Provisional restorations for altered occlusions

TEMPOROMANDIBULAR SECTION

GEORGE

JOINT

l

OCCLUSION

EDITOR

A. ZARB

Provisional

restorations

for altered occlusions

Clifford W. Fox, D.D.S.,* Bernard L. Abrams, D.D.S.,** and Asterios Doukoudakis, D.D.S., M.S.*** Case Western

Reserve University,

School of Dentistry,

Cleveland,

T

for achieving the desired results. The time required to produce an acceptable result frequently equals the time spent in tooth preparation and impressions. However, the expenditure of time is worthwhile to achieve the established goals and prevent frustration. Some of the criteria for provisional restorations are satisfactory gingival adaptation, proper contours, cleansable embrasures, acceptable contacts, innocuous occlusion, provision of space for pontics, and provision for acceptable phonetics. The concept of biologically acceptable provisional restorations demands that the prepared teeth be protected and the treatment restorations resemble the form and function of the final restorations. Provisional restorations also serve as a healing matrix for the gingiva and sedate the pulp.*

he importance of the provisional restoration is frequently underestimated and a superb restoration can be jeopardized as a result. It is unfortunate that the concept of temporary restorations has led to insufficient relegation of time for the procedures. If the construction of a provisional restoration is hastily performed, it will not afford adequate protection and/or can insult the prepared teeth and the supporting tissues. Knowledge of the criteria for treatment restorations and the provision of adequate time are requirements

Presented at the Greater New York Academy of Prosthodontics, New York, N.Y. *Associate Clinical Professor of Dentistry. **Associate Professor of Dentistry, and Chairman, Department of Comprehensive Dental Care. ***Associate Professor of Fixed Prosthodontics.

Table I. Construction MASTER

methods for provisional

CAST

Ohio

*Flocken, J.: Personal communication, 1980

restorations

METHOD

DIRECT

METHOD I

I Preformed Trmporarks (metal. acrylic. poly carbonab. clear plastic)

I

cast Metal copings

Equilibrabd andlor Waxed.up (Altered) Casts

I Fit Matal Sands (Gold 0, Copper)

---TImpression

Acrylic and Shape

I

Add Mass ol Auto.C”re Acrylic and Shape

of Casts

I

Flask

P,OCOSS

neawzurea

POlyStylelle .020 Matrix

ACryliC

(Alginste,

I I

I I Form T;mporarks on Underprepared Cast (Auto or He&Cured Acrylic)

I Compk1bly Fill Tooth Areas of Matrix or ImpressIon with Auto Or Her&Cured Acrylic. Hollow out and Shape FOR ALL METHODS

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-

Rabase

Impression wax. rubber. silkone,

and Reline

etc.)

I

.1 Form T@mporwier DincUy in tha Youth (AutoCund Acrylic) -

Form Thin Temporary Shell (Flow AutoCured Acrylic in and out 01 M&lx or ImpressIon.) as Necessary

567

FOX, ABRAMS,

Fig. 1. Diagnostic casts with modified occlusal surfaces and wax pontics replacing edentulous areas.

AND

DOUKOUDAKIS

Fig. 2. Altered mandibular cast with tongue space filled with clay 2 mm short of dentogingival junction.

Fig. 3. Maxillary stock trays are used for alginate impressions of water-soaked maxillary and mandibular casts

Fig. 4. Notched key is cut on distal of both casts for stone matrix. ,568

Various methods for fabrication of provisional restorations have been described, but some form of matrix is generally suggested. The matrix can be made from alginate (irreversible hydrocolloid),’ silicone putty, hard wax,? or heat-formed resin sheets3to fabricate the provisional restorations intraorally. However, some dentists prefer an indirect technique that permits constructing the provisional restoration on a stone cast4 Amsterdam and Fox,’ and Kornfeld’ described techniques in which an acrylic resin shell was fitted loosely on prepared abutment teeth. The abutment teeth were then fitted with gold bands, and the acrylic resin shell was filled with self-curing acrylic resin and adapted over the gold bands. Doherty’ reported a similar technique that used gold, copper, or aluminum bands, while Greenberg8 used thin stainless OCTOBER

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Fig. 5. Vacuum-formed

Fig. 6. Cast and template setting stone.

OCCLUSIONS

polystyrene

are place on patty of fast-

templates

of 0.02 inch material

for casts.

Fig. 8. Template and stone die are trimmed so that die stone does not cover facial surfaces of cast.

Fig. 7. With matrix on mandibular cast, lingual undercuts are blocked out with clay prior to pouring stone die.

Fig. 9. Abutment teeth are underprepared on cast for complete crowns while stone pontic is removed.

steel bands for his technique. Youdelis and Faucher’ reported an improved technique for fabricating provisional restorations with reinforcing stainless steel wires and acrylic resin cured in a pressure pot. Dawson”

described a vacuum-formed matrix with a stone core to minimize the distortion as acrylic resin polymerizes. He also incorporated gold copings and connecting bars

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into the provisional

restorations

to increase longevity.

569

FOX, ABRAMS,

AND

DOUKOUDAKIS

Fig. 10. Thin mix of self-curing acrylic resin is poured into matrix.

Fig. 12. Provisional restoration is removed from cast and trimmed. Sections can be cut off as needed.

Fig. 11. Prepared cast coated with tinfoil substitute is firmly seated into template on die. Pressure is maintained during polymerization of acrylic resin.

Fig. 13. Provisional restorations area rebased intraorally with self-curing resin after tooth preparation.

The flow chart in Table I categorizes formerly and currently used methods for fabrication of provisional restorations. A technique is described in this article for the construction of provisional restorations by the altered cast method for complicated and/or extensive restorative procedures. The method is recommended when alterations in morphology and/or occlusion are anticipated.

gival junction (Fig. 2). The mandibular and maxillary casts are soaked in water to prevent irreversible hydrocolloid from adhering to the casts. Irreversible hydrocolloid impressions are made of both casts in maxillary stock trays (Fig. 3). 3. The impressions are poured with mounting stone (Whip-Mix Corp., Lexington, KY.), 4. The stone casts are separated and trimmed on a cast trimmer. 5. Grooves are placed on the distal of the casts with Faskut stones (Dentsply International, York, Pa.). This serves as a key for the stone matrix (Fig. 4). 6, The casts are sprayed with silicone. 7. Templates of the casts are vacuum formed with CJ.OZinch polystyrene sheets (Fig. 5). 8. With the template in place, a fast-setting mounting stone is placed in the palate and then inverted onto a patty of the same stone (Fig. 6). 9. Step No. 8 is repeated for the mandibular cast

PROCEDURES :. Diagnosis and supportive clinical treatment should be completed prior to restorative dentistry. The diagnostic cast is then mounted on a semiadjustable or fully adjustable articulator and occlusal adjustments performed (Fig. 1j” 2. The tongue space of the waxed mandibular study cast is filled with clay or Play Doh (Kenner Co., Cincinnati, Ohio) 2 to 3 mm cervical to the dentogin570

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Fig. 14. Margins of provisional restorations refined with Roto Pro Perio Tip bur.

are

after lingual undercuts are blocked out with clay or Play Doh (Fig. 7). 10. After the stone has set, the template is separated and trimmed on the facial surface to 3 to 4 mm cervical of the dentogingival junction, and the casts and die are trimmed (Fig. 8). 11. The teeth that will receive complete crowns are conservatively prepared on the casts, and stone pontics are removed (Fig. 9). 12. The prepared teeth are liberally coated with a tinfoil substitute. 13. With the template on the index, Cold Pat (Motloid Co., Chicago, Ill.) is mixed to a thin consistency and poured into the prepared areas (Fig. 10). Precut stainless steel orthodontic mesh (Great Lakes Orthodontic Products, Buffalo, N.Y.) is then inserted into the acrylic resin to reinforce pontics. 14. The prepared cast is firmly seated into the template on the keyed index, and pressure is maintained until the self-curing acrylic resin polymerizes (Fig. 11). 15. The provisional restorations are removed and trimmed with acrylic resin burs or sandpaper disks. (Fig. 12). 16. The polishing is completed, and the provisional restorations are stored in water. The provisional restorations can then be rebased intraorally with a selfcuring resin after tooth preparation (Fig. 13). 17. The margins can be refined by careful use of the Roto Pro Perio Tip bur (Elman, New York, N.Y.) (Fig. 14). 18. The template is retained and used to check for sufficient tooth reduction during preparations (Fig. 15). The template permits formation of the provisional restoration directly in the mouth and/or on casts of the prepared teeth. However, if the final restorations are THE JOURNAL

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Fig. 15. Template is combined with periodontal probe to measure tooth reduction during preparation.

onlays, the provisional restorations should be fabricated intraorally. Casts from impressions of the adjusted provisional restorations can be used as indexes for establishing an acceptable anterior guidance for the final restorations.” SUMMARY A method for fabricating provisional restorations with specific criteria has been outlined and offers the following advantages: 1. Altered occlusion can be restored. 2. Select steps can be delegated to auxiliary personnel. 3. Commercial laboratory fees are eliminated. 4. It is inexpensive. 5. The restorations are durable and esthetic. 6. Restorations are readily modified intraorally. 7. This flexible procedure is used for short or long spans, and/or for segmented treatment. 8. Casts of acceptable anterior provisional restorations can provide a template for developing anterior guidance in the final restorations. Special thanks to Dr. David Burns and the participants of the Advanced Restorative Seminar, Greensboro, N.C.

REFERENCES 1.

Marheine, C., and Staele, G.: Possible dental uses of a new plastic. Quintessence Int 2:45, April; 229, May; and 2:21, June, 1971. 2. Weinberg, L. A.: Atlas of Crown and Bridge Prosthodontics. St. Louis, 1965, The C. V. Mosby Co., pp 26.31. 3. Jones, E. E.: Jaw formed clear resin shells. J PROSTHU DEXT 29:460, 1973. 4. Fisher, D. W., Shillingburg, Jr., H. T., and C’ewhirst, R. B.: Indirect temporary restorations. J Am Dent Assoc 82:160, 1971 _.

5.

Amsterdam, M., and Fox, L.: Provisional splinting-Princi-

571

FOX, ABRAMS,

pies and techniques. Dent Clin North Am March 1959. p[l 73-W C, Kornfeld, M.: hlouth Rehabilitation: CXnical and Laboratory Procedures. ed 2. SL. Louis, 1974, The (: V. Mosby Co.. pp 473490. T Doherty, M. J.: Fabrication of an acryll~, and metal band provisional restoration. J PROSTHKI‘ DF.N,T41:109, 1979. S Greenberg, .J. R.: The metal band-acrylic provisional restoration fealuring ultra-thin stainless strrl hands. Compendium of Continuing Education 2:7, 1981. ‘i I.oudelis, R. A., and Faucher, R.: Provisional restorations: An integrated approach to periodontics resrora[ive dentistry. Deni (Iin North Am 24:288, 1980.

Ii)

I I,

I.lniversity

DOUKOUDAKIS

Dawstrn, P. E.: Evaluation, Diagnosis and Treatment of Occlusal Problems. SC Louis, 1974. Thf C. V Mtrsby Co., pp 378-38 I. E‘ox, C W., Ruzicka, S. J., and Abrams, B. I,. Teaching Syllabus for Advanced Restorative Seminar. Orange, Calif.. 1978. Societv for Occlucal Studies, rwised 1980.

Comparison of the multiphasic dysfunction with lateral transcranial radiographs Carl E. Rieder, D.D.S.,* and James T. Martinoff,

AND

profile

Ph.D.**

of Southern California, Los Angeles, Calif.

L atera 1transcranial radiographs have commonly been used to study the temporomandibular joint (TMJ).‘-2” In recent years, tomography, arthrography, arthrotomography, and computed tomography have often replaced the diagnostic use of single plane techniques. However, conventional lateral transcranial radiographs (TR) are still the most commonly and may be the most frequently used method for radiographic evaluation of the TMJ. Although many authors describe the TR as inadequate, ?u’ others state that it is effective when used in conjunction with other techniques.42-4”Some claim the TR is diagnostic when used alone.“‘.” Ir is understood that a TR examination represents only the lateral aspect of the TMJ and has many inherent sources of error, especially when an uncorrected (nonindividualized) TR is used. In the present study, the TR was used as a radiographic screening procedure to augment a comprehensive occlusal and TMJ examinatiOll.‘l

MATERIAL

AND METHODS

The population and examination of the 1040 patients used in this study were described previously.54 The

multiphasic dysfunction profile and the interrelationship of the individual signs and symptoms found in the

“C Sn~cxl Professor of Prosthodontics, IIepartmrnt 01 Restoratiw Ih~istry. School nl Dentistry **I )Irrua)r of Educntion. Srhor~ls of Mrdicine and Pharmac\

patients have also been described.55The TRs used in the current study were obtained with the teeth in maximum intercuspation with the use of headholders and standard techniques such as those described by Weinbergz5 and Buhner.‘” A submentovertical exposure was not used to determine the condylar long axis in a horizontal plane. Of the original 1040 patients, 926 (89%) had acceptable radiographs and were included in this study. Condylar position, interarticular space (joint space), and overt morphologic changes were noted on each radiograph. .No quantitative measurements were made; judgment was based initially on the relationship of the superior portion of the condyle with the fossa (Fig. 1). Secondly, greatly increased or reduced joint space was noted (Fig. 2). Finally, clearly demonstrated condylar bony morphologic changes (that is, flattening and/or lipping) were also noted (Fig. 3). Data were statistically evaluated by means of chi square analysis: a conservative approach that determines whether the observed differences in prevalence of each sign are large enough to be statistically significant. In this article, differences between observed and expected prevalence of more than 95% will be considered statistically significant.

RESULTS The prevalence of five condylar positions was cross tabulated with sex and age (Table I). Fifty-three percent of patients had nonconcentric condylar positions; protrusion was more common in men and retrusion more OCTOBER

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