Received: 14 December 2023 Revised: 8 January 2024 Accepted: 9 January 2024

DOI: 10.1111/jerd.13197

CLINICAL ARTICLE

Timing implant provisionalization: Decision-making and

systematic workflow

Jonathan Esquivel DDS 1 | Ramon Gomez Meda DDS 2 | Milko Villarroel DDS, PhD 3

1
Adjunct Associate Professor, Department of
Prosthodontics, Louisiana State University
School of Dentistry, New Orleans,
Louisiana, USA
2
Adjunct Assistant Professor, Department of
Prosthodontics, Louisiana State University
School of Dentistry, New Orleans,
Louisiana, USA
3
Private Practice Prosthodontist, Curitiba,
Brazil
Correspondence
Jonathan Esquivel, 609 Metairie Rd #8106.
Metairie, LA 70005, USA.
Email: jesquiveldds@gmail.com
Abstract
Objective: Provisionalization is an important step to achieve esthetic results in
implant cases, and many different techniques for provisional restoration fabrication
have been described. However, depending on the clinical scenario, the provisionaliza-
tion strategy will require different approaches and timing. The clinician should modify
the provisional restorations efficiently to reduce the number of disconnections from
the implant, as repeated disconnections may have biological consequences. This arti-
cle aims to schematize different scenarios requiring implant provisionalization and
propose strategies to help the clinician condition the peri-implant tissues, respecting
perio-prosthodontic fundamentals for soft tissue, biological, and esthetic stability.
Clinical Considerations: The clinical outcomes of modern implant therapy aim to
achieve results that emulate natural dentition. Different scenarios may require
adjunct therapy, including hard- and soft-tissue grafting, which complicates treat-
ment. The provisionalization strategy will vary depending on the initial condition of
the tissues, the need for reconstructive procedures, and the timing of implant place-
ment. Selecting the right strategy based on the case type is necessary to reduce
treatment time and complications associated with inadequate prosthetic handling of
the soft tissues.
Clinical Significance: Proper emergence profile conditioning through provisional res-
torations will allow for biologically sound and esthetically pleasing outcomes in
implant restorations.

KEYWORDS
dental implants, emergence profile, esthetic dentistry, implant dentistry, provisional restorations

1 | I N T RO DU CT I O N the esthetic biological contour (EBC) concept for designing emergence

The complexity of achieving esthetically pleasing and biologically sta-
ble implant-supported restorations varies depending on factors such
as the implant position, the quality and quantity of hard and soft tis-
sues available, and the initial condition of the case. These factors
directly impact abutment design, material selection, and the esthetic
result.1–3 Proper tissue conditioning is essential for successful results
in implant therapy. The critical and subcritical zones of the emergence
profile and their manipulation for conditioning immediate implant sites
and healed ridges have been described.4,5 Another article introduced
profiles. It described three zones focusing on the biological aspects of
the peri-implant tissues and ideal abutment design based on implant
and tissue characteristics.6 Many techniques for conditioning peri-
implant tissues have been proposed. However, most techniques
involve arbitrary modifications to the provisional restorations, and
only a few have described approaches to reduce arbitrary changes,
but they are time-consuming.7–12 Conditioning of the soft-tissue con-
tours must be done efficiently to prevent excessive disconnections of
the implant abutment interphase and the consequences associated
with this.13,14 A systematic approach is needed to select and time the

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2 ESQUIVEL ET AL.

provisionalization method in various scenarios, including sites that the peri-implant tissues' esthetic and biological stability, which should
received reconstructive procedures like hard- and soft-tissue grafting. be considered in the provisional and definitive restorative designs
This article aims to schematize different scenarios requiring implant (Figure 1).
provisionalization and propose strategies to help the clinician select
the proper approach and staging to condition the peri-implant tissues,
respecting perio-prosthodontic fundamentals for soft-tissue stability. 2.1 | Space

Soft tissues around dental implant restorations require enough space

2 | PERIO-PROSTHODONTIC
FUNDAMENTALS FOR TISSUE
C O N D I T I O N I NG A N D S T A B I L I T Y
Peri-implant soft tissues behave differently from dentogingival tissues
because of the absence of a periodontal ligament, the different
arrangement of the collagen fibers, the lack of stimulus from a tooth,
and the lack of a strong seal between the tissues and the prosthetic
components.15–17 These, alongside implant-related factors such as the
implant's three-dimensional (3D) position and inadequate prosthetic
design, may lead to complications. Space, volume, and time are funda-
mental and interdependent perio-prosthodontic considerations for
to mature, organize properly, and creep as the healing process
occurs.18 The prosthetic design, material selection, and the implant's
3D position are responsible for providing this space
(Figure 2).1,3,5,6,19–21 Invading biologic spaces through convex or
overcontoured restorations is associated with a higher incidence of
soft-tissue recession. On the other hand, concave prosthetic designs
provide room for proper arrangement and support of the tissues,
reduce epithelial down-growth, and promote margin stability or coro-
nal displacement of the tissues.22–27 A study reported tissue creeping
on implant-supported restorations' buccal and interproximal surfaces
with a sub-contoured cervical third.27 Subcontoured areas have also
been recommended on pontic designs to promote coronal tissue

F I G U R E 1 Perio-prosthodontic
fundamentals: space, volume, and
time are interdependent with each
other to maintain biological and
esthetic tissue stability.

F I G U R E 2 Examples of the relationship between space and volume in the peri-implant environment. (A) Ideal implant placement and
prosthetic design provide the space for proper tissue volume. (B) Ideal implant placement and prosthetic design, but inadequate tissue volume
may lead to collapse. (C) Excessive prosthetic contour invades the space for soft tissues, limits creeping and may lead to gingival recession. (D). A
facially placed implant and flat emergence profile restrict the space for proper tissue volume and, consequently, lead to gingival recession.

ESQUIVEL ET AL.
displacement.28 However, tissues will only move into these spaces if
their volume is adequate or surgically augmented.
2.2 | Volume
Following an extraction, the bone and soft tissues undergo negative
dimensional changes; their ability to withstand them is related to their
phenotype.29,30 Thick bone phenotypes tend to maintain tissue stabil-
ity after extraction. In contrast, thin bone phenotypes are associated
with excessive buccal plate loss and an average vertical soft-tissue
loss of 1.6 mm.31,32 Adequate tissue volume promotes stable tissue-
restorative interphases as sites with thickened phenotypes have
higher gingival margin and crestal bone stability.2,33–36 Multiple
authors have reported soft-tissue creeping up to 0.8 mm after con-
nective tissue grafts (CTG) or free gingival grafts for root
coverage.37–43 This phenomenon has also been reported on implant
restorations.27,44–47 One article reported that cases that received a
CTG simultaneous to immediate implant placement exhibited volume
gain at 6 months compared to ungrafted sites, which exhibited shrink-
age.48 Also, a consensus statement concluded that implant restora-
tions that received CTGs had stable or increased tissue thickness and
keratinized gingiva width, stable margin position and improved
esthetics from 1 to 5 years.49 Appropriately timing tissue conditioning
after grafting is critical to achieving esthetic results.
2.3 | Time
After surgery, epithelial healing takes 1–2 weeks, collagen fiber orga-
nization 4–6 weeks, and epithelium and connective tissue maturation
6–8 weeks.50,51 Dimensional changes in the peri-implant tissues may
happen during or after the healing process. The buccal bone width,
implant staging, and dehiscences, among others, can alter bone and
52
tissue stability. A systematic review reported hard- and soft-tissue
dimensional changes, ranging from 0.1 to 6.1 mm horizontally and
0.9 mm to +0.4 mm vertically at 12 months, with most changes
happening during the first 3–6 months.53 Therefore, allowing tissues
to mature before modifying them is essential.47,54 Timing before pros-
thetic conditioning will vary depending on the surgical treatment.
Sites that received CTGs will require 2 months of healing before pros-
thetic manipulation. However, sites that also received bone augmen-
tation may require more time. Soft tissues require time to mature and
creep into the space provided by the provisional restorations. Inter-
proximal tissue creeping has been reported up to 1.5 years after res-
toration delivery.27,47 If the restorative process is accelerated, tissues
may not be fully mature, and embrasure and cervical spaces may be
erroneously filled with ceramics, altering the restoration's anatomy,
and limiting coronal tissue displacement. Long-term implant provi-
sional restorations for 6–12 months may be a good option,
especially in cases with extensive reconstructions, implant-supported
FP-1 restorations, or patients with high smile lines to allow dimen-
sional changes before delivering the final restorations.
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3
3 | I M P L A N T TH E R A P Y S C E N A R I O S
Depending on the initial condition of the implant site, the treatment
objective may be maintaining the existing tissue outlines or reestab-
lishing the site's contour through grafting procedures. Thus, these pro-
cedures can be divided into two groups: margin preservation
therapies (MPT) and margin reestablishment therapies (MRT).
MPT scenarios involve nonrestorable teeth with ideal tissue
dimensions and gingival outlines. This therapy aims to maintain the
existing gingival architecture through ideal provisional restorations.
However, cases with ideal tissue outline that have thin phenotypes or
bone dehiscences' should be classified and treated as MRTs, as margin
repositioning is needed after treating the deficiencies.
Contrary to MPT cases, most MRT scenarios have gingival
outlines apical to the ideal position. MRTs include recessions on
existing implants, cases with thin phenotypes, dehiscences, or
resorbed ridges. Sites with ridge defects, especially those requir-
ing vertical and horizontal reconstruction, are the most challenging
as they have lost tissue architecture and occasionally have proxi-
mal bone defects. Their treatment may involve soft-tissue grafting,
bone grafting, or both. Orthodontic therapy on neighboring teeth
may be advised in cases with proximal bone defects.54–59 The pro-
visionalization strategy varies depending on the adjunct therapy
done, and it is essential to prevent complications and increase
predictability.
4 | T Y P E S OF P R O V I S I O N A L I Z A T I O N
Tissues can be conditioned with two provisionalization approaches:
Full contour provisionalization (FP) or sub-contoured provisionaliza-
tion (SP). The difference between them is the relationship of their
esthetic (E), bounded (B), and crestal (C) zones with the underlying tis-
sues, which may promote apical, coronal, or no displacement of the
tissues.6 The selection of the provisionalization approach will depend
on the clinical scenario.
4.1 | Type 1: Full-contour provisionals
FPs have the ideal size and shape and have the final restorative Zenith
point established. FPs can be active or passive according to the rela-
tion of their E-zone with the underlying soft tissues.
Passive FPs are only used in favorable situations. Their E-zone is
set at the level of the ideal zenith point of the restoration but does
not exert pressure on the underlying tissues. Its main goal is to sup-
port the existing gingival architecture, emulating the preexisting or
contralateral teeth (Figure 3A).
Active FPs, on the other hand, aim to reestablish the ideal gingi-
val architecture on coronally positioned tissues. The provisionals'
E-zone is set at the level of the ideal zenith point of the restoration
and exerts pressure on the gingival margin to displace it apically
(Figure 3B).
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4 ESQUIVEL ET AL.

F I G U R E 3 Types of provisional restorations and their behavior with underlying tissues: (A) On passive full-contour provisionals (FPs), the
ideally set esthetic (E) zone and zenith of the provisional do not exert pressure on the soft tissues and maintain the position of the soft tissue
contours. (B) On active FPs, the ideally set esthetic (E) zone and zenith of the provisional exert pressure on the coronally positioned soft tissue to
promote apical displacement. (C) On sub-contoured provisionals, the esthetic (E) zone and zenith of the provisional are 2 mm coronal to the ideal
position to allow space for soft tissue grafting and creeping.

FIGURE 4 Flowchart for selecting the provisionalization strategy and timing based the initial clinical scenario.

4.2 | Type 2: Sub-contoured provisionals
SPs are passive as their zenith and E-zone are set 2 mm coronal to the
ideal position to allow space for tissue grafting and creeping
(Figure 3C). Even though the average tissue creeping reported is
0.8 mm, a space of 2 mm is recommended to allow for the maximum
potential of coronal displacement of the grafted soft tissue, which is
related to the quality and size of the graft.
Regardless of the provisionalization strategy, the provisional's
B-zone should be as concave as possible. However, this will be
affected by the implant's 3D position and the soft-tissue volume.3,6
The C-zone should be slim to promote space for the supracrestal
connective tissues, but the mechanical requirements of the restorative
material used may condition the restoration's dimension in this
area.3,6,19
5 | PROVISIONALIZATION STRATEGIES
FO R D I F F E R E N T S C E N A R I O S
The different clinical scenarios require specific or combined provisio-
nalization approaches to achieve esthetic results and prevent compli-
cations. Proper timing to modify the strategy is critical if needed
during tissue conditioning (Figure 4).
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ESQUIVEL ET AL. 5

F I G U R E 5 Margin preservation therapy scenario: (A) Nonrestorable maxillary left central incisor with thick phenotype and ideal tissue
outlines. (B) Temporary abutment seated over an adequately placed dental implant. (C) Crown of the preexisting tooth was used for the
provisional restoration and picked up intraorally with an omni-vacuum form matrix to ensure its correct position. (D) Bounded (B) and crestal
(C) zones of the emergence profile in the full-contour provisional (FP) restoration designed with flowable composite. (E) Lateral view of full-
contour provisional (FP) restoration's emergence profile. (F) Tissue maturing into the FP restoration. (G) Natural emergence of the FP restoration
from the tissues. (H) Provisional restoration removed for delivery of the final prosthesis. (I) Intraoral view of the final restoration with a high
esthetic outcome.

5.1 | Margin preservation therapy
Since MPT cases have ideal tissue outlines, thick phenotypes and do
not need a CTG during immediate implant placement, their provisio-
nalization strategy involves a passive FP to maintain the existing tis-
sue contours. These scenarios are the most favorable as the final
restorative outlines are designed in the immediate FP and replicated
in the final prosthesis, limiting the number of disconnections, and pro-
moting tissue stability.
1. Immediate implant sites with apically positioned gingival margins.
2. Immediate implant sites with ideal tissue contours and a thin
phenotype.
3. Cases presenting bone dehiscence with mild or no recession
present.
4. Sites where preextraction orthodontic extrusion was done to over-
compensate tissues vertically and a CTG is needed to enhance tis-
sue thickness.
5. Existing dental implant restorations with mild recessions.

However, on existing dental implants with a significant recession

5.2 | Margin reestablishment therapy
The provisionalization strategy on MRT cases will depend on the ini-
tial condition of the surrounding tissues.58,59 Generally, anytime tis-
sues are apical to the ideal position, or there is the need for grafting
due to thin phenotypes or dehiscences, the case will be treated as a
MRT, and a SP restoration will be delivered to allow space for the
grafted tissues.40 The SP will be transitioned into an active FP when
the tissues mature approximately 2 months after grafting and/or
osseointegration.
Scenarios that can be treated with this approach include:
and interproximal bone deficiency, the removal of the restoration,
delivery of a cover screw or narrow healing abutment, a CTG, and
orthodontics on neighboring teeth may be advised.41,55–57
In situations with bone defects, the ridge contours and gingival
architecture have been lost, and more extensive bone grafting, soft-
tissue grafting, or both are required. In healed sites with mild defects
(Class I) where the implant is placed and provisionalized with a SP
simultaneous to the reconstructive procedure, the transition to a FP
will start after the osseointegration of the implant.60 However, if the
defect is more extensive (Class II), and the implant placement and
grafting are done simultaneously, transitioning from a SP to a FP may
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6 ESQUIVEL ET AL.

be delayed up to 6 months after the reconstruction. If the defect is
severe (Class III), it will require alternative provisionalization means
like Maryland bridges or omni-vacuum forms. These scenarios are the
most complex, and the FP approach may be delayed up to 6–
12 months after the reconstructive procedure and implant placement.
Transitioning a SP to a FP to establish the definitive restorative
zenith point can be done gradually by adding composite resin to
the E-zone of the SP in situations with deficient papillae or done in
a single-stage in cases with ideal interproximal tissue volume. Gin-
givoplasty may be used to speed up the adaptation of the tissues to
FPs if excessive tissue is present. A single-stage transition can be
done digitally by fabricating a new provisional with ideal contours
through computer-aided design and computer-aided manufacturing
(CAD-CAM) technology. In very favorable scenarios
(e.g., premolars), a direct transition from an SP to a full-contour
final restoration can be done to reduce time, cost, morbidity, and
disconnections.
6.1 | Clinical scenario A
This MPT scenario presents a fractured maxillary left central incisor with
an ideal gingival outline and a thick phenotype (Figure 5A). A minimally
invasive extraction and immediate implant placement were done. The
crown of the preexisting tooth was used to fabricate a passive FP resto-
ration, which was picked-up intraorally with the help of an omni-vacuum
form matrix to ensure correct position (Figure 5B,C). The B and C zones
of the provisional were designed with flowable composite and polished
before delivery (Figure 5D,E). The natural tooth's outline was used to
maintain the soft-tissue contour, this is an advantage, as no modifications
to the provisional were made after delivery. When the tissues matured
and the implant integrated, a final impression was made (Figure 5F,G).
Only one disconnection was done before the delivery appointment of
the final restoration (Figure 5H). The provisional restoration's contour
was replicated in the final prosthesis, ensuring the existing gingival mar-
gin position and a proper esthetic balance (Figure 5I).

6 | CLINICAL SCENARIOS 6.2 | Clinical scenario B

The following clinical scenarios illustrate different provisionalization This MRT scenario presents an osseointegrated dental implant with
approaches and timing based on their initial condition. a mild gingival recession. After analyzing the tissues and

F I G U R E 6 Margin reestablishment therapy scenario depicting the importance of space, volume, and time for soft tissues: (A) Sub-contoured
provisional (SP) restoration with the zenith point and E-zone 2 mm coronal to the ideal position to create space for a connective tissue graft
(CTG). (B) Lateral view of highly SP restoration. (C) Lateral view of the soft tissue volume gained through a CTG, where the vertical deficiency is
still noticeable. (D) Soft tissue creeping into the space created in the provisional restoration. (E) SP transitioned into a full-contour provisional (FP).
(F) Intraoral view of the FP to condition the soft tissues. (G) Tissues maturing into the FP restoration. (H) Final layered zirconia screw-retained
restoration with ideal contours. (I) Intraoral view of the final restoration delivered with an esthetic outcome.
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ESQUIVEL ET AL. 7

F I G U R E 7 Margin reestablishment therapy scenario: (A) Seibert Class III defect, which required bone and soft tissue grafting. (B) An omni-
vacuum form used as a provisional restoration after extensive bone and soft tissue grafting to avoid pressure on the surgically reconstructed site.
(C) Scan bodies used to capture a digital impression of the osseointegrated dental implants to fabricate provisional restorations. (D) First, set of
milled active full-contour provisional (FP) restorations exerting pressure on the tissues. (E) Second, set of milled FP restorations to finish tissue
conditioning. (F) Computer-aided design of the substructure for a definitive fixed dental prosthesis (FDP). (G) 4-unit implant-supported FDP try-
in, emergence profiles, and E-zones evaluated. (H) A harmonious tissue scalloping achieved by allowing properly reconstructed tissues to mature
around long-term FP restorations. (I) Final restorations delivered with a proper esthetic result achieved.

neighboring structures, a 2 mm SP restoration was delivered to cre-
ate space for a soft-tissue graft (Figure 6A,B). After the CTG, the
thickness of the tissue significantly improved; however, there was
still a considerable subcontoured area in the provisional that
needed to be filled with soft tissue (Figure 6C). The tissue was
allowed to creep into this space for several months (Figure 6D).
Once the vertical position of the tissue was achieved, the SP was
transitioned to a FP by modifying the E-zone with composite resin
(Figure 6E), and the tissue was left to mature (Figure 6F,G). Minor
movement was also done on the maxillary left lateral incisor
through a removable appliance to enhance the outcome before the
final impression. A customized final impression was then made, and
the final restoration was fabricated and delivered (Figure 6H,I).
and a digital impression using scan bodies was made 3 months later to
fabricate a provisional restoration (Figure 7C). An active 4-unit milled
polymethyl methacrylate FP restoration over transmucosal abutments
was fabricated and delivered to displace and condition the tissue out-
lines apically (Figure 7D). After 2 months, a second set of implant-
supported provisionals was delivered and left for 9 months
(Figure 7E). In the meantime, neighboring teeth and implants on the
opposing arch were prepared and provisionalized. Final impressions
were made, and the emergence profiles designed on the provisional
restorations were replicated in the final prosthesis (Figure 7F,G). The
final restoration's E-zone and emergence profiles were checked
(Figure 7H), and the implant-supported layered zirconia 4-unit FDP
was delivered, exhibiting proper tissue outlines and esthetics
(Figure 7I).

6.3 | Clinical scenario C

This case is an MRT scenario exhibiting a Seibert Class III defect,
which required osseous and tissue reconstruction before implant
placement (Figure 7A). The case was provisionalized with an omni-
vacuum form to prevent pressure on the grafted tissues (Figure 7B).
Dental implants were placed 6 months after the grafting procedures,
7 | DI SCU SSION
Provisionalization strategies for implant-supported restorations will
vary according to different clinical situations. The initial condition of
the implant site plays a key role in the decision-making process. A
MPT must be followed if the implant site has a tooth with adequate

8 ESQUIVEL ET AL.
soft-tissue contours and a thick phenotype. If the existing gingival
margins are apical to the ideal position, or there is soft-tissue or bone
deficiencies an MRT and its provisionalization strategy are indicated.
The timing in these cases will vary depending on the need for osse-
ous and soft-tissue reconstruction to allow for implant placement
and final esthetics. Bone and tissue reconstruction or orthodontic
therapy are frequently needed to reestablish adequate contours.
After the overcorrection of the site to guarantee an excess tissue
volume, the amount of apical margin displacement to achieve ideal
contours may require multiple appointments. In the past, many tech-
niques describing the provisional restoration design for soft-tissue
manipulation have been proposed.4–12 Manipulating the position of
the gingival outline can be complex regardless of the technique used,
and an inadequate design of the EBC zones in the provisional will
lead to additional disconnections. Deficient restorative contours and
excessive disconnections may lead to epithelial downgrowth and
peri-implant bone and soft-tissue alterations.13,14,22 However, a lim-
ited number of disconnections may not cause significant changes in
the peri-implant environment.61,62 Therefore, implementing accurate
techniques that reduce the number of implant disconnections are
essential. Digital technology has helped optimize the provisionaliza-
tion workflow. Connecting technological advances to important
perio-prosthetic principles such as space, volume, and time when
designing prostheses and selecting the adequate provisionalization
strategy for each clinical scenario will produce more stable biological
and esthetic results.
8 | C O N CL U S I O N S
• Space, volume, and time must be respected when planning and
delivering implant-supported restorations to optimize outcomes
and promote the longevity of the restorations.
• Different clinical scenarios will demand specific provisionalization
strategies, selecting the ideal approach and timing the modifica-
tions of provisionals adequately is essential.
• Reducing the number of appointments and implant disconnections
will reduce complications; for this reason, understanding tissue
conditioning and implementing proper workflows to achieve ideal
tissue outlines is critical.
CONF LICT OF IN TE RE ST ST AT E MENT
The authors have no conflicts of interest to declare relevant to this
article.
DATA AVAI LAB ILITY S TATEMENT
Data sharing is not applicable to this article as no new data were cre-
ated or analyzed in this study.
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How to cite this article: Esquivel J, Gomez Meda R,
Villarroel M. Timing implant provisionalization: Decision-
making and systematic workflow. J Esthet Restor Dent. 2024;
1‐10. doi:10.1111/jerd.13197