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One-Stage Surgery and Immediate Provisionalization:Achieving Optimal Soft

and Hard Tissue Form

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One-Stage Surgery and Immediate Provisionalization:

Achieving Optimal Soft and Hard Tissue Form
Jin Y. Kim, DDS, MPH, MS*

1A 1B

Jin Y. Kim, DDS, MPH, MS Case 1. Figure 1A and 1B. A 73-year-old healthy
Private practice limited to periodontics and dental male presented with a non-restorable maxil-
lary central incisor due to root fracture and
implants, Garden Grove, CA; Diplomate, American
fistula formation.
Board of Periodontology; Diplomate, American Board
of Oral Implantology/Implant Dentistry

Achieving ideal form of soft and hard tissue around a dental implant is
critical for long-term functional and cosmetic success. Despite advances
in surgical techniques, provisionalization at the time of tooth extraction
and immediate implant placement has shown to be the most predictable
method for preserving fragile gingival topography.1-7 Provisionalization
using customized abutments that mimic the gingival embrasure form is
arguably the most ideal way to preserve the natural form of periodon-
tal tissues.8,9 One must carefully assess, however, the risks and benefits
of immediate provisionalization against inadvertent or purposeful imme-
diate loading of the implant.10 This article presents two cases where the
tissue form of periodontal embrasure is preserved using a customized
healing abutment, but immediate loading is prevented by a removable
provisional denture that is aesthetically pleasing.

Case 1
A 73-year-old healthy male patient presented with a maxillary central incisor that was
previously treated endodontically and with an all-ceramic restoration. The tooth was
deemed non-restorable due to a clinically detectable root fracture and resulting fistula
formation. The tooth was surgically removed without raising a flap (Figure 1). Upon
debridement of the extraction socket, an internal connection implant
(ie, BioHorizons Internal, BioHorizons, Birmingham, AL) was placed with the implant
shoulder approximately 2.5 mm apical to the free gingival margin of adjacent central
incisor (Figure 2). A circumferential socket defect of approximately 1.5 mm at the widest
portion was filled with mineralized freeze-dried bone allograft chips (ie, MinerOss,
BioHorizons, Birmingham, AL) (Figure 3). A polyetheretherketone (ie, PEEK, Victrex,
Greenville, SC) temporary abutment, which allowed direct bonding to its surface, with
light-cured flowable composite resin, was then used to pick up gingival architecture that
represented the emergence profile of extracted natural tooth. A custom healing

Science Simplicity Value

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abutment was therefore fabricated based on this

embrasure form, which was torqued to 20 NCm
(Figure 4). A flangeless removable partial denture
was used where space was created under the pon-
tic to ensure no occlusal load was applied to the
dental implant.
At 4 months, the implant had integrated clinically.
Upon removal of the customized healing abutment,
a natural shaped soft tissue form was found to be
preserved (Figure 5). A full-contoured screw-retained
provisional restoration was fabricated out of
bisacrylic material (ie, Protemp, 3M Espe, St. Paul,
MN) (Figures 6 and 7). This provisional was used in
a series of contour adjustments to achieve the most
desired soft tissue profile.
Figure 2. An internal connection implant was placed
2.5 mm apical to the free gingival margin.
Figure 3A. Occlusal view of the seated implant.
3B. A circumferential socket was filled with mineralized
bone allograft.
Figure 4A. A customized healing abutment was fabricated
to conform with the natural tooth embrasure.
4B. View of the customized healing abutment upon seating.
2

Case 2
A 55-year-old healthy male patient presented with
a fractured maxillary central incisor that was not
restorable. The tooth was surgically removed via
sectioning and without raising a flap (Figure 8).
The extraction socket was debrided, and an exter-
nal connection implant was placed with the implant
shoulder approximately 3 mm apical to the free
gingival margin of the adjacent central incisor
(Figure 9). The resulting circumferential socket
defect was filled with mineralized freeze-dried
bone allograft chips. Quick-setting acrylic resin 3A 3B
(ie, Alike, GC America, Alsip, IL) was applied to a
titanium abutment (ie, Maestro, BioHorizons
Implant Systems, Birmingham, AL), which was then
used as a customized healing abutment, preserv-
ing the soft and hard tissue around the extraction
site (Figure 10). The abutment was torqued to 20
NCm and a removable resin denture was placed
to ensure that there was a gap at the pontic site
during mastication (Figure 11). At approximately
4 months, the customized healing abutment was
modified chairside to a full-contoured screw-
retained provisional restoration (Figure 12). After
6 weeks of further tissue maturation, a definitive
restoration was delivered (Figures 13 and 14).

Discussion 4A 4B

At 4 months, both cases were able to develop ideal

soft tissue embrasure form around the respective cen-
tral incisor implant. At this time, the screw-retained
resin provisional restoration was fabricated chair-
side. The fixed restoration was subsequently
adjusted over a period of 2 to 3 months for the final
embrasure form to be established. A number of
impression techniques have been discussed where
the soft tissue profile can be transferred to the mas-
ter cast.8-11 A pickup-type impression using a dupli-
cated provisional to be used as a customized impres-
sion coping has been suggested to be the most accu-
rate replication of the soft tissue morphology.

BioHorizons Monograph 15
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Figure 5. At 4 months, the implant had integrated clinically. The soft-tissue complex was preserved to an ideal form.
Figure 6A. Preoperative radiograph of Case 1. 6B. Radiograph of the seated abutment.
Figure 7. An aesthetically pleasing provisional restoration was fabricated of bisacrylic material. Subsequently, the patient had porce-
lain veneers fabricated on the adjacent teeth, and the gingiva at the #8 site was contoured with a CO2 laser.

5 6A 6B

Case 2. Figure 8A and 8B. A 55-year-old male presented with a non-restorable fractured maxillary central incisor.
Figure 9A. The extraction socket was debrided thoroughly. 9B. An external connection implant was placed into the extraction
socket and grafted with mineralized allograft.
Figure 10A. Fabrication of anatomic, customized healing abutment. 10B. The customized healing abutment conformed to the extrac-
tion socket, ensuring preservation of the natural tooth embrasure.
Figure 11. The customized healing abutment was torqued and a removable resin denture was placed over the abutment and relieved.
Figure 12. The soft-tissue complex was preserved to an ideal form at 4 months.
Figure 13. Radiograph of the definitive implant restoration.
Figure 14. The patient was pleased with the definitive aesthetic restoration.

8A 8B 9A 9B

11 12A 13

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B 10A
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Conclusion
One-stage surgery of non-submerging allows the
original form of periodontal tissue to be unaltered.
A customized healing abutment is the key to sup-
porting the soft tissue form. A quick-setting material
is used to customize a prefabricated titanium or
temporary abutment. Whether the provisional
restoration is made to full contour and to conform
to full load of occlusion has to be a clinical deci-
sion based on individual risk assessment. Although
simple, the technique is reliable in achieving the
ideal soft tissue embrasure form with minimal surgi-
cal intervention. The risk of inadvertent overloading
of the implant is reduced by the use of a removable
partial denture relieved at the pontic site, above
the customized healing abutment.
The author mentions his gratitude to Dr. Katherine Ahn,
Huntington Beach, CA, for her restorative work on
Case 1 and Dr. Van Bui, Westminster, CA, for her
restorative work on Case 2.
References
1. Touati B, Guez G. Immediate implantation with provisional-
ization: From literature to clinical implications. Pract Proced
Aesthet Dent 2002;14(9):699-707.
2. Petrungaro PS. Implant placement and provisionalization in
10B extraction, edentulous, and sinus grafted sites: A clinical
report on 1,500 sites. Compend Contin Educ Dent
2005;26(12):879-890.
3. Block M, Finger I, Castellon P, Lirettle D. Single tooth immedi-
ate provisional restoration of dental implants: Technique and
early results. J Oral Maxillofac Surg 2004;62(9):1131-1138.
4. Kim JY. Preserving and maintaining optimal peri-implant soft-
tissue complex for function and aesthetics. Dent Implantol
Update 2004;15(9):65-72.
5. Groisman M, Frossard WM, Ferreira HM, et al. Single-tooth
implants in the maxillary incisor region with immediate provi-
sionalization: 2-year prospective study. Pract Proced Aesthet
Dent 2003;15(2):115-124.
6. Kan JY, Rungcharassaeng K, Lozada J. Immediate placement
and provisionalization of maxillary anterior single implants:
1-year prospective study. Int J Oral Maxillofac Implants
2003;18(1):31-39.
7. Kim JY. A prospective study of 17 consecutive immediate
load/immediate function cases in a private practice setting,
Presented at 52nd Annual Meeting of American Academy of
Implant Dentistry, Hollywood, Florida November 2003.
8. Hinds KF. Custom impression coping for an exact registration
of the healed tissue in the esthetic implant restoration. Int J
Periodontics Restorative Dent 1997;17(6):584-591.
9. Kim JY, Park A, Kim Y. Peri-Implant tissue contour transfer tech-
nique: An impression method allowing duplication of
groomed soft tissue contour to the definitive implant restora-
tion, Presented at 17th Annual Meeting of Academy of
Osseointegration, Dallas, Texas March 2002.
10. Chee WW, Cho GC, Ha S. Replicating soft tissue contours on
working casts for implant restorations. J Prosthodent
1997;6(3):218-220.
11. Donitza A. Prosthetic procedures for optimal aesthetics in
single-tooth implant restorations: A case report. Pract
Periodontics Aesthet Dent 2000;12(4):347-352.
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