Expedient direct approach for esthetic and functional provisional

restorations
Panagiotis C. Psichogios, DDS,a and Edward J. Monaco, DDSb
College of Dentistry, The Ohio State University, Columbus, Ohio; State University of New York
at Buffalo, Buffalo, N.Y.
This article describes a direct procedure for the expeditious fabrication of provisional restorations for
extensive fixed prosthodontic applications. Customary indirect or indirect-direct approaches require
extensive clinical time as well as laboratory support for their successful application. Provided that the
necessary preoperative steps are followed precisely, this treatment method allows for excellent clinical
results while being less time consuming. (J Prosthet Dent 2003;89:319-22.)

T he importance of provisional restorations as an in-

tegral part of fixed prosthodontic treatment is evident
from the abundance of literature pertaining to their im-
portance regarding margin fidelity, function, occlusion,
and esthetics. There are a variety of techniques available
to suit the individual needs of the clinician and of the
clinical situation, from a single unit to a complete-arch
provisional fixed prostheses.1-8
The indirect technique has been proven superior8 to
other techniques because the resulting provisional res-
torations have improved marginal fit, density, fracture9
and wear resistance, especially laboratory heat-processed
provisional prostheses. Additionally, potential pulpal
damage is diminished9,10 since polymerization is per-
formed extraorally. Known disadvantages of this ap- Fig. 1. Frontal view of existing failing rehabilitation of max-
proach include extended time and the need for labora- illary arch.
tory support.11 Because of these disadvantages,
clinicians might be inclined to choose the direct tech- preparation is begun. The major disadvantage of this
niques for fabrication of provisional fixed partial den- technique is that the existing tooth structure is essen-
tures. tially duplicated, which does not permit the advantage of
The challenge arises in situations of extensive fixed incorporating improvements from diagnostic wax-up
prosthodontic treatment, specifically complete-arch re- procedures.
habilitations, where the direct techniques fall short of Treatment situations requiring an extensive recon-
expectations because of shrinkage and polymerization structive effort, such as complete-arch rehabilitations,
heat.12,13 Liebenberg6 presented a direct technique for usually require major alterations in occlusion and crown
provisionalization of complete-arch rehabilitations that contours, making the diagnostic wax-up procedure an
overcomes this problem and allows for excellent clinical imperative step.14 The purpose of this article is to
results by using composite type (BIS-GMA) provisional present a direct technique for fabrication of complete-
resins. These products exhibit minimal shrinkage and arch provisional restorations on the basis of a detailed
are easily manipulated, but the resins used for this tech- diagnostic-preoperative laboratory procedure when sig-
nique should be of a dual-polymerized nature. Lieden- nificant changes in esthetics and occlusion are desired.
berg6 recommended these resins in conjunction with an
accurate dual-arch impression of the patients existing TECHNIQUE
crown contours and opposing arch before any tooth A 50-year-old white woman was referred to the Post-
graduate Prosthodontic Clinic at the School of Dental
Presented as a table clinic in the 50th Annual Meeting of the Amer- Medicine, State University of New York at Buffalo, for
ican Academy of Fixed Prosthodontics in Chicago, Ill., March prosthodontic assessment (Fig. 1). Other than receiving
2-3, 2001. medication for arthritis, there were no significant med-
a
Assistant Professor, Section of Restorative Dentistry, Prosthodontics
and Endodontics, The Ohio State University.
ical findings.
b
Assistant Professor and Director, Advanced Education Program in Clinical examination revealed partially dentate max-
Prosthodontics, State University of New York at Buffalo. illa and mandible. In the mandibular arch, a Kennedy

MARCH 2003 THE JOURNAL OF PROSTHETIC DENTISTRY 319

THE JOURNAL OF PROSTHETIC DENTISTRY PSICHOGIOS AND MONACO

Fig. 2. Full contour diagnostic wax-up. Fig. 3. Impression of both arches, with articulator in closure
(pin touching).

Class I removable partial denture replaced the bilaterally

missing first and second molars. The partially dentate max-
illary arch had been restored with metal-ceramic fixed pros-
theses, replacing the maxillary first premolars, and in the
anterior region the 4 incisors were restored with individual
metal ceramic crowns. This rehabilitation had been present
for a period of 10 years. Periodontal, clinical, and radio-
graphic examination revealed advanced loss of the peri-
odontal attachment of the maxillary anterior teeth. The
patient reported that the diastema between the central in-
cisors developed during the last year and that she disap-
proved of the esthetics of the existing crown restorations
and desired their replacement.
The comprehensive treatment plan for the maxillary
arch agreed upon with the patient involved extraction of
the left lateral incisor, comprehensive periodontal treat- Fig. 4. Removal of existing restorations and establishment of
ment, and replacement of the existing crowns, with the new finish lines.
intention to provide a complete-arch maxillary fixed partial
denture. The following procedures summarize the labora- (Extrude Medium; Kerr) around the diagnostic
tory and clinical steps followed for the successful imple- wax-up, interpose the tray between the upper and
mentation of this direct complete-arch provisionalization. lower members, close the articulator, and verify that
the pin is touching the incisal table (Fig. 3).
Laboratory Procedures 6. Remove and inspect the accuracy of the impression
1. Mount the diagnostic casts in a semi-adjustable ar- for both the treatment and opposing arches. A de-
ticulator with the aid of a facebow registration and tailed representation of the diagnostic wax-up, as
centric relation record. well as the cusp tips and incisal edges of the oppos-
2. Perform a full contour diagnostic wax-up (Fig. 2) of ing arch is required.
the desired new crown contours and the desired 7. On the treatment arch, trim the impression ma-
occlusal scheme. terial so that it extends 3 to 4 mm apical from the
3. Fabricate an open dual-arch custom impression tray gingival portion of the diagnostic wax-up. Repeat
that can be interposed between the upper and lower on the opposing arch so that only the cusp tips
members of the articulator without interfering with and incisal edges are represented. Leave the im-
pin closure. pression of the hard palate to assist in the accurate
4. Raise the pin on the articulator (2 to 3 mm) to seating of the impression tray after tooth prepa-
accommodate for the thickness of the impression ration. The tray is now ready for the clinical part
material. of the technique.
5. Coat the tray with silicone adhesive (VPS adhesive;
Kerr, Romulus, Mich.) and load the tray with putty Clinical procedures
addition silicone (Extrude XP Putty; Kerr). Simul- 1. Remove the existing fixed prostheses and diseased
taneously inject medium-body addition silicone hard tissues from the treatment arch (Fig. 4).

320 VOLUME 89 NUMBER 3

PSICHOGIOS AND MONACO
Fig. 5. Tray try-in.
Fig. 7. Retracted view of complete-arch provisional fixed
partial denture.
2. Try-in the custom impression tray (verify repeated
closure) (Fig. 5). Lightly coat the preparations with
lubricant (Petroleum Jelly; Quality King Inc,
Ronkonkoma, N.Y.).
3. Inject BisGMA provisional material (Luxatemp,
DMG Hamburg, Englewood, N.J.) in the corre-
sponding part of the treatment arch (Fig. 6), seat
the tray, and instruct the patient to close with firm
pressure. Remove the tray after 2 minutes. Remove
provisional restoration material and trim excess with
sharp scissors.
4. Return the provisional restoration to the impression
tray and bench-polymerize for 2 minutes.
5. Complete final trimming and polishing, and cement
with temporary luting agent (Temp-Bond Non-Eu-
genol; Kerr) (Figs. 7, 8).
DISCUSSION
This procedure allows for the fabrication of a full-arch
provisional fixed partial denture in an expedient and
MARCH 2003
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 6. Injection of BIS-GMA resin provisional material in
custom tray.
Fig. 8. Labial view of provisional complete-arch fixed partial
denture.
accurate way by use of a direct technique. The advan-
tages of this technique include accurate representation
of the diagnostic wax-up in the completed provisional
prosthesis, thereby satisfying the esthetic and occlusal
demands of the treatment. Disadvantages include the
inability to perform this technique when parallelism be-
tween the abutments is impossible, thereby necessitat-
ing the segmentation of the prosthesis, as well as the
inherent mechanical shortcomings of the necessary
composite type provisional material, mainly concerning
fracture resistance. It is of importance for this technique
to achieve parallelism of the preparations for the entire
arch, otherwise the provisional prosthesis will have to be
segmented. This can be readily accomplished through
the use of contour strips strategically placed intraorally.6
This technique is recommended only when the eden-
tulous areas involve 1 pontic or 2 pontics, when con-
nector size can be large and for patients that do not
exhibit excessive masticatory strength. For patients
with extensive edentulous areas or a strong muscula-
321
THE JOURNAL OF PROSTHETIC DENTISTRY PSICHOGIOS AND MONACO

ture, the use of customary indirect or direct-indirect
procedures is advocated.
SUMMARY
A procedure is described with a direct approach used
to fabricate a complete-arch provisional fixed partial
denture in an expedient and functional manner, dupli-
cating the diagnostic wax in an accurate manner. Al-
though this procedure requires significant laboratory
preparation for its implementation, it should expedite
chair-side procedures and provide accurate results, both
functionally and esthetically.
We acknowledge the assistance of Dr Alvin G. Wee, Assistant
Professor, Section of Restorative Dentistry, Prosthodontics and End-
odontics, The Ohio State University College of Dentistry.
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10. Castelnuovo J, Tjan AH. Temperature rise in pulpal chamber during
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11. Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics.
3rd ed. St. Louis: Mosby; 2000. p. 390.
12. Grajower R, Shaharbani S, Kaufman E. Temperature rise in pulp chamber
during fabrication of temporary self-curing resin crowns. J Prosthet Dent
1979;41:535-40.
13. Moulding MB, Teplitsky PE. Intrapulpal temperature during direct fabri-
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Reprint requests to:
DR PANAGIOTIS C. PSICHOGIOS
SECTION OF RESTORATIVE DENTISTRY, PROSTHODONTICS AND ENDODONTICS
COLLEGE OF DENTISTRY
THE OHIO STATE UNIVERSITY
POSTLE HALL
305 W 12TH AVE
COLUMBUS, OH 43218-2357
FAX: (614) 292-9422
E-MAIL: psichogios.1@osu.edu
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1067/mpr.2003.53

322 VOLUME 89 NUMBER 3