Quartz 4

M3 Temporization

12 min read

Temporarisation1

Synonyms

  • Provisional restoration/prosthesis
  • Interim restoration/prosthesis
  • Temporary restoration/prosthesis

Info

In the context of indirect restorations, this refers to temporary crowns.

Temporarisation1

Temporary prosthesis

A fixed or removable dental prosthesis, designed to enhance aesthetics, stabilize and give function for a limited period of time, after which it is to be replaced by a definitive dental prosthesis.

Assist determination of the therapeutic effectiveness of a specific treatment plan or the form and function of the definitive prosthesis.

  • Act as a 'trial' for the final restoration, allowing evaluation of the new shape, form, and bite, especially in cases involving an increase in the patient's vertical dimension.

Objectives of Provisional Restorations

The primary aim of a provisional crown is to fulfill a set of biological, mechanical, and aesthetic requirements during the interim period between tooth preparation and the placement of the final restoration.

  • Biological
  • Mechanical
  • Aesthetic
  • Part of adjunctive therapy
    • Endodontic treatment
    • Periodontal treatment
  • Communication with dental laboratory

Biological Requirements2

  • Prevent sensitivity
  • Maintain pulp vitality
  • Maintain periodontal health
  • Resolve gingival inflammation
  • Prevents caries (prolonged application)

Pulp Protection3

  • Provisional restoration must seal and insulate the prepared tooth from oral environment
    • Thermal, bacterial and chemical irritants

Warning

If the provisional is lost, bacteria can infiltrate the exposed tubules, potentially leading to future complications even if the patient does not experience immediate pain.

  • Inevitable pulp trauma can become irreversible if adequate provisional restoration cannot be made

Use of Desensitizers

  • Applying a desensitizing agent or a dentin sealing agent can help seal the tubules and improve the bond of the final restoration.
  • ==Caution: Routine use is not recommended for all cases. In situations with deep preparations, a desensitizer might mask underlying sensitivity that could become a problem after the final crown is cemented. The final cementation process (e.g., etching for a resin cement) may remove this protective layer, leading to delayed onset of symptoms.==
  • Used to assess questionable pulpal vitality before completing definitive restorations
  • Ideal when dealing with teeth with “cracked cusps”

Diagnostic Use in Cracked Tooth Syndrome

  • ==Symptoms: Patients with cracked tooth syndrome often present with sharp pain on biting and release, without visible decay. The pain is caused by the movement of dentinal fluid as the crack flexes under occlusal load.==
  • ==Provisional as a Diagnostic Tool: A full-coverage provisional crown is placed to splint the cracked cusp, preventing it from flexing. The patient is monitored for several weeks. If the symptoms resolve, it indicates that a permanent crown will likely solve the problem.==
  • ==Alternative Management: An orthodontic or metal band can be placed around the tooth with a GIC (Glass Ionomer Cement) filling inside. This also holds the cusps together, simulating the effect of a crown. If this resolves the pain, a permanent crown is the indicated final treatment.==
  • ==Prognosis: If the crack is too deep or has already led to irreversible pulpitis, further treatment like root canal therapy or extraction may be necessary. Endodontists often need to trace the extent of the crack to ensure a proper seal can be achieved before beginning root canal treatment.==
  • Good anchorage for rubber dam clamps

Maintain Periodontal Health4

  • Provisional restoration must facilitate plaque control by:
    • Good marginal fit
    • Proper contour
    • Smooth surface
  • ==Avoid Overextensions: Overextended or poorly fitting margins act as plaque traps, leading to gingival inflammation, bleeding, and potential decay.==
  • Provisional restoration can be used to promote healing of soft tissues and allows resolution of gingival inflammation
  • If the existing restoration preclude proper plaque control, then a well made provisional restoration could help to restore gingival health

Foundation for Final Restoration

Healthy gingiva is crucial for taking an accurate final impression and for the successful cementation of the permanent crown.

  • Provisional restoration - periodontal tissues to stay or become healthy.
  • Possible implications on
    • Adequate tissue management and definitive impressions
    • Possible recession and aesthetic dissatisfaction
  • Monitor healing after crown lengthening surgery

Mechanical Requirements5678

  • Maintain tooth position (occlusal stability)
  • Protection against fracture
  • Resist functional load
  • Resist removal forces (retention and resistance)

Occlusal stability9

  • Preserve intra-arch relationship:
    • Provisional restoration should establish and maintain proper contacts with adjacent teeth
    • Prevents movement or drifting
    • Significant implication on bridge fit

Occlusal stability9

  • Preserve inter-arch relationship:
    • Establish and maintain proper contacts with the opposing dentition
    • Prevents extrusion
    • Observes the effects of occlusion before the definitive restoration

Clinical Considerations

  • While tooth movement may be minimal in a periodontally stable patient, it is a significant risk for patients who have recently undergone orthodontic treatment. In these cases, the periodontal ligament is not yet fully stabilized, and teeth can move quickly if not held in place by a well-fitting provisional with tight contacts.
  • Any tooth movement between the impression and insertion appointments can prevent the final crown from seating correctly.

Protection Against Fracture10

  • Protection of weakened tooth structure after preparation
  • Protection of core restoration
  • Protection of preparation features
  • Even small fracture will increase chair side time and, in extensive cases, might require remake

Resist Functional Load11

  • Provisional restoration should be strong enough to resist functional load:
    • Preparation reduction
    • Provisional restoration adjustment
    • Material selection
  • Should preserve intercuspal contacts to maintain tooth position
  • Occlusal interferences must be removed

Resist Removal Forces12

  • Retention and resistance forms of the preparation
  • Fit of provisional restoration
  • Cementation material

Aesthetic Requirements1314

  • Colour compatibility
  • Translucency
  • Colour stability

Depends on:

  • Material

  • Morphology

  • Choose material that is close to final shade

  • Choose material carefully if long term provisional restoration is required

  • After major alterations

    • Clinician and patient can assess tooth form, gingival contours, shade requirements and effects on phonetics prior to final definitive restorations
    • Once approved, an impression of the provisional restorations allows the technician to build new crowns to the same shape
    • Alteration of the palatal surfaces or the incisal tips of the upper anterior teeth can cause problems in forming ‘S’, ‘F’, ‘V’ & ‘Th’ sounds

MATERIALS151617

Selection depends on:

  • Anticipated load
  • Prosthesis design
  • Span length
  • Duration of provisional restoration Materials include:
  • Polymethyl Methacrylate (PMMA)
  • Polyethyl Methacrylate (PEMA)
  • Bisacryl Composite Resin
  • Light-Cured Composite Resin

Metal Reinforcement with base metal alloy

Ideal Properties of a temporary restoration18

  • Adequate strength
  • Abrasion resistance
  • Biocompatible
  • Non-irritant
  • Dimensional stability
  • Ease of contouring and polishing
  • Good appearance
  • Convenient handling
    • Working time
    • Setting time
    • Application
    • Easily modifiable

PMMA19

Advantages2021222324

  • High strength
  • Colour stability
  • Can be characterized
  • Easily smoothed and polished
  • Easily repaired
  • Low cost

Disadvantages

  • Highly exothermic: can be traumatic to the pulp
  • Significant polymerization shrinkage
  • Monomer release
  • Unpleasant odour

Indications25

  • Should not be used directly in the mouth
  • Laboratory construction (indirect method)
  • Shell construction in the laboratory then can be relined by PEMA intraorally (indirect-direct method)
  • Suitable for long-span provisional restoration

Examples: Jet, Polyvicron

PEMA26

Advantages2021222324

  • Less exothermic reaction than PMMA (but higher than Bisacryl composite)
  • Moderate strength
  • Can be smoothed and polished
  • Can be characterized
  • Easily repaired
  • Low cost

Disadvantages

  • Weaker than PMMA
  • Discoloration
  • Unpleasant odour
  • Susceptible for polymerization shrinkage

Indications25

  • Single crowns (direct method)
  • Short span bridge
  • Short term provisional restoration (2-3 weeks)
  • Relining pre-formed or laboratory made shell

Examples: Trim, Snap

Bisacryl Composite Resin27

Advantages2021222324

  • Low exotherm
  • Minimal polymerization shrinkage
  • Ease of application (Cartridge system)
  • Can be smoothed and polished
  • Can be characterized

Disadvantages

  • Brittle
  • Difficult to repair
  • Does not bond to polycarbonate crown
  • High cost

Indications25

  • Single crowns (direct method)
  • Ideal for intraoral application with matrix or template
  • Short span bridge

Examples:

Protemp (3M), Luxatemp (DMG), Structor (Voco), Integrity (Dentsply)

Light-Cured Composite Resin28

Advantages2021222324

  • Controlled setting (light-cured)
  • Highly aesthetic
  • Can be characterized
  • Easily polished and smoothed

Disadvantages

  • Brittle
  • Transparent template is necessary or freehand application
  • Can be time consuming
  • High cost

Indications25

  • Single unit restoration (direct method)
  • Inlays, onlays and veneers
  • Repairing open margins of Bisacryl composite crowns
  • For laboratory application (indirect method)
  • Overlaying metal reinforcement

Example: Symphony (Flowable composites)

FABRICATION TECHNIQUES29

  • Direct (chairside)
    • Preformed
    • Custom
  • Indirect (laboratory)
  • Indirect-Direct (laboratory and chairside)

Direct: Preformed30

  • Based on preformed mould (not a complete restoration)

  • Must be relined with an acrylic material

  • Used for single unit restoration

  • Available moulds:

    • Polycarbonate
    • Cellulose acetate
    • Aluminum
    • Tin-silver
    • Nickel-chromium

Polycarbonate crowns31

  • Part of the provisional restoration
  • Bond to PEMA
  • Colour stable. Only one shade

Polycarbonate crowns31

  1. Select the correct crown
    • Morphology
    • Mesiodistal width
  2. Adjust the height accordingly until passively fitting
    • Green stone
    • Soflex discs
  3. Lubricate the prepared tooth with thin petroleum coat
    • Protection from monomer
    • Avoid bonding of the acrylic to the tooth
  4. Mix PEMA
  5. When the mixed PEMA loses its gloss, place it in the shell
  6. Fit the crown on the prepared tooth and align it adequately
  7. Immediately eliminate marginal excess material before the rubbery stage
  8. After the rubbery stage (about 2 minutes) remove and reseat the crown
    • Facilitate removal
    • Minimize thermal irritation
  9. After full setting (5 minutes), the excessive material can be adjusted
  10. Adjust the occlusion

Acetate strip crowns32

  • Determine the tooth morphology
  • Does not bond to acrylic
  • Should be removed after setting

Metal crowns3334

  • Molar and premolar
  • Easily adjustable
    • Occlusal surface
    • Contact area
  • Part of the provisional restoration
  • Bond to PEMA

Direct: Custom353637

  • Requires a mould
  • Can be:
    • Silicone
    • Clear thermoplastic material
  • Can be used with any provisional material

Construct the mould with one of the following techniques:

  • Intraorally (silicone)
  • Extraorally: on diagnostic cast or wax-up (silicone, thermoplastic template)

  • Lubricate the prepared

  • Acrylic PEMA Bisacryl

  • Apply the material to the mould

  • Seat the mould

  • Trim the excess

  • Polishing

Advantages2021222324

  • Easy to apply
  • Applied in the same visit
  • Incorporates wax-up modifications
  • Cheapest

Disadvantages

  • Inferior mechanical properties
  • Optimal fit is compromised
  • More overall clinical time

Indirect38

  • Impression of the prepared teeth
    • Elastomeric
  • Laboratory construction of the provisional restoration
    • With the aid of template
    • In pressure pot

Advantages2021222324

  • Superior mechanical properties
  • Better fit
  • Better finish and polish
  • Less clinical time
  • Incorporates wax-up modifications
  • Possibility of metal reinforcement

Disadvantages

  • Time consuming (additional clinical appointment)
  • Additional cost
  • More suitable for extensive restorations

Metal reinforced provisional restorations39

  • Long term temporary restorations
  • Extensive areas

Indirect - Direct40

Indirect

  • Stone model is conservatively prepared in the laboratory
    • Supragingival margins
  • Provisional restoration is constructed in the laboratory with the aid of template

Direct

  • Provisional restoration is tried in the mouth and adjusted accordingly
  • Relined with suitable material

Advantages2021222324

  • Superior mechanical properties
  • Better finish and polish
  • Incorporates wax-up modifications

Disadvantages

  • Additional laboratory cost
  • More time consuming than indirect technique
  • Suitable for bridge provisional restoration

CAD-CAM4142

TEMPORARY CEMENTS

Objectives

  • Provide adequate seal
  • Retain provisional restoration
  • Minimal solubility
  • Adequate handling and mixing
  • Adequate working and setting time
  • Cleansable
  • Compatible
    • Pulp and gingiva
    • Tooth structure, core restoration and provisional restoration material
  • Allows for restoration removal

Examples4344

  • Zinc-oxide eugenol cement (Tempbond)

  • Eugenol free cement

  • Polycarboxylate cement (harder cement)

  • Tempbond clear (Aesthetic option)

  • Zinc-oxide eugenol is the most commonly used cement

  • Strength can be minimised by the addition of petroleum gel

  • High strength cements should be avoided since restoration removal can damage either the restoration or prepared tooth.

Indications:

  • Lack of retention in tooth preparation

  • Long span or long-term use of provisional restoration

  • Parafunctional activities

  • Free eugenol acts as a plasticiser of methacrylate resin

  • Possible effects on:

    • Resin provisional restoration, composite core
    • Bond strength of resin cements

  • Some studies have shown that eugenol-containing temporary cements can reduce bond strength of resin cements, but there are other in vitro studies showing no difference

Cementation Process454647

  1. Mix the base and activator
  2. Apply a small quantity just short to the margin
  3. Seat the crown and hold tightly (or ask patient to bite over a cotton roll)
  4. Remove the excess with an explorer and dental floss
  5. Make sure no cement is left in the gingival sulcus
  6. Occlusion should be checked and adjusted after cementation

Footnotes

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