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Using a Reliable, Quick, Aesthetic Bisacryl for Provisional Restorations Terrance J. O’Keefe, DDS

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by Terrance J. O’Keefe, DDS
I am a sole proprietor dentist practicing in upstate New York. Every day in my office is an adventure in time management. Meeting patient expectations in a timely manner is a daily goal. So I'm always looking for dental products that can help me meet that goal. The following is one of those products.

Crown and bridge dentistry is and has been a staple of my practice for 20 years. The ability to properly diagnose, painlessly prepare teeth, accurately impression, provisionalize and finalize well-fitting, aesthetic inlays, onlays, crowns and bridges is expected by my patients. Our fine local anesthetics help me provide painless care, and patients will tolerate five minutes of impressioning (no matter how goopy), but if you cannot make a good provisional they won't trust you for the permanent crown. Remember, patients wear their provisionals outside of the friendly confines of your office; wouldn't it be nice if they had kind words about them? For years the provisionalization stage was a struggle. Methyl methacrylate resins required a pre-operative model with a suck-down template (Fig. 1) or immediate preoperative impressions that were difficult to reseat, smelled and tasted bad, took too long to set, became very hot, and provided inadequate aesthetics. It was difficult explaining to discerning patients how fabulous their final crown would be when the provisional looked dull and lifeless. It is hard to expect patients to sing your praises when their provisionals look or feel bad.



Making the temporary was not fun. In my office, I like to do the fun stuff, and allow my staff to do the not-so fun stuff. Unfortunately, because of the requirements of mixing, allowing adequate setting time to remain dimensionally stable without locking on or frying the tooth, made delegating this step difficult for me. Then of course there was all of the time needed in trimming the unit – all in the face of the resin snowstorm and the lovely chemical smell left behind.

Several years ago I started using Structur Premium by VOCO (Fig. 2) for my provisionals. Structur Premium comes in self-mix cartridges (or small Structur Premium QM syringes), so I no longer measure or mix. Then there is the issue of a template or matrix. While I can still use a suck-down, I don't have to. If I would like, I can use the handy dandy Matrix Button (Fig. 3) thermoplastic (Advance Dental products) to create a pre-operative shell for the Structur Premium. Bisacryls do not heat up and damage or stick to thermoplastics like methacrylates do. Simply place the Matrix Button into hot water to soften and form over tooth, teeth or model to make a well-fitting template that can be cooled in moments with a stream of air from the three-way syringe. With the matrix in hand, I simply prepare the patient's tooth or teeth (painlessly of course), fill said matrix to form a wonderful provisional in about five minutes. The Structur Premium has an interim rubbery phase that allows you to easily remove without the dreaded lock-on. The total set time is about four to five minutes. Of course there will be a little flash to remove, but this is really easy. The margin definition is fabulous so I now use one of the used preparation diamonds in a highspeed handpiece to maintain my precision. Once the flash is removed, I try the provisional, check and make any corrections to the occlusions, and interproximals (with a well-fitting matrix there are almost no adjustments) and polish for cementation. If there are any bubbles, small voids or interproximal inadequacies, Structur Premium can be added to a flowable resin. Ta da – you have a well-fitting, aesthetic provisional that will give your patient confidence to smile and say what a great dentist you are! And this step can be easily accomplished while the impression sets by yourself, or any member of your staff.

Case 1:
The Emergency Provisional Crown
Our first patient came in for emergency care. He felt that he had something stuck between two of his lower left back teeth, which were tender when he chewed. This patient had a history of chewing on ice. We soon determined that the patient had fractured a freely mobile distal cusp of his lower left first molar #19 (Fig. 4). I removed the piece surgically (Fig. 5), and decided that this tooth would need extensive care to remain part of his dentition. I performed a pulpotomy procedure, placed a bonded resin temporary filling and referred to an endodontist.

In about a week, our patient returned with a lovely root canal treatment, and a Cavit (3M ESPE) temporary (Fig. 6). This is where Structur Premium can make you look like a hero. I placed a bonded core material (in this case ParaCore – Coltene Whaledent) to contour (Fig. 7), made a Matrix Button template (Fig. 8) and prepared the tooth for full coverage. In no time at all I was able to use Structur Premium shade A3 to make a superb provisional (Fig. 9), which was trimmed, polished (Fig. 10) and cemented into place (Fig. 11). So during a regular appointment slot our patient was able to get rid of his temporary and get form and function back.

This provisional allowed the tissue to heal so that a periodontist could complete a crown lengthening procedure and we could finish this complex case. After the crown lengthening, I reprepped the tooth, made an impression for our lab and remade the provisional (using the original template). As I stated earlier, the fabricating of the provisional was done while the impression material set (and it was fun, so I did it). Again our patient left with a well-fitting provisional, so that even though there were many steps in his care, he was happy, comfortable and able to look forward to having an acceptable final restoration (Fig. 12).

Case 2:
The Conservative Tooth Replacement
In these days of very predictable implant tooth replacement, there are still some patients that cannot or will not accept this option, and still don't want to cap their adjacent teeth to replace the missing one. While we have conservative, aesthetic, final restorative options such as bonded bridges, the provisional has always been a problem. Patients do not like wearing flippers if they can help it. Also I have found that the methyl methacrylate-based provisional materials needed excessive bulk so that they didn't bend away from the teeth, or just break. No one wants the "broken temp bridge" call from the not-so-happy patient at 10 p.m. before a holiday… I had one of these cases.

My patient had a periodontally failed upper right lateral tooth (Fig. 13) that was retained (most of the time) with a blob or two of composite stuck to the adjacent teeth (Fig. 14). Obviously this was not a healthy situation. We discussed replacing the already lost tooth. For several reasons an implant-retained crown was not an option, and neither of us wanted to cut down the adjacent teeth for full crowns. The lingual occlusion of the central and cuspid eliminated the option of a no preparation bonded wing (Maryland Bridge) restoration. I recommended an inlay-retained bridge using a zirconium framework. I made a few study models to design my restoration, cut a supportive wire, and made a suck-down template using a denture tooth. My patient made his extraction/preparation/provisionalization appointment for just prior to a holiday, so that his extraction site could heal while he was away from work.

As we had planned, during our preparation appointment, we needed to remove the lateral tooth (along with the blobs of composite), prepare the inlays, make the impression for the lab to make the final restoration, make and place an acceptable provisional. This is a pretty tall order considering that our patient doesn't want to spend all day in our office and expects to look good when he leaves. The days of saying "don't worry it's just a temporary" are long gone so this temporary had better look natural and stay in place until the final restoration is placed. We were able to remove the tooth with the extra plastic blobs (Fig. 15) and prepare the inlays (Fig. 16) painlessly in a short period of time. This leaves only to make the impression and provisional. I know how comfortably the Structur Premium sets up, so I start my provisional first, which allows me to contour it during the five minutes that the impression material needs to set. I find that my patients really enjoy watching me "make their tooth" and it seems to take their mind off of the impression step. Of course I would lose some of my cool if I can't finish this job in the allotted time. No problem because this stuff cuts so nicely!

I placed a supportive wire (I probably did not need it because the Structur Premium is very strong, but it is a fast easy step and remember the holiday was coming) with a dab of flowable resin on the unetched dentin (Fig. 17), filled the suck-down template with Structur Premium shade A2, and placed it over the preparations (Fig. 18). I easily removed the template in a few minutes during the rubbery phase and allowed final set of the fairly small inlays in the template, which allowed us to start the impression. When the impression tray was seated, I removed the provisional and began contouring with the used preparation diamond burs – no bending, breakage, tearing or snowstorms! We beat the impression so easily that I had time to polish with flour pumice on a rag wheel and take a picture (Fig. 19). Yes – polish before checking the occlusion! These provisionals seat great without the drag of the methyl methacrylate, and they fit just as designed. The worst thing is if they are a bit high, they can be adjusted with a 12-fluted composite finishing bur before or after cementation without losing the surface. Now we just had to wait for the impression material (nice problem, huh?), try-in the provisional, show our patient and cement. There is a little delay waiting for the patient to finish his praise of your skills in making this marvel that he watched as his impression set. I used TempBond (Kerr) to temporarily affix our provisional (Figs. 20 & 21) for the two-week lab time over the holiday. When our patient returned for the final restoration, I simply removed the provisional (intact as I had planned), cleaned the preparations and bonded the final restoration in place (Fig. 22). At no time did my patient have to deal with the embarrassment of a missing tooth or unsightly provisional. Remember that a happy patient might tell a few people about you, but an upset patient will tell everyone! I enjoy my holidays too much to risk them being ruined by problems with provisionals… especially since Structur Premium make them so fast and easy to make.
Author’s Bio
Dr. Terrance O’Keefe earned his dental degree from the State University of New York at Buffalo and practices in Penfield, New York. He is member of the American Dental Association (ADA), the Dental Society of the State of New York, the Seventh District Dental Society, and the Monroe County Dental Society. He has served on the Monroe County Dental Society board of directors, and is past president of the Rochester Dental Study Club. You can contact Dr. O'Keefe at info.DrOKeefe@rochester.rr.com.
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