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C D A

O N V E N T I O N

Diagnostic Provisional Restorations in

Restorative Dentistry: The Blueprint for Success

Terry E. Donovan, DDS

George C. Cho, DDS
J

famous prosthodontist once wrote, When esthetics is

the prime motivating factor in any restorative procedure, the restoration will assuredly fail.1 While it is
difficult to take issue with the intent of these words, it is certain that a significant number of elective restorative dental
services are primarily esthetically driven. It is also certain that
even when restorations are placed primarily for functional reasons, it is critical to address the patients esthetic concerns.
In the authors experience, the restorative dentist must
clearly understand the esthetic expectations of the patient, and
the patient must understand the inherent limitations of any
type of restorative therapy. One often neglected modality at
the clinicians disposal to aid in communication between the
dentist and patient is the provisional restoration. These
restorations can often be used before any irreversible treatment
to preview potential esthetic outcomes and discover the limitations of specific restorative therapies. In other situations,
provisional restorations can be placed and readily modified
after tooth preparation but before fabrication of the definitive
restoration. In these cases, the provisional can be modified
until the patient is satisfied, and then the modified provisional restoration serves as the blueprint for the technician fabricating the definitive restoration.2,3
This article discusses and illustrates how provisional
restorations can be used diagnostically to meet the patients
esthetic expectations before the definitive restorations are fabricated. Techniques for transferring this critical information to
the laboratory technician are also described.

Materials and Methods

Many materials and techniques can be used when fabricating provisional restorations. It is beyond the scope of this article to discuss these material and procedures. The technique
generally followed by the authors is the indirect technique that
has been adequately described in the literature.4-7 The material of choice for such restorations is poly (methyl-methacrylate)
(Jet Acrylic Resin, Lang Dental Manf. Co., Chicago, IL),
which is cured in a pressure pot (Acri-Dense III, GC Dental,
Scottsdale, AZ). Research has demonstrated that indirect provisional restorations are stronger and denser and have better
marginal integrity than direct provisional restorations.8-11 In
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addition, when the indirect technique is used, the prepared

tooth is not exposed to the exothermic reaction inherent with
acrylic resin materials. Research has shown that sufficient heat
is generated during the setting reaction to potentially result in
irreversible pulpal damage.12-15
Numerous contemporary materials are available for fabricating acceptable provisional restorations with the direct technique (e.g., Iso-Temp, 3M Dental, St. Paul, MN; Temp-Phase,
Kerr Corporation, Orange, CA). Many of these materials have
multi-phasic setting reactions and are readily trimmed during
a rubbery phase. These types of materials generally are used
with conformative dentistry where significant changes in size,
shape and general morphology of the teeth are not being considered. While these materials can certainly be very useful in
certain aspects of clinical dentistry, they are inferior to the poly
(methyl-methacrylate) materials for long-term diagnostic and
esthetic provisional restorations.
The following basic approach is used when considering
placement of esthetic restorations.
1. A thorough clinical and radiographic examination is completed along with a comprehensive medical and dental history.
2. The patients chief complaint and esthetic expectations are
determined during a detailed initial interview.
3. Impressions are made with irreversible hydrocolloid and the
diagnostic casts mounted in an appropriate articulator using a
facebow and an interocclusal record made in centric relation.
4. If indicated, a diagnostic wax-up is completed, and an
impression of the wax-up is made with irreversible
hydrocolloid. A cast of the wax-up is recovered from the
impression.
5. Provisional restorations are fabricated using matrices from the
cast to determine the morphology of the restorations. These
provisional restorations are previewed in the patients mouth
and are adjusted to provide optimum lip support and the
desired length, shape, colour and overall esthetic appearance.
They are tested for phonetics using fricative and sibilant
sounds, and finally are evaluated for comfort and function.
Journal of the Canadian Dental Association

Diagnostic Provisional Restorations in Restorative Dentistry: The Blueprint for Success

Fig. 1: This patient wanted the maxillary central incisors lengthened

for esthetic reasons.

Fig. 2: Acrylic resin shells were fabricated from a cast of the

diagnostic wax-up. They will be used to evaluate the length of the
central incisors.

Fig. 3: The acrylic resin shells have been placed on the incisors before
tooth preparation. After they have been adjusted for proper length, they
aid in evaluating the optimum length for the lateral incisors. These will
be lengthened with direct composite resin bonding.

Fig. 4: The maxillary central incisors have been prepared for porcelain
laminate veneers; the shells have been relined and will serve as
provisional restorations. The lateral incisors have been lengthened
with direct composite resin.

Fig. 5: The porcelain laminate veneers have been luted to place. Note
the excellent soft tissue response and the harmonious length relations
of the central and lateral incisors and the canines.

Fig. 6: This patient presented with a 6-unit fixed partial denture with
gingival recession around the crowns on the abutment teeth.

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Donovan, Cho

Fig. 7: The diagnostic wax-up deliberately created minor tooth

rotations and different incisal edge positions in the hopes of creating
a more natural appearance.

Fig. 8: This provisional restoration was made from a cast of the

diagnostic wax-up illustrated in Fig. 7.

Fig. 9: This provisional restoration was made from a cast of the new
diagnostic wax-up after trying in the original provisional restoration,
which was unacceptable to the patient. The patient approved the
esthetic result provided by the new provisional restoration, and the
definitive restorations could be fabricated with confidence.

Fig. 10: The definitive restorations for the patient illustrated in Fig. 9
are very similar to the approved provisional restorations.

6. When the patients esthetic and functional demands are satisfied, an impression is made of the acceptable provisional
restorations and the recovered cast is sent to the laboratory
to be used as a guide for the definitive restoration.

Patient No. 1

In certain clinical situations the provisional restorations can

be used to indicate the final results without preparing the
teeth. If the patients esthetic demands cannot be met, neither
the dentist nor the patient is committed to irreversible treatment. In other situations, the teeth must be prepared before
fabricating the provisional restorations, which commits the
patient to restoration. Nonetheless, it is always much easier to
modify and alter acrylic resin restorations than to modify
definitive restorations fabricated with metal, ceramic or
metal-ceramic materials.
The following narratives and illustrations demonstrate the
utility and flexibility of this approach.
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This patient presented with moderate wear on the maxillary anterior incisor teeth (Fig. 1). He sought care primarily
because he wanted to lengthen the central incisors for esthetic
reasons. A diagnostic wax-up was completed on mounted
casts, an impression was made of the wax-up, and a gypsum
cast was recovered from the impression. Acrylic resin shells
were made to try in the mouth (Fig. 2). When the shells were
adjusted to the length preferred by the patient, it became
apparent that the lateral incisors would need to be lengthened
slightly to harmonize the appearance of the maxillary anterior
teeth (Fig. 3). It was decided that the lateral incisors would be
lengthened with direct bonded composite resin (Herculite
XRV, Kerr Corporation, Orange, CA). The central incisors
were prepared for porcelain laminate veneer restorations, and
the lateral incisors were restored with direct composite resin.
Journal of the Canadian Dental Association

Diagnostic Provisional Restorations in Restorative Dentistry: The Blueprint for Success

The acrylic resin shells were then relined and luted to the central incisors as provisional restorations (Fig. 4).
One week later the porcelain laminate veneers were luted to
the central incisors using a light curing composite resin luting
agent (Opal Luting Composite, 3M Dental, St. Paul, MN).
Figure 5 illustrates the completed restorations, with direct composite resin bonded to the incisal edges of the lateral incisors
and porcelain laminate veneers on the central incisors. The key
to predictability in this case was that the optimum length of the
central incisors was determined in the patients mouth using the
acrylic resin shells. The shells were then used to help determine
the length of the directly bonded lateral incisors, and the cast of
the provisional restorations was used to guide the laboratory
technician in fabricating the porcelain laminate veneers.

Patient No. 2
This patient presented with a fixed partial denture from the
maxillary left canine to the right canine, with pontics replacing the two central incisors and the left lateral incisor. Gingival recession had occurred on all the abutment restorations,
exposing the cervical margins of the abutment crowns. In addition to the esthetic deficiencies resulting from the recession,
the incisal edges of the anterior teeth formed a relatively
straight line, which resulted in a rather artificial appearance
(Fig. 6). Diagnostic casts were mounted and a diagnostic
wax-up completed (Fig. 7). This wax-up intentionally created
minor tooth rotations and irregularities in incisal edge position
to obtain a more natural appearance.
The fixed partial denture was removed, the abutment teeth
were re-prepared, and a provisional restoration was fabricated
from a cast of the diagnostic wax-up (Fig. 8). After intraoral
evaluation, both the patient and the dentist agreed that the
esthetics provided by the provisional restoration were less than
optimum. A new wax-up was made taking into account the
patients wishes and comments, and a new provisional restoration was fabricated from a cast of the wax-up (Fig. 9). This
provisional restoration more closely resembled the original
fixed partial denture, and the patient was very pleased with the
esthetic result, even though the appearance seemed somewhat
artificial to the dentists eye. An irreversible hydrocolloid
impression of the cemented provisional restoration was made
and the resultant cast sent to the laboratory technician along
with appropriate directions for shade mapping and pontic
design. The definitive restoration was fabricated using the provisional restoration as a blueprint (Fig. 10).
The key factor in attaining predictable success with this
patient was the relative ease with which esthetics could be tested and modified with the provisional restoration. Once patient
acceptance was obtained, the definitive restoration could be
fabricated with confidence.

Summary and Conclusions

There is no question that patients today demand a sophisticated level of restorative dentistry, in terms of both esthetics
and function. No elective restorative dentistry should be
undertaken without a clear understanding of the patients
expectations and the limitations of restorative therapy. The
dentist should have a clear picture in mind of the final results
before initiating irreversible therapy. The use of mounted diagJournal of the Canadian Dental Association

nostic casts, diagnostic wax-ups and provisional restorations

permits patient acceptance to be obtained before the definitive
phase is initiated. Too often the dentist does not take advantage of this important restorative option, with disastrous
results when definitive restorations are viewed by the patient
for the first time. By following the plan of treatment outlined
in this article, such disasters can be avoided. a
Dr. Donovan is professor and executive associate dean, chairman,
department of restorative dentistry, and co-director, advanced education in prosthodontics, University of Southern California School of
Dentistry, Los Angeles, Calif.
Dr. Cho is assistant professor, department of restorative dentistry, and
clinic director, advanced education in prosthodontics, University of
Southern California School of Dentistry, Los Angeles, Calif.
Reprint requests to: Dr. Terry E. Donovan, University of Southern California School of Dentistry, 925 W 34 St., Los Angeles CA 90089, USA.
The authors have no declared financial interest in any company manufacturing the types of products mentioned in this article.

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