Provisional restoration options in implant dentistry

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1 CLINICAL REPORT Australian Dental Journal 2007;52:(3): Provisional restoration options in implant dentistry RE Santosa* Astract Unlike their use in conventional crown and ridge, provisional restorations during implant therapy have een underutilized. Provisional restorations should e 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 etween memers of the treatment team which, in most cases, consists of the restorative clinician, implant surgeons, laoratory technicians, and the patient. This article descries and discusses the various options for provisionalization in implant dentistry. Clinicians should e 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 pulication 27 April 2007.) INTRODUCTION Implant supported restorations for partially and fully edentulous patients are a well-accepted and predictale treatment modality. Success rate of implant retained prostheses for complete and partial edentulism has een shown to e over 90 per cent. 1-3 With the increase in treatment acceptance for dental implants, oth 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 e functional, aesthetic, and in harmony with the surrounding hard and soft tissues. Today, implant integration is given with the greater knowledge of the iological asis 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. healing period, patients may have to wear a removale 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 ale 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 e strong, durale and aesthetic to last throughout the duration of the treatment. A traditional provisional prosthesis may consist of an existing or newly constructed removale provisional denture which can e utilized until delivery of the final prosthesis. However, removale provisional prostheses may place undesirale 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 possiility for soft tissue contact may e more eneficial for implant integration and soft tissue maintenance. Tooth orne 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 ased 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 stailization and/or function for a limited period of time, and should e replaced y 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 availaility of one. Provisional restorations can e 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 234 Australian Dental Journal 2007;52:3.

2 Tale 1. Provisionalization prior to implant loading Type of support Removale Fixed tooth supported Fixed implant supported Prosthesis type Partial acrylic dentures Essix appliance Archwire supported pontic Resin onded pontic Resin onded, cast metal framework ridge Transitional implants phase. A provisional restoration immediately placed with ovate pontics extending into the extraction sockets can also e 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 laoratory. 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 e in the form of removale or fixed prostheses. Removale provisional prostheses are generally tooth and/or soft tissue orne. Fixed provisional restorations can e supported y adjacent teeth or implant retained. They can e faricated chairside, using similar techniques as in conventional prosthodontics; or in the laoratory on working casts; or as a comination of indirect-direct technique, where a provisional shell is faricated efore the patient s appointment, reducing chairside time. Provisional restorations may e constructed prior to tooth extraction, during socket healing, prior to implant placement, or during osseointegration period (Tale 1). Provisional restoration could also e constructed after implant loading, allowing maturation of peri-implant soft tissue, and during construction of the final prostheses. Provisionalization prior to implant loading Removale prosthesis Removale partial acrylic dentures have commonly een 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 removale dentures with minimal cost. However, they may reduce the effectiveness of any additional surgical one and gingival augmentation procedure used to optimize the implant site. Care must e taken to prevent the gingival portion of the provisional partial denture from contacting the healing soft tissue or an exposed healing autment. Soft tissue orne prostheses used during healing may cause uncontrolled implant loading Fig 1. Modified removale 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 one loss, and/or failed integration. Often provisional dentures are adjusted to minimize contact with the healing implants (Fig 1). There are alternatives to tissue orne provisional restorations. An Essix appliance 12,13 (Fig 2) may e used as a removale prosthesis in these cases, as well as in limited interocclusal space or deep anterior overite. This prosthesis is made from an acrylic tooth onded 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 inaility to mould the surrounding soft tissue, and lack of patient s compliance can cause rapid occlusal wear through the vacuform material. However, some patients may not like to wear, or are unale to tolerate, a removale 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 rackets 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. Australian Dental Journal 2007;52:3. 235

3 a c d e Fig 3a. Pre-operative radiograph. The patient had generalized refractory periodontitis, especially in the maxillary arch. Fig 3. Pre-operative facial view. One of the patient s 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 compatile self cure resin to fit over the prepared autment teeth. Fig 3f. Fixed provisional restorations cemented on strategic natural autments. The molars have een retained temporarily to maintain the vertical dimension of occlusion. f implant site with an attached pontic. An alternative method is the use of resin onded provisional pontic, which are tooth supported and retained y acid etching the neighouring teeth. Sometimes small retentive grooves within enamel on the adjacent teeth can e used to increase retention of the pontic. The pontic can e in the form of an acrylic tooth, porcelain, or decoronated extracted tooth. The resin onded acrylic or natural tooth may e reinforced with composite resin and/or ultra high molecular weight polyethylene rion (Riond Bondale Reinforcement, Rion; Riond Inc, Seattle, Wash., USA). 8,14 These prostheses may continue to e reused as provisionals after an appropriate implant healing period. The archwire/resin retainer can e removed and reattached etween the different surgical and prosthetic stages. They can also e used to guide the surgeon during grafting procedures and as a template for the final restoration. 236 Australian Dental Journal 2007;52:3.

4 provisional restoration, and the transitional implants are acked 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 onded, cast metal framework prosthesis such as Maryland Bridge is suitale 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 ond strength etween the metal retainer and the enamel can e unpredictale during removal and reattachment etween procedures. Furthermore, the laoratory costs are relatively high. In some cases, a staged extraction and implant placement approach can e 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 autments with poor prognoses are used as interim autments and can e extracted when the implants have integrated. The teeth supported provisional restoration is then converted into an implant supported provisional restoration. This indirect direct technique is often used in a full arch situation, where the patient s dentition is failing due to periodontal disease (Figs 3a 3f) 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 autments to support a provisional restoration, one or more transitional implants may e used. 16 These transitional implants are loaded immediately to support the provisional restoration. They can e used to support fixed restorations or to retain complete mandiular dentures. Care should e taken in planning the position of these implants and with their maintenance post-loading. They should not interfere with potential implant sites, or e placed in poor quality one. When the depth of availale one is less than 14mm or the amount of cortical one is insufficient to provide stailization, the immediate provisional implant may e contraindicated. 16 Once the implants integrate, the supporting provisional restoration will e converted into implant supported Post-implant placement Implant retained provisional restorations Provisional restorations may e 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 enefits to memers 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 e confirmed clinically at the time of implant placement with appropriate assessment of implant staility, one quality, and general site health. In a recent consensus review, 18 four implants in an edentulous mandile, rigidly splinted with a fixed restoration on a framework (acrylic and/or metal) or hyrid prosthesis, can provide patients with a reasonale degree of confidence for evidence-ased treatment. Primary staility of these implants is crucial in the decision for immediate provisionalization. 9,19 The implants need to e well distriuted across the mandiular arch to provide cross-arch stailization. The final implant positions are ased on the proposed restoration through the use of templates/surgical guide. In immediate loading of edentulous mandile, the patient s existing denture can e converted into screw retained provisional fixed hyrid prosthesis. The technique involves the placement of temporary cylinders onto the implants and the modification of patient s existing mandiular 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 hyrid fixed prosthesis with minimal cantilever and occlusal contacts (Figs 5a 5c). A lingual wire may e used within the acrylic framework to provide reinforcement. The provisional hyrid restoration will need to remain during the recommended period of implant healing to allow the implants to fully osseointegrate. 17 This technique may also e used in early or delayed loading implant protocols. The provisional hyrid restoration may have multifunctional uses. It can e 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 Australian Dental Journal 2007;52:3. 237

5 a c d Fig 5a. Patient s existing complete mandiular 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 5. Try in of the mandiular 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 hyrid was used as verification jig over the master cast. The soft tissue moulage was removed to verify the fit of the provisional on the sugingival implant restorative margins. Fig 5e. The same provisional hyrid was articulated with a ite registration material, against the previously articulated study cast. e to each other. It can also e 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 on the final prosthesis. The decision whether to cement or screw retain a provisional or final implant restoration would e dependent on the clinical situations and clinicians preference towards the method of fixation. Most implant companies have prefaricated autments for cement retained restorations. These autments 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 autments are torqued onto the implants, left in situ and a complementing pick-up coping component may e used for impression and transfer of the autment position to the master cast. A plastic protection cap, usually cylindrical in shape, may e cemented on the prefaricated autment until the delivery of the final prosthesis. This technique is often used y clinicians in non-aesthetic regions of the mouth. 238 Australian Dental Journal 2007;52:3.

6 a d c e f Fig 6a. A cement on, prefaricated autment was torqued to the recommended value, six weeks post-placement. The autment was chosen to allow adequate space for crown construction within the availale interocclusal space. Fig 6. 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 autment extra-orally. Fig 6c. The denture tooth was relined intra-orally using self cured acrylic resin to capture the indexing component of the autment. 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 e constructed for such autments during the period etween impression and prosthesis delivery. 8 The provisional restorations are usually made from a prefaricated custom shell (prefaricated 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 autment, and then completed extraorally to fit the implant restorative margins (Figs 6a 6f). To facilitate treatment, the crown form can e waxed up, or selected, sized, and trimmed ahead of time to fit the edentulous site on the study cast. Care should e taken during the cementation procedure where the crown margin is placed deep sugingivally, especially in the anterior aesthetic region of the mouth. Access to the deeply placed implant shoulder can e difficult, and excess residual cements are difficult to clean and may cause peri-implant inflammation. 22 Alternatively, a temporary meso autment would allow a machined connection at implant shoulder, and customized cement margin that can e modified to allow a slightly sugingival restorative margin for ease of cement removal. This autment can e modified intra- or extra-orally, prepared using diamond ur with accessile cement level placed just elow the gingival margin, and correction of any angulation prolems to retain the provisional crown can e made. A cementale provisional crown is then constructed using conventional crown and ridge technique (Figs 7a and 7). Australian Dental Journal 2007;52:3. 239

7 a a Fig 7a. A temporary meso autment, one piece temporary autment fits directly into the implant ody. The autment is made of PEEK (Polyetheretherketone) plastic and titanium inlay. Fig 7. Unaltered temporary meso autment on the soft tissue working cast. The autment can e prepared in the laoratory or chairside with altered cement margin and corrections of any angulation prolems. Fig 8a. A screw retained provisional crown was made at chairside from the patient s 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 patient s occlusion. Fig 8. 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 possiility of having any temporary cement present in the peri-implant tissue. This can e achieved using temporary cylinders directly placed on the implant level. The provisional crown can then e uilt up in the laoratory on the master cast or chairside y using self or light cure resin or composite resin according to the diagnostic wax up. The temporary cylinder often has to e adjusted to fit into the occlusion (Figs 8a and 8). 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 estalish a natural and aesthetic soft tissue form that will help the laoratory farication with an anatomically appropriate soft tissue model A wellshaped peri-implant tissue including interdental papillae will facilitate seating of the final prosthesis. The provisional restoration can e modified over several appointments to achieve the desired emergence profile (Fig 9). final prosthesis must e ale to imitate the natural tooth crown form when emerging from the gingival tissues with narrow margins to fit the implant head. This transition zone etween the implant shoulder to the gingival crest, often up to the contact points is shaped y the sugingival part of the provisional restorations. The transition zone can e up to 5mm deep, especially in the palatal and interproximal tissues of teeth in the aesthetic zone. The peri-implant tissues Communication with laoratory using provisionals One of the challenges faced y the restorative clinician is the circular shape and small diameter of the implant compared to the root of a natural tooth. The Fig 9. Moulded soft tissue from screw retained, 3 unit fixed acrylic provisional ridge. 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. 240 Australian Dental Journal 2007;52:3.

8 a a Fig 10a. Resultant emergence profile shaped y the provisional restoration in Fig 8, after approximately 4 weeks of provisionalization. The mature peri-implant tissue has an olong shape compared to the circular implant restorative collar. Fig 10. A custom impression coping with screw on impression coping replicated from the provisional restoration was placed over the implant prior to final impression. c must e 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 e accomplished with a custom impression coping or y retrofitting the provisional restoration to the working cast (Figs 10a and 10). 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 e altered using composite modifiers (Figs 11a 11d). Shades and surface characterization on the provisional restoration can e used y 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: d Fig 11a. Screw retained, 3 unit fixed acrylic provisional ridge constructed to replace the modified removale partial denture from Fig 1. The provisional restoration had a monochromatic shade similar to the pre-existing denture teeth. Fig 11. Colour modifiers for tooth shading characterizations. The modifiers can e 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. Laoratory shade prescription for the final ceramic restoration, incorporating the custom shade characterization.

9 Various provisionalization options were discussed with some examples presented. Provisionalization of implants is often overlooked, as the time etween impression and delivery of the final prosthesis can e short. Fixed provisionals would also help those patients that have not had removale prostheses efore, providing a restoration which has superior comfort and aesthetics. Clinicians need to e aware of the range of techniques, materials and temporary implant components for short, medium and long-term provisionalization. The need for provisionalization should e considered during the treatment planning stage, and reassessed continually throughout the implant therapy. Clinicians also need to e ale to transfer the information gathered from the provisional restoration to the laoratory. Construction of provisional restoration may take up more chairside time ut they may save time and expense at susequent appointments, hence producing etter restorations. There may e added costs associated with increased chairside time and additional components, however these will e offset y 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 Dera McAuslan in the preparation of this document. REFERENCES 1. Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10: Buser D, Mericske-Stern R, Bernard JP, et al. Long-term evaluation of non-sumerged ITI implants. Part 1: 8-year life tale analysis of a prospective multi-center study with 2359 implants. Clin Oral Implants Res 1997;8: Weer C, Crohin CC, Fiorellini JP. A 5-year prospective clinical and radiographic study of non-sumerged dental implants. Clin Oral Implants Res 2000;11: Wohrle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: fourteen consecutive case reports. Pract Periodontics Aesthet Dent 1998;10: Garer DA. The esthetic dental implant: letting the restoration e the guide. J Am Dent Assoc 1995;126: Garer DA, Belser U. Restoration-driven implant placement with restoration-generated site development. Compend Contin Educ Dent 1995;16: Kan JYK, Rungcharassaeng K, Kois JC. Removale ovate pontic for peri-implant architecture preservation during immediate implant placement. Pract Proced Aesthet Dent 2001;13: Priest G. Esthetic potential of single-implant provisional restorations: selection criteria of availale alternatives. J Esthet Restor Dent 2006;18: Ciirka RM, Lineaugh ML. The fixed/detachale implant provisional prosthesis. J Prosthodont 1997;6: The glossary of prosthodontic terms. 8th edn. J Prosthet Dent 2005;94: Margeas RC. Predictale peri implant gingival esthetics: use of the natural tooth as a provisional following implant placement. J Esthet Restor Dent 2006;18: Sheridan JJ, Ledoux W, McMinn R. Essix retainers: farication and supervision for permanent retention. J Clin Orthod 1993;27: Moskowitz EM, Sheridan JJ, Celenza F, Tovilo K, Munoz AM. Essix appliances. Provisional anterior prosthesis for pre and post implant patients. N Y State Dent J 1997;63: Smidt A. Esthetic provisional replacement of a single anterior tooth during the implant healing phase: a clinical report. J Prosthet Dent 2002;87: Perel ML. Sequencing and integration of periodontal, prosthodontic and implant therapies. Int J Oral Implantol 1990;7: Baush CA. Provisional implants: surgical and prosthetic aspects. Implant Dent 2001;10: Morton D, Jaffin R, Weer HP. Immediate restoration and loading of dental implants: clinical considerations and protocols. Int J Oral Maxillofac Implants 2004;19 Suppl: Cochran DL, Morton D, Weer HP. Consensus statements and recommended clinical procedures regarding loading protocols for endosseous dental implants. Int J Oral Maxillofac Implants 2004;19 Suppl: Balshi TJ, Wolfinger GJ. Immediate loading of Brånemark implants in edentulous mandiles: a preliminary report. Implant Dent 1997;6: Michalakis KX, Hirayama H, Garefis PD. Cement-retained versus screw-retained implant restorations: A critical review. Int J Oral Maxillofac Implants 2003;18: Heel KS, Gajjar RC. Cement-retained versus screw-retained implant restorations: achieving optimal occlusion and esthetics in implant dentistry. J Prosthet Dent 1997;77: Pauletto N, Lahiffe BJ, Walton JN. Complications associated with excess cement around crowns on osseointegrated implants: a clinical report. Int J Oral Maxillofac Implants 1999;14: Chee WW, Donovan T. Use of provisional restorations to enhance soft-tissue contours for implant restorations. Compend Contin Educ Dent 1998;19: Higginottom F, Belser U, Jones JD, Keith SE. Prosthetic management of implants in the esthetic zone. Int J Oral Maxillofac Implants 2004;19 Suppl: Sadan A, Blatz MB, Salinas TJ, Block MS. Single-implant restorations: a contemporary approach for achieving a predictale outcome. J Oral Maxillofac Surg 2004;62 Suppl: Biggs WF. Placement of a custom implant provisional restoration at the second-stage surgery for improved gingival management: a clinical report. J Prosthet Dent 1996;75: Chee WW, Cho GC, Ha S. Replicating soft tissue contours on working casts for implant restorations. J Prosthodont 1997;6: Buskin R, Salinas TJ. Transferring emergence profile created from the provisional to the definitive restoration. Pract Periodontics Aesthet Dent 1998;10: Address for correspondence/reprints: Dr Roert Santosa Suite 44, Level Macquarie Street Sydney, New South Wales r_santosa@hotmail.com 242 Australian Dental Journal 2007;52:3.

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