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Provisional Restorations

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"CUSTOM PROVISIONAL RESTORATIVE MATERIALS"

By: LCDR GUNNING Provisional restoration: A dental prosthesis, worn for various periods of time, which maintains esthetics, provides masticating surfaces and protects the hard and soft tissues prior to the delivery of the definitive prosthesis.

PURPOSE
One of the most important aspects of dentistry is to provide a predictable outcome to any oral rehabilitation, and the use of the provisional restoration is a critical phase in the treatment of the dental prosthetic patient. An interim prosthesis generates specific information about the functional and aesthetic requirements of the definitive restoration. The design for a provisional restoration begins with a thorough and complete gathering of diagnostic information and includes a determination of the final result desired by the patient and practitioner.

FUNDAMENTAL REQUIREMENTS
An optimum provisional restoration must satisfy the three fundamental requirements: Biologic, Mechanical, and Esthetic REQUIRMENTS Patient comfort and function Periodontal Health Aesthetics and Phonetics Strength and Retention Biologic Requirements Pulp protection: The provisional must seal and insulate the prepared tooth surface from the oral environment to prevent sensitivity and irritation to the pulp. No temporary cement will overcome the problems inherent in patients comfort and function from an inadequate provisional restoration. Periodontal health: Health of the surrounding periodontal structure is maintained by
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Occlusal Functon Pulpal Protection Position Stability Margin Protection

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creating a restoration that has proper contour, adequate gingival adaptation, optimal embrasure space, and a smooth surface to facilitate plaque removal. Positional Stability: The provisional restoration must maintain the position of the prepared tooth in relation to the adjacent and the opposing teeth. Prevention of enamel fracture: The provisional must protect teeth weakened by crown preparation. Mechanical Requirements Function without fracture: Ability to withstand the forces of mastication. Indications for heat processed provisionalLong span posterior FPD. Prolonged treatment time. Patient unable to avoid excessive forces on the prosthesis. Above average masticatory muscle strength. History of frequent breakage. Easily removed: Does not damage tooth upon removal. Diagnostic aid: Establishment of occlusal plane. Replacement of missing teeth. Evaluation of pontic design. Establishment of proper tooth contour and form. "Proving" anterior guidance in the mouth. Esthetic Requirements Proper texture, color, and translucency Color stability Guide to achieve optimum esthetics in definitive restoration Ideal Properties Convenient handling: Adequate working time, easy moldability, rapid setting time. Biocompatibility: Nontoxic, nonallergic, nonexothermic. Dimensional stability Easily contoured and polished
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Adequate strength and abrasion resistance Esthetic

PSYCHOLOGICAL IMPLICATIONS
In addition to affording recognition of mechanical, biomechanical, and clinical problems, the transitional restoration serves as a medium of communication of many fo the patient's fears, anxieties, and deep concerns about the loss of facial appearance, "normal expression", retention clarity of speech, and the ability to continue participation in social and vocational requirements.

PHASES OF THERAPY
Diagnostic Casts and Wax-up Articulated diagnostic casts facilitate evaluating the plane of occlusion, amount of interarch space, tooth inclination, arch form, and size and shape of the existing dentition which are essential in formulating an accurate diagnosis and treatment plan. A diagnostic wax on a second set of articulated casts is utilized as a template for the fabrication of matrix in the provisional phase of treatment and as a guide for the laboratory technician during fabrication of the final restorations. The diagnostic casts and wax-up is instrumental to gain patient acceptance during case presentation. Matrix Fabrication Tooth Preparation and Provisional Restoration Construction Interim Stage Treatment Evaluation Preformed Provisional Materials 1. Polycarbonate Most natural appearance of all preformed crown materials. Available in only one shade, but can be modified with the shade of the lining resin. Supplied in incisor, canine, and premolar shapes. 2. Cellulose Acetate Thin transparent material available in all tooth shapes and range of sizes. Shades are entirely dependent on the resin utilized.
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Interproximal contacts need to be added following the removal of the cellulose acetate. 3. Aluminum Suitable for posterior restorations. Inexpensive but requires modification to achieve acceptable occlusal and axial surfaces. 4. Nickel-Chromium Generally more suitable for primary teeth. Crowns are trimmed and adapted with contouring pliers to fit extensively damaged teeth. Provisional Restoration Matrices 1. Acetate: Placing a hole in the area of the tongue or palate on the cast will facilitate fabrication and ensure intimate adaptation of the acetate material. May be used as a preparation guide. 2. Silicone putty 3. Polyvinyl siloxane 4. Alginate 5. Baseplate wax

Custom Fabricated Provisional Materials 1. Polyethyl methylacrylate These are best used with a direct technique. Their advantages include low curing heat, low curing shrinkage, relative nonadherence to tooth structure, extended working time, and low cost. However, these materials do demonstrate poor wear resistance, poor esthetics, poor color stability, an unpleasant odor, and they are radiolucent. Splintline (Lang) is an example of this type of material. Vinyl ethyl methacrylates, such as Snap (Parkell), Trim II (Bosworth), or Vita KHB (Vident), are modifications with very little clinical difference. Temp Plus (Ellman) is a butyl methacrylate that behaves very similarly to the ethyl methacrylates. 2. Polymethyl methacrylate: These are similar to denture resin. Although chemically similar, there are important
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differences between the clinical properties of ethyl and methyl methacrylates. Methyl methacrylates, such as Alike (G-C), Duralay (Reliance), Jet (Lang), Neopar (Kerr), Tab (Kerr), and True Kit (Bosworth), are usually preferred for provisionals made with an indirect technique because the marginal fit can be improved by as much as 70% over a direct technique.(4) Methyl methacrylates demonstrate good wear resistance, good color stability, high polishability, good esthetics, and low cost. However, their disadvantages include high curing heat, high polymerization shrinkage (8%), adherence to tooth structure in the absence of a separator, short working time, unpleasant odor, and radiolucence. Both ethyl and methyl methacrylates can be used with an indirect technique. Usually, ethyl methacrylates demonstrate less polymerization shrinkage and thus better marginal integrity. Methyl methacrylates exhibit greater hardness and durability. Both materials are more dense when cured in a pressurized container. 3. Epimines: A resin material. The material exhibits low exothermic heat reaction during polymerization, low residual monomer content, and low volumetric shrinkage. The main disadvantage of this resin is that it cannot be altered or repaired and it has a low degree of hardness. AN example is "ScutanTM" (ESPE) 4. Composite provisional materials Bis-acryl resins are similar to BIS-GMA resins and possess several advantages, including low curing temperature, minimal polymerization shrinkage, high tensile strength and surface hardness, improved marginal fit, good color stability, minimal odor, and high polishability. Most products are available in automix systems, which improve their ease of use. However, automix systems limit the practitioner's ability to alter the viscosity of the material. The primary disadvantage associated with these systems is their high cost. Bis-acryl resins can be used for most types of provisional restorations. They make exceptional single partial veneer provisionals and are good materials for directly fabricated long span provisional fixed partial dentures. Bis-acryl composites are available as autocure systems: Protemp II (ESPE), Luxatemp (Zenith/DMG), Integrity (Caulk), Protemp Garant (ESPE); and dual cure systems: Provipont DC (Vivadent) and Iso-Temp (3M). Dual cure systems exhibit a chemical cure preceding the final light cured set. In addition, Intertemp (E&D) is light cured only and Triad VLC (Dentsply) is light cured followed by postcuring in a light chamber. Triad demonstrates an early temperature rise and a greater marginal opening as compared to other bis-acryl composite resins and acrylic resins.

Fabrication Techniques
Direct Technique
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-Impression of diagnostic wax-up -Matrix fabrication with vacuum form resin, wax, or elastomeric impression materials. -Shade selection. -Lubricate prepared teeth. -Place mixed provisional material in matrix. -Utilize air and water spray to prevent damage to pulp. -Remove and replace several times to offset shrinkage during polymerization. -Trim after final polymerization. -Polish with pumice

Indirect Technique -Does not subject the to direct exposure to monomer. -Avoids pulpal damage. -Less chairside time but is more expensive. -Involves impression of prepared teeth. -Matrix from diagnostic cast with provisional material is fitted over lubricated cast of prepared teeth. -Curing at 100 degrees F for 10 minutes at 20 p.s.i. increases strength. -Restoration is polished and cemented.

Indirect - Direct Technique -Produces a prefabricated restoration that is subsequently relined at time of tooth preparation.

Extrinsic Characterization: Colored chalk Minute stain Light cured resin

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These methods allow the placement of colorants and modifiers in specific areas. Lowering the value, increasing the intensity or modifying the color, placing specific details of characterization and accenting interproximal areas are a few of the applications.

Microfill Light Cured UDMA Composites: Microfill light cured materials provide interim coverage for nonstress-bearing preparations, such as small inlays and endodontic access openings with enamel-to-enamel contacts in occlusal and proximal areas. These polyester UDMA materials include Fermit (Ivoclar/Vivadent) and Barracaid (Caulk/Dentsply). Advantages of the microfill light cured UDMA materials are low curing temperature, low shrinkage, no mixing, low odor, ease of use, ease of repair, and no requirement for cement. However, if mechanical retention is minimal, the restoration can be cemented with a eugenol free cement. These materials remain elastic after curing, therefore making its removal simple and quick even if small undercuts are present. Damage to the preparation margins is thereby avoided. However, these materials are expensive, radiolucent, and nonpolishable. Furthermore, they demonstrate low strength and wear resistance, and do not prevent teeth from drifting. Implant Provisionals Aid in proper soft tissue healing and as a guide to determine proper form fo the final restoration. Evaluate speech patterns and esthetic changes to the final restoration faabrication. Chairside Direct Provisional coping is attached to the abutment. Reduction to obtain space for the restorative material. Acetate matrix is used to verify clearance and space for resin. The template is filled with the selected resin shade and placed over the provisional coping. Laboratory Indirect Technique Indications Situations with minimal retention. Subgingival margins. Full arch restorations Technique using standard gold cylinders and guide pins Following stage II surgery, tapered impression copings are placed on the definitive abutments and an impression is made. Attach brass analogs to copings and pour impression. Wax up to ideal contours and duplicate. Fabricate a vacuform template.
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Widen stone around analogs using guide pins which are long enough to extend through template. Carry autopolymerizing resin in selected shade to working cast and cure in pressure vessel. Remove restoration and trim, contour, stain, and polish. Seated restoration should fit passively and can be attached with gold screws. Gingival contours can be evaluated and soft tissue modifications made. As soft tissue healing progresses gingival marginal height will stabilize allowing for proper abutment selection and final restoration contours. Provisional Cements Ideal properties: Good marginal seal Low solubility Adequate working time Convenient dispensing and mixing Compatible with provisional polymer Strong but easily removed

Types: Noneugenol provisional luting agents (Nogenol and Dycal) Eugenol provisional luting agent (Temp-bond, IRM) Provilink: a light and self curing provisional cement. When used for temporarily luting veneers, only the base paste is used. Adequate translucency of the provisional is needed to ensure proper polymerization.

TECHNIQUES TO REINFORCE PROVISIONALS

Newer materials provide increased fracture resistance. However, long span restorations and restorations with an intended long duration may require additional methods to improve their durability. If a properly contoured existing prosthesis is available, relining the rigid metal may provide an acceptable provisional restoration. Other means of strengthening include heat processing and reinforcing materials. Reinforced Heat-Processed Acryl Resin Provisionals: Heat-processed acrylic resin is inherently stronger, more stable, and more resistant to polymer breakdown than is autopolymerized resin. Heat processing is indicated for multiple preparations. Heat-processed provisional restorations can be fabricated from prepared
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diagnostic casts and relined clinically. Their advantages include improved color stability, maintenance of surface finish, and wear resistance. With heat-processed materials, incisal translucency and improved esthetics can be achieved. These restorations can be reinforced with nonprecious metal for added strength in the interproximal areas, permitting open embrasures to facilitate the patient's oral hygiene. In addition, occlusal contacts and vertical dimension are well maintained. Composite Reinforcement Fibers: Composite resin fiber reinforcement provides greater strength and fatigue resistance than does metal wire reinforcement. Available products include CONNECT (Kerr), GlasSpan (Glass Span Inc.), Lee Cosmetic Splinting Kit (Lee Pharmceuticals), RIBBOND (Ribbond Inc.) and Splint-It (Jeneric/Pentron). Reinforced bis-acryl composite resin and polymethyl methacrylate resin restorations demonstrate significantly higher fracture strength than unreinforced restorations. However, reinforced bis-acryl composites demonstrate higher fracture loads than reinforced polymethyl methacrylates. Esthetics is not compromised because the fiber becomes invisible when incorporated into the acrylic or resin. These restorations can be repaired easily with the addition of acrylic or resin.

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