DEPTT OF PROSTHODONTICS CROWN AND BRIDGE

PROVISIONAL
RESTORATIONS IN FIXED
PARTIAL DENTURES
SEMINAR

DR VIKAS AGGARWAL






INDEX
1. INTRODUCTION
2. DEFINITION
3. RATIONALE FOR PROVISIONAL TREATMENTS
4. FUNCTIONS OF PROVISIONALS
5. REQUIRMENTS OF PROVISIONAL RESTORATIONS
6. MATERIALS
7. INFLUENCE OF MATERIAL PROPERTIES ON TREATMENT
OUTCOME
8. FABRICATION OF PROVISIONAL RESTORATIONS
9. TECHNIQUES OF MAKING PROVISIONAL RESTORATIONS
10. CUSTOM SINGLE UNIT PROVISIONAL RESTORATIONS
11. PREFABRICATED PROVISIONAL RESTORATIONS
12. CEMENTATION
13. REMOVAL, RECEMENTATION AND REPAIR
14. CONCLUSION
15. REFERENCES












INTRODUCTION
It is important that the prepared tooth be protected and that patient be kept
comfortable while a cast restoration is being fabricated. By successful
management of this phase of the treatment, the dentist can gain the patients
confidence and favourable influence for the ultimate success of the final
restoration. The important role of provisional restorations is often overlooked as
they generally do not need to last for long. However, not only can good
provisional restorations help produce better final restorations, they can also save
a lot of time
Failure to do so will result in the eventual loss of more time than initially
thought saved. If the provisional restoration is not up to the mark, it may lead to
unnecessary repairs as well as need to treat gingival inflammation and it can
further prolong the treatment schedule. Whatever the intended length of time of
treatment, a provisional will have to be adequate to maintain patient health.
Thus it should not be casually fabricated on the basis of expected short term
use.
It can be said that provisional restoration is frequently the patients first
impression of final prosthesis so it should be representative of the final esthetic
result.
During the time between the preparation of the tooth and the placement of the
final restoration, the tooth is protected by a provisional restoration. This type of
restoration has also been known for many years as a temporary restoration.
The word provisional means established for the time being, pending a
permanent arrangement.
DEFINITION (ACC TO GPT-8)
Fixed or removal prosthesis designed to enhance esthetics, stabilization and or
function for a limited period of time, after which it is to be replaced by
definitive prosthesis. Often such prosthesis is used to assist in determination of
the therapeutic effectiveness of a specific treatment plan or the form of function
of the planned definitive prosthesis.
Rationale for Provisional Treatment (JPD 2003, 90, 474-497)
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
Provide an environment conductive to periodontal health
Evaluate and reinforce the patients oral home care
Assist with periodontal therapy by providing visibility and access to
surgical sites when removed
Provide a matrix for the retention of periodontal surgical dressings
Stabilize mobile teeth during periodontal therapy and evaluation
Provide anchorage for orthodontic brackets during tooth movement
Aid in developing and evaluating an occlusal scheme before definitive
treatment
Allow evaluation of vertical dimension, phonetics, and masticatory
function
Assist in determining the prognosis of questionable abutments during
prosthodontic treatment planning





FUNCTIONS OF PROVISIONAL RESTORATIONS
1) Comfort/tooth vitality: To cover exposed dentine to prevent sensitivity,
plaque builds up, subsequent caries and pulp pathology.
2) Occlusion and positional stability: To prevent unwanted tooth movement
by the maintenance of intercuspal and proximal contacts. It may be necessary to
establish a holding contact on the provisional restoration. Depending on the
patients occlusal scheme, the provisional restoration may need to provide
guidance in protrusive and lateral excursions, or disocclude to prevent working
or non working interferences. Interproximal contacts also need to be maintained
to prevent food packing.
3) Function it restores patients functions
4) Gingival health and contour: To facilitate oral hygiene and prevent gingival
overgrowth provisional restorations require accurate margins and cleansable
contours. They can be used in the interim where the level of the gingival margin
has yet to stabilise (e.g. after crown lengthening or removal of a crown with
defective margins).
5) Aesthetics: To provide an adequate interim appearance provisional
restoration should either mimic the tooth just prepared, or the final intended
restoration.
6) Diagnosis: If any change in the esthetics or occlusion is required, the
provisional restoration is your trial run. Changes are easily made in the
temporary stage. Once final contours are obtained, the temporary can be
duplicated and sent to the laboratory as a guide for construction of the final
restoration
Provisional restoration can be very useful in diagnosis for the following factors:
Establishment of occlusal plane
Determining path of insertion
Evaluation of pontic design
Evaluation of patients esthetic demands
Evaluation of patients phonetics

7) Other practical uses: To measure tooth reduction, to isolate during
endodontics, to assess prognosis, to act as a matrix for core construction

REQUIREMENTS OF PROVISIONAL RESTORATION

There are three basic requirements that is biological, mechanical and esthetics.
There should be optimal balance between these factors for the success of any
restoration.
A) BIOLOGICAL REQUIREMENTS
1) PULPAL PROTECTION
It must seal and insulate the prepared tooth surface from oral environment, to
prevent sensitivity and further irritation to pulp. Tooth has already been
traumatized to certain extent during tooth preparation; if provisional restoration
does not seal the tooth properly it can lead to irreversible pulpitis.



BIOLOGICAL
Protect pulp
Maintain periodontal
health
Provide occlusal
compatibility
Maintain tooth position
Protect against fracture
MECHENICAL
Resist functional loads
Resist removal forces
Maintain
interabutment
alignment
ESTHETICS
Easily contourable
Colour compatibility
Translucency
Colour stability
2) PERIODONTAL HEALTH
To facilitate plaque removal, an interim fixed restoration must have good
marginal fit, proper contour, and a smooth surface. This is particularly
important when the crown margin is placed apical to the free gingival margin. If
the interim fixed restoration is inadequate and plaque control is impaired,
gingival health deteriorates. It will lead to delay in placement of final prosthesis.

3) OCCLUSAL COMPATIBILITY AND TOOTH POSITION
It should establish proper contact with adjacent and opposing teeth. It will
prevent supraeruption and horizontal movement of prepared tooth. Any such
movement will require adjustments or a remake of the final restoration at the
time of cementation.
4) PREVENTION OF ENAMEL FRACTURE
The interim fixed restoration should protect teeth weakened by crown
preparation, particularly true with partial coverage designs in which the margin
of the preparation is close to the occlusal surface of the tooth and could be
damaged during chewing. Even a small chip of enamel makes the definitive
restoration unsatisfactory and necessitates a time-consuming remake

B) MECHANICAL REQUIREMENTS
1) FUNCTION
Greatest stresses on interim fixed restorations are likely to occur during
chewing. The strength of temporary prosthesis is increased by increasing the
size of connectors in comparison with definitive restorations. Greater strength is
achieved by reducing the depth and sharpness of the embrasures. This increases
the cross-sectional area of the connector while reducing the stress concentration
associated with sharp internal line angles.
The biologic and sometimes the esthetic requirements place limits on just how
much larger connectors can be made. To avoid jeopardizing periodontal health,
they should not be overcontoured near the gingiva.
2) DISPLACEMENT
Interim restoration should avoid displacement that is best prevented by proper
tooth preparation and well adapted internal surface.
3) REMOVAL FOR REUSE
Interim restorations often need to be reused and so should not be damaged when
removed from the teeth. In most instances, if the cement is sufficiently weak
and the interim restoration has been well fabricated, it does not break upon
removal.
C) ESTHETIC REQUIREMENT
The appearance of an interim fixed restoration is particularly important for
incisors, canines, and sometimes premolars. The temporary must have adequate
contours, colour, translucency and texture. The provisional can be a "testing
ground" for esthetic changes such as tooth shape, length or colour. The
temporary can be easily altered until the patient is satisfied with the esthetics.
Cosmetic modification should be made with input from the patient and used as a
guide for the fabrication of the final prosthesis.
To summarize: (JPD 2003, 90, 474-97)
Good marginal adaptation; adapts well to a tooth and matrix surface
Adequate retention and resistance to dislodgment during normal
masticatory function
Strong, durable, and hard
Nonirritating to pulp and other tissues; low exothermicity
Nonporous and dimensionally stable
Comfortable
Esthetically acceptable shade selection; translucent tooth-like appearance
Colour stable
Physiologic contours and embrasures
Easy to mix and load in the matrix, fabricate, reline, and repair; relatively
short setting time
Physiologic occlusion
Conductive to routine oral home-care cleaning procedures
Finishes to a highly polished, plaque- and stain-resistant surface
Easy to remove and re-cement by the dentist
Relatively inexpensive
Low incidence of localized allergic reactions

PROVISIONAL RESTORATIVE MATERIALS:

Ideal properties:
1. Convenient handling.
2. Biocompatibility.
3. Dimensional stability during solidification.
4. Ease of contouring and polishing.
5. Adequate strength and abrasion resistance.
6. Good appearance.
7. Good patient acceptance.
8. Ease of adding to or repairing.
9. Chemical compatibility with provisional luting cements

Provisional materials can be classified as:
A) Custom fabricated materials.
B) Preformed materials

CUSTOM FABRICATED MATERIALS.
These are one of the best choices for provisional restorative treatment. The
technique allows for intimate contact between a provisional restoration and
prepared tooth. It provides a continuous mechanism for a variety of alterations
during treatment such as marginal adaptation, contour change, shade
adjustment, occlusal modification and repair.
These materials can be divided based on their mode of polymerization
1. chemically activated autopolymerizing acrylic resins
2. heat activated acrylic resins;
3. light-activated acrylic resins
4. dual light and chemically activated acrylic resins
Acrylic resins are most common choice of provisional restorative material.
Generally, acrylic resins used for provisional restorations are brittle, but their
great advantage is the ease with which they can be altered by additions and
subtractions. Several types of acrylic resin materials are available for interim
restorative treatment.
(1) Polymethyl methacrylate resins
(2) Polyethyl methacrylate resins
(3) Bis GMA composite
(4) Visible light cure resin
Poly methyl methacrylate.
Autopolymerizing polymethyl methacrylate (PMMA) first appeared around
1940 and remains the most frequently used material for fabrication of interim
restorations
Advantages
Low cost
Good wear resistance
Good esthetics and colour stability
Capable of high polish
Good marginal finish
Disadvantages
Significant amount of heat given off by exothermic reaction
High degree of shrinkage (about 8%)
Strong, objectionable odour
Short working time
Hard to repair.
monomer irritating to pulp
eugenol deteriorates resin
Products: Coldpac, Duralay, Jet,Temporary bridge resin., Trim Plus etc.
Poly-ethyl Methacrylates
Ethyl methacrylate was introduced in the 1960s, has a number of advantages
and disadvantages relative to methyl methacrylate. One study, showed the
highest value of fracture resistance with an ethyl methacrylate material relative
to methyl methacrylate and bis-acryl materials. Ethyl methacrylate may be a
better selection for direct interim prosthesis fabrication and is best suited for
short-term use relative to methyl methacrylate.
Advantages:
Lower exothermic heat.
Low polymerization shrinkage.
Good handling properties.
Good polishability.
Less pungent odor
Good toughness
.
Disadvantages:
Low tensile strength.
Poor surface hardness.
Poor wear resistance.
Poor durability.
Poor colour stability
Products: Splintline
COMPOSITES
Composite provisional materials are chemically comprised of a combination of
2 or more types of material. Most of these materials use bis-acryl resin, a
hydrophobic material that is similar to bis-GMA. When this resin is mixed with
inorganic, radiopaque filler it combines to provide an interim treatment material
that is similar to composite restorative materials. Typically these materials use a
variety of multifunctional acrylic resin monomers that produce high-density
cross linkages during polymerization.
These materials are available as
Autopolymerized.
Dual polymerized.
Visible light polymerized.
Advantages
Less shrinkage than acrylics
Minimal heat generated during setting reaction
Relatively high strength
Minimal odour
Excellent esthetics
Most products use automix delivery
Can be repaired or characterized using resin composite
Easy to trim

Disadvantages
Poor surface hardness
Expensive
Brittle
Alterations and repairs are difficult
Poor stain resistance
Less polishability
Poor handling characteristics
Poor colour stability
Products: Protemp Garant,
VISIBLE LIGHT CURE RESIN / UDMA BASED
The visible light polymerized (VLC) materials, first introduced in the 1980s,
require the addition of urethane dimethacrylate, a resin whose polymerization is
catalysed with visible light energy and a camphoroquinone/ amine photo
initiator. These materials usually incorporate a filler such as microfine silica to
improve physical properties such as reduced polymerization shrinkage. Unlike
methacrylate resins, they do not produce residual free monomers after
polymerization, which explains why they exhibit significantly decreased tissue
toxicity relative to methacrylate resins. Eg Triad.
ADVANTAGES
Controlled working time
Good surface hardness and wear resistance
Good transverse strength
Low temperature change
Good colour stability
DISADVANTAGES
Poor marginal fit
Poor stain resistance
Limited shade availability
Expensive
PREFORMED MATERIALS
Various types of preformed crowns are available from several manufacturers.
Such products find greatest use for protection of individual teeth that are being
restored and need protection for only a short period of time
Polycarbonate Crowns:
They are most natural appearance of all the preformed materials. Very colour
stable resin. Colour can be modified by shade of the lining resin
These are available for incisors, canines and bicuspids. There is a range of sizes
for each tooth form. They are highly esthetic and 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.

Cellulose acetate
These are shells made of cellulose acetate (0.2m to 0.3 mm) and are available in
all tooth forms. 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 necessitated the further
addition of acrylic in the areas of the proximal contacts.
Aluminum and Tin Silver:
They are suitable for posterior teeth. They are available in anatomic an form,
which has elaborated occlusal and axial surfaces. Non-anatomic forms are least
expensive and they have to be modified to suitable occlusal surfaces. Care must
be taken to avoid fracturing the delicate cavo surface margin of the tooth
preparation when fitting a metal crown. The risk is greater if the cervical
contours are constricted and if the patient is asked to bite directly on it for
adaptation. Direct stretching on the tooth should be done only if the preparation
has featheredge margins or else cervical enlargement has to be done on swaging
block, which are supplied with the crown kit.
NICKEL -CHROMIUM
They are used in children primarily with extensively damaged primary teeth.
Nickel-chromium usually is not lined instead; they are contoured with pliers and
are luted with high strength cements. They are hard and can be used for long-
term provisional restorations.

INFLUENCE OF MATERIAL PROPERTIES ON TREATMENT
OUTCOME (JPD 2003, 90, 474-497)
1) Marginal accuracy
Accurate marginal adaptation of resinous provisional restorations to the finish
line of a prepared tooth assists in protecting the pulp from thermal, bacterial,
and chemical insults. The accuracy could be significantly improved by relining
the restoration after the initial polymerization.
A number of studies have focused on the marginal accuracy of provisional
crown.
(1) Crispin etal 1980 evaluated marginal accuracy with direct and indirect
techniques. They reported that indirect fabrication provided significant
improvements in marginal fit relative to direct techniques
(2) Improved marginal accuracy of PMMA provisional restorations occurred
when a shoulder finish line was used compared with a chamfer marginal design.
(Hung et al 1993)
(3) Light-polymerized materials provided significantly improved marginal
accuracy relative to auto polymerizing PMMA resin after thermocycling.
(Dubious et al 1999)
(4) Nearly 20% improvement in the retention of interim crowns made with
polymethyl methacrylate compared to those fabricated with composite
materials. It was concluded that polymerization shrinkage occurring with the
polymethyl methacrylate material might have allowed for a tighter fit of the
restoration on the prepared tooth, which had a direct influence on improved
retentive quality. (Lepe et al 1999)
(5). Acrylic resin provisional crowns demonstrated dimensional degeneration
and enlarged marginal gaps resulting from thermocycling and occlusal loading.
(Ehernberg and Weiner 2000)

2) COLOUR STABILITY
In esthetically critical areas it is desirable for provisional restoration to remain
colour stable over the course of provisional treatment. Discolouration of
provisional materials can produce serious esthetic complications, especially
when long term provisional treatment is required. Modern provisional materials
use stabilizers that decrease chemically induced colour changes, but these
materials are susceptible to other factors that will promote staining. Most
provisional materials are subject to sorption, a process of absorption and
adsorption of liquids that occurs relative to environmental conditions. When
provisional materials contact pigmented solutions such as coffee or tea,
discolouration is possible. Porosity and surface quality of provisional
restorations as well as oral hygiene habits can also influence colour changes.
1) Crispin and Caputo (1979) studied the colour stability of provisional
materials. They found that methyl methacrylate materials exhibited the least
darkening, followed by ethyl methacrylate and vinyl-ethyl methacrylate
materials.
2) Yannikakis et al (1998) immersed provisional materials in various staining
solutions for up to 1 month. They reported that all materials showed perceptible
colour changes after 1 week. The methyl methacrylate materials exhibited the
best colour stability and bis-acryl materials the worst.



3) GINGIVAL RESPONSE
Inflammation and recession of the free gingival margin associated with
provisional treatment is a common occurrence
Donaldson 1973 indicated that the occurrence of gingival recession before
provisional treatment was directly linked to further recession observed after the
completion of definitive prosthodontic treatment. He also found a direct relation
between the degree of pressure applied by a provisional restoration and gingival
recession. An anatomically contoured provisional restoration caused less
recession than did a non-anatomically contoured one. Periodontal inflammation
associated with provisional treatment could be expected to be a reversible
process provided that the amount of gingival irritation is minimal and
provisional treatment occurs over a short time span.
MacEntee etal 1978 in histological evaluation of tissue response reported no
detectable change in gingival tissue associated with provisional restorative
treatment over 3 weeks period.
Garvin et al 1982 concluded that periodontal inflammation associated with
provisional treatment could be expected to be a reversible process provided that
the amount of gingival irritation is minimal and provisional treatment occurs
over a short time span.

4) PULPAL RESPONSE
Dental pulp inflammation can be caused by either thermal or chemical insult
resulting from materials used to produce direct provisional restorations.
Temperature rise of more than 5.6C are considered unacceptable because of a
potential for loss of pulp vitality and this should be considered when fabricating
direct provisional restorations. The amount of heat generated is directly
proportional to the amount of material used. Hence temperature will be high
when using multiple units. Use of air and water coolants, as well as by use of a
matrix material, can dissipate heat rapidly and the pulp temperature rise might
be reduced.
Grajower et al.1979 showed faster polymerizing acrylic resin materials could
generate higher temperatures than slower polymerizing resins.
The authors concluded that
(1) Provisional acrylic resin restorations might be fully polymerized on prepared
teeth by appropriate methods such as in impressions or with external cooling,
without causing excessive heating of the dental pulp
(2) Removal of a provisional restoration before complete polymerization,
leading to potential deformation of the acrylic resin material, is therefore
unnecessary
(3) A thin insulating layer should be applied to a prepared tooth before contact
with nonpolymerized acrylic resin to avoid chemical injury.

4) HYPERSENSITIVITY
Hypersensitivity from provisional materials has been reported but appears to be
rare. Autopolymerizing methacrylate materials have greater potential for
producing allergic contact stomatitis than similar heat-polymerized materials.
The residual monomer in the material has been implicated as the causative
factor. Indirect material processing methods are recommended for individuals
showing evidence of hypersensitivity.
Residual monomer content in heat polymerized acrylic resin ranges from
0.045%-0.103%, whereas in autopolymerizing acrylic resins it is 0.185%.
Unpolymerized monomer can be substantially removed by placing auto
polymerized provisional restoration in a pressure pot with warm water for 20
mins.



FABRICATION OF PROVISIONAL RESTORATION

Many procedures using a wide variety of materials are available to make
satisfactory provisional restorations. Common to all is the fact that all the
procedures have in common the formation of a mould cavity in to which a
plastic material is poured or packed.

The mould cavity is made of two correlated parts; one forms the external
contour of the crown or fixed partial denture and the other forms the prepared
tooth surface and (when present) the edentulous ridge contact area. They are
called the external surface form (ESF) and tissue surface form (TSF)
respectively.
External surface form (ESF)
Two categories
Preformed
Custom
a. Custom ESF:
Custom ESF is a negative reproduction of either the patients teeth before
preparation or a modified diagnostic cast.
Custom ESF can be formed directly with any impression materials ie,
impression made in quadrant tray using alginate or silicone rubber. This can be
accurately reseated if thin areas of impression materials are trimmed using a
sharp knife (as found interproximally or around the gingival margin). Moldable
putty materials are good out of this because they can be trimmed easily reused
and also facilitates subsequent removal of the polymerized resin.
A custom ESF can be made out of transparent sheets made of cellulose acetate
or polypropylene, which comes in various sizes and thickness. A 125 x 125 mm
sheet of 0.5mm thickness is recommended for provisional restorations.

Polypropylene is preferred because it produces
Better surface detail
More tear resistant
Can be used more than once
Thermoplastic sheets are heated and adapted to a stone cast with vacuum air
pressure. Disadvantages of thermoplastic sheets are:
- It is thin
- Poor dissipater of heat
- Base plate wax can also be used to form custom ESF.
b. Preformed ESF:
They are a variety of performed crowns, which are available commercially.
They rarely satisfy the requirements of a provisional restoration, but they can be
finished to suitable form by lining with autopolymerizing resin. Most of them
require modifications (Eg: internal relief, axial recontouring, occlusal
adjustment). If extensive adjustments are required then custom ESF is always
superior. Performed ESF is always used for single restorations because using
them, as pontics are not feasible.
Tissue surface form (TSF)
There are three categories of tissue surface form, which depends on the
procedures:
Direct TSF (TSF forms the prepared tooth)
Indirect TSF (TSF forms a plaster cast or elastomer)
Indirect -direct TSF (combination of both plaster cast and patients mouth)





Techniques of making provisional restorations:
There are basically three techniques
Indirect technique.
Direct technique.
Indirect-direct technique.
1. Indirect technique:
In this technique the provisionals are produced or made outside the mouth
from a plaster cast poured out from an impression of prepared teeth and ridge
tissue.
Advantages:
No contact of free monomer with the prepared tooth or gingiva, which
may cause allergic reaction or tissue damage.
This procedure avoids subjecting the prepared tooth to the heat treated
from polymerizing resin.
The margin fit is more accurate in indirect techniques because the
restorations have been undisturbed in the stone cast. The shrinkage
caused during polymerization is restricted by stone cast while in direct
technique the distortion causes because of the removal of the restoration
before complete polymerization. Directly made long span temporaries
likely to have unacceptable marginal discrepancies due to shrinkage and
distortion
When a dimensionally stable elastomer is used as TSF it can be retained
with possible reuse with ESF. This helps the provisionals to be made
without the presence of patient there by gaining the patients confidence.
This technique gives the patient a chance for rest and allows the dentist to
perform other task, provided a technician is trained for it.


2. Direct technique:
The patients prepared teeth and gingival tissues (in the case of a partial FDP)
directly provide the TSF
Advantage:
Steps for indirect fabrications are avoided.
Convenient if adequate laboratory facilities and auxiliary personals are
not available.
Disadvantages:
Exothermic heat produced causing pulp damage.
Free monomer causes allergic reaction.
Poor marginal fit.

3. Indirect- direct techniques (Egg shell technique):
This is a combination of indirect and direct technique where a shell is first
created by indirect technique and later relined in the patients mouth after
preparation, which is the direct component of it.
Advantages:
Chair side time is reduced and most of the procedures are completed
before the patients visit.
Less heat is generated in the mouth because the volume of resin used
during lining is comparatively small.
Contact between the resin monomer and soft tissues are minimized
compared to direct procedures.
Disadvantage:
Even with the diagnostic cast method adjustments are frequently needed to seat
the shell completely on the prepared tooth.


PROCEDURES
CUSTOM INDIRECT PROVISIONAL FIXED PARTIAL DENTURES
The custom indirect procedure is probably the best overall technique for FPDs
and should provide the most predictable results with least risk to patient health.
Technique
Two techniques can be followed
a) Template method
b) Over impression method

To make a template place a metal crown form or denture tooth in the edentulous
space on the diagnostic cast. All of the embrasures should be filled with putty.
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. Adapt the plastic sheet using
vacuum former or hand manipulating techniques. Remove the template and trim
the excess. This will give us ESF in form of a template

In an over impression technique diagnostic wax up of the pontics and abutments
can be done and then over impression is made using hydrocolloid or putty. A
laboratory knife with a no. 25 blade is used to trim off all excess material. 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. This will give us ESF in form of over impression.
Step-by Step procedures:
1. After shade selection the tooth is prepared and impression is made out
using irreversible hydrocolloid. A sextant tray can be used if atleast one
tooth remains beyond abutments. Gingiva can be displaced if necessary.
2. Pour the impression with quick setting plaster and allow it to set for 8
minutes.
3. Remove the cast and trim excess and make sure that it fits passively and
completely with ESF. ( template/ overimpression)
4. Paint the cast with separating medium completely and allow it to dry.
5. Mark the cavosurface margin with pencil if necessary. Mix
autopolymerizing resin (methyl methacrylate) and load it into
polypropylene syringe with 2-3mm diameter tip.
6. Slowly fill the ESF with material from one side to another while keeping
the syringe tip in constant contact with the resin to avoid air bubble
entrapment and fill until the level of gingiva. Do not over fill.
7. Seat the tissue surface form into the external surface form and lightly held
together by rubber bands. The assembly is then placed in warm water 40
C(100 F) in a pressure vessel and air is applied at about 0.15 MPa (20
psi). Pressure curing will reduce porosity.
8. Remove the assembly after 5 minutes. Separate the external surface form
from the cured resin restoration, which usually remains in contact with
the tissue surface form. The bulk of the stone can be removed on a cast
trimmer and if necessary the cast can be broken to remove the restoration.
9. Eliminate resin flash with an acrylic-trimming bur and a fine-grit garnet
paper disk.
10. Contour the pontic according to the design procedures.
11. Finish the restoration with wet pumice and do not forget the gingival area
of the pontic. If necessary Robinson brush can be used on a straight hand
piece.
12. Remove any resin bleb or stone parts within the restoration and do the
try-in patients mouth.
13. The evaluation of following should be done during try-in:
Proximal contacts
Imperfections in contour
Any surface defects can be corrected by bead brush technique.
Unacceptable marginal fit can be corrected by reline technique. Occlusal
adjustment can be done if necessary using articulating paper and 12 fluted
tungsten carbide finishing bur.
14. After proper infection control procedures have done the restoration is
brought back to the laboratory for final polish using wet pumice and dry
polishing using resin compound.

DIRECT PROVISIONAL FIXED PARTIAL DENTURES
Direct technique is most commonly used for single crown restorations. An
acrylic resin other than methylmethacrylate is used in these techniques. ie,
polymer methacrylate or bisacryl can be used.
Step-by-Step procedure:
1. Make an over impression from diagnostic cast which is modified by
diagnostic waxing using putty or irreversible hydrocolloid. Check for
completeness and trim excess of material from the crevice area using BP
blade. If hydrocolloid impression wrap it in a wet paper towel and place it
in a plastic bag. This serves as ESF.
2. Alternative to this is formation of a template from a cast poured in the
overimpression.
3. After the teeth are prepared, and the soft tissue displaced from the
subgingival margins, silicone grease is applied to the prepared tooth
surfaces for protecting against the monomer.
4. Autopolymerizing resin other than polymethyl methacrylate (ie. Poly R
methacrylate or Bis-acryl composite resin) is placed in the ESF and is
seated over the prepared teeth. If plastic matrix is used patient is able to
close his teeth there by allowing the occlusion to develop more
accurately.
5. The setting of the resin should be checked at regular intervals. The
restoration must be removed during rubbery stage that is about 2 minutes
in the mouth or 6 minutes from start of mix.
6. Place the resin in a cup of warm water (37o) for 5 minutes.
7. Excess material on the restorations is trimmed and contoured.
8. The restoration is refitted to the teeth. Any marginal discrepancies can be
corrected by addition of small increments of new resin with a small hair
brush.
9. Occlusion is refined; the restoration is removed from the teeth, polished
and cemented with provisional cement.

Indirect-Direct Provisional Fixed Partial Dentures (Egg Shell Technique)
The custom indirect -direct procedure may be a good compromise when
laboratory support is not immediately available and chair time must be
minimized.
Step-by-step Procedure:
Indirect component:
1. Mount the diagnostic cast on articulator and prepare the abutment teeth
minimally or more conservatively than the eventual tooth preparation and
should have supragingival margins.
2. Make an irreversible hydrocolloid impression of the diagnostic
preparations to duplicate them in stone.
3. Coat the stone cast with separating medium and this serves as TSF.
4. Perform a diagnostic waxing procedure on the prepared articulated casts
and duplicate the wax up and pour it to form a cast.
5. A template or ESF is formed from this.
6. Make sure that the external and tissue surface forms fit together
accurately.
7. Syringe the resin into the external surface form and complete provisional
restoration.
8. If the wax has been removed from the diagnostic cast after duplication,
seat the completed provisional on it and refine the occlusion with the
articulating paper.
9. Finish and clean the preformed ESF for try in, which will follow tooth
preparation.
Direct component:
1. Prepare the patients teeth in the usual manner.
2. Try in the preformed ESF. If it is not compatible with occlusion (ie if it
does not seat completely) and the teeth have been reduced adequately, the
internal surface of the ESF should be relieved until the occlusion is
acceptable. If necessary, reduce the teeth further; the ESF should then be
re-evaluated and adjusted. The adjustment procedure might be tedious if
the preliminary steps were not properly done. This is one of the
disadvantages of indirect- direct technique.
3. Apply a uniform coat of petrolatum on the prepared abutment teeth,
gingival tissues and external surface of ESF.
4. Make a vent hole with a round bur through the occlusal (or lingual)
surface of each abutment retainer.
5. Fill the retainer with poly R methacrylate and seat the restoration.
Placing fingertips over the vent holes can control the quantity of excess
resin expressed around the margin. When a small amount of excess resin
appears around the entire periphery of the margin, the fingertip is lifted,
allowing the trapped air and remaining excess resin to escape. Resin on
the occlusal surface can be wiped away immediately.
6. When the rubbery stage of polymerization is reached (about 2 minutes in
the mouth) engage the facial and lingual surfaces of an abutment retainer
with Backhaus forceps and rock the restoration buccolingually to loosen
it. Move to the other retainer and do the same.
7. Remove the restoration and place it in warm water to hasten
polymerization for 5 minutes.
8. Mark the margins with a sharp pencil and eliminate the excess resin. The
bulk can be removed with an acrylic resin trimming bur or carborundom
disk. A fine grit garnet paper disk completes axial shaping.
9. Confirm the marginal fit and occlusion refinish and polish wherever
necessary and cement the restoration.

Custom single unit provisional restorations:
a. Complete Crowns:
Single unit complete crowns or splinted crowns may be made directly or
indirectly. Because pontics are not involved, creating an external surface form is
simpler. Diagnostic procedures or wax up is not required unless if extensive
changes are required Eg: increase in vertical dimension. If this is not there an
alginate impression is only required before tooth preparation which serves as
ESF either directly or indirectly.
b. Onlay and partial veneer crowns:
Making onlay and inlay are similar to the custom single crowns. The
provisional may easily be distorted on handling because of the conservative
tooth preparation that interrupts the continuity of the axial wall. They can be
made directly or indirectly. The direct method should be carefully handled and
better results are expected with the indirect method.

Points to be noted:
1. When trimming the polymerized resin to the margin, leaving excess resin at
the occlusal cavosurface margin is recommended because this will help to
prevent fracture of enamel at this area because of the low strength of the resin
when compared to metal.
2. There is no need to give vent holes if lining procedures are required because
adequate space is there for the resin to escape.
c) Inlays
Inlays present the problem of being small and difficult to handle, especially
during trimming. Making interim restorations requires a number of
modifications.
Step-by-step procedure:
1. For a two-or three surface inlays apply the matrix band and wedges in the
same manner for class II amalgam restoration. The band must seal all aspects of
the proximal cavo surface margins.
2. Apply petrolatum in all sides of cavity preparation by using small cotton
pellets.
3. Make a handle to remove the resin using unwaxed dental floss preferably 2 to
3 cm long by placing one end in to the preparation cavity.
4. Mix small amount of poly R methacrylate and introduce it in to the cavity
during dough stage using an amalgam condenser.
5. Be careful not to push in to undercuts past the matrix and remove excess of
material immediately using spoon excavator.
6. Monitor the resin with a hand instrument by light probing. When the resin
reaches the late rubbery stage remove it by tugging. The floss handled with
cotton roll forceps along the path of withdrawal.
7. Place the resin in a cup of warm water (37oC) for 5 minutes.
8. Mark the margins with a sharp pencil and trim away any flash.
9. Return it back to the cavity preparation and check for occlusion and adjust
using slow speed hand piece.
10. Remove the restoration and make the definitive impression and then cement
the provisional restoration.
11. Remove the excess cement using explorer and spoon excavator. Carefully
cut of the floss handle with scalpel blade.

d. Laminate Veneers:
Step by step procedure:
1. Select the most appropriate composite resin shade or combination of shades
before preparing the tooth.
2. Apply a thin layer of petrolatum when tooth preparation is complete to the
prepared tooth surface.
3. Form the preselected shade of light cured resin using plastic instrument on
the prepared surface. Curing can also be accomplished by incremental curing
technique.
4. Light cure the resin and remove it from the tooth surface.
5. Thoroughly clean the petrolatum from the tooth surface and internal surface
of the veneer. Apply etching gel to three 1mm diameter areas to form an
equilateral triangle. (Two corners at the mesioincisal and distoincisal line angles
and the third centered more cervically) Allow the etchant to remain for 20
seconds. Rinse completely with water and dry.
6. Place unfilled bonding agent in the etched areas and immediately place the
veneer on the tooth. Hold it in place and light cure for 10 seconds. Remove any
excess bonding agent, and then cure for 60 seconds.
7. At the patients return visits remove the veneers using a spoon excavator.

Alternative method: Another method is by forming the veneers indirectly by
creating a TSF and an ESF, in the same manner for fixed partial provisional
restoration. This method is very efficient especially if multiple veneers are to be
made.


e. Post and Core provisional restorations:
Step-by-step procedure:
1. A piece of wire (Eg: a straightened paper clip) is placed in the post space, so
that it extends passively to the end of the space
2. At the mouth of the post space the wire is marked using a pencil and a 180
bend is made using pliers.
3. Lubricate the tooth and surrounding soft tissue with petrolatum. Paper points
may be used to lubricate the post space.
4. Fill the ESF with provisional resin (poly R methacrylate is recommended).
5. When the resin loses its surface gloss, place the wire in the post space and
seat the ESF over it. Care should be taken to protect the patient from aspirating
the wire.
6. Remove the ESF while the resin is still rubbery (about 2 to 2 1/2 minutes).
The stage of polymerization can be monitored. Usually the provisional comes
along with the ESF if it doesnt, it should be removed and then reseated several
times and then removed before the resin fully polymerizes.
7. Put the restoration in water. Care should be taken not to disturb the wire.
8. Mark the margins with a pencil and trim and contour the restoration with
disks or carbide burs.
9. Try in the restoration and adjust as necessary. Polish, clean and cement the
restoration.

Template fabricated VLC provisional restorations:
A transparent template is required as ESF is required to use visible light
cured (VLC) to fabricate provisional restoration. It can be fabricated using
direct or indirect techniques.
Step-by-step procedure:
1. Fabricate a template ESF using a duplicated cast from diagnostic wax up.
2. Trim the template as required and replace it back on the cast. Mix a scoop of
silicone putty and mold it around the template to prevent displacement by the
highly viscous resin later.
3. Make an alginate impression after the tooth preparation and pour a cast in
quickset plaster. Coat the cast with separating media.
4. Lay a stand of resin inside the template and also around the margins of the
preparation. (Enamel resin can be used in the incisal or occlusal portion first to
enhance esthetics on the cast)
5. Seat the template using firm pressure. Compress the silicone putty index over
the template to insure complete seating of the template and an even thickness of
resin in the provisional restoration. Remove the putty index from the cast
leaving the resin and template in position on the cast.
6. Place the cast in triad curing unit to polymerize the resin in the template for 4
minutes.
7. Carefully remove the template and then the provisional restoration from the
cast. Paint all surfaces of the restoration with air barrier coating material.
8. Place the provisional back in the curing unit, tissue side up for an additional 6
minutes. Retrieve the restoration from the curing unit and remove the entire air
barrier coating material with a brush and water.
9. Trim as much excess material as possible with a pair of curved scissors.
Finish trimming the axial surfaces to the margins with discs. Open the
embrasures around the pontic with discs and burs. Remove the saddle form and
highly polish the restoration.
In an alternative technique the restoration can be cured directly in the mouth
using hand held curing light for 10 seconds. After the restoration is frozen in
this manner it is removed from the mouth and further exposed to high intensity
curing light in the laboratory.


PREFABRICATED PROVISIONAL RESTORATIONS
A custom external surface form will produce the best results in the shortest
time in most circumstances. But there will be times when a custom ESF or time
recommended is not available for example, first-visit emergency in which
crown is missing and must be replaced. In these cases a preformed crown can be
employed to protect the tooth for sufficient time moreover, this can gain
patients confidence also.
a. Polycarbonate crown forms:
They are useful for provisional restorations on single anterior teeth and
premolars. They frequently will require extensive alteration to correct
morphologic discrepancies and improper contours. If they are not carefully
contoured, they will have horizontal overhangs that will be damaging to the
gingiva. They need to be lined with resin to meet the basic requirements.
Step-by Step procedures:
1. Measure the mesio-distal width of the crown space with dividers and select a
shell with the same or slightly larger width. (Shade can be selected using shade
guide provided).
2. Mark the crown height (From the incisal edge) with a pencil. The distance
from the pencil mark to the margin should equal the length discrepancy between
the incisal edge of the crown form and the incisal edges of the adjacent teeth.
The excess gingival length is trimmed away with a large carborundom stone or
an acrylic bur, using the pencil line as a reference mark.
3. Try the shell on the prepared tooth. The incisal edges and labial surface of the
shell should align properly with those of adjacent teeth. The internal surface of
the shell may often need reduction to achieve this match. Occlusion can be
adjusted later since it is possible to adjust it after reline. When the shell can be
properly positioned without forceful gingival contact, it is ready to be lined by
resin.
4. Apply a uniformly thin coat of petrolatum to the prepared teeth and adjacent
gingiva. This will prevent direct contact of the monomer with these tissues.
5. Mix the autopolymerizing resin and fill the shell (poly R methacrylate).
When the surface just loses its gloss or the resin forms a peak without slumping,
place the shell over the tooth and align incisal and labial surfaces with those of
the adjacent teeth.
6. Immediately eliminate any marginal excess and once the rubbery stage of
polymerization is reached (about 2 minutes) rock the crown faciolingually to
loosen and remove it.
7. Keep reseating and removing the crown few times and then put it in warm
water (37C).
8. When the resin has fully polymerized mark the margins with a sharp pencil.
The axial surfaces can be shaped and flash eliminated with straight hand piece
carbide burs and disks.
9. Try on the newly lined crown and adjust the lingual surfaces to desired
occlusion and contour using articulating paper.
10. Remove the crown out, and smooth out the rough abraded areas in the
lingual and incisal areas as well as those surfaces recontoured near the margin
with a Burlew wheel in the straight hand piece.
11. Polish all surfaces of the provisional restoration with polishing compound
and cement the restoration.

Alternative technique:
The relining of the polycarbonate shell can be done indirectly also. Here the
tooth preparation is done and an impression is made using alginate. The
impression is poured in quick set plaster. The cast is obtained and the crown
selected and the procedure is done. Polymethyl methacrylate can be used here.


b. Preformed Metal Crowns:
Emergency cases involving fractured molars are one of the best indications
for the use of preformed metal crowns. Zinc oxide and Eugenol alone will not
adhere to the tooth, and there is rarely enough time at the emergency
appointment to fabricate a custom acrylic resin provisional crown. By using the
preformed anatomic metal crown, it is possible to provide the patient with
temporary coverage to protect both the tooth and tongue. This procedure
consists of:
Minimal tooth preparation
Measurement and selection of crown.
Trimming and adaptation of gingival margin
Occlusal adjustment
Cementation
Step-by-Step procedure:
1. The tooth should be prepared minimally to create space for the restoration.
Occlusal reduction, which follows the inclined planes.
1mm on the non-functional
1.5mm on the functional cusps.
Functional cusp bevel is given is placed to a dentin of 1.5mm to
complete the occlusal reduction.
Slight proximal reduction is done to permit the seating of crown.
2. Measure the mesiodistal width of the crown space with dividers and select an
appropriate shell type with a width as close as possible. A slightly larger or
smaller shell can be deformed with contouring pliers to achieve the proper fit.
3. Measure the occlusocervical height and trim the shell with crown and collar
scissors. So that it extends about 1mm apical to the cavo surface margin. Sharp
margins should be smoothed using burs.
4. Place the trimmed shell over the prepared tooth and gradually apply seating
pressure while observing the gingiva. Trim the margins further wherever the
gingiva blanches. The shell margins should not engage the prepared tooth
margin.
5. If it is an aluminum shell the patient can be asked to close with moderate
force. The soft aluminum should deform until normal intercuspation reaches.
6. Apply petrolatum to prepared tooth and adjacent gingival tissues, mix poly R
methacrylate and fill the shell.
7. When the resin loses its gloss surface place the shell over the tooth and guide
it to a slight supraocclusal position and ask the patient to close.
8. Immediately remove the excess. When rubbery stage is reached remove the
crown with Backhaus forceps. Loosen and remove the crown by rocking it
buccolingually or by using the thumb and index finger of the other hand to
apply occlusally directed force.
9. Place the shell in a cup of warm water (37oC) for five minutes.
10. Mark the margins and trim away any excess. To establish periodontally
healthy axial contours, the aluminum shell frequently is ground away in certain
areas.
11. Replace the crown and adjust the occlusion as deemed necessary. If
proximal surface lack contact, resin can be added to correct the deficiency.
12. Polish clean and cement the restoration.


High strength provisional restorations:
Indications:
A long span posterior FPD
Prolonged treatment time
Patient unable to avoid excessive forces on the prosthesis.
Above average masticatory muscle strength.
History of frequent breakage.
Examples:
- Cast metal
- Fiber reinforced
- Heat cured provisional restorations
Heat cured provisional restorations:
1. A thin plastic matrix is made out from diagnostic wax up.
2. After the tooth preparation, an impression is made and a cast is poured.
3. The matrix is filled with ivory- coloured wax and guided in to position upon
the cast after applying wax release agent.
4. The waxed up restoration is invested in a suitable flask and heat cure resin
with appropriate shade is used to process.
5. The resin is polymerized by immersing in water at 100C for 30 to 60
minutes.
6. Gross trimming of the resin is accomplished with large burs and disks.
7. Contouring is refined with small laboratory burs to trim marginal areas and
blend facial and lingual contours in to the proximal embrasures.
8. The occlusion should be adjusted to provide positive uniform but minimal
contact areas in maximal intercuspal position. Contact in lateral excursions
should be eliminated if possible in the posterior region and provide proper even
contact in the anterior.
9. Polishing of the smooth axial surfaces of the restorations should be
performed with pumice and rag wheel running at slow speed. Interproximal
areas should be polished with flexible rubber cup and pumice.





CEMENTATION
The primary function of the provisional luting agent is to provide a seal,
preventing marginal leakage and pulp irritation. The luting agent should not be
relied upon to resist occlusal forces, because it is purposely formulated to have
low strength. Unintentional displacement of a provisional restoration is
frequently caused by a non-retentive tooth preparation or excessive cement
space rather than the choice of luting agent.
Materials:
Zinc oxide eugenol cement is the most satisfactory material. Weaker ZOE
cements allow easy removal, which enables reuse of the restoration.
Advantages of zinc eugenol cement:
They are weaker cements and facilitate easy removal.
They have acceptable sealing properties.
They have obtundent effect on the pulp.
Disadvantages of zinc oxide eugenol:
Free Eugenol acts as plasticizer of methacrylate resin and affect its
surface hardness and strength.
They results in softening of the resin, which is added to, polymerized
resin previously in contact with free eugenol. The R-methacrylates are
more affected followed by methyl methacrylate and composites.
They have shown to reduce the tensile bond strength of resin luting
agents.
In situations when the tooth preparation lacks retention, when a span is great
or long term use is anticipated or when parafunction exists, using higher
strength cements may be desirable. A good compromise would be reinforced
zinc oxide eugenol or eugenol free zinc oxide, which has slightly greater
strength than zinc oxide eugenol.

Points to be noted:
Correct proportions of the cements should be mixed to reduce unreacted
or free eugenol as much as possible.
Residue of ZOE or non-eugenol cement can reduce the tensile bond
strength of resin luting agents.
Air abrasion with aluminum oxide or etching with 37% phosphoric acid
after cleaning with pumice may be done to remove ZOE.
Step-By-Step procedure for cementation:
1. Apply petrolatum to the polished external surfaces of the restoration to
facilitate easy removal of excess cement.
2. Mix the material and apply a small quantity just occlusal to the cavosurface
margin. A marginal bead of cement forms the required seal against oral fluids.
Filling the crown or abutment retainers should not be done, because it increases
the risk of debris in the sulcus and prolongs clean up.
3. Seat the restoration and allow the cement to set.
4. Carefully remove excess with an explorer and dental floss.
5. The sulcus should be checked for remnants and irrigated with air water
syringe or else can lead to severe periodontal problems

Removal, Recementation, and Repair:
The provisional restoration must be removed either for cementation of
definitive restoration or modification of tooth preparation.
Removal forces must be directed parallel to the long axis of the
preparation. The backhaus forceps or haemostatic forceps is effective on
a single unit. A slight buccolingual rocking motion will help to break the
cement seal.
Damages are most common in removal of fixed partial denture ie, if one
abutment retainer suddenly breaks, the other can be subjected to severe
flexure stresses where FPD acts as a lever arm. Looping dental floss
under connector at each end of the FPD might be helpful.

Step-by step procedures for recementation:
1. Clean out the bulk of previous cement with a spoon excavator and by placing
the provisional in a cement -dissolving solution and setting it in the ultrasonic
cleaner.
2. If required, line the provisional restoration again and cement it.
Repairs can be accomplished by adding resin by bead-brush technique.

CONCLUSION
Quality restorative dentistry needs quality provisional restorations for
predictable results. Dentists therefore need to be familiar with the range of
materials and techniques for short term, medium-term and long-term
temporization. Forethought and planning are also needed to ensure the most
appropriate provisional is used, especially when multiple teeth are to be
prepared or where occlusal or aesthetic changes are envisaged. Such changes
are best tried out with provisionals so that modifications can easily be made
intra-orally and when satisfactory copied into the definitive restorations. In this
respect an initial diagnostic wax-up is invaluable to facilitate the construction of
laboratory formed provisionals or matrices.






REFERENCES
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2. H.T Shillingburg, Sumiya Hobo, Lowell D. Whitsett. Fundamentals of
fixed Prosthodontics.1997 3
rd
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3. Dental Laboratory Procedures: Rudd Morrow. 2
nd
edition
4. Bennani, V (2000)Fabrication of an indirect-direct provisional fixed partial
denture. J Prosthet Dent. Sep;84(3):364-5
5. Wassell RW, Barker D, Steele JG. (2002) Crowns and other extra-coronal
restorations: provisional restorations. Br Dent J. Jun 15;192:619-630.
6. Burns DR, Beck DA & Nelson SK. (2003) A review of selected dental
literature on contemporary provisional fixed prosthodontic treatment: report
of the Committee on Research in Fixed Prosthodontics of the Academy of
Fixed Prosthodontics J Prosthet Dent. Nov; 90(5):474-97.
7. Christensen, GJ. (2004) Making provisional restoration easy predictable
and economical. JADA, vol 135 :625-627