Dr. Martin Goldstein DMD FAGD

Temporization, or, as it’s often called, “provisionalization,” might be considered its own subdivision of restorative dentistry. Before we plan any type of dental rehab, we need to “pre-think” how we’ll maintain our patient’s appearance and function and keep him or her comfortable for the duration. We also need to decide on the particular technique, materials and cement we will use.

“Pre-think” is the operative term. We must know the specific requirements of our temporization in advance. Will it be worn for three weeks or three months? Will it need to be removed and recemented several times? Is the patient a bruxer? Are exquisite esthetics critical? What costs will the provisional add to the treatment plan? Must you involve a laboratory to generate a satisfactory result, or can a satisfactory result be had chairside?  

This figure outlines a simplified rationale for choosing the appropriate temporization technique for our smile rehab projects. It differentiates when a clinician might choose a laboratory-processed temporary and when a chairside-fabricated temporary might be more appropriate. The lower portion of the diagram focuses on the chairside, template-driven provisional, which is the focus of this article. Such indexed or template-driven provisionals, most likely fabricated from one of the many bisacryl formulations available today, are practical for short-term provisionalizations (three to six weeks). 

Bisacryl materials, while excellent in appearance and handling, prove to be somewhat brittle and prone to leakage. This contributes to the lack of flexibility ascribed to this material class. Provisionalizations that feature several months of wear and multiple removal and recement cycles are often best served by lab-processed acrylic and its inherent toughness and flexibility. On the plus side, bisacryls may be easily added to or subtracted from when trial esthetics and/or occlusal schemes are planned. They are also easily repaired and marginated simply by applying appropriate amounts of your favorite composite. 

And, finally, when multiple preps (i.e. four to eight) are to be included in your provisional, a template-driven technique using a bisacryl material is less difficult than attempting to match your own preps to your lab’s when employing a lab-fabricated provisional.

Watch the following video for a step-by-step case presentation:

In that vein, let’s examine a rather mundane (but frequently called for) chairside fabrication of a posterior three-unit temporary bridge. In this case, a span from Nos. 12 to 14 is seen pre-operatively, No. 14 having been compromised by recurring caries, as well as an intracoronal fracture. As the  pre-operative anatomic form is suitable for “indexing” (i.e. creating a silicone matrix or template), and the temporary’s time in service will be limited to how long it takes to have the new bridge returned from the lab, a chairside bisacryl provisional would appear to be the perfect solution. 

 A silicone-based putty index was created by having the patient occlude into a triple tray filled with a silicone impression putty (Coltene’s Affinis

 The built-up (No. 12) and prepared bridge abutments are prepared for provisional fabrication.

3 bisacryl formulation is placed into the putty index  with subsequent placement into the patient’s mouth. Structur

3 is a nano-filled bisacryl material said by the manufacturer to possess high fracture resistance and compressive strength (>500 MPa). It sets in 45 seconds intraorally. The manufacturer’s coined phrase “wipe and go” refers to the sheen obtained with the use of an alcohol wipe after one’s provisional has been trimmed. A natural gloss emerges as surface monomers are wiped away. Structur

The newly minted, but still curing, provisional is gently trimmed with a No. 15 scalpel blade assisted by the firm putty backing.

The provisional is refined with an eight-bladed carbide finishing bur (Brasseler ET Finishing Bur #ET9). This proves to be the gentlest way to create accurate margins, particularly in thin zones of resin. Use of a heavier lab-style acrylic bur is more likely to overtrim or, even worse,  fling your temporary into your trimmings pan. 

The blade and finishing bur approach described here along with Structur

3’s “auto-polish” feature will eliminate the need to plant yourself at the lab bench to finish your temporary. 

3’s relative shade accuracy,  the VITA shade tab (right side of tab display) bears a strong resemblance to the shade of our new provisional. The shade, opacity and opalescence can vary between products of the same shade designation so operators should do their best to match the bisacryl brand to the task.

demonstrates our finished provisional following cementation with VOCO’s Bifix

 Temp, a new composite-based provisional cement featuring a translucent tooth shade that does not shine through the provisional restoration. The auto-mix cement self-cures in four minutes but allows for light-curing to accelerate the process.  A particular note is the ability to employ the “tack-cure” technique, which makes cleanup of excess cement a breeze. Yet, another time-saving process.   

A “pre-awareness” of the service needs of our provisionals, as well as handling and appearance characteristics of the materials we employ, allows us to streamline and improve our temporizations. Doing so reduces the number of patient distress calls reporting ill-fated temporary restorations that require immediate attention. Patient, doctor and staff will certainly benefit from being spared such inconveniences.

Dr. Goldstein, a fellow of the International Academy of Dento-Facial Esthetics and the Academy of General Dentistry, practices general dentistry in Wolcott, Conn. Recognized as one of the Leaders in CE by Dentistry Today since 2002, and for his expertise in the field of dental digital photography, he lectures and writes extensively about cosmetics and the integration of digital photography into the practice. He has authored numerous articles for dental periodicals in the United States and abroad. He can be contacted at martyg924@cox.net.

Articles

 Temporization, or, as it’s often called, “provisionalization,” might be considered its own subdivision of restorative dentistry. Before we plan any type of dental rehab, we need to “pre-think” how we’ll maintain our patient’s appearance and function and keep him or her comfortable for the duration. We also need to decide on the particular technique, materials and cement we will use.

How to choose the most suitable temporization approach

Small-headed handpieces are nothing new. I’m guessing most of us have owned one at some point in our careers. We’ve been enamored by their compact size but underwhelmed by their ability to cut tooth structure. We also don’t care for the high-pitched screeching often associated with earlier generation models. Ultimately, they have found their way to the rear of our “back-up” handpiece drawer, and we only look for them when we’re called upon to restore the disto-buccal of No. 18 on a patient who has ultra-limited opening. We then go searching for the short shanked burs because our mini handpiece doesn’t work with normal length cutting instruments. They’re on the shelf somewhere. This has to sound familiar! (Unless of course you are a pediatric dentist who uses micro handpieces on a daily basis.)

A few months back the good people at J. Morita asked if I would like to try out their soon-to-be-introduced 

. I was told I would be quite surprised by the ability of such a small handpiece to cut like a full-sized counterpart. I thought to myself, “Sure…what have I got to lose? Try it for a day and then give it back. You’ve got enough handpieces.” It occurred to me afterward that J. Morita has come out with some great gizmos over the years, so there might be something to this new handpiece (Recall the Root ZX, great and getting even better).

The TwinPower Ultras arrived as promised in two flavors. The UltraM (the smaller of the two) intended for use with short shank burs and normal burs up to 20 mm in length, and the UltraE, slightly larger, to be used with standard burs. I grabbed the UltraM and offered the UltraE to my partner, who was more than happy to participate in the evaluation. 

For those of you who haven’t owned a micro (sometimes called mini) handpiece it is one of those items that, as alluded to above, can save your day when working in a tight spot. Not only can it afford you straight line access to the occlusal surfaces of No. 18 or No. 15 in a “hostile” environment, it can dramatically increase the visibility of the target zone. This can be incredibly helpful, for example, when creating endodontic access portals, allowing you to actually see what you’re doing. Pediatric dentists deal with limited access every day. In this instance, I’m quite sure that I am preaching to the choir. Common sense tells us that the better we see what we are doing, the better and the faster we do it. It’s not rocket science. 

So why don’t we use micro handpieces all of the time? As mentioned above, these micro handpieces sacrifice cutting ability and bur compatibility too much to make them “prime time players.” It would appear that J. Morita is attempting to change that line of thinking. Ironically, I began using the TwinPower UltraM right after I installed a highly touted air-driven handpiece from another well-known manufacturer. The manufacturer claimed this air-driven handpiece could cut like a muscle bound electric and not break a sweat (actually, it could, but that’s another story). The point here: I was able to use, side by side, a handpiece designated as a heavy hitter next to the UltraM, ready to attain expanded duty. 

As we began using the J. Morita handpiece, the first thing my assistant and I noticed is how difficult it was to tell if the handpiece was running when I engaged the rheostat. Why? The UltraM kind of “whispers” as it runs. The annoying handpiece whine (6000-7000 Hz range) has been all but eliminated. We also noticed the concentricity of the bur spinning in place. It sounds crazy to say but the revolutions are so smooth and chatter free that the bur looks like it isn’t moving. We also liked the fact that when I remove my foot from the rheostat, the bur immediately stops spinning with not so much as a single drop of water dripping from the water jets. 

OK, that’s all great but how does it cut? Did it hold me back with respect to speed of operation? After working with the handpiece for a month, I’ve become accustomed to using the heavy hitter handpiece and the UltraM interchangeably. When it comes to “everyday” tooth preparation, the differences in cutting ability between the two handpieces are non-discernable. In fact, when I need “peace and quiet,” I’ll grab the UltraM rather than the noisy big brother. The one instance I might not use the UltraM would be to cut off an old crown. Why tempt fate?

In summary, the UltraM has changed my opinion of mini handpieces. By the way, my partner, using the UltraE, shared my sentiments. It would appear that owing to J. Morita’s ingenuity, the micro handpiece, as a class of dental handpiece, is ready for prime time. 

Dr. Martin Goldstein, a Fellow of the International Academy of Dento-Facial Esthetics as well as the Academy of General Dentistry (FAGD), practices general dentistry in Wolcott, Conn. Recognized as a Dentistry Today Top 100 CE Leader for the last seven years and for his expertise in the field of dental digital photography, he lectures and writes extensively concerning cosmetics and the integration of digital photography into the general practice. 

Small-headed handpieces are nothing new. I’m guessing most of us have owned one at some point in our careers. We’ve been enamored by their compact size but underwhelmed by their ability to cut tooth structure.