Fixed Prosthodontics II

6th Lecture

Temporary Crown or Interim Fixed Prosthodontics

(Provisional Restoration)
Provisional crowns or fixed partial dentures are essential to prosthodontic
therapy. The word provisional means established for the time being,
pending a permanent arrangement. Even though a definitive restoration
may be placed as quickly as 2 weeks after tooth preparation, the
provisional restoration must satisfy important needs of the patient and
dentist.

REQUIREMENTS
An optimum provisional restoration must satisfy many interrelated factors,
which can be classified as biologic, mechanical, and esthetic (Fig. 6-1).

Fig. 6-1: Factors to be

considered in making an interim
restoration. The central area
represents the optimum, in
which biologic, mechanical &
esthetic requirements are
adequately met

Biologic Requirements
Pulp Protection
A provisional restoration must seal and insulate the prepared tooth
surface from the oral environment to prevent sensitivity and further
irritation to the pulp. Because of the sectioning of dentinal tubules, a
certain degree of pulp trauma is inevitable during tooth preparation (Fig.
6-2). When healthy, each tubule contains the cytoplasmic process of a
cell body (the odontoblast), whose nucleus is in the pulp cavity.
In severe situations, leakage can cause irreversible pulpitis and the
resulting need for root canal treatment.

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Fig. 6-2: Pulp trauma

and exposure of the
dentinal tubules from
tooth preparation.

Periodontal Health
To facilitate plaque removal, a provisional restoration must have good
marginal fit, proper contour, and a smooth surface. This is particularly
important when the crown margin will be placed apical to the free
gingival margin. If the provisional restoration is inadequate and plaque
control is impaired, gingival health will deteriorates.
Inflamed or hemorrhagic gingival tissues make subsequent procedures
(e.g., impression making and cementation) very difficult. The longer the
provisional restoration must serve, the more significant any deficiencies
in its fit and contour become (fig. 6-3).

Occlusal Compatibility & Tooth Position

The provisional restoration should establish or maintain proper contacts
with adjacent and opposing teeth. Inadequate contacts allow supra-
eruption and horizontal movement. Supraeruption is detected at try-in
when the definitive restoration makes premature contact.
Horizontal movement results in excessive or deficient proximal
contacts (Fig. 6-5).

Fig. 6-3: A provisional restoration should have good marginal fit, proper contour, and
a smooth surface finish. A, The properly contoured provisional. Smoothly continuous
with the external surface of the tooth. B, Overcontouring. Irregular transition from the
restoration to the root surface and inadequate marginal adaptation. These factors
contribute to plaque accumulation and an unhealthy periodontium.

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Fig. 6-4: Proper occlusal &

proximal contacts promote patient
comfort & maintain tooth
position.

Fig. 6-5: A missing proximal

contact allows tooth migration.
The resulting root proximity may
require surgical or orthodontic
correction for impression making.

Prevention of Enamel Fracture

The provisional restoration should protect crown preparation margins.
This is 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 (Fig. 6-6).
Fig. 6-6: The provisional restoration
must protect the tooth. Fracture of a
tooth after the impression phase delays
treatment and jeopardizes restorability.

Fig. 6-7: The connectors of a

provisional fixed partial denture are
often purposely overcontoured.
A, In the anterior region, the
degree of overcontouring is
substantially limited by esthetic
requirements.
B, In the posterior region, esthetics
is less restrictive, but
overcontouring still must not
jeopardize maintenance of
periodontal health.

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Mechanical Requirements
Function
The greatest stresses in a provisional restoration are likely to occur during
chewing.
A partial fixed dental prosthesis (FDP) must function as a beam in
which substantial occlusal forces are transmitted to the abutments.

Removal for Reuse

Interim restorations often need to be reused and therefore should not be
damaged when removed from the teeth. In most instances, if the cement
is sufficiently weak and the interim has been well fabricated, it does not
break upon removal.

Esthetic Requirements
The appearance of a provisional restoration is particularly important for
incisors, canines, and sometimes premolars. Although it may not be
possible to duplicate exactly the appearance of an unrestored natural tooth,
tooth contour, color, translucency, and texture are essential attributes.

MATERIALS AND PROCEDURES

Many procedures using a wide variety of materials are available to make
satisfactory provisional restorations (Fig. 6-8). As new materials are
introduced, associated techniques are reported, creating even more variety.

External Surface Form

There are two general categories of external surface forms: custom and
preformed.

Custom
A custom ESF is a negative reproduction of either the patient's teeth
before preparation or a modified diagnostic cast. It may be obtained
directly with any impression material. Impressions made in a quadrant
tray with irreversible hydrocolloid or silicone rubber are convenient. The
higher cost of silicone rubber may be offset by its ability to be retained
for possible reuse at any future appointment.

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Fig. 6-8: Although there are many variations, molds used in making provisional
restorations consist of an external surface form (ESF) and a tissue surface form (TSF).
Direct techniques use the patient's mouth directly as the TSF.
A, Indirect technique: ESF, An alginate impression; TSF, a quick-set plaster cast.
B, Direct technique: ESF, A baseplate wax impression; TSF, the patient.
C, Direct technique: ESF, A vacuum-formed acetate sheet; TSF, the patient.
D, Direct technique: ESF, A polycarbonate preformed shell; TSF, the patient.
E, Indirect-direct technique: ESF, A custom preformed three-unit FDP shell made
indirectly; TSF, the patient.
F, Indirect technique: ESF, A silicone putty impression; TSF, a quick-set plaster cast.

Fig. 6-9: Shortening proximal projections of

the impression material facilitates complete
reseating of the ESF. Note that excess
impression material palatally and facially has
been trimmed away with a sharp knife for this
reason. The anterior sextant tray shown was
selected because it adequately captures the
teeth adjacent to the proposed provisional
restoration.

A custom ESF can be produced from thermoplastic sheets, which are

heated and adapted to a stone cast with vacuum or air pressure while the
material is still pliable (Fig. 6-10). This produces a transparent form with
thin walls.

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Fig. 6-10: A, inexpensive system for

producing external surface forms
from thermoplastic sheets. B, After
heating, the sheet is formed with
reusable putty; finger pressure is
applied over a stone cast. C, A more
expensive system, incorporating an
electric heating element and a
vacuum source. D, Trimmed
polypropylene external surface form.
Note the detail that can be captured
with this material.

Preformed
A variety of preformed "crowns" is available commercially (Fig. 6-12).
When extensive modification is required, a custom ESF is superior
because it is less time consuming. Preformed crowns are generally
limited to single restorations, since using them as pontics for fixed partial
dentures is not feasible. Materials from which preformed ESFs are made
(Fig. 6-13) include polycarbonate, cellulose acetate, aluminum, tin-silver,
and nickel-chromium. These are available in a variety of tooth types and
sizes.

Fig. 6-11: A, The thinness and transparency of these ESFs allow their use directly as tooth
reduction guides both in and out of the mouth. B, Tooth reduction may be assessed by using
the ESF to mold alginate over the prepared tooth. When the alginate is set, the ESF is
removed, and a periodontal probe is pushed through the alginate for measurements at desired
locations.

Fig. 6-12: A, The time required to modify this

particular preformed crown outweighs the advantages
it might provide. If a custom external surface form
were available, it would be more efficient and more
economical. B, The excessively tapered internal
lingual wall of this preformed crown requires
grinding to accommodate a properly prepared tooth.
(The stone cast in the lower portion of the illustration
duplicates the internal surface of the preformed
crown).

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A\ Cellulose Acetate
Cellulose acetate is a thin (0.2 to 0.3 mm) transparent material available
in all tooth types and a range of sizes (see Fig. 6-13, A). Shades are
entirely dependent on the autopolymerizing resin. The resin does not
chemically or mechanically bond to the inside surface of the shell, so
after polymerization the shell is peeled off and discarded to prevent
staining at the interface. However, removing the shell requires the
addition of resin to reestablish proximal contacts.

Fig. 6-13: A, Preformed anterior crown

forms: polycarbonate (left) and cellulose
acetate (right).
B, Preformed posterior crown forms:
aluminum shell (left), aluminum anatomic
(center), and tin-silver anatomic (right).

B\ Aluminum and Tin-silver

Aluminum and tin-silver are suitable for posterior teeth (Fig. 6-14).
Fig. 6-14: Aluminum anatomic crowns.
Available in a variety of sizes & shapes.
The manufacturer has produced two
maxillary and four mandibular shapes for
the left and right side of the mouth, each
in six sizes.

C\ Nickel-chromium
Nickel-chromium shells are used primarily for children with extensively
damaged primary teeth (Fig. 6-15).

Fig. 6-15: Nickel-chromium anatomic

crowns. Available also in an array of sizes &
shapes, including ones for the primary teeth,
with straight and contoured axial surfaces.

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PROVISIONAL RESTORATIVE MATERIALS

Ideal Properties
An ideal provisional material has the following characteristics:
Convenient handling: adequate working time, easy moldability,
rapid setting time.
Biocompatibility: non-toxic, non-allergenic, non-exothermic.
Dimensional stability during solidification.
Ease of contouring and polishing.
Adequate strength and abrasion resistance.
Good appearance: translucent, color controllable, color stable.
Good patient acceptance: nonirritating, odorless.
Ease of adding to or repairing.
Chemical compatibility with provisional luting agents.

Currently Available Materials

The ideal provisional material has not yet been developed. A major
problem still to be solved is dimensional change during solidification.
These materials shrink during polymerization, which causes marginal
discrepancy. In addition, the resins currently used are exothermic and not
entirely biocompatible.

The materials can be divided into four resin groups:

1. Poly(methyl methacrylate).
2. Poly(R' methacrylate)*.
3. Microfilled composite.
4. Light-cured.

By:
Noor Al-Deen M. Al-Khanati

*
The R' represents an alkyl group larger than methyl (e.g. ethyl or isobutyl).

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