Long-Term Composite Provisionalization: The Staged Rehabilitation

Weíve all encountered patients whose dentitions cry out for full rehabilitation. Excessive wear and loss of vertical dimension in such cases make any other approach nothing more than a Band-Aid. We might win the skirmish but lose the war.
When we take it upon ourselves to recommend a full-mouth restoration, a frequently encountered objection is cost. A $30,000 or more dental bill is beyond the immediate reach of many, if not most, of our patients. In an effort to make such treatment more accessible, it makes sense to consider a staged approach that allows the patient to have the rehab done over several years. One logically asks, "How is this possible, since it is often necessary to alter vertical dimension?" We cannot ask our patients to occlude on a single quadrant for extended periods as we probe for a comfortably restored occlusal scheme.
The following two cases demonstrate a method of long-term provisionalization and trial, if you will, that relies upon a bonded intraoral mock-up of the planned full-mouth restoration. It is performed instead of traditional cemented temporization, as we are all aware of the perils of long-term, leaking temps. We become married to them.
The approaches to be outlined should be considered with one very important caution. You and your patient should be reasonably certain that replacement of the bonded trial rehab with a porcelain counterpart is feasible over an agreed upon time period, and that the patient is willing to pay for repairs that may become necessary over the life of the provisionalization. Two to 4 years is not an unreasonable time period to be considering. Obviously, the briefer the staging process, the better. You should also plan on protecting your creation with a bruxism splint as soon as it is placed, as this will extend the life of the restorations.
That said, letís explore two cases (Michele and Phil) that follow a similar path but rely upon different materials for provisionalization. Both cases were initiated similarly with respect to record-taking and are presently being held in their provisionals. Case work-up and provisionalization were accomplished via the assistance of Smile-Vision of Newton, Mass. Photo simulation portraits of the proposed rehabs preceded initiation of both cases. For more information on this process see smile-vision.net.

PRELIMINARY RECORDS

Figure 1. Preoperative image of Phil's dentition, presently edge to edge with considerable wear throughout.

Figure 2. Leaf gauge used to obtain opened and retruded jaw position.

Figure 3. Recording CR with Coltène/Whaledent's Jet Blue Bite Fast Set.

Figure 4. The Kois Dento-Facial Analyzer System used to orient the maxillary cast.

Figure 5. Michele's worn dentition, preoperative view.

Figure 6. Smile-Vision Resin Replica mock-up of upper and lower dentition.

Polyvinyl impressions were taken of each arch followed by an "opened" centric relation record assisted by the use of a leaf gauge (Great Lakes Orthodontics). The leaf gauge allows the patient to easily slide into a reproducible, retruded position. The number of leaves used depends upon how much space will be needed to restore the shapes of the dentition, with special emphasis on the central incisors. Once visually satisfied with the jaw relationship to which you wish to restore (and ultimately try out), record the relationship with a fast-setting polyvinyl bite paste such as Coltène/Whaledent's Jet Bite Fast (Figures 1 to 3).

Figure 7. Phil's wax-up prior to resin conversion.

The maxillary cast can be conveniently mounted to a Panadent articulator via the Kois Dento-Facial Analyzer System (Panadent) as shown in Figure 4, and the mandibular model is related to it with the leaf gauge-generated bite record. The lab may now create a wax-up of your intended restoration assisted by the patient-approved cosmetic simulation portrait. A Smile-Vision Resin Replica mock-up of Michele's dentition (Figures 5 and 6) was accomplished, while Figure 7 demonstrates the wax-up of Phil's dentition (his preoperative dentition is shown in Figure 1) prior to Resin Replica composite conversion. (Note: The resin model is then reproduced in stone to facilitate template fabrication.)
Phil and Michele's provisional restorations, termed OverTemps by Smile-Vision, will be placed without any tooth preparation, with the exception of Micheleís front 6 teeth. That is, the new shapes will be directly bonded to existing tooth surfaces, restoring to the new shapes and vertical in a single session in both cases. In Michelleís case, teeth Nos. 6 to 11 were prepared owing to restorative concerns and the need for increased retention of the mock-up via full-coverage bonded composite.

THE PROVISIONAL FABRICATION

Method 1: Michele's Case

Figure 8. Smile-Vision hard/soft templates readied for provisional formation.

Figure 9. A clear reduction template seated over prepared teeth is useful for determining adequate reduction.

Figure 10. Soft template loaded with DENTSPLY Caulkís TPH3.

Figure 11. Michele's anterior 6 teeth formed under the hard/soft template combination.

Figure 12. Soft template again loaded with TPH3 to form the upper left posterior occlusal surfaces.

Figure 13. One-month retracted postoperative view of Micheleís provisional restoration.

Figure 14. One-month postoperative occlusal view of Micheleís new smile.

Figure 15. One-month postoperative portrait of Micheleís case.

As seen in Figure 8, Smile-Vision has generated its ìhard/softî template in full-arch fashion. It will carry the composite restorative material to the readied dentition. In this instance, it was elected to deliver the restorative material TPH3  (DENTSPLY Caulk) in sectional fashion, beginning with teeth Nos. 6 to 11, continuing with the maxillary posterior quadrants, followed by the lower anterior teeth Nos. 22 to 27, and finally with the lower posterior quads (6 sections in all; tooth No. 19 was missing and was not replaced for this restoration). Figure 9 shows teeth Nos. 6 to 11 as viewed under a Smile-Vision reduction template after having been prepared, electrosurged with a Parkell Sensimatic (to expose more coronal structure), and bonded with DENTSPLY Caulkís Xeno IV self-etching bonding agent. Figure 10 demonstrates the soft template filled with TPH3 prior to it being seated over the  prepared and bonded teeth Nos. 6 to 11. TPH3 was chosen for its flow characteristics as well as this clinicianís experience with TPH3, having found it to be a tough micro-hybrid that possesses considerable staying power. Figure 11 shows the maxillary anterior segment under the hard/soft templates ready for curing. The role of the hard shell, sandwiched over the soft template, is to allow the operator to generate a significant but evenly applied force to the composite resin that resists deformation of the soft template under digital pressure, thus preserving the anatomy created in the mock-up.
Figure 12 demonstrates how only the occlusal surfaces of teeth Nos. 12 to 14 have been loaded within the template. Following phosphoric acid-etching of occlusal tooth surfaces and micro-etching of remaining alloy and ceramic (using Gromanís Micro Air Abrasion system), the templates are again placed over the readied dentition for composite bonding. Figures 13 to 15 demonstrate the one-month postoperative results. Needless to say, considerable time was spent trimming flash and fine tuning the occlusion. Nonetheless, the entire provisional rehab was delivered in a single session approximating 5 hours. In this instance, most units were left splinted. Considerations regarding this approach will be discussed at the conclusion of this article.

METHOD 2: PHIL'S CASE

Figure 16. View of Radica OverTemps on stone model.

Figure 17. Loading the Radica OverTemps with DENTSPLY Caulkís Calibra luting cement.

The second approach involves the same process up to the point regarding what the actual provisional is fabricated from. Enter Radica Provisional and Diagnostic Resin (DENTSPLY Prosthetics). It is a light-cured resin (Triad System [DENTSPLY Prosthetics] or similar) used in a laboratory setting designed specifically for long-term provisionals. While the spec sheet uses 6 months longevity as a guideline, the material property statistics make this appear to be a very conservative estimate. Falling somewhere between Cristobal (DENTSPLY Ceramco) and an IPN denture tooth (DENTSPLY Trubyte) with respect to strength and wear resistance (as determined by manufacturer testing), Radica also is available in the most common Vita shades. To that end, Smile-Vision offers pre-fabricated OverTemps in sectional form as is demonstrated in Figure 16 (Philís case). Youíll note that the segments fabricated were Nos. 2 to 5, 6 to 11, 12 to 15, 20 to 21, 22 to 27, and 28 to 29 (6 segments in all). The lower molars were left untouched.
Immediately prior to bonding in the 6 segments, Phil was allowed to look at his smile after having seated them with Calibra Try In Paste (DENTSPLY Caulk). It is just gooey enough to hold it all in so that Phil could sit up and see what the add-ons looked like, and I could get a sense that all was in order, thus allaying the anxiety often experienced when wondering if there will be an inordinate amount of adjusting after placement, or even worse, that my patient doesnít approve of the aesthetics.
Prior to OverTemp placement, phosphoric acid etching of Nos. 6 to 11 was performed (typically a 5- to 10-second "detergent" conditioning), followed by application of the same Xeno IV bonding resin used for Micheleís case. In Figure 17, Calibra luting cement is being used to bond the Radica OverTemps to the readied teeth. In essence, the Radica provisionals may be bonded as if they were veneers since they will be completely cut off at final preparation time. One may even spot-tack a segment to allow for easier cleanup of excess resin. Additionally, fit discrepancies (remarkably few in number) may be patched with conventional composite, flowable, or paste form. The end result is a provisional full-mouth rehabilitation that took only one morning, as is shown in Figures 18 to 20. (Note: The lab-polished Radica surface is very pleasing to the eye, looking much like a finished restoration.)
It should be noted that at final preparation, hard/soft templates such as those used for Micheleís case will be available (derived from the same wax-up as the Radica segments) to create the usual bisacryl provisionals.

Figure 18. Maxillary occlusal view of Phil's restorations.

Figure 19. Fully retracted view immediately after placing Philís OverTemps case.

Figure 20. Portrait of Phil immediately after placement of his OverTemp provisional restorations.

DISCUSSION

Certainly, the approaches covered here add time and cost to oneís rehab case. The question arises, other than the ability to stage case completion, what advantages does this approach offer and where might one use Method 1 versus Method 2?
In either method, let us agree that an OverTemp provisional restoration is appropriate for moderate to advanced wear cases in which tooth arrangement is found to be in relatively good order and where a need exists to alter vertical dimension; that is, we aren't using this approach when performing "instant ortho cases." We might also agree that both doctor and patient are provided an excellent opportunity to test drive a new occlusal scheme and smile design, not really locked into it at any point, as typically there isnít a need for tooth reduction when taking this approach. Contrast that to former methods of providing the patient a removable bite-opening splint for establishing a new vertical in hopes that your patient would actually wear the appliance.
Perhaps the biggest boon of such a trial rehabilitation is that the clinician can proceed to restore the case at his or her own pace, electing to convert one segment at a time or more, as desired. The clinician may do so knowing full well that the newly created occlusal scheme remains constant, as the uncut provisionals remain in place to keep the vertical and jaw relationships constant.

WHICH WAY TO GO?

When long-term means 2 to 5 years, this clinician takes comfort in knowing that TPH3 can handle this stretch of service so long as a bruxism splint is provided (as was done for Michele). She didnít achieve that level of wear (Figure 5) without overwhelming parafunction. Additionally, TPH3 lends it-self to easy repairs when the need arises.
As Radica is new to the profession, it may be prudent, at least at this juncture, to employ it when the service required falls within the 6 months to one year restorative time line, as is the case with Philís rehab. Note that in this instance the staging is more ìtrial-drivenî as opposed to budget management. Time may prove, however, that Radica can stay the course for considerably longer, thus providing us with a more convenient method of initiating a wear-related rehab case. Needless to say, periodic recall (3-month intervals) is a good way to monitor the status of such cases.

CONTACTS

The question remains: what about all of those connections? Do you leave them open or closed? For those of us intent upon providing a pathway for floss, fine diamond separating discs that operate on a slow-speed handpiece can be used to recreate individual teeth. While not as easy in the posterior, it can be accomplished and likely should be if one intends for the provisionals to be in place for more than a year. If one is judicious when placing TPH3 or the like in the soft template, the connections shouldnít be more than 2 mm thick. The same holds true for Radica. That said, this clinician has found that if papillae are not impinged upon by the splinted provisional, and emergence profiles are anatomically correct, simply maintaining good home care with an electric brush accompanied by a chlorine dioxide daily rinse, such as Oxyfresh (Oxyfresh Worldwide) with fluoride, can be sufficient to keep tissue happy. One can also employ floss threaders where spacing allows. In many respects the connections typical of trial provisionals are not unlike what might be had with periodontal crown and bridge splinting. That is, it requires vigilance but it is maintainable.

CONCLUSION

 

Two similar approaches to long-term provisionalization with OverTemps have been presented along with a logic set as to why and how each approach might be usefully employed. To say the least, it is imperative when going this route that lab costs and time needed to deliver the provisional be factored into what fees are presented. It is also advisable to have the patient sign a release form that acknowledges that the provisional is just that...a trial temporary that must be converted to a more permanent solution within the time frame agreed upon by patient and doctor. When these ducks are in a row, the practitioner who formally shied away from the larger undertaking of full-mouth rehabilitation might find the pace afforded him by the OverTemp approach enough incentive to jump in.


Addendum

A DVD-based video demonstrating the OverTemp technique will soon be available on Dr. Goldsteinís Web site at drgoldsteinspeaks.com.


Dr. Goldstein, a Fellow of the International Academy of Dento-Facial Esthetics, practices general dentistry in Wolcott, Conn. Noted as one of Dentistry Today's Top Clinicians in Continuing Education for the last 5 years, he lectures and writes extensively concerning cosmetics and the integration of digital photography into the general practice. A Contributing Editor for Dentistry Today, he has also authored numerous articles for multiple dental periodicals both in the United States and abroad. He can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it . His current speaking schedule can be found at drgoldsteinspeaks.com.

Disclosure: Dr. Goldstein consults with DENTSPLY Caulk, Parkell, ColtËne/Whaledent, and Smile-Vision.