Provisional Restorations
10
Jorge Perdigão and George Gomes
Abstract
Teeth prepared for partial or full-coverage restorations must be protected and
stabilized with provisional restorations that reproduce the form and function of
the final restoration. Provisional treatment may also provide an important tool for
the management of patients, as a common perception of the treatment outcome
and respective limitations can be identified. It is therefore imperative to fabricate
high-quality provisional restorations to achieve a successful treatment. This
chapter will focus on current materials for provisional restorations, their advan-
tages and limitations.
10.1 Introduction
According to The Academy of Prosthodontics (2005), an “interim restoration is a
fixed or removable dental prosthesis, or maxillofacial prosthesis, designed to
enhance esthetics, stabilization and/or function for a limited period of time, after
which it is to be replaced by a definitive dental or maxillofacial prosthesis. Often
such prostheses are used to assist in determination of the therapeutic effectiveness
of a specific treatment plan or the form and function of the planned for definitive
prosthesis – Synonyms – PROVISIONAL PROSTHESIS, PROVISIONAL
RESTORATION.”
J. Perdigão, DMD, MS, PhD (*)
Post-Graduate Program in Esthetic Dentistry, Division of Operative Dentistry, Department of
Restorative Sciences, University of Minnesota, 515 SE Delaware St, 8-450 Moos Tower,
Minneapolis, MN 55455, USA
e-mail: perdi001@umn.edu
G. Gomes, DMD, MSD
Rey Juan Carlos University, Madrid, Spain
© Springer International Publishing Switzerland 2016 205
J. Perdigão (ed.), Restoration of Root Canal-Treated Teeth:
An Adhesive Dentistry Perspective, DOI 10.1007/978-3-319-15401-5_10
206 J. Perdigão and G. Gomes
The fabrication of excellent provisional restorations is crucial to the success of
the definitive restoration, playing a determining role in the outcome of the overall
treatment (Table 10.1) (Vahidi 1987; Gratton and Aquilino 2004). The prerequisites
and expectations for provisional restorations are identical to those of definitive res-
torations, except for longevity. Nevertheless, provisional restorations must be strong
enough to maintain their structural integrity, as they may be used during long peri-
ods of time while other treatments, such as a surgical crown lengthening procedure,
are being finalized. In other instances provisional restorations are left in place for
extended periods when questions subsist regarding the restorability or the pulp
vitality of a tooth.
Provisional restorations are essential as a diagnostic tool for testing out the
changes in esthetics, position, contour, size, and occlusion, before they are incor-
porated in the definitive restoration (Zinner et al. 1989; Wassell et al. 2002;
Hammond et al. 2009). Provisional restorations are also an excellent checking tool
for the adequacy of tooth reduction. Therefore, provisional restorations have an
essential role as a blueprint for the definitive restoration to foresee the ideal treat-
ment outcome prior to carrying out the definitive rehabilitation (Fox et al. 1984;
Luthardt et al. 2000). Additionally, highly esthetic provisional anterior restorations
may make the patient more confident in the clinician’s ability to perform the
treatment.
10.2 Materials
There are many choices of materials for provisional restorations. For single-unit
restorations, these choices include acrylic resin for custom-made provisional
restorations, bis-acryl-based composite resin (bis-acryl), bisphenolA-diglycidyl-
Table 10.1 Rationale for provisional treatment
Protect pulpal tissue and sedate prepared abutments
Protect teeth from caries lesions
Provide comfort and function
Provide method for immediately replacing missing teeth
Prevent migration of abutments
Improve esthetics
Maintain or improve periodontal health
Reinforce the patient’s oral home care
Assist with periodontal therapy by providing visibility and access to surgical sites when
removed
Provide a matrix for the retention of periodontal surgical dressings
Stabilize mobile teeth during periodontal therapy and evaluation
Provide anchorage for orthodontic brackets during tooth movement
Aid in developing and evaluating an occlusal scheme before definitive treatment
Allow evaluation of vertical dimension, phonetics, and masticatory function
Assist in determining the prognosis of questionable abutments during prosthodontic treatment
planning
10 Provisional Restorations 207
methacrylate (bis-GMA)-based composite resin, prefabricated polycarbonate
crowns, metal crowns, celluloid crown forms, composite resin crowns, and direct
composite resin. For FPDs, acrylic resins, bis-acryl or bis-GMA automix composite
materials, or laboratory-fabricated resin shells are preferred.
The selection of materials for provisional restorations is based on their mechani-
cal and physical properties, as well as their biocompatibility (Duke 1999). Materials
for provisional restorations are classified using several different criteria. Some
authors have suggested using chemical composition, which divides these materials
into methacrylates and composite resins.
Anterior provisional restorations usually have more complex esthetic demands
than those desirable for the posterior region (Sham et al. 2004). These esthetic
requirements have become more relevant within the past years as a result of patients
being more aware of dental esthetics. Provisional restorations in single anterior
crowns do not require high resistance to compression. On the other hand, the mate-
rials used for provisional restorations in long-span FPDs must provide greater ten-
sile strength as opposed to those used for single units (Koumjian and Nimmo 1990).
Long-term provisional restorations require materials that are more durable (Amet
and Phinney 1995). The requirements for materials used in provisional restorations
are displayed in Table 10.2.
Table 10.2 Requirements for provisional restorations
Biological Preserve pulpal health (excellent sealing)
Non-irritating to pulp and other tissues
Low exothermicity
Minimal residual monomer
Maintain periodontal health, promote guided tissue healing
Physiological emergency profiles and embrasures
Do not hinder routine at-home oral hygiene
Physical/mechanical Dimensionally stable, nonporous
Mechanically strong and durable
Good marginal adaptation
Low thermal conductivity
Excellent handling (ideally automix), short setting time
Easy to remove without damaging the tooth
Esthetic Esthetically acceptable with variety of shades; toothlike
appearance
Serve diagnostic purposes for esthetics
Good polishability, stain resistant
Functional Provide and maintain stable occlusal relationships
Have adequate proximal contact to avoid shifting after the final
impression is taken
Serve diagnostic purposes for occlusion
Easy to repair or remake
Other Inexpensive
Odorless
Easy to implement infection control measures
208 J. Perdigão and G. Gomes
Provisional restorations are usually made using different techniques: (1) custom
fabrication and (2) fabrication with preformed materials. These procedures can be
accomplished with direct techniques in the clinic, indirect laboratory techniques, or
direct/indirect combined techniques (Vahidi 1987). While indirect techniques may
involve laboratory costs and increased time for fabrication, custom fabrication has
been known to be the best choice for provisional restoration fabrication (Christensen
1996).
10.2.1 Materials for Custom-Fabricated Provisional Restorations
Custom fabrication allows for intimate contact between a provisional restoration
and prepared tooth. The most common materials used for custom-made provisional
restorations are (1) polymethyl methacrylate (PMMA) resin, (2) polyethyl methac-
rylate (PEMA) resin, (3) bis-acryl resin, (4) urethane dimethacrylate (UDMA)
resin, and (5) Bis-GMA resin (Krug 1975; Lui et al. 1986; Vahidi 1987; Wassell
et al. 2002; Strassler 2009). PMMA- and bis-acryl-based temporary restorations are
currently the most popular materials.
Acrylic materials are the oldest materials currently in use. Auto-polymerizing
acrylic-based materials are easy to use to fabricate provisional restorations and
easily fill in the shape defects, allowing for a simple and quick manipulation.
Among their disadvantages, the most important are their significant polymeriza-
tion shrinkage, a short working time, an unpleasant odor, and a pronounced exo-
thermic setting reaction, which may injure the dental pulp (Grajower et al. 1979;
Michalakis et al. 2006; Chen et al. 2008). Residual methacrylate monomer may
trigger cytotoxicity and potential allergic reactions (Lee et al. 2002; Lai et al.
2004).
Acrylic resin provisional materials typically refer to two different chemical
materials, PEMA and PMMA. There are other acrylic resins for provisional restora-
tions, but the authors will refer to the two most commonly used acrylic resins in this
chapter.
10.2.1.1 Polymethyl Methacrylate (PMMA)
PMMA-based materials were introduced in the 1940s and have been the preferred
material for fabricating provisional restorations with the direct and indirect tech-
niques (Kaiser and Cavazos 1985; Duke 1999; Burns et al. 2003; Christensen 2004).
Auto-polymerizing PMMA-based resin is available in various shades as a powder
and liquid formulation. PMMA-based provisional restorations have a long record of
use, low cost, acceptable marginal adaptation (Wang et al. 1989; Duke 1999;
Christensen 2004), and high mechanical strength compared to other methacrylate
resins (Wang et al. 1989). However, PMMA has a low abrasion resistance, which
leads to wear of the material over time (Vallittu et al. 1994).
Achieving optimal esthetics with PMMA-based resin can be difficult and time-
consuming. This material has poor color stability and poor surface texture/porosity
(Luthardt et al. 2000; Bidra and Manzotti 2012), which might be the reason why
10 Provisional Restorations 209
Table 10.3 Examples of materials for custom-fabricated provisional restorations
Material Commercial name Manufacturer
PMMA resin Alike GC America
Trim Plus Harry J. Bosworth Company
Jet Set-4 Lang Dental Manufacturing, Co
Unifast LC GC America
PEMA resin Trim Harry J. Bosworth Company
Trim II Harry J. Bosworth Company
Snap Parkell
Splintline Lang Dental Manufacturing, Co
UDMA composite resin Revotek LC GC America
Triad VLC Provisional Material Dentsply
Bis-GMA composite resin TempSpan Pentron Clinical
Bis-acryl composite resin Access Crown Centrix
Cool Temp Natural Coltene
Integrity Dentsply
Luxatemp Solar DMG America
Protemp Plus or Protemp 4 3M ESPE
Structur VOCO
Telio CS C&B Ivoclar Vivadent
Temphase Kerr
Ultra-Trim Harry J. Bosworth Company
Bis-GMA bisphenol A diglycidyl-methacrylate, PEMA polyethyl methacrylate, PMMA poly-
methyl methacrylate, UDMA urethane dimethacrylate
esthetics is still problematic with these resins. Some authors have suggested the
use of a surface liquid polish coating to prevent biofilm formation by preventing
protein adsorption (Davidi et al. 2008). Other materials, such as polycarbonate
crowns and bis-acrylic resins have been suggested in lieu of acrylic resins (Bidra
and Manzotti 2012).
The temperature increase during polymerization of PMMA is significantly
higher than those of polyvinyl ethyl methacrylate, light-cured urethane dimethacry-
late, and bis-acryl resins (Lieu et al. 2001). The intra-pulpal temperature rise associ-
ated with the polymerization of PMMA-based materials could be up to five times
that associated with the normal consumption of thermally hot liquids (Plant et al.
1974). The use of PMMA in fabricating provisional restorations should be discour-
aged when the direct technique is used. However, when provisional restorations are
made using the indirect technique, PMMA is a good option owing to its superior
physical properties (Kaiser and Cavazos 1985). Some of the commercially available
PMMA materials are displayed in Table 10.3.
10.2.1.2 Polyethyl Methacrylate (PEMA)
PEMA-based materials for provisional restorations were introduced in the 1960s
and have a number of advantages and disadvantages relative to PMMA-based
materials. One study showed a higher fracture resistance relative to PMMA and
bis-acryl materials (Osman and Owen 1993). PEMA has been considered a good
210 J. Perdigão and G. Gomes
option for direct provisional restorations for short-term use (Vahidi 1987;
Christensen 1996). Some of the commercially available PEMA-based materials are
shown in Table 10.3.
10.2.1.3 Composite Resins
Bis-Acryl
The introduction of bis-acryl composite resin was aimed at overcoming the short-
comings of methacrylates. It has been reported that bis-acryl resins used for provi-
sional restorations have advantages over other resin-based provisional materials
(Table 10.4).
Bis-acryl-based composite resin, a hydrophobic material similar to Bis-GMA-
based composites, is available in a two-paste automix delivery system. Bis-acryl
resin-based materials are easy to use but are expensive compared to other materials
for custom-made provisional restorations. They also exhibit low polymerization
shrinkage, leading to a good marginal fit and good transverse strength (Strassler
et al. 2007). The presence of a thick oxygen inhibited layer on the surface upon set-
ting makes them less stain resistant compared to methacrylates but easier to repair
using flowable composites (Hagge et al. 2002; Bohnenkamp and Garcia 2004).
While bis-acryl-based materials exhibit enhanced microhardness and resistance to
wear over PMMA (Diaz-Arnold et al. 1999; Strassler et al. 2007), they are more
brittle. Bis-acryl composites can be polished using the same polishing points used
for direct restorative composite materials. The resulting surface texture depends on
the filler particle size (Fig. 10.1).
Comparing bis-acryl and PMMA materials in terms of occlusion, contour, mar-
ginal fidelity, and finish, bis-acryl materials were significantly superior to PMMA
for both anterior and posterior teeth (Solow 1999; Young et al. 2001). The use of
bis-acryl resin in a polyvinyl siloxane impression matrix significantly reduced tem-
perature increases in the pulpal chamber compared with those obtained when bis-
acryl resin was used in vacuum-formed polypropylene matrix (Castelnuovo and
Table 10.4 Advantages of bis-acryl resins*
Filled composite resins, therefore they are harder, more resistant to dietary solvents, and more
resistant to occlusal wear than unfilled acrylic resins
Quick and easy to use
Set rapidly and can be removed from the mouth after 60–75 s
Flexible to make insertion and removal easier
Low elastic modulus to withstand occlusal forces
Undergo minimal polymerization shrinkage
Minimal heat from polymerization, do not cause thermal damage to the pulp
Radiopaque
Can be easily repaired with a flowable composite resin
Excellent color stability and stain resistance
Little odor when mixed
*From Hagge et al. (2002), Gratton and Aquilino (2004), Strassler (2009)
10 Provisional Restorations 211
a b
Fig. 10.1 Atomic force microscope images of bis-acryl composite resins polished with Sof-Lex
(3M ESPE) disks of decreasing abrasiveness. The field dimensions are 5 μm × 5 μm. (a) Protemp
Plus or Protemp 4 (3M ESPE). (b)Structur (VOCO)
Tjan 1997). Table 10.3 displays some bis-acryl-based composite resins currently
available.
This material is currently the top choice for provisional restorations in many
private dental practices and dental schools in the USA.
UDMA
Light-cured resin-based materials for provisional restorations, such as urethane
dimethacrylate (UDMA)-based resins, were first introduced in the 1980s (Emtiaz
and Tarnow 1988). Some of these materials contain filler, such as silica particles, to
improve physical properties such as reduced polymerization shrinkage (Passon and
Goldfogel 1990). Light-cured UDMA-based resins do not leave residual monomers
as PMMA does, the reason why they exhibit significantly decreased tissue toxicity
(Khan et al. 1988). These materials are less expensive and time-consuming than lab-
oratory-made provisional restorations and other materials used for direct provisional
restorations (Haddix 1988). Besides, they are adaptable intraorally because of their
putty-like consistency and are repairable with flowable composites. However,
UDMA-based materials for provisional restorations do not result in good marginal
fidelity compared to bis-acryl- and PEMA-based materials (Tjan et al. 1997). Light-
cured UDMA-based materials are brittle, which makes them contraindicated for high
strength posterior restorations (Prestipino 1989). For anterior restorations, they are
not as stain resistant as other materials and are available in limited shades. Examples
of UDMA-based materials currently available for use are displayed in Table 10.3.
Bis-GMA
Dual-cured resin materials for provisional restorations are also available (Table 10.3).
An example is TempSpan (Pentron Clinical), which is carried into the mouth in a
212 J. Perdigão and G. Gomes
Table 10.5 Materials for CAD/CAM-generated provisional restorations (Güth et al. 2013; Keul
et al. 2014)
Commercial name, manufacturer Composition
artBloc Temp, Merz Dental Unfilled PMMA
Telio CAD, Ivoclar Vivadent Unfilled PMMA
Telio CAD for Zenotec, Wieland Unfilled PMMA
Dental
Cercon base PMMA, Dentsply Unfilled PMMA
VITA CAD-Temp, VITA PMMA, 14 % micro-filler fillers
Zahnfabrik
polycon ae, Straumann Highly cross-linked PMMA (IPN, interpenetrated
polymer network)
New Outline, Anaxdent Unfilled PMMA
Quattro Disc eco PMMA, Unfilled PMMA
Goldquadrat
clear vinyl polysiloxane putty matrix (TempSpan Clear Matrix Material, Pentron
Clinical). Compared to methacrylate-based materials, Bis-GMA resins have good
marginal fit, excellent polishability, low polymerization shrinkage, and minimal exo-
thermic reaction and are repairable with flowable composites. As with all resin-based
materials, Bis-GMA resins more expensive than methacrylate-based materials.
10.2.1.4 Materials for CAD/CAM
Highly esthetic provisional restorations can now be milled out of high-density
PMMA monolithic blocks using CAD/CAM technology (Table 10.5). These resto-
rations are precision milled to fit single- and multi-unit preparations, offering
increased strength. There are several drawbacks of this new technology. One draw-
back is cost, as the impression must be sent to a laboratory for the provisional res-
toration to be fabricated prior to the clinical procedure.
The variation in light transmission is wide among brands. The total transmission
values varied from 33.1 to 54.5 % in a recent study that included 11 CAD/CAM
PMMA blocks (Güth et al. 2013). Another study found that CAD/CAM resins have
a lower wear rate than resins polymerized manually. However, CAD/CAM resins
showed higher wear values than glass-ceramic, with the exception of Telio CAD
(Ivoclar Vivadent) (Stawarczyk et al. 2013).
10.2.2 Materials for Preformed Provisional Restorations
Preformed provisional crowns or matrices usually consist of tooth-shaped shells of
polycarbonate resin, PMMA resin, celluloid, or metal. They are adapted to the prep-
aration by relining them with acrylic resin to provide a tight fit, but they usually
need considerable margin adjustments as well as occlusal reduction. They are com-
mercially available in various tooth sizes and are usually selected for a particular
tooth anatomy. Nonetheless, available sizes and contours are limited. Compared
with custom-fabricated restorations, this treatment method is fast but is more likely
to result in an inadequate outcome. This can result in ill-fitting provisional
10 Provisional Restorations 213
restorations (Christensen 1996). For minor discrepancies, the “bead-brush” tech-
nique or a flowable composite may be used (Hammond et al. 2009).
10.2.2.1 Clear Celluloid Crown Forms
Clear celluloid crown forms are made from a thin shell of cellulose acetate (Strassler
2009). Crowns Forms (Dentsply), Full Forms (Directa AB), and Odus Pella
Transparent Crown Forms (Moore Co.) are some of the commercial names. They
can be filled with acrylic resin or with composite resin after they are trimmed and
adapted to the gingival margin.
10.2.2.2 Tooth-Colored Resin Crowns
Polycarbonate resin crowns have long been used in prosthodontics to fabricate
provisional restorations for single-unit restorations (Bidra and Manzotti 2012).
These crowns are reinforced with microfibers to strengthen their structure and
improve esthetics. As with other preformed crowns, they fit poorly and must be
relined with acrylic resin. Final adjustments of margins and occlusal contacts
may be time consuming (Gratton and Aquilino 2004). Polycarbonate resin
crowns have a number of superior properties compared to PMMA-based materi-
als, including color stability, abrasion resistance, hardness, esthetics, and
mechanical strength (King et al. 1973; Federick 1975; Bidra and Manzotti 2012).
Practitioners commonly use polycarbonate resin shell crowns as a matrix mate-
rial around a prepared tooth that is relined with acrylic resin to customize the fit.
Among others, the two most common polycarbonate crowns are made by 3M
ESPE and by Directa AB.
PMMA resin crowns, such as GC Crowntek (GC America), are also available. As
with polycarbonate crowns, PMMA preformed crowns can be relined with PMMA-
or PEMA-based resin.
10.2.2.3 Metal Crowns
Aluminum There are two major aluminum-based provisional crowns available,
Aluminum Shell Crowns (Miltex) and Golden Anodized Crowns (3M ESPE).
Aluminum-based crowns provide quick tooth adaptation due to the softness and
ductility of the material, but this same positive quality may result in rapid wear that
leads to perforation in function and/or extrusion of teeth (Lui et al. 1986). An
unpleasant taste is sometimes associated with aluminum materials.
Tin Tin Crowns (Directa AB) are made of tin, whereas Iso-Form Crowns (3M
ESPE) are made of tin-silver. Like aluminum, they possess reasonable ductility and
can be contoured quickly, but the occlusal table is reinforced so they are more resis-
tant to wear (Lui et al. 1986) than aluminum crowns. They are indicated for short-
term provisional restorations in the posterior area and can be used as a template for
a tooth-colored provisional restoration.
Stainless steel For longer-term use, stainless steel crowns are available (Stainless
Steel Permanent Molar Crowns, 3M ESPE), but may be more difficult to adapt to a
214 J. Perdigão and G. Gomes
prepared tooth because they are harder and lack ductility compared to the other two
types of metal crowns.
Metal provisional materials are generally esthetically limited to posterior
restorations.
10.2.2.4 Protemp™ Crown
The Protemp Crown Temporization Material (3M ESPE) is a preformed malleable
bis-GMA-based composite resin used as provisional crown for single-unit tempori-
zation of posterior teeth and canines (Fig. 10.2). The crown size is selected and
trimmed with scissors to achieve the proper height. Once it is molded to the prepara-
tion with composite instruments and contacts established, the patient is instructed to
bite on the crown to achieve adequate occlusion. The crown is then light-cured for
2–3 s from occlusal, buccal, and lingual surfaces. The provisional restoration is then
removed, light-cured for 1 min, and finished with a carbide bur and polishing points
prior to cementation. The margins may be modified using a flowable composite. It
combines the advantages of composite resins (good polishability, esthetics, wear
resistance, marginal fit) with those of prefabricated provisional crowns, such as ease
of use, easy clean-up, and no need for a template matrix (Strassler 2009). The
Protemp Crown is currently available in universal shade.
10.3 Provisional Luting Materials
While it is required that they allow for an easy removal of the provisional restora-
tion, it is very crucial that these luting agents provide good marginal sealing to
prevent pulpal irritation in a vital tooth or reinfection of the root canal environment
in an endodontically treated tooth. Provisional luting agents should have good
mechanical properties, low solubility, and tooth adhesion to resist bacterial pene-
tration and their by-products (Baldissara et al. 1998). The most common luting
materials used for provisional purposes include (1) calcium hydroxide cement, (2)
zinc-oxide eugenol cement, and (3) eugenol-free zinc-oxide cements (Baldissara
et al. 1998). Polycarboxylate cement, indicated for definitive restorations, may be
used with provisional restorations when the preparation is not ideal, such as in
short preparations or those with excessive draw (Wassell et al. 2002).
Polycarboxylate cements bond chemically (Tyas and Burrow 2004) to calcium in
enamel and dentin, which provides a better seal than other cements used for provi-
sional restorations.
Provisional luting materials have poor mechanical properties that tend to
deteriorate over time.
10 Provisional Restorations 215
a b
c
d
e
f
Fig. 10.2 Clinical sequence showing a provisional restoration made with Protemp Crown
Temporization Material (3M ESPE). (a) Preoperative view of an endodontically treated mandibu-
lar first molar restored with composite-build-up composite resin. (b) Buccal view. (c) Tooth was
prepared for a monolithic zirconia crown. (d) The approximate mesial-distal width was determined
using the Protemp Crown Size Tool. (e) The same tool was used to measure the approximate crown
height. (f) The Protemp Crown size corresponding to the measurements was selected. (g) The
Protemp Crown was trimmed with scissors. (h) The provisional crown was adapted to the slightly
moist prepared tooth. (i) Patient was asked to gently close. The buccal surface was adapted with a
composite instrument, and the restoration was tack-cured from the buccal aspect for 3 s. The lin-
gual and occlusal surfaces were then adapted and tack-cured for 3 s. (j) The Protemp Crown was
gently removed from the preparation and light-cured for 40 s from each surface. (k) The provi-
sional crown was tried in and occlusion adjusted. (l) Finishing was carried out with carbide finish-
ing burs, Sof-Lex (3M ESPE) disks and PoGo finishing points (Dentsply). (m) After the impression
was taken, the provisional restoration was cemented with Temp-Bond NE (Kerr Co.) and excesses
removed. (n) Buccal view of provisional restoration. (o, p) A monolithic zirconia crown was fab-
ricated in the dental laboratory. (q) The intaglio surface was sandblasted with aluminum oxide
particles. (r) The definitive restoration was cemented with a self-adhesive resin cement. (s, t)
Postoperative view
216 J. Perdigão and G. Gomes
g h
i j
k l
m n
Fig. 10.2 (continued)
10 Provisional Restorations 217
o p
q r
s t
Fig. 10.2 (continued)
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