:584–91.

18. Buser D, Chen ST, Weber HP, Belser UC. Early implantplacement following single-tooth extraction in theesthetic zone: biologic rationale and surgical procedures.Int J Periodontics Restorative Dent 2008;28:441–51.

19. Buser D, Wittneben J, Bornstein MM, et al. Stability ofcontour augmentation and esthetic outcomes ofimplant-supported single crowns in the esthetic zone:3-year results of a prospective study with early implantplacement postextraction. J Periodontol 2011;82:342–9.

20. Belser UC, Bernard JP, Bser D. Implant-supportedrestorations in the anterior region: prostheticconsiderations. Pract Periodontics Aesthet Dent1996;8:875–83.

21. Cooper LF. Objective criteria: guiding and evaluatingdental implant esthetics. J Esthet Restor Dent2008;20:195–205.

22. Chee WW. Provisional restorations in implants.Periodontol 2000 2001;27:139–47.

23. Santosa RE. Provisional restoration options in implantdentistry. Aust Dent J 2007;52:234–42.

24. Priest G. Esthetic potential of single-implant provisionalrestorations: selection criteria of available alternatives.J Esthet Restor Dent 2006;18:326–38.

25. Redemagni M, Cremonesi S, Garlini G, Maiorana C. Softtissue stability with immediate implants and concaveabutments. Eur J Esthet Dent 2009;4:328–37.

26. Iglhaut G, Schwarz F, Winter RR, et al. Epithelialattachment and downgrowth on dental implantabutments-a comprehensive review. J Esthet Restor Dent2014;26:324–531.

Reprint requests: Jung Nam, D.M.D., M.S., M.S.D., Department of

Integrated Reconstructive Dental Sciences, Arthur A. Dugoni School of

Dentistry, University of the Pacific, 1848 Saratoga Avenue, Suite 6B,

Saratoga, CA 95070, USA.Tel.: 408-871-1211; Fax: 408-871-1245;

email: [email protected]



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