Provisional restoration in fixed partial denture

condensation of various techniques of temporization in fpd

1. PROVISIONAL RESTORATION IN FIXED PARTIAL DENTURE BHUVANESH KUMAR.D.V

2. Hu- friedy -- Gregg 4/5

3. Emergence profile  The contour of a tooth or restoration where it emerges from the gingiva. The contour of an implant abutment where it arises from the implant platform.

4. DOUBLE CORD TECHNIQUE M aking an impression for single or multiple abutments The finish line is located sufficiently below the gingival margin R educe the collapse of the gingival tissue Gingival Displacement for Impression Making in Fixed Prosthodontics Contemporary Principles, Materials, and Techniques Nadim Z. Baba, DMD, MSDa , *, Charles J. Goodacre , DDS, MSDb , Rami Jekki , DDSb , John Won, DDS, MSb

5. Contents Synonyms Definitions Requirements for fixed provisional restorations Provisional luting materials Types of provisional restorations Various techniques of fabrication: Direct fabrication techniques Putty index technique /shell-fabricated provisional restoration Indirect method (alginate impression technique)

6. Template method Technique used in the fabrication of provisionals using light cured resin. Using prefabricated crowns Provisional treatment for all ceramic veneer restorations Removal of provisional restoration Recementation of provisional restoration Review of literature Summary References

7. SYNONYMS Provisional restoration, Treatment restoration (Temporization), Interim prosthesis, Provisional prosthesis. The word provisional means established for the time being pending a permanent arrangement

8. Temporary restoration Unfortunately temporary often conveys the notion that, requirements are unimportant. Experience reveals that time and effort spent fulfilling the requisites of provisional restoration are well invested.

9. Definition A fixed or removable prosthesis designed to enhance esthetics, stabilization and function for a limited period of time after which it is to be replaced by definitive prosthesis.( GPT-8 )

10. Rationale for Provisional trt : (Fredrick and Krug) Protect pulpal tissue and sedate prepared abutments Protect teeth from dental caries Provide comfort and function Evaluate parallelism of abutments Provide method for immediately replacing missing teeth Prevent migration of abutments Improve esthetics J Prosthet Dent 2003;90:474-97

11. 8 . Evaluate and reinforce the patient’s oral home care 9 . Provide a matrix for the retention of periodontal surgical dressings 11. Stabilize mobile teeth during periodontal therapy and evaluation. 12.Provide anchorage for orthodontic brackets during tooth movement J Prosthet Dent 2003;90:474-97

12. 13. Aid in developing and evaluating an occlusal scheme before definitive treatment 14. Allow evaluation of vertical dimension, phonetics, and masticatory fun ction 15. Assist in determining the prognosis of questionable abutments during prosthodontic treatment planning J Prosthet Dent 2003;90:474-97

13. A PROVISIONAL MATERIAL SHOULD SATISFY FOLLOWING CRITERIA Convenient handling : adequate working time, easy moldability , rapid setting time. Bicompatibility : nontoxic, nonallergic , nonexothermic Dimensional stability during solidification .

14. Ease of contouring and polishin g. Adequate strength and abrasion resistance. Good appearance ,color controllable, colour stable. Good patient acceptance, non irritating , odorless. Ease of adding to or repairing . Chemical compatibilit y with provisional luting agents i.e., should establish Mechanical bond for retention of the prosthesis rather than a chemical bond

15. Rosensteil , Land ,Fujimoto – CFP -4 TH ED

16. REQUIREMENTS FOR FIXED PROVISIONAL RESTORATIONS: 1. Biologic - Protect pulp

17. - Maintain periodontal health

18. This provisional has overextended margins that have caused gingival irritation. This inflammation will progress during the time that the provisional is worn and could result in necrotic tissues or bone destruction around the tooth

19. -Provide occlusal compatibility

20. Without occlusal contacts, the prepared tooth may extrude. This will make the permanent restoration too high in occlusion and further adjustment of the final restoration may result in an occlusal surface that is too thin or that is perforated.

21. 2. Mechanical - Resist functional loads - Resist removal forces - Maintain inter abutment alignment - Maintain tooth position

22. Provisionals must be of adequate thickness to withstand occlusal forces without cracking. In a fixed partial denture, the connector area may need to be slightly enlarged to prevent breakage

23. - Protect against fracture

24. 3 . Esthetics - Color compatibility - Translucency - Color stability

25. Proper contours The emergence profile must be the same as the original tooth to facilitate plaque removal. Embrasure areas must be contoured to allow for the interdental papilla. T he pontic must be contoured so that it is as self cleansing as possible.

26. In this improperly contoured fixed partial denture, There is not enough embrasure space. The dental papilla are impinged upon and signs of gingival inflammation are present.

27. an example of tissue damage that can occur from over-contoured or over-extended margins on a provisional and may result in # of the prepared teeth

28. Provisional luting materials Provisional luting agents should possess : -good mechanical properties, -low solubility, - tooth adhesion to resist bacterial and molecular penetration. The most important function of these materials is to provide an adequate seal between the provisional restoration and prepared tooth . This is necessary to prevent marginal leakage and pulpal irritation.

29. There are a variety of luting materials used for interim purposes. The most common include (1) calcium hydroxide (2) zinc-oxide eugenol (3) non- eugenol materials.

30. The retentive requirements for provisional luting materials are that they be: strong enough to retain a provisional restoration during the course of treatment but, allow easy restoration removal when required. This paradoxical necessity for good retentive and sealing quality and easy restoration retrieval may lead to a compromise in material behavior , particularly regarding mechanical properties.

31. Baldissara et al recommended that interim restorations be frequently evaluated and used for only short periods of time. Literature reports advise that if provisional treatment is required over a protracted time period , it is best to remove and replace the provisional luting agent on a regular basis .

32. Some of the most commonly used cements with provisional prostheses are those containing zinc-oxide and eugenol . They provide: sedative effects that reduce dentin hypersensitivity possess antibacterial properties. Unfortunately, free radical production necessary for polymerization of methacrylate materials can be significantly hampered by the presence of eugenol found in eugenol based provisional luting materials.

33. Eugenol interferes with the acrylic resin polymerization and hardening process . Therefore Eugenol -free provisional luting materials are commercially available and have gained popularity due to the absence of resin-softening characteristics .

34. Types of Provisional restorations

35. 1 Custom temporaries – - those that are made with a matrix derived from the original tooth or a modified diagnostic cast.

36. Direct: these are constructed with a matrix lined with provisional material that is placed directly on the prepared tooth Indirect: these are constructed by placing the filled matrix over a model of the prepared tooth, thus the provisional is constructed out of the patient's mouth .

37. Indirect-Direct: These are made by forming a temporary in an indirect manner and then relining this directly in the patients mouth. This method is useful when constructing temporary bridges because most of the work can be done in the laboratory.

38. 2- Prefabricated temporaries - these are preformed crowns that can be purchased and may be modified to fit a prepared tooth. In most cases these require relining with an acrylic material.

39. Direct fabrication. For urgent situations, in the absence of any matrix or opportunity to create a matrix , a provisional restoration can be fabricated by adapting a block of freshly mixed acrylic resin directly to a tooth. After the acrylic resin block has polymerized, the tooth contours can be carved with acrylic resin burs of choice and the restorative margins perfected intraorally .

40. Three techniques encompass virtually all of the literature on direct provisional restorations: (1) use of a pre manufactured provisional sheIl (2) use of an impression material, or pressure or vacuum formed translucent matrix and (3) use of a custom, pre­fabricated acrylic resin shell.

41. If the direct technique is employed, seat the shell on the prepared teeth in the mouth

42. Direct provisional restorations made particularly of PMMA and, to a lesser degree, polyethyl methac­rylate (PEMA) must be cooled if the material is allowed to polymerize completely on a tooth. Polymethyl methacrylate can increase pulpal temperatures as much as 7°C . Cooling the material during polymerization by its removal at initial polymerization and allowing complete polymerization to be completed while it is off the tooth, cooling with air-water spray , periodic removal, and flushing with water will limit temperature increase to less than 4°C , minimizing the exothermic risk .

43. Indirect fabrication to fabricate multiple unit provisional restorations . (1) avoid exposure of patient to adverse properties of provisional acrylic resins (2) optimize the properties of provisional acrylic resins (3) allow the use of materials that are difficult to polymerize intraorally (4) make significant contour or occlusal changes

44. Indirect techniques generally use either approximate tooth preparations made on a duplicate cast or a cast of the actual tooth preparations made after the clinical procedure has been accomplished. Advantages of the indirect technique: Can be allocated to auxiliary personnel. Reduces exposure of oral tissues to monomer , heat, shrinkage, and reduces the volume of volatile hydrocarbons inhaled by a patient.

45. It has been reported that provisional restorations fabricated indirectly have superior margins to those from direct techniques because the acrylic resin polymerizes in an undisturbed manner . Reinforcing the vacuum or pressure formed matrix allows it to be secured to the cast on which the provisional shell is polymerized.

46. Indirect method (Alginate impression technique)

47. The over-impression frequently is made in the patient's mouth while waiting for the anesthetic to take effect. However, if the tooth to be restored has any obvious defects, the overimpression should be made from the diagnostic cast .

48. When the alginate has set, the overimpression is removed from the diagnostic cast and checked for completeness . Thin flashes of impression material that replicate the gingival crevice are removed to insure that there will be no impediments to the complete seating of the cast into the overimpression later .

49. The impression is wrapped in a wet paper towel and placed in a zip lock plastic bag for later use. When the tooth preparation is completed, another quadrant impression is made in alginate. This impression is poured up with a thin mix of quick-setting plaster .

50. Properly trimmed plaster cast

51. Mix tooth-colored acrylic resin in a dappen dish with a cement spatula. Place the resin in the over impression so that it completely fills the crown area of the tooth for which the provisional restoration is being made .

52. Application of separating medium

53. Seat the prepared tooth cast into the over impression, making sure that the teeth on the cast are accurately aligned with the tooth impressions.

54. Once the cast has been firmly seated and the excess resin has been expressed, hold the cast in place with a large rubber band.

55. It is important that the cast be oriented securely in an upright position so that the space between the cast and the impression that is filled with the resin forming the provisional restoration will not be distorted. If the cast is torque to one side by the rubber band, the cast may be forced through the soft tissue in some areas resulting in a provisional restoration that may be thin in those areas and thicker than desirable in others.

56. PUTTY INDEX TECHNIQUE / Shell-Fabricated Provisional Restoration DIAGNOSTIC CAST

57. DIAGNOSTIC WAX UP

58. Putty index made from the diagnostic wax up.

59. Trimmed acrylic shells oriented in the putty index

60. Auto polymerizing resin filled in the putty index

61. The index stabilized on the prepared sectional cast.

62. Finished provisional.

63. TEMPLATE METHOD To make a template, place a metal crown form or a denture tooth in the edentulous space on the diagnostic cast . To facilitate removal of the template, a thin strand of putty can be placed around the periphery of the cast and on the lingual surface of the cast, apical to the teeth .

64. Use a large acrylic bur to cut a hole through the middle of the cast ( midpalatal or midlingual ). Place a 5 x 5-inch sheet of 0.020-inch-thick resin . Turn on the heating element of the machine and swing it into position over the plastic sheet .

65. As the resin sheet is heated to the proper temperature, it will droop or sag about 1.0 inch in the frame. The cast should be in position in the center of the perforated stage of the vacuum forming machine. Turn on the vacuum.

66. Grasping the handles on the frame that holds the heated coping material, forcefully lower the frame over the perforated stage . Turn off the heating element and swing it off to the side. After approximately 30 seconds, turn off the vacuum and release the resin sheet from the holding frame .

67. SHEET IS CUT TO REMOVE THE TEMPLATE FROM THE DIAGNOSTIC CAST

68. VACCUM NOT PRESENT

69. Place the softened sheet over the cast.

70. Forcefully seat the tray of silicone putty over the coping material

71. To accelerate cooling, blow compressed air on the plastic sheet and the impression tray. After about a minute, snap the tray off the cast . If the silicone putty sticks to the resin sheet, the putty can be easily removed by pulling it off in quick jerks. Rapid separation causes the silicone putty to exhibit brittleness that will result in easy removal. Separate the template from the diagnostic cast.

72. Upon completion of the preparations , make an alginate impression of them and pour it in fast-setting plaster. Trim the cast so that it includes only one tooth on either side of the prepared teeth.

73. Try on the template to verify its fit .

74. Coat the cast with separating medium and allow it to dry. Mix the acrylic resin in a dappen dish. As the resin begins to lose its surface gloss and becomes slightly dull, fill the area for which the provisional fixed partial denture is being made .

75. Wrap rubber bands around the template and cast, being careful not to place them over the abutment preparations, lest they cause the template to collapse in that area .

76. Place the cast in warm (not hot) tap water to hasten polymerization. Remove the fixed partial denture from the cast. Do not hesitate to break the cast if necessary. Trim off the excess acrylic resin. Use discs to trim the axial surfaces down to the margins. The pontic should have the same general shape that the pontic on the permanent prosthesis has.

77. Remove the saddle configuration that was created by the crown form in the edentulous space .

78. Technique used in the fabrication of provisionals using light cured resin.

79. .

80. Resin placed on the finish line for better adaptation.

81. Template is filled with light cured resin.

82. PREFABRICATED CROWNS

83. Polycarbonate Crowns:

84. These are available in incisors, canines and bicuspids . There is a range of sizes for each tooth form. It should be relined with acrylic in order to provide a good internal fit . After lining with acrylic, they may be trimmed to provide a good marginal adaptation and further adjusted into proper occlusion.

85. MOLD SELECTION FOR TEMPORARY POLYCARBONATE CROWNS

86. SIZING IT UP

87. IMPROVING FIT WITH RESIN

88. Cemented temporary in place

89. Ion Crown Formers: These are shells made of cellulose acetate and are available in all tooth forms.

90. These shells come in various sizes for each tooth form and are lined with acrylic resin. After the acrylic resin has polymerized, the cellulose shell is peeled away from the crown . This usually necessitates the further addition of acrylic in the areas of the proximal contacts .

91. Tin Silver: Tin Silver preformed crowns are available for posterior teeth.

92. This alloy is very soft and the margin of the crown can be flexed prior to seating. This produces a close marginal fit after the shell is trimmed with a bur. These should also be lined with acrylic resin to provide good internal adaptation and retention of the temporary.

93. Aluminum Shell Crowns: Similar to the tin silver, aluminum shell crowns are available in the anatomic form -that requires extensive occlusal contouring. Adjusting results in perforation of the aluminum into the layer of acrylic beneath

94. Provisional treatment for all ceramic veneer restorations

95. All-ceramic restorations including laminate veneers have become a large part of dental practice. Most of what has been published regarding provisional treatment for veneers has focused on technical procedures.

96. Provisional veneers are indicated when: esthetics and intelligible speech are important; dentin is exposed; proximal contacts are broken; maxillary teeth are inverted lingually and the veneer surface affects occlusion; the preparation margin invades the gingival sulcus ; the final veneer is dependent on patient approval of form, color, contour, and position.

97. Provisional restorations allow patients to have a trial period for making notes about esthetics so that their desires can be taken into account with the definitive veneer. Preparations for porcelain veneers may not have mechanical retentive features and thus one concern regarding a provisional restoration is tooth attachment while avoiding irreversible contamination or alteration of the luting surface of a prepared tooth .

98. Elledge advocated placing 2 small dimples on opposing surfaces of the preparation to provide mechanical retention for the provisional veneer that is luted with a cement of the clinician's choice. Elledge DA, Hart JK, Schorr BL. A provisional restoration technique for laminate veneer preparations. J Prosthet Dent 1989;62:139-42

99. One method that avoids excess cement while sealing the margin area is the " peripheral seal technique " that uses a 3-second etch of the preparation periphery and then bonding a provisional restoration primarily at the etched periphery. Similarly, a colored luting resin may facilitate removal of excess resin and reduce contamination of a tooth surface.

100. Another technique known as the "spot etch" method incorporates provisional restorations that are luted with light polymerized acrylic resin to an etched spot near the center of the preparation.

101. A variety of methods for fabrication of veneer provisional restorations have been reported and are not unlike the methods advocated for conventional provisional restorations including, a removable hand ­formed visible light-polymerized material provisional, polycarbonate provisional crowns, acrylic resin shells , splinting together adjacent provisional veneers.

102. Anterior provisional restorations should provide the following esthetic benefits: (1) optimum periodontal health; (2)visualization of the anticipated esthetic outcome; (3)ability to test the incisal edge position and cervical emergence; (4)development of appropriate anterior guidance (5)determination of the need for periodontal surgery.

103. Methods for improving or customizing colors also include coloring provisional luting cements and coloring a provisional restoration with porcelain stains and visible light-polymerized acrylic resin. Custom color guides for provisional restorations have also been recommended.

104. REMOVAL OF PROVISIONAL RESTORATION

105. The provisional is removed when the patient returns for the definitive restoration or for continued preparation. Risk of damage to the prepared tooth can be minimized if removal forces are directed parallel to the long axis of the preparation. The Backhans or hemostatic forceps are effective. Slight buccolingual rocking motion will help break the cement seal.

106. Sometimes it is helpful to loop dental floss under the connector at each end of the FPD, providing a more even force distribution for removal.

107. RECEMENTATION OF PROVISIONAL RESTORATION

108. If provisional is to be recemented clean out the bulk of cement with a spoon excavator, then place the provisional in a cement dissolving solution in an ultrasonic cleaner. Line it with a fresh mix of resin if necessary (as when a tooth preparation has been modified, eg). The internal surface is relieved slightly and painted with monomer to ensure good bonding of the new lining.

109. LITERATURE REVIEW

110. In an in vitro study of surface contamination associated with provisional bonding, a polyurethane isocyanate surface treatment left the cleanest tooth structure a non eugenol provisional cement left: significant but removable residue; a dual polymerizing resin cement left tenacious residue that could only be removed with a bur . Mojon P et al,A comparison of methods for removing provisional cement, Int J Prosthodont 5:78, 1992

111. A study was done on the Colour stability of provisional materials. This study evaluated the in vitro discoloration of seven resins over a 9 week period . Resin specimens were prepared and placed in the facial flange of maxillary complete dentures and the lingual flange of a mandibular complete dentures. Patients were given tooth brushes and tooth paste and told not to use any chemical agents for cleaning the dentures. Observations were made at 1, 5 and 9 weeks, Jack Koumi Jian et al ' Colour stability of provisional materials in view jpd 1998

112. All materials tested were acceptable from the standpoint of colour stability for short term (5 weeks or less) provisional restorations. Therefore, the dentist using provisional restorations for a short period of time may consider other properties of the materials, such as resistance of fracture, marginal accuracy, rate of fabrication and cost.

113. PERIOD AUTHOR STUDY INFERENCE  April 2015 Takuya Mino et al The aim of this article was to investigate the accuracy in the reproducibility of full-arch implant provisional restorations to final restorations between a 3D Scan/CAD/CAM technique and the conventional method . Scan/CAD/CAM method enables a more precise and accurate transfer of provisional restorations to final restorations compared to the conventional method.  Dec 2007 Ralf Buergers The purpose of this in vitro study was to compare 10 commonly used provisional fixed prosthodontic materials (2 acrylic polymethyl methacrylates , 2 improved methacrylates , and 6 bisacrylate composite resins), based on their susceptibility to adhere to Streptococcus mutans , and examine the influence of surface roughness and hydrophobicity.   Bisacrylate composite resins and acrylic polymethyl methacrylates had significantly lower adhesion potentials than improved methacrylates . 

114. PERIOD AUTHOR STUDY INFERENCE March 2015 Tritala Vaidyanathan et al Evaluate the short to medium term stability of temporization materials { Acrylic resins (poly(methyl) and poly(ethyl) methacrylate) and bis -acryl composite resins  } under controlled loading to study their stress relaxation behavior The results showed that PMMA and composite resins were superior in their ability to maintain constant strain without excessive dissipation of applied stress than PEMA resin.  Dec 2015 Sqn Ldr   K.S. Naveen et al Evaluated the effect of silanation of the various types of glass fibre impregnation on the flexural strength of resin interim restorations. Flexural strength of the reinforced PMMA interim fixed dental prosthesis was significantly higher ( P  < 0.0001) when compared to the unreinforced PMMA interim fixed dental prosthesis. The use of silane treated unidirectional glass fibres is an effective method of reinforcing interim fixed restorations made of PMMA resins.

115. USING THE LAMINAR IMPRESSION TECHNIQUE FOR PROVISIONAL RESTORATIONS DOUGLAS E. McMASTER , D.D.S .

116. Protemp ™ Crowns (3M ESPE) • A Bis -GMA light-cured composite • Come in single units, • Adaptable , • Have a single shade only, • Have good wear resistance • Good polishability , • But because of their single shade are somewhat limited unless one is prepared to custom stain 

117. Luxatemp Ultra • Incorporating proprietary nano technology • Luxatemp Ultra surpasses all leading provisional materials in flexural strength • The key to provisional stability and long-term durability, especially with multi-unit temporaries . • Luxatemp Ultra delivers improved initial hardness and superior break resistance

118. VISIBLE LIGHT CURED RESINS • Many clear composites, glazes, or lighter composite shades may not use a camphorquinone photocatalyst because it imparts a yellowish or orange hue, • Here it is critical to use a broad-spectrum light like the VALO™ ( Ultradent Products) or bluephase ® 20i ( Ivoclar Vivadent ) that cures all photo-initiators and composites 

119. Cling 2 provisional cement • A resin-optimized non- eugenol temporary cement with a unique polycarboxylate resin • This optimizes adhesion, • Soothes the tooth , • Bacteriostatic, and • Provides an excellent seal to promote tissue health

120. How to take care of undercuts ?? • OraSeal ® Putty or OraSeal ® Caulking ( Ultradent Products) • A cellulose material that sticks to wet teeth , • Easily placed into the undercuts, and can be simply shaped with a plastic instrument to eliminate the undercut. • This makes removal of the temporary much more predictable. & can be removed with a plastic instrument and water after the temporary is fabricated. 

121. SUMMARY Although provisional restorations are usually intended for short ­term use and then discarded, they can be made to provide pleasing esthetics, adequate support, and good protection for teeth while maintaining periodontal health. They may be fabricated in the dental office or in laboratory from any of several commercially available materials and by a number of practical methods . The success of fixed prosthodontics often depends on the care with which the provisional is designed and fabricated.

122. References REFERENCES

123. Rosenstiel et al, Contemporary fixed prosthodontics, provisional restorations. Third edition, pg 380-416. Anusavice KJ, Phillips science of dental materials, ed 11, philadelphia,WB Saunders, pg 285-431. Shillinburg et al, Fundamentals of fixed prosthodontics, provisional restorations. Third edition, pg 225-256. Mojon P et al,A comparison of methods for removing provisional cement, Int J Prosthodont 5:78, 1992 Jack Koumi Jian et al 'Colour stability of provisional materials in view j prosthet dent, 1998, vol21, 233-235. Millstein et al, The effect of aging a temporary cement retention in vitro quintessence journal 2002, vol 21, 312-314. Timothy M. Campbell et al, a vinyl polysiloxane to make interim restorations as provisionals j prosthet dent 2001, vol22, 112-114. Douglass B. Roberts, indirect interim restorations using flexible casts, vol24, bdj 2004

124. Thank u