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Fabrication of Provisional Crowns and Bridges

Cynthia M. Cleveland, CDA; Angela D. Allen; Niki Henson, RDA, AS

Importance and Purpose

Provisional restorations are used as a short-term or interim (medium-term) step. They aid in diagnosis,
treatment planning and communication to the laboratory for the clinical success of definitive fixed
restorations. They may also provide coverage and support during periodontal treatment including implant
therapy in developing the morphology of perio-implant periodontal tissues, over strategic extraction sites,
during grafting techniques, furcation and endodontic treatment, and serve as a guide for the final
restoration. Changes can be made during this phase to correct esthetics, phonetics, and function. The
provisional may only be required for two to six weeks, or in some situations, must remain in a satisfactory
condition in the oral cavity for twelve to eighteen months.
It is important to provide protection for the teeth during these times. The provisional must be properly
fabricated and cemented. The treatment performed reflects the entire dental practice. Therefore, when a
provisional is esthetically pleasing, remains intact, cemented and is comfortable, you have gained much
more than a well-fitting provisional.
There are five basic purposes for a provisional. Each purpose relates both to the individual tooth or teeth
and the patient as a whole.
1.
2.

3.

4.

5.

Protection of tooth and/or restoration The provisional provides protection for the tooth from the time
of preparation until the final crown is cemented.
Tissue conditioning and healing The provisional restoration can be used to assist the gingival tissue in
establishing good contour, and with the healing process. Ideally, the tooth should not be prepared more
than 1/2 mm under the gingiva unless it is necessary for retention, esthetics, or function.
Esthetics The provisional crown can act as a rough draft for the dentist and patient to discuss the
appearance of the permanent crown. After wearing the provisional for some time, the patient may request
changes to the final crown. Changes may include color, shape, length, embrasure, and many
others. Provisional crowns allow the patient to become accustomed to the new shape, contour, and length
if these were altered for cosmetic or functional purposes.
Maintaining Space for New Restoration The provisional restoration is responsible for maintaining
space for the final restoration. The provisional must touch the tooth to the mesial and distal of the
prepared tooth as well as the opposing tooth. This contact will help reduce, and hopefully prevent, the
adjacent teeth from moving. If the provisional is too small and does not provide adequate contact, the
adjacent teeth will move into the open space. When the restoration is complete and ready to be seated, it
may be too tight or not fit at all. An accurately sized provisional, both mesially and distally, will also
prevent food from being trapped between the teeth. Trapped food can cause gingival inflammation, pain,
and infection.
Function Function is one of the most basic purposes of a provisional crown. The patient needs to be able
to eat (on a modified diet) during the period of time he/she is waiting for the permanent crown. Occlusion
should be slightly lighter than traditional occlusion to allow the pulp and periodontal ligament (PDL) to heal
after the procedure.
With these five primary purposes in mind, evaluate the tooth, surrounding tissues and teeth, and identify
any special circumstances. Use this knowledge to determine the best material, fabrication technique,
necessary adjustments, cementation, and post operative instructions for the patients provisional
restoration.
Table 1. Provisional Crown or Bridge Requirements

Pulpal protection. The restoration must be fabricated of a material that will prevent
the conduction of temperature extremes. The margins should be sufficiently adapted to
prevent leakage of saliva.
Positional stability. The tooth should not extrude or drift in any way. Any such

movement would require adjustments or a remake of the final restoration costing the
dentist and the patient time and money.
Interproximal Contact. Mesial and distal contacts should be tight enough to prevent
food and debris from packing between the teeth while still permitting flossing.
Occlusal function. The tooth should fit properly against opposing teeth. This will aid
patient comfort and will also prevent tooth migration. If the occlusion is too high, the
pulp may become inflamed and cause the patient pain. Too light occlusion may result
in tooth extrusion and loss of function.
Easily cleaned. The restoration must be made of a material and contour that will
encourage the patient to keep it clean. If the gingival tissue remains healthy during the
wearing of the provisional, there is less likelihood of a problem arising after
cementation of the final restoration and a better chance of a dry environment for
cementation.
Margins non-impinging. The gingival margins of the provisional restoration must not
impinge on the gingival tissue. The resulting inflammation could cause hypertrophy,
gingival recession and, at the very least, hemorrhage during cementation. A damaging
overhang can result from a preformed metal or plastic provisional restoration that has
not been contoured properly. Custom acrylic provisional crowns can produce a
horizontal overhang if they are not trimmed properly. A restoration with drastically
under contoured margins is likely to result in tissue proliferation. It is very important
to trim properly to avoid such situations (Figure 1).
Strength and retention. The restoration must stand up to the forces to which it is
subjected without breaking or coming off the tooth. Replacing a provisional is timeconsuming and does not aid in patient rapport. The restoration should remain intact
during removal, so that it can be reused if necessary.
Esthetics. In some cases, the restoration must provide a good cosmetic result,
particularly on anterior teeth and on maxillary molars.
Figure 1. Properly Trimmed Provisional

Courtesy of 3M ESPE

Provisional Crown and Bridge Materials


Today, we have many choices of materials to fabricate a provisional crown and bridge. We can choose from
the traditional self-cured acrylic polymers, or the more advanced light-cured or dual-cured resins, as well as
pre-fabricated provisional crowns.
Provisional materials can be categorized as follows:
I.
a.
i.
ii.
II.
a.
b.
c.
d.
III.
a.
i.
ii.
iii.
iv.
v.
b.
c.

Bis-acrylic
Dimethacrylate- identified as:
bisphenol A-glycidyl methacrylate (BIS-GMA)
urethane dimethacrylate (UDMA)
Acrylics
Methal Methacrylate (MMA)
Ethyl Methacrylate (EMA)
Polymethyl methacrylate (PMMA)
Polyethyl methacrylate (PEMA)
Pre-Fabricated
Metal (Ion)
stainless steel
aluminum
anodized gold
tin
tin-silver
Polycarbonate
Light-cured methacrylate composite crown
There are many advantages and disadvantages to each of these common materials. You should thoroughly
investigate the brands you are interested in before you discuss using a new material with your dentist. Be
ready to discuss the pros and cons of using different materials and /or techniques.
Bis-acrylics
Among the possible materials available are composite fillers such as dimethacrylate, identified as bisphenol
A-glycidyl methacrylate (BIS-GMA), or urethane dimethacrylate (UDMA). These materials are classified as
Bis-acrylics.
Bis-acrylics are multi-functional methacrylate esters filled with glass and/or silica particles. Bis-acrylic
materials are popular because of their easy manipulation and comfort for the patient. They produce minimal
odor, heat and shrinkage during the polymerization process. Shade variations are somewhat limited,
ranging from two to five shade options.
Materials that are compatible with composite resins, such as Integrity by Dentsply Caulk or Protemp Plus
by 3M ESPE, are available in an automix cartridge. This can open up the door to an almost perfect color
match. These materials are polymerized either by being chemically activated or visible-light
activated. Chemically activated materials are packaged as a catalyst and base. They must be stored in two
separate containers and mixed just prior to use. Many of these materials are dispensed in an automix
cartridge. The automix cartridge prevents operator error, allows for easy clean up and avoids unnecessary
waste (Figure 2).

Figure 2. Automix Cartridge

Courtesy of 3M ESPE

Directions for some chemically activated bis-acrylic materials recommend utilizing a pressure pot for the
final cure (Figure 3). Examples of these chemically cured materials are Ultra Trim by The Bosworth
Company and BIS-Jet by Lang Dental Manufacturer. Provipoint by Ivoclar Vivadent is a dual-cured
material and so is TCB Dual Cure by SciCan. Radica by Dentsply also uses a tri-ad oven to fully cure the
material.

Figure 3. Pressure Pot

Courtesy of The Bosworth Company

The final stage of curing using a dual-cured material can be achieved by self-cure or light-cure. Light curing
the material will reduce setting time by half. Initial polymerization is achieved by mixing the catalyst and
base together. When you are ready for the final set, you expose the material to a visible-light curing
machine. Light-activated materials must be stored in a light-proof container to prevent the material from
polymerizing prematurely. An example of this type of material is Revotek LC from G C America.
Acrylics
Traditional acrylic resins are also known as Methal methacrylate (MMA), Ethyl methacrylate (EMA),
Polymethyl methacrylate (PMMA), and Polyethyl methacrylate (PEMA). These materials have been used in
dentistry for many years. Self-cured acrylic polymers, which are chemically activated, require a liquid
(monomer) and powder (polymer) that are mixed to a fluid consistency.

Exothermic reactions are part of the polymerization process of polymethyl methacrylate. The larger the
amount of this material used, the larger the exothermic reaction. Completion of the curing process is
increased by this temperature rise and explains why frail, thin areas of cold-curing acrylic do not reach
maximal hardness.
Polyethyl methacrylate materials have a longer working time between the initial and final set. They also
produce a lower exothermic reaction. This material lacks resistance to abrasion, hardness and color
stability. Using a pressure pot at 20 to 25 psi for 5 minutes will alleviate the hardness and color stability
problem. Trim from The Bosworth Company is an example of a polyethyl methacrylate acrylic resin (Figure
4).

Figure 4. PEMA - Monomer and Polymer

Courtesy of The Bosworth Company

Both of these acrylics are affected by the eugenol in provisional cements. This makes repair of the acrylic
difficult. To overcome this, lubricate the outer surface of the provisional before placing the cement
inside. Different materials have different shrinkage rates. When acrylic polymerizes, the crown undergoes a
shrinkage of approximately seven percent. If the final curing takes place without a supporting form, there
will be distortion and a less optimal fit. A study of the marginal adaptation of provisional restorations found
that the marginal fit of ethyl methacrylate provisional restorations can be improved by nearly 70 percent by
fabricating them using the indirect technique (see Technique section).
When using acrylics, we recommend that you submerge the provisional in water if it is kept outside the
mouth for an extended length of time.
Pre-Fabricated
Prefabricated provisionals come in a variety of materials. They can be used for anterior or posterior, and
are often used when a preliminary impression is not possible. Metal pre-fabricated crowns are used in the
posterior. They provide good coverage, strength, and fit best when the interior is customized. Stainless
steel as a provisional crown will last longer (in most cases) than the other materials. Metal crowns come in
a variety of sizes and are grouped by type of tooth. For a slightly more esthetic posterior provisional, the
tooth colored methacrylate composite crown should be used. Polycarbonates are anterior prefabricated
anterior crowns. They may be used alone, with acrylic to customize the interior, or as a template to create
a preliminary impression.
All characteristics of a material should be acknowledged and proper steps taken to prevent any undesirable
post-operative sensitivity or pulp pathology. With the proper knowledge, an assistant can safely utilize
these materials.
There are many techniques available to provide provisional coverage for teeth while you are fabricating
permanent restorations. The type of provisional needed, condition of the gingiva, desired outcome, and any
special circumstances all should influence which technique you choose. There are three basic techniques we
will explore in this text: direct, indirect, and a combination of the two.
The direct provisional technique is where a provisional restoration is made inside the patients mouth. The
indirect technique uses a model to fabricate the provisional (outside of the patients mouth). The
indirect/direct technique utilizes both techniques.
The indirect technique has advantages and disadvantages. When a patient reports a previous history of
tissue irritation after a provisional crown was fabricated directly, you can decrease the possibility of
sensitivity by utilizing the indirect technique. You would also use the indirect technique to fabricate a
multiple unit bridge. This allows the patient to be comfortable while the bridge is being constructed. It also
allows better visibility of margins, contours and contacts. By using this technique, you can allow the

material to completely set on the prepared model. The indirect technique does, however, require several
additional steps. These additional steps result in increased chair time and materials. The indirect technique
is preferred over the direct technique for pulpal protection and accuracy. The use of acrylic monomers and
polymers on a freshly cut tooth can be an irritant. The tooth has probably already had a large restoration,
may have additional caries and has been subjected to the trauma of a high-speed handpiece.
The direct technique decreases chair time and material, however the patient is more uncomfortable because
the mouth has to stay open while the provisional is being fabricated. The patient may be subjected to the
unpleasant aroma from the materials and to the injurious effects of the placement and removal of the
provisional until final set is achieved. If the restoration is not removed from the tooth during the curing
process, it may be necessary to destroy the provisional in order to remove it from the preparation.
The indirect-direct technique is usually chosen when multiple units are involved. This allows for relining at
the chair with minimal contouring and improved esthetics. This technique requires preliminary work,
additional chair time and laboratory costs.
All three techniques described have advantages and disadvantages. In consultation with the dentist, an
assistant who knows these procedures and the associated effects can choose an appropriate technique to
meet the needs of the patient.
The direct technique is performed by making the provisional directly in the mouth. It is usually chosen
when a single unit or small span bridge is being fabricated. It is cost-effective to fabricate the provisional
directly and requires less chair time.
Using the direct technique can be quite simple. For instance, choosing a polycarbonate crown form for an
anterior tooth and relining it with acrylic will save time since it is not necessary to take impressions, pour
models or make a template. There are numerous ways to fabricate a provisional utilizing the direct
technique. The most common ones are the polycarbonate crown forms, alginate impressions, preformed
crowns, clear matrices and baseplate wax.
A polycarbonate crown is a tooth-colored plastic form that comes in a variety of sizes. This technique may
only be used for single units. The technique described does not involve using the crown form by itself, but
requires relining it with acrylic. You can, however, use a preformed acrylic crown without relining, if it is
properly trimmed and cemented with a provisional cement (Figure 5).

Figure 5. Polycarbonate Crown Forms

Courtesy of www.doctorspiller.com

Table 2. Steps using Polycarbonate Crown Forms

1. Select the crown form with the best fit. The fit will probably not be perfect, but it
can be adjusted. The width of the adjacent teeth is important when selecting the
polycarbonate form. If the length is long, trim the margins down by utilizing an
acrylic bur or crown and collar scissors. Do not trim the incisal edge to correct the
length. Keep trying the form on the tooth after each trimming until the length and
width are approximately the correct size.
2. Open the contact areas. Make a V-shaped cut into the mesial and distal contacts by
utilizing a pointed acrylic bur. Make this opening approximately 3/4 of the way
down the contact area. This allows the acrylic to pick up the adjacent teeth contacts.
3. Coat the tooth with a separating medium.
4. Mix the acrylic material until it is homogenous and then pour the acrylic into the

crown form. Placing your fingers on the mesial and distal walls will help form the
acrylic until the shell is placed on the tooth.
5. Insert crown on prepared tooth once the acrylic loses its shine.
6. When the material starts to set, gently remove and replace the crown form from the
tooth in approximately 10-second intervals, until it reaches final set. This should be
done for approximately 2 to 3 minutes until material is set.
7. Remove the crown.
8. Trim accordingly.
Hints

Keep the plastic tab on the polycarbonate crown form until it is ready to be trimmed. This will help in trying in
and removing the crown form during fitting.

Do not allow the acrylic to completely set on the model or prepared tooth. This will cause the provisional to
lock onto the preparation.

Wax Technique

This technique can be used to easily fabricate all single unit provisionals. No crown forms or alginate
impressions are necessary, which make this technique fairly inexpensive.
Table 3. Steps Using Wax Technique

1. Warm up a piece of baseplate wax and place over unprepared tooth.


2. Trim and save the wax impression.
3. After preparation, dispense material and fill the wax impression.
4. Place on prepared tooth.
5. Follow steps 3 through 8 as in the polycarbonate technique to
complete.

Alginate Paint Thin Shell Technique

Next

This technique utilizes an alginate impression prior to the tooth preparation. If you cannot obtain an
impression, you cannot use this technique.
Table 4. Steps Using Alginate Paint Thin Shell Technique

1. Prior to tooth reduction, prepare the tooth by adding wax to fill in any missing
tooth structure. Take an accurate alginate impression, preferably with a triple tray
to accurately reproduce the occlusion. Wrap impression in a moist paper towel or
store in a humidor until ready to use.
2. Utilizing two dappen dishes or a triple dappen dish, place acrylic monomer in one
and polymer in the other.
3. Use a paint brush to transfer the acrylic material to the impression.
4. Paint the acrylic into the impression until the buccal/lingual or facial/labial walls
are covered. If the material is too thick, use a little monomer on the brush to thin
out what was placed in the impression. The contact areas should not be included.
5. Once the material is set, use a pointed instrument to remove the shell from the
impression.
6. If upon removal you notice any voids, paint a small amount of acrylic over the
discrepancies.

7. It may be necessary to hollow out the inside. This can be done using a #8 round
bur.
8. Use this shell to make your provisional by relining with acrylic.
9. Place on tooth and have patient bite into place.
10. Carefully place and remove until set.
11. Trim accordingly.

Free-hand (Block) Technique

Next

You can choose the freehand technique when you have become more skilled at making a provisional. No
matrices or impressions are used with this technique. It allows for good marginal adaptation and proper
occlusion.
Table 5. Steps Using Free-hand Technique

1. Lubricate prepared tooth.


2. Mix a thick viscosity of acrylic.
3. When the acrylic has lost its luster, place an appropriate amount of material (about
the size of the tooth or teeth that are prepared) on top of the tooth or teeth and form.
4. Form the acrylic buccally and lingually to the adjacent teeth and have the patient bite
down to establish occlusal height.
5. Once the material has started to get firm and before final set, place and remove from
preparation to prevent provisional from locking in undercuts or on tooth.
6. Before final set, place a very thin mix (pouring consistency) of acrylic inside the
crown and place it back on the tooth. This will give you a more definite margin and
reduce the need for touch-up with a brush later.
7. Once final set is achieved, trim and finish.

Preformed Metal Crown Technique

Next

Aluminum, gold anodized and stainless steel crown forms all fall into this category. They come in a variety
of sizes for premolars and molars. They can be used by themselves, relined with acrylic or a combination of
both. These crown forms cannot be utilized for multiple units. They can provide all the requirements of a
well-made provisional when prepared properly. The technique utilized for these crowns is a bit different than
what you may be used to. The gold anodized forms seem to work the best for this technique because of the
softness of the material (Figure 6).

Figure 6. Preformed Metal Crowns

Courtesy of www.doctorspiller.com

Table 6. Steps Using Preformed Metal Crown Forms

1. Select the most appropriate size form.

2. Check occlusal height. If the height is too high, utilize crown and collar scissors to
trim the gingival margin.
3. Cut a U out of both the mesial and distal contacts only if there is an adjacent
tooth. If no adjacent tooth, cut slit on proximal surface.
4. Gently pull the buccal and lingual walls open.
5. Mix the acrylic and place into preformed crown.
6. When the acrylic has lost its shine insert on the lubricated prepared tooth in the
mouth or on a model.
7. When material starts setting, gently remove and insert the crown on the tooth until
the acrylic has set, approximately 2 to 3 minutes.
8. Trim the flash.
9. Remove the metal crown form with the crown and collar scissors.
10. Refer to trimming section to finish.

Aluminum Shell Technique

Next

A posterior tooth can be protected by an aluminum provisional crown. These are available in a wide range
of sizes. Always remember that crowns tried and not used must be sterilized before reuse. You may need
to use a millimeter ruler to determine the size, measuring the mesial-to-distal distance.
Table 7. Steps Using an Aluminum Shell

1. Once you have found the appropriate size, try it on the tooth to make sure the
distance between contacts is correct.
2. See how much is necessary to trim at the gingiva. If the crown is 2 mm above the
adjacent teeth, then you would trim 2 mm all around at the gingiva using a crown
scissors. It is important to trim in a smooth manner so as not to leave sharp or
uneven edges that can irritate the gingiva.
3. Use contouring pliers to crimp the margins of the crown inward (Contouring pliers
Nos. 112, 114 and 115 are most common.) Using the contouring pliers helps in
adapting the crown to the finish line. It is possible to omit the contouring and reline
the shell with methylmethacrylate (self curing acrylic). This will give you a better
internal fit and more exact margins and is probably preferable since it helps avoid a
metal overhang.
4. Once the crown is seated on the prepared tooth, instruct the patient to bite down
normally. This helps establish an initial occlusal anatomy onto the soft aluminum
shell.
5. Further check the occlusion with articulating paper and make adjustments.
6. Check crown for rough metal margins. These can be smoothed using sandpaper,
discs or a rubber wheel.
Hint

If you dont reline the aluminum crown with acrylic, cement it using IRM or Zinc Oxide Eugenol (ZOE).

Pre-fabricated Light-cured Composite Crown Technique

Next

These crowns are malleable, light cured, preformed, and are available in a variety of shapes and sizes. They
are a simple and esthetic solution for posterior provisionals. These types of tooth-colored pre-fabricated

crowns can be quickly adjusted prior to light curing. With no impression or matrix needed, fabrication is
quick and relatively easy (Figure 7).

Figure 7. Pre-fabricated Light-cured


Composite Crown Form

Courtesy of 3M ESPE

Table 8. Steps Using Pre-fabricated Light-cured Composite Crown

Measure mesial to distal width to determines width of provisional.


Select the appropriate size according to the manufacturers chart.
Open unidose container and remove from the protective plastic covering.
Using crown and bridge scissors, trim following gingival contour of the tooth.
Seat trimmed crown gently on the preparation. Using your gloved fingers, ensure
that the crown is in line with the teeth. Establish interproximal contacts and
margins.
6. Have the patient gently close to establish occlusion.
7. Once the provisional is correctly adapted and adjusted, tack cure the provisional
crown with a curing light - while in the patients mouth - for 3 seconds on
buccal/labial, occlusal and lingual.
8. After tack cure, remove crown, then carefully put the crown back in place a couple
of times to ensure fit before the final cure.
9. Final cure for 60 seconds, per manufacturers directions.
10. Finish and polish
1.
2.
3.
4.
5.

Hints

Start with the smaller size crown, as it can easily be contoured to modify to a slightly larger size.
Trim the crown short, rather that leaving it too long.
The tack cure should be no longer than 2-3 seconds per surface.

Acrylic Preliminary Impression Technique

Next

This procedure requires an accurate impression prior to and after the tooth preparation. If the tooth is
broken down, or a bridge is being constructed to replace a missing tooth, this technique may not be
effective without adding wax to those areas.
Table 9. Steps Using Preliminary Impression with Acrylic

1. Add wax to re-create any missing tooth structure.


2. Obtain an accurate impression before the teeth are prepared. Make sure the
impression is free from debris and tears in the area.
3. Disinfect the impression. If using alginate, keep moist until needed. Do not let an
alginate impression dry. This will alter it, causing distortion.
4. After the teeth are prepared, place a small amount of a selected shade of self-curing
acrylic in your dappen dish. Rubber dappen dishes work nicely for this since they
are easy to clean.
5. Dispense enough monomer to saturate the polymer. Always cover your monomer
container since it is very volatile.
6. Use a spatula or instrument to mix to a homogenous consistency.
7. Wait 2-3 minutes until resin has lost its luster and has reached a doughy stage.
8. Rinse disinfectant off the impression and place material in the area of the prepared
teeth.
9. Use a separating medium, as in other techniques.
10. Place the impression filled with acrylic back in the mouth.
11. Carefully remove the provisional from the impression and place back on the
prepared teeth. This will avoid additional shrinkage during final setting. Excess
acrylic can be trimmed during the doughy stage using a scissors.
Hint

Always remember to place the provisional on and off during setting to prevent locking provisional on the
tooth.
This procedure requires an accurate impression prior to and after the tooth preparation. If the tooth is
broken down, or a bridge is being constructed to replace a missing tooth, this technique may not be
effective without adding wax to those areas.
Table 10. Steps Using a Composite Resin with Preliminary Impression

1. Add wax to re-create any missing tooth structure.


2. Obtain an accurate impression, using a triple tray, before the teeth are
prepared. Make sure the impression is free from debris and tears in the area.
3. Disinfect the impression. If using alginate, keep moist until needed. Do not let an
alginate impression dry. This will alter it, causing distortion.
4. After the teeth are prepared, try in the impression to determine the appropriate path
of insertion. Remember how it fits into the mouth so you are able to repeat this
when the provisional material is inside the impression.
5. Using a composite-resin auto mix cartridge, dispense a small amount of the
material onto your tray or a piece of gauze. This will help determine when the
material is set.
6. Place the provisional material from the automix cartridge into the area needed. Fill
the impression for the teeth involved only about 75% full (or less). Prevent air
bubbles by keeping the tip of the cartridge under (inside) the material as it is
extruded.
7. Place the impression into the mouth, following the correct path of insertion.
8. Instruct the patient to close into the impression. Once closed, the patient must not
open or move their teeth until the provisional material is set.

9. Monitoring the small amount of material you dispensed on your tray, determine
when the material is set. It may set faster in the mouth due to the increased
temperature.
10. Remove the impression from the mouth. The provisional may remain on the tooth
or inside the impression.
11. Remove the provisional.
12. Using crown and bridge scissors, cut away any excess material.
13. Try the provisional on the tooth. Adjust as needed.
14. Polish and cement.
Hint

Select the provisional material that is the closest to the natural tooth color. You can adjust the color by
mixing colors or by adding a veneer of flowable composite to the exterior of the provisional after adjusting.

Vacuum Form Acetate Shell Technique

Next

This procedure utilizes the vacuum forming machine. It allows you to duplicate existing teeth prior to
preparation. However, it also duplicates broken or missing portions of the teeth. Therefore, after the
alginate is taken and poured, you should repair any existing discrepancies prior to using the vacuum
former. If a tooth is missing, there are many ways to fill the space prior to making your template. They
include: use of an acrylic tooth (denture tooth), use of a mix of acrylic formed using opposing model to
establish occlusion, and the use of light-cured resin to form a tooth (Figure 8).

Figure 8. Vacuum Form Acetate Shell

The clear matrix has the following advantages:

Allows easy access and visibility throughout the procedure.


Can serve as a tooth preparation/reduction guide.
Provides a smooth, void-free surface that gives a better finish to the surface of the provisional.
Can be used with self- or light-cured materials.
Is inexpensive to produce.
Table 11. Steps Using a Vacuum Form Acetate Shell

1.
2.
3.
4.

Obtain an alginate prior to preparation.


Pour with quick setting stone.
Separate and trim models.
Repair any discrepancies or add missing teeth.

Heat vacuum former until material sags 1-1 inches.


Turn motor on and pull frame over model that is facing up. Let run for 15 seconds.
Trim material around model using scissors and lab knife.
Cut out area to be used in mouth. For instance: if making #13, you would trim
keeping #12, #13 and #14 intact. Always trim material keeping one tooth mesial
and
distal. This will prevent over seating the template or matrix.
9. Lubricate teeth.
10. Mix a homogeneous mass of material to be used.
11. Place provisional material into matrix using either bulk-mix method or a syringe
method.
12. If using acrylic, wait till luster has gone.
13. Fully seat the matrix, allowing excess to extrude beyond the borders.
14. Instruct patient to bite down.
15. If using a light-cured material, cure for 1 minute and remove. Place in machine for
final cure. Cure according to material directions.
16. If using an acrylic resin, when material becomes rubbery, trim excess with scissors
and replace. The matrix should be placed and removed a few times to prevent
excess
material from locking in embrasure spaces.
17. When final set is achieved, separate and peel away matrix with an instrument.
18. Reline or remarginalize the provisional to pick up the fine details with an
incremental powder/liquid (Nealon) technique.
19. Trim and polish.
5.
6.
7.
8.

Table 12. Use of a Vacuum Former Machine

1. Place the model on the platform of the vacuum former with the teeth upright (Figure
9).
2. Mount a sheet of plastic coping material on the holding frame (.020).
3. Turn on the heating element and soften the coping material. When the material sags
in the middle approximately 1 to 1 inches, turn on the vacuum motor. Quickly
lower the holding frame over the model. The vacuum will draw the material onto
the model and tightly adapt to the shape of the teeth.
4. Turn off the machine after 15 seconds of adaptation and remove the model.
5. The coping material can be initially cut away from the model with a scalpel blade or
lab knife. Remove template from model and trim with a crown and collar scissors
for a more precise trimming. Trim to 3 to 4 mm below the gingival margins of the
teeth, along the gingival tissue. This is important to give a more positive seat on the
preparation model. The tooth to be prepared and at least half of each adjacent tooth
should remain intact to create the mold or matrix for the provisional. If you are
making a roundhouse or a three or more unit provisional, you need a core. A core
fits over the vacuum form and is made of stone and slurry water. This is helpful to
insure proper placement of the vacuum form over the prepared teeth model.
Figure 9. Vacuum Former

Courtesy of Keystone Industries

Reline Previous Crown Technique

Next

An existing crown can be used as a provisional if it remains intact upon removal and is smooth and
aesthetically pleasing. When a crown is removed or remade, keep in mind the reasons for replacement. If
it is for esthetics, you would want to make a new provisional. If it is because of poor fit, you can reline with
acrylic to serve as a provisional. In most cases, it is best to make a new well-fitting provisional.

Celluloid Crown Form Technique

Next

A celluloid crown form can be used to fabricate a single unit provisional. It is extremely helpful when using
light-cured materials because the material can be cured through the clear form.
Table 13. Steps Using a Celluloid Crown Form

1. Select an appropriate size.


2. Trim at gingival margin to correct incisal height.
3. Place material inside and position on tooth.
4. Once material is set, score celluloid form with an explorer and
remove shell.
5. Trim to fit and polish.

Indirect Techniques

Next

The indirect fabrication of provisional restorations has several advantages over the direct technique. The
main advantage is the patient does not have to keep their mouth open during the fabrication of the
provisional. In addition, if acrylic material is used in fabrication, injurious effects of applying acrylic
monomer to the tooth are eliminated, the patient is not subjected to the unpleasant odor and taste of the
acrylic resin materials, and the resin is allowed to completely cure under pressure on a cast of the prepared
teeth. This results in a well-fitting, nonporous provisional restoration. The indirect technique is the most
effective technique to fabricate a large multiple unit provisional.
Table 14. Steps in Indirect Techniques

1. When the tooth preparation is complete, take an accurate alginate impression of the

prepared teeth.
2. Examine the impression for any imperfections and pour.
3. Separate model and trim to buccal fold. Examine for any defects that might prevent
the template from seating properly on the model. The matrix must fit the cast
accurately, as any discrepancies can significantly alter the positional relationship of
resulting provisional restoration (hyper occlusion or thin axial contours, for
example), which may require additional application of the material used.
4. Make matrix (Table 12).
5. Construct a core when you are making a full arch. Placement of the core allows for
a more positive seat on the model and will hold the template secure against the
model. The core is a mixture of stone and slurry water mixed to a doughy
consistency. Place this mixture on top of the template on the original
model. Leave some height of the stone above the teeth so you have a handle for
easy removal. The core should cover approximately 3/4 of the occlusal
surface. This will prevent the core from locking on the model.
6. After the core is set, you can remove it from the template.
7. Then remove the template from the original model.
8. Try matrix on the preparation model. Be careful not to break any teeth off the
model! If any teeth break off, you must take a new impression, which is very timeconsuming! The matrix must fit exactly on the model. If it does not fit properly,
look for poured bubbles and remove them, check to see if matrix is infringing on
frenum, is too long in the buccal fold area, or to see if an imperfection in the
alginate is preventing it from seating properly.
9. Liberally coat the model with a suitable separating medium and blow dry briefly
with air.
10. Before mixing materials, make sure you have chosen an appropriate shade for the
provisional.
11. Dispense desired material into the matrix and vibrate into the template. Fill only
the areas for which you will be making a provisional.
12. Place the prepared model into the matrix, making sure you line the matrix up with
the appropriate teeth. Do not push the matrix into place. Use your core to insure
firm and even pressure of the template onto the model.
13. Next, gently secure the model, matrix and core with a rubber band, taking care that
the template is not distorted nor its orientation on the model altered (Figure 10).
14. Once the material has set for approximately 5 minutes, you can remove the rubber
band and separate core.
15. Trim excess acrylic off with lab knife and remove plastic matrix. Note: the palate
or lingual should be paper thin and easily removed. If they are not, you have not
seated the matrix completely or properly.
16. Remove the cured provisional restoration from the model. Save your model to use
for further trimming.
17. Remove the excess acrylic resin and make sure the restoration is properly
contoured, starting with your margins, as always (Figure 11).
Figure 10.

Figure 11.

Hints

Use separating mediums to prevent the provisional material from sticking to the tooth or model. In most
cases, a tooth moist with saliva will not allow the acrylic to adhere. It is a good idea to use the air/water
syringe and, using the air, blow the excess separating medium off the tooth.

When taking an alginate, apply a small amount of impression material to the critical areas before placing
the tray. Make sure the teeth remain moist. If the teeth are too dry, the alginate will remain on the
preparation and the impression will not be accurate. It is important to obtain an accurate impression so
that the secondary retentive features, such as grooves, box forms and the gingival third of the perforations
are accurately reproduced.

Slurry water: To facilitate the setting time of the stone, slurry water can be used. You can sometimes
obtain slurry water from the water residue of your model trimmer. Some model trimmers are set up in such
a way that it is impossible to obtain slurry water. In such cases, you can make a solution of slurry
water. You can use a plastic jug to save such water so it is on hand when needed. Always shake the bottle
of slurry water before adding the water to stone. From start to finish, the setting time should be about 5
minutes. Work fast when using slurry water or the stone will start to set.

Take care to avoid incorporating air bubbles into the acrylic, as air bubbles can cause voids in the
restoration. When you use vacuum formed acetate templates, you should not see air bubbles. You can
eliminate air bubbles by penetrating the template with a sharp instrument, such as an explorer.

To ensure proper alignment of your core, you may need to make index marks using a permanent marker
(Figure 10).

Indirect/Direct

Next

When the doctor chooses to use the indirect/direct technique, he/she has chosen to have the laboratory
fabricate a thin acrylic shell over mocked preparations that were done on a study model of the patient. This
provisional shell will then be relined in the patients mouth. The laboratory indirectly fabricates the
provisional on the model and the doctor or assistant relines it directly in the mouth, giving the technique its
name. Refer to steps 3 through 8 in the polycarbonate technique.

Advanced Techniques

Next

Once an assistant has mastered the single unit and multiple units, he/she can move on to more challenges,
such as fabricating a provisional over an implant or fabricating a provisional as an abutment for an existing
partial. The following are a few advanced techniques.

Inlay and Onlay Provisional Technique

Next

An inlay and onlay should be fabricated by a proficient assistant. This technique requires skill to achieve
good marginal adaptation. The small size and intricate margins require precise fabrication and
trimming. This technique closely relates to the freehand technique discussed earlier. The only difference
with this technique is that the whole clinical crown is not covered.

Provisional Over Implant Technique

Next

To fabricate a provisional over an implant, the assistant must be familiar with implants and their
coordinating parts. We suggest using the indirect technique.
Table 15. Steps for Provisional Over Implant

1. Take an impression of the implant.


2. Place the corresponding analog on the impression coping and back into the
impression.
3. Pour, separate and trim the impression.
4. Screw on the corresponding provisional cylinder and adjust the occlusal height to
fit under the template. Use a diamond disc. Upon grinding, the metal can get very
hot. Place water in a disposable cup and dip periodically during the grinding
process.
5. Place block out material in cylinder to prevent material from covering screw.
6. Process material over implant.
7. Access screw hole using #8 acrylic bur.
8. With an air hose, blow out excess block out material or remove it with explorer.
9. Remove screw.
10. Trim provisional, keeping it off tissue and making sure it can be easily cleaned and
maintained.

Long-term Provisional Technique

Next

Provisional crowns may have to be fabricated to last several months. In such instances, metal bars or a
mesh material may be used to help provide durability. For an anterior provisional, the material should be
placed on the lingual surface; for posterior teeth, the material should be placed on the occlusal surface.
Placing mesh prior to pouring material can be very difficult. The mesh may move during the pouring
process and be in the wrong position while final set occurs. For the inexperienced, it is easier to cut a long
groove in the occlusal or lingual surface. Then place the bar or mesh and cover with material.
Table 16. Steps for Long-term Provisionals

1. Fabricate the provisional.


2. After initial trimming, hollow out an area from the middle of the most anterior
abutment to the most posterior abutment. The area should be deep enough not to
interfere with occlusion, but not too deep to sit on the preparation.
3. Cut the chosen material to the proper length of the bridge.
4. Place the reinforcement into the groove.
5. Mix the material.
6. Place the material on top of the reinforcement.
7. Have the patient close or articulate models, depending on the technique.
8. Trim and polish.
Hint

Before placing the material over a metal bar reinforcement, make sure the bar will not interfere with the
patients occlusion.

Abutment For Partial Technique

Next

When making a provisional as an abutment for an existing partial, use a free-hand or custom-made
technique. This will allow for proper clasp placement, rests and correct size. This technique requires some
practice. It also requires a skillful eye to know
how much and where to trim.
Table 17. Steps for Abutment Provisional

1. After tooth is prepared, lubricate tooth and partial. (Use petroleum jelly for partial.)
2. Dispense material and place on prepared tooth.
3. Form material buccally and lingually.
4. Place partial on top and instruct patient to bite into place.
5. Remove and replace the partial with provisional in place until final set is achieved.
6. Trim margins and remove excess bulk until provisional can be separated from
partial.
7. Once separated, trim as usual but try to maintain shape where clasps and rests are
located.

Laminate Provisional Technique

Next

Depending upon the length of time between preparation and cementation appointments, a provisional may
be placed. If the laboratory can process the laminate within a week, a provisional might not be necessary.
For multiple units, the provisional is made using a matrix and acrylic. However, laminate provisionals tend
to come off frequently and you should cement the final restoration as soon as possible.
For single units, the doctor can etch a few spots on the facial and you can form and place the composite
temporarily. This technique is rather simple, but does tend to stain around the edges over time. Make sure
to tell the patient that this can happen. When a patient is aware of what to expect, there will be no phone
calls to ask questions later.

Finishing Procedures

Next

Finishing a provisional crown or bridge takes skill using materials and a proper slow speed technique. This
entails correct positioning of the handpiece in relation to the area being trimmed. A well-finished provisional
will provide a smooth and an esthetically pleasing appearance.

Trimming

Next

An operator must have general knowledge of proper handpiece operation, including how to correctly position
the handpiece in relation to the area to be trimmed. Check state regulations for laws or rules
regarding assistant permitted duties to see if you are permitted to adjust intraorally.
When trimming margins, place the cone-shaped acrylic bur parallel to the crown, but avoid disturbing
contact points. A cone-shaped bur has a sharp point for definition and a large base for bulk reduction. A
larger bur will be easier to maneuver since it requires less revolutions and/or vibrations.

Trimming Recommended Materials

Next

Straight handpiece using the following attachments:

Diamond disc for separating teeth and opening the embrasure areas.

#35 bur to help define anatomy on the occlusal surface.

#8 bur for hollowing out prior to relining or removing any internal imperfections and reduction in occlusal
height.

Long, pointed acrylic bur to define embrasure areas and final contours.
Carbide egg shaped bur to adjust occlusion.
Cone-shaped acrylic bur for bulk reduction and initial trimming of margins.

Initial Trimming

1.

2.

Next

Determine your margins first. You may mark the margins with pencil to clearly identify them. Start with
a cone-shaped bur and trim close to margins. Continue until all margins are clearly trimmed. Margins
should be trimmed to 1 mm. The margins must remain thin and intact.
When constructing a multiple unit provisional

Change burs to a separating disc, such as a diamond disc. Start by separating the teeth following the
original lines on the
provisional.

Separate and open the embrasure areas.


To shape further, switch to a cone shaped bur.
Use the long, pointed acrylic bur to further open your embrasure areas from the buccal and lingual. This
is best done on the prepared model. This will help you see any additional trimming and shaping that you
will need to do.

3. Try-In Stage
4. Next
Try the provisional in the mouth at this point. It may be necessary to remove additional undercuts
internally, which may prevent the provisional from seating properly. A #8 acrylic bur is sometimes used to
hollow out the inside of the crown. Close marginal discrepancies by using a small brush, powder and liquid
to fill the deficient areas when using acrylic.

Final Trimming

Next

Trim excess again and adjust occlusion using articulating paper. At this point you should check:

margins to make sure they are closed and there are no overhangs.

for any irregularities that might make the provisional uncomfortable.

for proper contours.


occlusion with articulating paper. Confirm fit by asking patient how it feels. If it feels strange, make
adjustments.

Polishing

Next

The polishing of a provisional crown is an important step. A non-polished crown will have a rough surface
which can cause plaque to build up. This is especially dangerous around gingival margins. Periodontal
problems can result from a non-polished crown. Because of the constant movement of the tongue, the
patient may also become uncomfortable if the surface is rough.

Polishing Recommended Materials

Next

You will need a sterile rag wheel and pumice.


To use the dental lathe:
1.
2.
3.
4.

Moisten the rag wheel and place it on the lathe mandrel.


Cover the tray with aluminum foil and place the pumice on top.
Mix a small amount of water with the pumice in a dappen dish or small paper cup to make a thick
consistency.
Make sure the protective plastic shield is in position and the operator is wearing personal protective
equipment (PPE) and turn the machine on low.

5.
6.

7.
8.

Using gloves, coat the provisional with pumice, and secure your grasp on the crown. Use care because a
rag wheel can cause overheating and warpage during polishing.
The incisal edge or occlusal surface should be facing you. With a back-to-front motion, run the
provisional along the bottom side of the rag wheel. Carefully turn provisional to polish all sides except
the contact areas. When you use all acrylic resins, take care when polishing so as not to buff away
margin areas.
Replenish the provisional with pumice when necessary.
Once you have completely polished the provisional with pumice, place a dry rag wheel on the lathe and
add polishing compound to the turning rag wheel. Completely polish the provisional with the compound.

Figure 12. Dental Lathe

Courtesy of National Dental Supplies

You can do the same technique utilizing the slow speed and laboratory handpiece. This also provides a high
shine. You also may use a glaze to provide a high gloss. If the provisional restoration is on an anterior
tooth, the patient may insist on a close color match. This can be accomplished with stains and glazes after
the provisional has been polished. Minute stains cure and bond to all dental resins, including ethyl and
methyl methacrylates, polycarbonates, vinyl methacrylate copolymers, resin crowns and laminates.
To Use Sandpaper Discs:
1.
2.
3.
4.
5.
6.
7.

This technique is typically only used for tooth color composite resin based materials, but can be used in
with other materials.
Beginning with the most coarse disc, attach the disc to a mandrel (Figure 13).
Using the slow speed handpiece, lightly polish any areas of the provisional that were rough or had been
adjusted with a handpiece.
Continue polishing using increasingly less coarse discs until the provisional is smooth.
Use your gloved finger to feel for any sharp edges, and look closely to observe any significant texture
change.
For an ultra smooth finish, follow the sandpaper discs up with a composite polishing cup or disc without
without polishing compound.
For an extra touch, brush on a light glaze (such as Luxa Glaze) and light cure.

Figure 13. Sandpaper Discs

Courtesy of Shofu Dental

Cementation

Next

Remember that eugenol containing cements can interfere with the setting of acrylic and prevent bonding of
the final restoration. This may become important if repairs are needed. Cements that are light-cured and
dual-cured are also available.

Isolate the area with cotton rolls and/or 2 x 2s and keep area dry. (Use air/water syringe to blow dry
tooth.)

Mix the cement according to directions.

Request patient to bite down.

Coat the inside of the crown with cement. (Be careful not to overfill the crown. This could result in
improper placement and the need for excessive cement to be removed).

Excess Cement Removal

Next

Insuring all excess cement is removed is important to the health of the gingiva. If all the cement is not
removed, the gingiva can become irritated and inflamed.

When the cement has set, use an explorer to remove the excess along the margins and contacts.

Take a wet cotton roll and wipe crown clean.

Use the air/water syringe to keep the area clean and give you a view into the gingival sulcus.
Take a piece of floss and pass it down through the occlusal contact and out the buccal or lingual. Do not
remove the floss through the contact area. If cementing a bridge, you need floss threaders.
Instruct the patient to bite down to see how it feels.
Hints

If it feels high, the provisional may not be seated correctly or the occlusion may not have been adjusted
properly during try in. To see which is the case, check your margins. If they are open, you have not seated
the provisional correctly. In this case, remove the provisional, clean out the cement and repeat the
process. If the margins are closed, the provisional is seated properly, but the occlusion is high. Mark it
with articulating paper and have your dentist adjust the height. This should only take a few minutes to
do. It should, however, be avoided by checking your occlusion several times before cementation. Make
sure to have the patient bite down several times and slide teeth from side to side to check for proper
occlusion.

Coat the outside of the crowns with petroleum jelly before placing the cement internally.
Tie knots in the floss. This will help remove large pieces of cement interproximally.
Tie floss around the pontic of a bridge and make a loop prior to cementation. This will avoid the need for
floss threaders. Make sure to tie the floss loosely and have the ends easily accessible so it can be untied
and manipulated for cleaning cement under the pontic areas of a bridge.

Post Operative Instructions

Next

Inform the patient to continue brushing the area as usual. Good home care is essential. Flossing is
necessary, but the floss should be pulled through the buccal or lingual. The patient should use a floss
threader to floss under a bridge. Pulling the floss through the contact can help prevent the crown from
dislodging. The patient should also avoid chewing on the side of the provisional for a few hours. This will
allow some materials, such as cements, to fully set. During the time the provisional is in place, the patient
should avoid sticky foods, such as gum, caramel and taffy. Instruct the patient to contact the office as soon
as possible if the provisional becomes dislodged. In the meantime, the patient can place a little petroleum
jelly in the crown and place it back on the prepared tooth. It is always important to give post operative
instructions to the patient both verbally and in written form.

Arranging Appointments

Next

It is important to establish a routine technique for provisionals, so you can determine how long to make
appointments. To achieve the desired results in provisional therapy, the dentist must allot adequate time to
fabricate the interim restoration. You should allow adequate time to prepare the teeth and make a final
impression.
A properly trained assistant can take over the role of fabricating and cementing the provisional
restoration. Appointment times must be altered to accommodate these changes in staff and roles. The
dentist/assistant time with the patient must be shortened and assistant-only time be lengthened. This time
will include time for final cementation and clean up after fabrication of provisional.

Once a routine has been established, a designated amount of time should be allotted for each unit of the
provisional. During this time, utilizing an assistant, the dentist can be performing another procedure,
making full use of his/her talents.

Conclusion

Next

The provisional restoration is an important stage in the prosthetic treatment. It must provide a suitable
means for an provisional restoration. It is the responsibility of the dentist and dental assistant to provide
the best possible coverage with the minimal amount of discomfort, and to meet the criteria for a well fitting
provisional.

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