Received: 7 November 2018 Revised: 14 January 2019 Accepted: 16 February 2019

DOI: 10.1111/jerd.12466

CLINICAL ARTICLE

Use of extracted anterior teeth as provisional restorations

and surgical guide for immediate multiple implant placement:
A clinical case report
Luis G. Ladino1 | Diego Rosselli2

1
Implant Dentistry and Clinical Epidemiology
and Biostatistics, Medical School, Pontificia
Universidad Javeriana, Bogotá, Colombia
2
Clinical Epidemiology and Biostatistics
Department, Pontificia Universidad Javeriana,
Bogotá, Colombia
Correspondence
Luis G. Ladino, Av 19 No 128B-66, Bogotá,
Colombia.
Email: luisgaladino@gmail.com
Abstract
Objective: The aim of this article is to describe the use of natural anterior teeth as a surgical
guide to implant placement and provisional restoration for a young patient with root resorption
of upper central incisors and left-lateral incisor.
Clinical considerations: Achieving soft tissue esthetics is quite a challenge in implant dentistry.
Here, a case of immediate implant placement using the natural teeth of the patient as an immediate
provisional restoration, which achieves satisfactory results in terms of soft tissue architecture.
Conclusions: Post-extraction implant placement in combination with immediate loading of dental
implants has been evolving into an appropriate procedure for the treatment of partially edentulous
anterior maxilla. Different techniques that include use of the own teeth as provisional implant sup-
ported restoration helps to maintain architecture of gingival contour, specially papilla.
Clinical significance: Natural architecture of anterior soft tissue is a big challenge in implant den-
tistry. Use of natural teeth as a surgical guide and provisional restorations might be helpful to
obtain an optimal outcome.

KEYWORDS

dental implant, esthetic zone, immediate dental implant, immediate loading, provisional
restoration

1 | I N T RO D UC T I O N
Anterior implant restorations are probably one of the most challenging
procedures in implant dentistry. Critical analysis of the smile, the type of
load and provisional restoration material to be used, and patient's expec-
tations are some of the essential issues to take in account. In addition,
predictable success requires a complete presurgical planning regarding
the type of restoration needed and the space it will require. Several pro-
soft tissue contour. Besides, use of patient's own teeth can further
provide a comfortably transition to definitive restorations. One of
the main complications on anterior implants is mucosal recession; to
reduce the risk of this complication, literature suggest keeping facial
bone intact in cases with a medium to thick tissue biotype.2 Regard-
ing provisional and definitive implant-supported restorations, the
gold standard, concerning abutment shape, remains the one with a
divergent profile to establish an emergence profile similar to a natu-

cedures options had been identified to reach the predictability of the ral tooth3; the use of natural teeth could be the better way to use as

esthetic outcome. These procedures include: the implant position,
the communication of the optimal implant position using templates, and
the use of implant-supported provisional prostheses.1 Young patients
who lose one or multiple teeth in the esthetic zone may have a psycho-
logical and social negative impact. However, the placement of dental
implants into a fresh extraction socket followed by an immediate provi-
sional restoration supported by the implant can help to solve this dis-
comforting experience, functionally and esthetically, maintaining the
provisional in terms of morphology to obtain an ideal emergence
profile, as has been described by Margeas, in 2006.4
2 | CLINICAL REPORT
A 21-year-old female patient was clinically evaluated and presented
mobility of the upper central incisors and the left-lateral incisor and
were diagnosed with severe external root resorption due to a long

J Esthet Restor Dent. 2019;1–4. wileyonlinelibrary.com/journal/jerd © 2019 Wiley Periodicals, Inc. 1

2 LADINO AND ROSSELLI
FIGURE 1 Initial view (A). Frontal view (B). Periapical radiographic of patient
history of orthodontics, the long-term endodontic prognoses was not
favorable; the teeth were indicated for extraction (Figure 1). Cone
beam computed tomography revealed the presence of good buccal
plate, the treatment was plan consisted of the immediate implant
placement and immediate provisionalization for the central incisors
and left-lateral incisor using her own natural teeth. The procedures for
all the three teeth were performed in a single visit seeking to maintain
the integrity of interproximal bone as well as the soft tissue contour.
After local anesthesia, central incisors and left-lateral incisor were
drilled at the palatal surface with a cylindrical drill to use the teeth as
a surgical guide (Figure 2).
The two initial drills from the protocol were used to prepare the
implant bed and the teeth were removed with extraction forceps
(Figure 3). The integrity of the buccal wall was verified. Three implants
were placed at central incisors sites and left-lateral incisor site, respec-
tively. The implants were placed toward the palatal wall of the extrac-
tion sockets to a depth of 3 mm from the free gingival margin.
A minimum torque value of 35 Ncm upon implant placement was con-
firmed prior to immediate provisionalization. A screw-retained provi-
sional abutment was placed onto the implants (Figure 4A). The natural
crowns were cleaned, treated, and connected to the temporary abut-
ment with resin composite resin intraorally with an aid of a position
index (Figure 4B). Then, the connected provisional restoration was
removed from the implant and composite resins were smoothed and
used to contour the subgingival portion to capture the cervical gingi-
val emergence of the extracted teeth given the importance of subgin-
gival contour which supported the peri-implant tissue in anterior
zone (Figure 5). The interface between teeth and composite was
extremely polished forming a smooth surface to reduce the risk of
FIGURE 2 Initial drill protocol (A), 2.0 mm pilot drill (B) occlusal view of access holes
peri-implantitis which represents a heterogeneous mixed infection
that includes colonization of periodontopathic microorganisms.5
Esthetics, phonetics, and fit were confirmed. After shade match-
ing with composite resin, the provisional restorations were polished
and inserted in the patient's mouth. Finally, the occlusal scheme was
refined and verified intraorally. Provisional crowns were screwed to
15 Ncm of torque, and palatal access hole was sealed with resin com-
posite. One week after surgery, the soft tissue was assessed identify-
ing healthy surrounding peri-implant tissue (Figure 6).
In the follow-up examination after 6 months, the provisional teeth
were removed, and healing evaluated; oral hygiene was verified to be
excellent, without any complaints in terms of occlusion, mastication,
or esthetics. An adequate emergence profile and dimensions of papil-
lae were obtained with provisional restoration (Figure 7). At the radio-
graphic evaluation, a peri-implant marginal bone level loss was 1 mm.
In the absence of functional and esthetic problems, definitive indivi-
dual restorations were manufactured (Figure 8).
3 | DI SCU SSION
External apical root resorption is an undesirable side effect associated
with orthodontically induced tooth movement. Root shortening
results from a combination of biological activities in the region of the
periodontal ligament, which will interact with force exerted during
orthodontic treatment. Factors such as shape of teeth roots, patient's
age at orthodontic treatment onset, treatment time, as well as ortho-
dontic mechanics and magnitude of force have been reported as
significant for the occurrence of external apical root resorption.6
LADINO AND ROSSELLI 3

FIGURE 3 Extracted anterior teeth. A, Fresh sockets; B, extracted crowns

FIGURE 4 Positioning provisional restorations. A, Temporary plastic abutments with natural crowns; B, silicon matrix to position guide

FIGURE 5 Postoperative view. A, Frontal view of Immediate provisional restoration. B, Maxillary occlusal view of screw-retained provisional
restoration. C, Radiographic view of implant position

Achieving soft tissue as well as previous restorations esthetics is Currently, different materials like: acrylic polymethyl methacrylate,
quite a challenge in implant dentistry. Immediate implant placement is resin composites and more recently bis-acrylate resins are commonly
the treatment of choice in a flapless procedure of sites with specific ana- used to manufacture provisional crowns and fixed partial dentures for
tomical conditions such as an intact facial bone wall with a thick wall
phenotype and a thick gingival biotype.7 This approach offers a low mor-
bidity and the possibility to receive an immediate provisional restoration
the same day of extraction.8 Drilling through existing teeth might lead to
possible infectious complications; which did not occur in this patient.
Immediate or delayed provisional restorations are a tool used for
arranging irregular occlusal plans, increasing vertical dimension, and
contour soft tissue,9–11 features required to improve the patient's
conditions and achieve the final esthetic and functional outcomes.

FIGURE 6 One week after surgery FIGURE 7 View of papillae 6 months after surgery
4 LADINO AND ROSSELLI
FIGURE 8 Final restorations. A, Intraoral frontal view. B, Periapical
radiography
the oral cavity. One of the factors that influence the microbial adhe-
sion to materials is the composition of the materials, which determines
the surface roughness.12 The use of nanotechnology resin composite
in combination with natural tooth structure offers an option of a very
smooth surface that prevents the microbial adhesion and could be
a very useful tool in immediate provisionalization stage. In addition,
nonsplinted restorations allow flossing and easier interproximal
hygiene preventing microbial adhesion and improving esthetics by
offering better emergence profile.13
The provisional restoration can be screw-retained or cement
retained. When provisional restoration is cemented there is a higher
risk of gingival inflammation at the abutment-cement-restoration
interface, as well as cement debonding.14 In this clinical report, screw-
retained restorations were selected to improve the soft tissue contour
according to Wittneben et al they described as ideally, that implants
must be placed in a position with the access hole of the planned
crown below the planned incisal edge to facilitate screw retention; in
addition, to avoid the problems associated with residual cement and
benefit from the technical and biological complications exhibit by
screw retained prostheses.15
4 | CO NC LUSIO N
The use of healthy natural teeth that have been recently extracted
due to an immediate implant placement is an alternative to be used
as a provisional restoration to achieve an optimal tissue contour and
improve the conditions of the final rehabilitation. Natural teeth
anatomy could help to maintain soft tissue architecture after extrac-
tions reaching good esthetic outcomes.
CONFLIC T OF INT E RE ST
The authors do not have any financial interest in the companies
whose materials are included in this article.
ORCID
Diego Rosselli https://orcid.org/0000-0003-0960-9480
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How to cite this article: Ladino LG, Rosselli D. Use of
extracted anterior teeth as provisional restorations and surgi-
cal guide for immediate multiple implant placement: A clinical
case report. J Esthet Restor Dent. 2019;1–4. https://doi.org/
10.1111/jerd.12466