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Cores and Provisional Restorations Howard Chasolen, DMD

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As restorative dentists, today, we are basically treating either tooth-related restorations or implant related restorations. And, as pro-implant as I am, there are many instances when a properly treated tooth is the correct clinical decision over that of a dental implant. Often, when we are making decisions to retain or remove a tooth, and formulating a definitive restorative treatment plan, we think about a dental implant. In today’s world, an implant is a predictable and relatively expedient treatment option.



An implant eliminates a major etiology of restorative recurrent failure – dental caries. However, there are many decisions to make regarding the placement of an implant:
  1. Is there adequate quantity of bone in both height and width?
  2. Is there adequate quality of bone in intended receptor site?
  3. Are the restorative goals fulfilled with an implant?
  4. Will the angulation or trajectory of an implant be aesthetically, biologically or biomechanically manageable?
  5. Is there enough attached tissue?
  6. How will the patient be temporized during the healing phase of an implant treatment or will the implant be immediately temporized?
  7. Do and/or should the finances of implant treatment influence the decision to keep a tooth?
It seems in recent years, we are all quick to remove a tooth and replace it with an implant. But, do we have a decision algorithm that helps us decide? For many, questionable teeth are selected for extraction because they do not have a protocol for ensuring success when treating moderate to questionable prognosis teeth. And, if this protocol were to be applied to teeth earlier on in the continuum of the disease process, we would likely save many teeth from progressing to the questionable stage.

This paper will discuss the protocol of treating teeth with a team approach of periodontal and restorative treatment. Whether you are using a true team approach or you are a solo practitioner executing treatment in its entirety, the process remains the same. I will state that proper surgical training is necessary to apply the periodontal aspect of this treatment protocol. Several papers have been published on this perio/restorative protocol however; it is strongly recommended that a surgical course given by an expert in the technique is completed before attempting the surgical aspect of treatment.

Many of us treat patients with existing restorative dentistry. Often, this restorative dentistry is in a state of break down. The result is caries, subgingival margins, furcation involvement, root flutes, root concavities and biologic width problems.

When replacing old subgingival restorative dentistry, it is necessary to correct the biologic and structural conditions that result from caries removal, thin attached tissue and furcation exposures. Traditionally, crown lengthening was the procedure of choice. However traditional crown lengthening can be destructive and may leave a patient with a poor prognosis, often worse than before treatment began.

Traditional crown lengthening to correct these problems may necessitate the unnecessary removal of excess bone as well as worsening crown to root ratios, exposing root surfaces that may become thermally sensitive and creating cosmetically displeasing outcomes.

A classic example of this is crown lengthening a molar with a high furcation. Removing bone in this area to create a biologic width often creates a deep Class 2 furcation rendering a poor prognosis., exposed root surface leading to sensitivity and a potential cosmetic issue.

Preforming biologic shaping and placing soft tissue grafts provides a sound, healthy foundation for a definitive crown. However, prior to the periodontal correction, a core and a provisional restoration must be placed by the restorative dentist.

Once we have decided that periodontal correction is advantageous, we now need to set up the case for our periodontist. All old restorative dentistry must be removed, and an adhesive core and provisional should be placed prior to the periodontal surgery. Because caries dictates definitive margin placement, it does not make sense to perform any perio/restorative procedure without first establishing the restorative endpoint (the margin). This can not be predictably accomplished without a core and a provisional. And without a provisional restoration, the periodontist can never have 360-degree access to perform biologic shaping and idealize periodontal conditions.

The benefit of placing a core and provisional followed by a referral for periodontal correction in the form of Biologic Shaping (Dr. Danny Melker) and soft tissue grafting has many benefits:

Benefits of Core Build-ups
  1. Caries removal
  2. Pulp protection
  3. Biologic periodontal template
  4. Allows for impressions with no tearing from undercuts
  5. Allows for a uniform thickness of restorative material and less unsupported restorative material resulting in less material fracture.
Indications for biologic shaping
  1. There are biologic width problems.
  2. There are furcation problems, especially early or class 1.
  3. There are abfractions on the facial root subgingival to the restorative margin.
  4. There are root surface divots or irregularities below my margin that can be visualized.
  5. There are root flutes or concavities such as are almost always present on first premolars.
  6. There are lingual or distal undercuts under my margin.
  7. There are periodontal lesions undercut to my margin.
  8. I need to move a margin in a coronal direction without orthodontics.
Having a repeatable protocol and routine for saving teeth ensures good long term success. It allows the restorative dentist to assign a prognosis to a tooth prior to a periodontal procedure and allows the periodontist the opportunity to visualize not only the surgical field in 360 degree fashion, but also the restorative endpoint before supporting bone is removed. Followed in the manner described, biologically sound and cosmetically pleasing restorative dentistry can be commonplace using teeth as abutments.


Author’s Bio
Dr. Howard Chasolen graduated from the University of Medicine and Dentistry of New Jersey in 1991. He earned a specialty certificate in Prosthodontics and a fellowship certificate in Implant Prosthodontics from the University of Pittsburgh School of Dental Medicine from 1991 to 1994. He is a Diplomate of the American Board of Oral Implantology and a Fellow of the American Academy of Implant Dentistry. He is the founder of The Chasolen Education & Research Center, a Center for educating Dentists around the world and teaches across the country giving more than 75 hours of continuing education per year. His private practice is located in Sarasota, Florida, and is limited to prosthodontics, cosmetics, implant dentistry and the restoration of the complex interdisciplinary patient. He has restored more than 11,000 units of crown and bridge and more than 4,200 implants.





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