Provisionalization is a necessary stage in the prosthetic
restoration of the majority of patients that require tooth reduction during
aesthetic enhancement. Through this process, the members of the treatment team
are able to evaluate and perform aesthetic, phonetic, and functional
adjustments to the provisional restoration while simultaneously preserving or
enhancing the state of the dental and gingival tissues during the fabrication
of the definitive prosthesis.1,2 Although provisionalization can be
performed in numerous manners that include acrylic resin,3 the
"sandwich technique,"1 direct composite bonding,2,4
and laboratory-fabricated provisional veneers,4 these techniques are
often inefficient based upon the handling properties of the provisional
material, the durability of the provisional restoration, or the expenses
involved. These procedures may be complicated by the duration or difficulty of
the chairside fabrication process as well. Provisional materials also exhibit a
tendency to lose their color stability when placed intraorally for extended
Consequently, it is essential that clinicians have a fundamental
understanding of a provisionalization technique that maintains the intraoral
structures while facilitating the adaptation of the provisional restorations to
achieve the objectives of the treatment. In order to become a standard addition
to the existing restorative armamentarium, this procedure must satisfy patient
aesthetic concerns as well as be cost effective and easy to perform chairside.
Presentation and Evaluation
A 20-year-old female patient presented with unaesthetic white
spots on the maxillary anterior teeth that were caused by enamel mottling
(Figures 1 and 2). The shade of the tooth structure that surrounded this
mottling was unacceptable to the patient - even following tooth whitening. Once
the patient's history had been documented, comprehensive clinical and radiographic
examinations were performed. In addition, an occlusal analysis was completed to
determine if the patient had any contributing temporomandibular joint pathology
or occlusal discrepancies. Based on these findings, the patient's aesthetic
expectations, and the objectives of the restorative team, porcelain veneers
were selected to restore the natural aesthetics and function to the patient.
Nevertheless, it was necessary to determine an optimal means of
provisionalization that would permit the chairside fabrication and adjustment
of the prosthesis while providing an efficient interim solution with a reduced
Formulation of the Treatment Plan
While the definitive porcelain veneer restorations were fabricated
in the laboratory, a single-unit provisional restoration would be created with
acrylic resin and placed for a period of 3 weeks. The following preoperative
measures were performed for the fabrication of the provisional restoration:
* The maxillary anterior teeth of the preoperative study model
were waxed up to the ideal arch alignment and incisal plane position (Figure 3).
* An additional 0.5 mm of wax was added to the facial surface of
the waxed-up model (Figure 4).
* A polyvinylsiloxane matrix was created from the waxed-up model.
The additional layer (0.5 mm) of wax facially would allow the provisional
veneers to be thicker buccolingually for increased strength and durability.
The six maxillary anterior teeth and the maxillary first premolars
were conventionally prepared for veneer restorations (Figure 5). The premolar
teeth were included in the treatment plan since the patient requested
significant modification of tooth hue and chroma as well. Under water
irrigation, the facial surfaces of the teeth were reduced 0.5 mm and the
incisal edges of teeth #6 through #11 were reduced approximately 1.5 mm.
Although the preparations extended halfway through the interproximal contacts,
they did not in this instance completely break the contacts. All line angles
were rounded with fine diamond burs. While the margins were extended less than
0.5 mm subgingivally with a fine chamfer bur, retraction cord was not utilized
during this process.
A bis-acrylate composite material was flowed through a syringe gun
into the polyvinylsiloxane matrix that had been fabricated on the model. The
tip of the syringe remained buried in the provisional bis-acrylate material as
it was dispensed in the matrix so that air bubbles were not incorporated into
the mixture. From the maxillary left first premolar to the right first
premolar, the polyvinylsiloxane matrix was filled from the incisal to the
gingival aspect of each tooth form (Figure 6). The preparations were thoroughly
rinsed with water and left slightly moist. The loaded matrix was placed
directly onto the maxillary arch until complete seating was accomplished.
Excess provisional material was separated from the polyvinylsiloxane matrix
with a periodontal probe and a round-end explorer to prevent iatrogenic damage
to the gingival tissue.
The matrix remained in place for approximately 1 minute to allow
the bis-acrylate to initially harden. While the material was stable at this
phase, it did maintain a degree of flexibility. The matrix was removed from the
preparations with a facial to lingual rocking motion. Flashing was trimmed from
the restoration with thin surgical scissors and then with a fine sandpaper disk
and a thin, fine diamond bur (Figure 7). Polishing was subsequently performed
with wet pumice on a bristle brush. The eight provisional veneers remained
connected. The embrasures were trimmed gingivally to the interproximal contact
so that the embrasure areas could be rinsed thoroughly each day with a 12%
chlorhexidine rinse. Once the accuracy of seating and marginal adaptation were
confirmed, a sealing agent was applied to the facial surface of the restoration
and light cured for 60 seconds to achieve a glassy sheen.
The preparations were cleaned with wet pumice in a prophy cup,
rinsed with water, and wiped with a cotton ball soaked in a disinfectant. The
teeth were dried and then isolated with cotton rolls. An adhesive agent was
subsequently placed on the facial aspects of the preparations and the contact
surfaces of the provisional veneers. Acid etching was not performed at this
stage, and no dentin primer was applied to the preparations or the veneers. The
provisional veneers were then placed intraorally on the preparations with
finger pressure, which was followed by two cotton-tipped applicators. Firm
seating pressure displaced excess adhesive from the gingival, lingual, and
interproximal margins. As the provisional restorations were compressed against
the teeth with the applicators, an air syringe was used to gently blow away the
excess adhesive (particularly from the interproximal regions) onto cotton
squares that were placed adjacent to the prepared teeth on the facial and
lingual aspects. The margins of the provisional restorations were then wiped
with a cotton ball, and the restoration was simultaneously polymerized from the
facial and lingual aspects with two curing lights for 60 seconds.
Once the provisional restoration had been light cured into place,
the incisal plane, centric occlusion, eccentric occlusal movements, and
envelope of function were examined and adjusted as necessary. The incisal plane
was parallel with the mandibular lip line, and the central incisors were
dominant to the adjacent teeth (Figure 8). The patient received instruction on
the maintenance of the provisional restoration. A postoperative regimen that
consisted of daily hydrogen peroxide (3%) rinses and gentle brushing with a
mechanical toothbrush was also prescribed. A 30-second chlorhexidine rinse
(twice daily) was similarly recommended, and the patient was recalled after 2
weeks to permit evaluation of the adjacent gingival tissues. The tissue
appeared healthy, and no inflammation or bleeding was apparent upon periodontal
and Cementation of the Porcelain Laminate Veneers
The definitive porcelain veneers were seated 4 weeks following
tooth preparation. Prior to their final seating and cementation, the
provisional restoration was removed using a round-end coarse diamond bur in a
high-speed handpiece, which was used to place vertical depth cuts into the
length of each provisional veneer. A plastic instrument was then placed
progressively in each depth cut and turned (Figure 9), which created a torquing
force on the provisional restoration. This force separated sections of the
provisional veneer from the underlying tooth structure. Since the teeth had not
been etched prior to the placement of the provisional restorations, the
majority of the adhesive remained on the veneers. Any adhesive that remained on
the preparations was removed with a pumice slurry applied with a prophy cup in
a slow-speed handpiece. The placement of the definitive porcelain veneers -
which is beyond the scope of this article - was then completed, and the final
aesthetics satisfied the objectives of the patient as well as the restorative
team (Figures 10 and 11).
When porcelain veneers are to be utilized in restorative
treatment, the provisionalization phase should be time-efficient, aesthetic,
functional, and cost effective. This presentation demonstrates a predictable
means of achieving these objectives. In the use of this technique, however, it
is important to 1) provide an additional 0.5 mm of thickness in the ideal
preoperative waxup, 2) fabricate the polyvinylsiloxane matrix of the waxed
model, and 3) fill the matrix with the bis-acrylate resin, and place it directly
on the preparations. When each of these criteria is addressed in the clinical
phase, the success of the final result is ensured.
* Private practice, Waco, Texas.
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