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Temporization & Defi nitiveRestoration Placement

A Clinical Update on

Knowledge for Clinical Practice

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Jeff Blank, DDS

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LEARNING OBJECTIVES

The overall objective of this article is to provide the reader with information on the provision of temporary restorations following single tooth preparation, and the placement of the defi nitive restoration. After reading this article, the reader will be able to:

• List the reasons for providing single-unit temporary resto-rations;

• Review the types of materials and cements that can be used to provide temporary restorations;

• Delineate the step-by-step process for the chairside fabri-cation of tooth-colored temporary restorations;

• List and describe the types of luting cements that are available and which cements should be used for different materials; and

• Describe the chairside steps involved in luting of a defi ni-tive crown or veneer.

ABSTRACT

Esthetic restorative dentistry with indirect restorations is a treat-ment that is in demand by patients. Careful consideration is required in selecting such cases and the restoration material for an individual patient. Based on the type of restoration selected, the adhesive technique and luting cement can then be selected. Options for ceramic restorations include etch-and-rinse and self-etch tech-niques for adhesives, together with the use of light-cure or dual-cure resin luting cements, or the use of more traditional luting agents, depending on the type of ceramic restorations. An understanding of the properties of restorative materials, adhesives and luting agents is necessary for correct selection and good clinical results.

ABOUT THE AUTHOR

Jeff Blank, DDSDr. Blank maintains a full-time practice, focusing on cosmetic and restorative dentistry. Dr. Blank has lec-tured extensively at major dental meetings throughout the United States as well as overseas in Germany, Sweden and the Pacifi c

Rim on cosmetic materials and techniques. He is an Adjunct Instructor in the Department of Gener-al Dentistry, and guest lecturer for graduate and undergraduate studies, at the Medical University of South Carolina, College of Dental Medicine. Dr. Blank graduated from MUSC in 1989, and is an active member of the American Academy of Cosmetic Dentistry, the Pierre Fauchard Acad-emy, the American Dental Association, and the Academy of General Dentistry. AUTHOR DIS-CLOSURE: Dr. Blank does not have a leadership position or a commercial interest with 3M ESPE, the commercial supporter of this course or with products and services discussed in this educational activity. Dr. Blank can be contacted by emailing [email protected].

Temporization & Defi nitiveRestoration Placement

A Clinical Update on

DENTAL LEARNING

SPONSOR/PROVIDER: This is a Dental Learning, LLC continuing education activity. DESIGNATION STATEMENTS: Dental Learning, LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dental Learning, LLC designates this activity for 2 CE credits. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2016 - 1/31/2020. Provider ID: # 346890. EDUCATIONAL METHODS: This course is a self-instructional journal and web activity. Information shared in this course is based on current information and evidence. REGISTRATION: The cost of this CE course is $29.00 for 2 CE credits. ORIGINAL RELEASE DATE: May 2012. REVIEW DATE: April 2015. EXPIRATION DATE: March 2018. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, par-ticipants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most current information available from evidence-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the par-ticipant being an expert in the fi eld related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Casey Warner, does not have a leadership or commercial interest in any products or services discussed in this educational activity. She can be reached at [email protected]. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/REFUND POLICY: Any participant who is not 100% satisfi ed with this course can request a full refund by contacting Dental Learning, LLC, in writing. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected]. Go Green, Go Online to www.dentallearning.net take your course. © 2015

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Introduction One of the more frequent procedures in practice is the

placement of single- and multiple-unit indirect restorations. These may be placed as a result of functional and esthetic requirements. Caries and prior endodontic treatment can result in the loss of a substantial amount of tooth structure that necessitates placement of a crown, as can fracture of a tooth and/or previous restorations. Increasingly, indirect restorations are also required where implants have been placed. Following preparation of teeth, or implant place-ment, temporization is required prior to later placement of the definitive indirect restoration. The focus of this article is on temporization following tooth preparation for a single crown or veneer and on the placement of the definitive restoration.

Temporization for Single-Unit Crowns Temporization is required for single-unit crowns for

several reasons. For both vital and nonvital teeth, tempori-zation helps prevent damage to the prepared tooth, prevents tooth movement of the adjacent teeth (mesial or distal drift) that could result in space closure while the definitive restoration is being fabricated, and similarly helps prevent movement of the opposing teeth that could result in changes to the occlusion (extrusion or intrusion of teeth). The pro-visional restoration also protects the preparation margins from assault and the gingival margins from irritation and potential overgrowth.1-3 Tooth coverage is also required to prevent sensitivity in vital prepared teeth and must com-pletely cover the exposed prepared tooth structure in vital and nonvital teeth. In addition, if the temporary restoration is intended as an interim/medium-term solution, coverage is required to prevent caries. Temporization may also be used to help define tooth shape and esthetics for patients and to assess phonetics and may be required to assess function when multiple units and extensive restorative procedures are planned. Immediate temporary restorations can also be used following crown-lengthening performed to re-store the biologic width, and in this situation will promote soft-tissue healing if properly fabricated with the correct contours and form.4 As a result of all requirements, accu-

rate temporization following tooth preparation is essential and must satisfy the case-specific esthetic requirements. Provisional crowns also must be strong enough to with-stand functional loading, and materials used for temporary restorations should ideally meet all criteria.5 A prerequisite for good clinical outcomes for definitive restorations is the preparation form – all preparations should have the proper retention and resistance form.6 Reasons for the provision of temporary restorations can be found in Table 1.

Temporization MaterialsTemporization materials used for single-unit crowns

include prefabricated metal, tooth-colored temporary crowns and materials that are used for indirect or chairside fabrication of temporary crowns and veneers. Prefabricat-ed crowns offer the advantage of requiring less chairside time, while chairside or indirect fabrication of a provisional allows for more customization and shade options.

Prefabricated temporary crownsMetal prefabricated crowns have been available for

decades, including stainless steel crowns for long-term pro-visional restorations in both permanent and primary teeth. While acceptable for the posterior primary dentition, these are now less frequently used for permanent provisional res-torations. Aluminum shell crowns are also available; how-ever, in addition to offering poor esthetics, these are soft and highly malleable. While this is perhaps an advantage during fabrication, repeated occlusal loading changes their form and they do not maintain good contact points during use.7

Table 1. Rationale for single-unit provisional restorations

Comfort Covers exposed dentin to prevent sensitivityPrevents food impaction, gingival irritation and gingival overgrowth

EstheticsReplaces lost tooth structureHelps develop soft-tissue contoursRequires tooth-colored provisional material

Stability Prevents movement of adjacent teeth Prevents movement of opposing teeth

Function Enables patients to eat and drink normally

A Clinical Update on Temporization & Definitive Restoration Placement

5April 2015

The selection of polycarbonate crowns is common for single anterior temporary crowns; however, these are available in a limited number of shapes and the shade may not be suitable. A fourth option is the use of prefabricated composite resin provisional crowns. In contrast to the polycarbonate crowns used mainly for anterior teeth, and which are difficult to ad-just, prefabricated composite resin provisionals are available for molars, premolars and canines. These are easy to adjust, by first trimming and then by having the patient gently bite down on the provisional prior to adapting the margins and curing.

Chairside fabrication of temporary crowns and veneersProvisional crowns can be fabricated chairside using

one of several acrylic resins. These provisionals can be fully customized for a given clinical situation to provide a result that more closely matches the shade and anatomical form of the patient’s teeth. If the tooth structure and an old resto-ration are present prior to preparation, an index/impression of this is taken prior to fabricating the provisional and acts as a template. If tooth structure or a restoration is absent, first placing a temporary filling material enables the index/impression to be taken. For the index, one of the follow-ing can be used: 1) a polyvinylsiloxane (PVS) or polyether (PE) index, 2) a wax index, 3) an alginate impression, 4) a silicone index or 5) a prefabricated matrix, which avoids the need to take a separate impression. Vacuform trays can also be made, usually used only for multiple units. Wax and algi-nate indices/impressions are single-use and therefore cannot be used to create a second provisional crown should this become necessary. Alginate impressions/indices are quick to take and less expensive than other options but have a rougher surface, which results in the temporary restoration requiring more polishing and finishing to obtain a smooth surface. In contrast, a PVS or PE impression is smoother, as is the wax index (which is inexpensive and does not require mixing of impression material). PVS and PE can also be used to fabricate a second temporary crown if necessary. One study found that no one matrix was best for all pro-visional materials and that the combination influenced the resulting smoothness of the material.8 After the index/im-

pression has been taken, this is then used to create the tem-porary restoration after the tooth has been prepared. The index is filled with the resin material at the site of the tooth that was prepared and reseated over the preparation until the material has set. If either wax or impression material is used, the resin must be self-curing, as the light from a curing light will not penetrate through the impression material.

Material selection criteria for chairside provisional restorations

Available resin materials for provisional restorations include polyethyl methacrylate (PEMA), polymethyl meth-acrylate (PMMA) and bisacrylate composite (bis-acryl). Each has different attributes that need to be considered. A low/no exothermic reaction is desirable for provisional materials that will be used on vital teeth, particularly if only a thin layer of dentin remains, to avoid the possibility of pulpal insult.9,10 In this regard, bis-acryl has been shown to result in less increase in temperature during setting than occurs with other options.11 In turn, PEMA has been shown to have lower exothermic reactions than PMMA.12 The higher exothermic setting and polymerization shrink-age are disadvantages of PMMA when using the chairside fabrication method, along with the high amount of free monomer present (which has the propensity to result in pulpal and gingival insult).3,13 PEMA and PMMA are both less expensive than bis-acryl; however, they exhibit higher polymerization shrinkage than bis-acryl, which can affect marginal fit and overall contours. Bis-acryl has been shown to have higher fracture toughness, flexural strength and edge strength; to offer a good marginal fit; and in one in vitro cytotoxicity test using fibroblasts to be absent of cytotoxic effects.5,14-16 The strength of materials must also be consid-ered, particularly if they will be subjected to a heavy occlu-sal load. PMMA offers higher strength than PEMA, while bis-acryl offers adequate strength. Esthetics vary depending on which provisional material is used. If the provisional res-toration is to be seated for no more than a couple of weeks, staining and color retention are less critical or variable; the color retention and color stability of PMMA and bis-acryl are higher than for PEMA.17 Bacterial adhesion in one test

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was found to vary within bis-acryl and PMMA materials tested, with similar ranges, while the adhesion on acrylic resin and composites was higher as shown by fluorescence measurements of bacteria.18 A more recent development has been the introduction of bis-acryl with nanofillers. As with nanofillers contained in regular composites, these contribute to strength, greater polish and a smooth finish. Since a high polish has been shown to reduce the accumulation of plaque on restorations, this can help influence the bacterial load present and therefore may help reduce the risk of gingivitis at the provisional restoration margins.

Cementation of the Provisional Restoration Care must be taken to select temporary cement that

will be compatible with the intended short-term or interim/longer-term use of the provisional and must provide a good marginal seal. Eugenol-containing cements are frequent choices as temporary cements due to their ability to re-duce sensitivity, ease of use and low cost. However, they have been found to reduce microsurface hardness of resin materials and can interfere with bonding and materials used for definitive restoration placement (as well as having been

shown to inhibit complete curing of resins).19-21 Although some studies have, in contrast, found no effect from the use of eugenol-containing temporary cements,22 it is generally recommended that a non-eugenol-containing cement be used for short-term provisionalization with resin resto-rations, due to their compatibility. Non-eugenol temporary cements are available that offer sufficient strength and adhesion for a temporary restoration, without offering so much adhesion/retention that it is difficult to remove the temporary at the time of definitive restoration placement (unlike with permanent luting cements). Non-eugenol temporary cements are also available with antimicrobial in-gredients such as fluoride, triclosan or chlorhexidine as well as with potassium nitrate for desensitization. Alternatively, a luting cement may be used, provided a separating layer (i.e., varnish that can later be easily removed) is first applied to prevent excess retention of the temporary crown – this is more suitable for a longer-term provisional. When filling the provisional with the temporary cement, care should be taken to place sufficient cement in the crown on its internal surfaces, without completely filling it.23

Definitive Restoration Placement and Luting Cements

Definitive single crowns can be fabricated from cast high noble/noble alloys, porcelain, porcelain fused to metal, glass-ceramic materials (leucite, fluorapatite or feldspathic porcelain), and high-strength ceramic materials that are suitable for anterior and posterior restorations as well as veneers (zirconia, lithium disilicate or alumina). Each has different attributes, and each requires different treatment at the time of definitive placement using a luting cement. The primary goals for permanent luting cements are to secure the definitive restoration to the tooth, to fill the microgap between the crown and the preparation, and to seal it against microleakage. Zinc phosphate, polycarboxylate, glass ionomer, composite resin and compomer have all been used as luting cements, each with different applicability, ad-vantages and disadvantages. Important considerations for a material include whether it will shrink during setting (which can result in marginal gaps, leakage and sensitivity), its solu-

Table 2. Material selection criteria

Biocompatibility Ease of Use

Absence of chemical cyto-toxicity

No/low exothermic reaction during setting

Lack of gingival irritation

High polish to reduce bacteri-al adhesion

Patient Comfort

Odorless and tasteless

Good marginal fit

Nonirritating to pulp and gingivae

Esthetics

High polish and good range of shades

Adequate working time

Suitable setting time

Ease of mixing

Appropriate viscosity

Impression/index material compatibility

Ability to add on material to voids/defects if necessary

Physical Attributes

Adequate compressive, ten-sile and flexural strength

Fracture resistance

Dimensionally stable

Resistant to fracture


7April 2015

bility, the coefficient of thermal expansion, its strength, its biocompatibility, and its ability to bond to tooth structure and the intaglio surfaces of crowns. Conventional luting cements, glass ionomer and resin-modified glass ionomer cements, and resin luting agents can all be used for metal and metal-based indirect restorations. In the case of ceramic restorations, the luting agent of choice depends on the type of ceramic. Glass-ceramic restorations and low-filled ceram-ics have low strength and fracture resistance and mandate the use of a resin adhesive cement to aid strength and fracture resistance.

Historically, polycarboxylate and zinc phosphate ce-ments have been popular as luting agents; their use has decreased.24 Zinc phosphate is clinically successful and is still used for metal and porcelain-fused-to-metal crowns; it offers high strength initially and reliability. Disadvantages include its highly acidic setting reaction, which can result in pulpal irritation and sensitivity, and its solubility over time.25 Zinc phosphate is not suitable for ceramic restorations. Polycarboxylate cements have a greater film thickness compared to contemporary resin modified glass ionomers, compomers and resin luting cements. This can interfere with complete seating of indirect restorations. Advantages include its high tensile strength and the fact it does not result in the setting reaction at low pH associated with zinc phosphate cements. In the case of glass ionomer (GI) cements, the film

thickness is suitable for all crown restorations, and res-in-modified glass ionomers (RMGIs) offer low solubility, a quicker set and greater strength than do conventional glass ionomers.25 While glass ionomers and resin-modified glass ionomers will bond to tooth structure and release fluoride, they do not bond to restorative materials, limiting their use for certain restorations. Resin cement luting agents offer the ability to bond to the tooth structure as well as ceramic restorations, while compomers are a hybrid between glass ionomer cements and resin cements. Compomers have great-er strength than conventional glass ionomer cements while still releasing fluoride.26 Based on a review of electronic databases, it was concluded by one group of researchers that resin cements are the luting agent of choice for metal-free restorations due to their superior esthetics and physical at-tributes.27 Table 3 contains information on restoration types and suitable permanent luting agents.

Resin luting cements utilize etch-and-bond technology, first discovered by Buonocore and applied to composite res-in restorations. As with composite resin restorations, resin luting cements are available for use with either an etch-and-rinse (total-etch) or self-etch adhesive system. The surface of the dentin and enamel margins is etched and bonded, either in separate steps or in one step depending on the technique and system, and the resin cement then bonds to the tooth and the restoration through micromechanical locking. Use

Table 3. Permanent luting cement and restoration type

Conventional cements RMGI cements Resin cements

Indirect restoration type

Metal/metal-based restorations ✓ * ✓ ✓

Glass-ceramic crowns — — ✓

High-strength ceramic crowns ✓ ** ✓ ✓

Ceramic inlays and veneers — — ✓

* Note that conventional cements are also acceptable for metal-based crowns with porcelain margins, except for polycarboxylate cement. All nonretentive indirect restorations should be bonded with resin cements.

**Conventional cements can be used for high-strength ceramic only if the form is retentive.

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of a universal adhesive and resin cement reduces the number of steps required compared to use of a total-etch (etch-and-rinse) technique. Self-adhesive resin luting cements are also available that remove the need for any separate etching or bonding steps. Although some in vitro studies have shown lower bond strength with self-adhesive resin cements, these reduce the number of steps required and therefore the risk of operator error.28 Depending on the particular resin cement, it may be self-cured, light-cured or dual-cured. For crowns that do not permit the transmission of light, because either they are fabricated with metal or the ceramic is too thick for light transmission (at least 1.5 to 2.5 mm thickness), self-cured or dual-cured resins must be used.29 Using a dual-cured resin rather than a self-cured resin enables the margins to receive supplemental light-curing after placement of the crown. The intaglio surface of ceramic crowns must also be pretreated to provide for surface roughness and en-hance bonding of the resin luting cement to the crown. De-pending on the ceramic material, either the intaglio surface is pretreated with hydrofluoric acid (feldspathic porcelain, leucite and lithium disilicate) before being rinsed, dried and silanated; or, they are pretreated with air abrasion, with the powder depending on which ceramic material is present.30 The cases below show the use of resin luting cement with high-strength ceramic veneers and crowns.

Case Study #1A 22-year-old female attended for examination, with

the chief complaint that she did not like the appearance of her upper teeth, also thought they sloped to the side, and wanted them to be even and one shade. After discus-sion, the patient elected for veneers to give an esthetic and even result. Figure 1 shows the retracted facial view of the patient’s dentition prior to treatment, with an old fractured composite, several striae and white/discolored spots, and uneven shades. The patient’s periodontal condition was good. At this appointment, alginate impressions were taken for a wax-up that the patient could see before deciding to proceed. At the first treatment visit, a silicone index was taken of the diagnostic wax-up – this would serve as the template for the provisional restorations. (Figure 2) The

teeth were then prepped and impressions taken using PVS impression material. (Figure 3) The provisional veneers were then fabricated using the index and bis-acryl resin (Pro-temp™ Plus, 3M ESPE), polished and wiped with ethanol to

Figure 2. Taking the silicone index of the diagnostic wax-up

Figure 1. Pretreatment retracted view

Figure 3. Veneer preparations


9April 2015

achieve a high gloss before placement, then placed using a non-eugenol temporary cement. The veneers were then fab-ricated in the laboratory from a high-strength ceramic. On the patient’s return at the seat visit one week later, the provi-

sional restorations were still acceptable. (Figures 4-7)After removing the provisional veneers, the laboratory-

fabricated veneers were first tried in, using the shade of try-in paste that was the same as the shade of luting agent

Figure 5. Provisional veneers on removal of the silicone index

Figure 4. Injecting bis-acryl resin into the silicone index

Figure 7. Provisional veneers at one-week visit

Figure 6. Minor adjustments to the provisional restorations using a diamond bur

Figure 8. Preparations after removal of provisional veneers

Figure 9. Try-in of veneers with matching shade try-in paste

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(RelyX™ Ultimate) that matched the veneers. (Figures 8-9) After determining that all the margins and proximal contacts were accurate, the shade was correct, and the patient was pleased with the result, the teeth were first

cleaned using a non-fluoridated pumice and soft rubber cup. An etch-and-rinse technique (total-etch) with universal adhesive (Scotchbond™ Universal, 3M ESPE) and dual-cure resin luting cement was selected for restoration placement.

Figure 11. Application of adhesive to the intaglio surface of the veneers

Figure 14. Application of multiple coats of adhesive to the preparations

Figure 10. Cleaning of preparations with non-fluoridated pumice and a soft rubber cup

Figure 13. Application of etchant to the veneer preparations

Figure 12. Air-thinning of adhesive on the intaglio surface

Figure 15. Air-thinning of adhesive on preparations


11April 2015

The preparations were etched for 15 seconds, after which the etchant was rinsed off and the teeth gently air-dried. A light coat of adhesive (the universal) was then applied to the intaglio surfaces of the restorations, air-thinned and left un-

cured. (Since this adhesive contains an active silane primer, no separate priming step is required.) Multiple thin coats of the same adhesive were next actively applied to the prepa-rations for 20 seconds, again air-thinned for five seconds

Figure 17. Placement of all restorations and brief polymerization

Figure 16. Placement of adhesive resin luting cement into the veneers

Figure 19. Removal of residual cement interproximally using floss

Figure 18. Teasing away of partially polymerized excess cement

Figure 20. Final restorations at one week

Figure 21a & b. Pre-and post-operative views

a

b

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and left uncured. The matching shade of the adhesive resin cement (RelyX Ultimate) was next placed over the un-cured adhesive on the intaglio surface of the veneers, using the disposable tip and taking care not to overfill the area. (Figures 10-16) (Resin luting cements containing small filler particles or nanoparticles aid the placement of the adhesive with a thin film thickness, as does careful application and air-thinning after placement of the adhesive.) The prepara-tions were then lightly air-dried and the veneers seated and then briefly polymerized for three to five seconds to provide a tack cure. After this, excess cement was carefully teased away at the margins using a sickle scaler, and floss was used to remove any residual excess cement interproximally. (Fig-ures 17-19) Each restoration was then light-cured from the labial aspect for one minute to complete polymerization of the resin adhesive cement. The postoperative view shows the

completed restorations, which the patient was pleased with. (Figures 20-21)

Case Study #2In this case, the patient presented with a fractured

buccal cusp in tooth #5, with a large pre-existing MOD amalgam. It was decided to place a crown on this tooth, using a high-strength ceramic. The preparation was created at the first treatment visit, a PVS impression taken and the temporary restoration fabricated. On the patient’s return for the seat visit, the crown was first tried in before using the adhesive on the intaglio surface, cleaning the prepara-tion, etching the preparation and margins, and applying the adhesive to the preparation. After air-thinning of the adhesive, resin luting cement was used for placement of the crown (RelyX Ultimate). Although conventional

Figure 24. Crown with prepared intaglio surface

Figure 25. Crown cemented using resin luting cement

Figure 22. Preoperative view of fractured tooth #5

Figure 23. Preparation for high-strength ceramic crown


13April 2015

cements and RMGI cements are also suitable for high-strength ceramic restorations, they were contraindicated in this situation. Resin luting cement was selected due to its compatibility with ceramic restorations and especially in this case also because of the limited retention offered by the preparation due to the loss of tooth structure.31 After placing sufficient resin luting cement on the intaglio surface of the crown, it was seated, tack-cured using light polymerization, and the excess removed carefully using a hand instrument and dental floss. The restoration was then simultaneously light-cured buccally and palatally. The patient was pleased with the result. (Figures 22-25)

Summary The selection of an adhesive technique and luting agent

for indirect restorations requires careful consideration. Factors involved in their selection include the compatibility of the luting agent with the material from which the resto-ration is fabricated, its strength, its ease of use, and in the case of ceramic restorations also the availability of a range of shades to ensure matching of the luting agent and the ceramic shade. Luting agents have developed considerably in recent years, with the availability of advanced light-cure and dual-cure cements that offer thin film thicknesses compatible with modern restoratives. As shown here, the clinical outcomes are excellent when a careful technique is used with suitable adhesive and luting techniques.

References 1. Burke FJ, Murray MC, Shortall AC. Trends in indirect dentistry: provisional

restorations, more than just a temporary. Dent Update. 2005;32(8):443-52. 2. Christensen GJ. Provisional restorations for fixed prosthodontics. J Am Dent

Assoc. 1996; 127;249-52. 3. Wassell RW, St. George G, Ingledew RP, Steele JG. Crowns and other extra-cor-

onal restorations: provisional restorations. Brit Dent J. 2002;192(11):619-30. 4. Tseng SC, Fu JH, Wang HL. Immediate temporization crown lengthening.

Compend Contin Educ Dent. 2011 Apr;32(3):38-43. 5. Balkenhol M, Köhler H, Orbach K, Wöstmann B. Fracture toughness of

cross-linked and non-cross-linked temporary crown and fixed partial denture materials. Dent Mater. 2009 Jul;25(7):917-28. Epub 2009 Feb 26.

6. Hyde JD, Bader JA, Shugars DA. Provisional crown failures in dental school predoctoral clinics. J Dent Ed. 2007;71(11):1414-19.

7. Christensen GJ. Provisional restorations for fixed prosthodontics. J Am Dent Assoc. 1996; 127;249-52.

8. Ayuso-Montero R, Martinez-Gomis J, Lujan-Climent M, Salsench J, Peraire M. Influence of matrix type on surface roughness of three resins for provisional crowns and fixed partial dentures. J Prosthodont. 2009;18(2):141-4.

9. Seelbach P, Finger WJ, Ferger P, Balkenhol M. Temperature rise on dentin caused by temporary crown and fixed partial denture materials: influencing factors. J Dent. 2010;38(12):964-73.

10. Whalen S, Bouschlicher M. Intrapulpal temperature increases with temporary crown and bridge materials. Gen Dent. 2003;51(6):534-7.

11. Seelbach P, Finger WJ, Ferger P, Balkenhol M. Temperature rise on dentin caused by temporary crown and fixed partial denture materials: influencing factors. J Dent. 2010;38(12):964-73.

12. Michalakis K, Pissiotis A, Hirayama H, Kang K, Kafantaris N. Comparison of temperature increase in the pulp chamber during the polymerization of mate-rials used for the direct fabrication of provisional restorations. J Prosthet Dent. 2006;96(6):418-23.

13. Moulding MB, Teplitsky PE. Intrapulpal temperature during direct fabrication of provisional restorations. Int J Prosthodont. 1990;3:299-304.

14. Rosentritt M, Behr M, Lang R, Handel G. Flexural properties of prosthetic provisional polymers. Eur J Prosthodont Restor Dent. 2004;12(2):75-9.

15. Kim SH, Watts DC. In vitro study of edge-strength of provisional poly-mer-based crown and fixed partial denture materials. Dent Mater. 2007;23(12):1570-3. Epub 2007 Aug 13.

16. Ulker M, Ulker HE, Zortuk M, Bulbul M, Tuncdemir AR, Bilgine MS. Effects of current provisional restoration materials on the viability of fibroblasts. Eur J Dent. 2009;3(2):114-9.

17. Lang R, Rosentritt M, Leibrock A, Behr M, Handel G. Colour stability of provi-sional crown and bridge restoration materials. Br Dent J. 1998;185:468-71.

18. Burgers R, Rosentritt M, Handel G. Adhesion of Streptococcus mutans to temporary crown and bridge material. IADR Pan-European Federation 2006. Abstract #0704, Dublin, Ireland.

19. Bayinder F, Akyil MS, Bayinder MZ. Effect of eugenol and non-eugenol tem-porary cement on permanent cement retention and microhardness of cured composite resin. Dent Mat J. 2003;22(4):592-9.

20. Ganss C, Jung M. Effect of eugenol-containing temporary cement on bond strength of composite to dentin. Oper Dent. 1998;23(2):55-62.

21. Cohen BI, Volovich Y, Musikant BL, Deutsch AS. The effects of eugenol and ep-oxy-resin on the strength of a hybrid composite resin. J Endod. 2002;22(2):79-82.

22. Ganss C, Jung M. Effect of eugenol-containing temporary cements on bond strength of composite to dentin [Abstract]. J Dent Res. 1996;75:127.

23. Cardoso M, Torres MF, Rego MR, Santiago LC. Influence of application site of provisional cement on the marginal adaptation of provisional crowns. J Appl Oral Sci. 2008 May-Jun;16(3):214-8.

24. Clinical Research Associates. Materials use survey. CRA Newsletter. 1990;14(12):1; 1995;19(10):3-4; 2001.

25. Hill EE, Lott J. A clinically focused discussion of luting materials. Aust Dent J. 2011 Jun;56 Suppl 1:67-76.

26. Robertello FJ, Coffey JP, Lynde TA, King P. Fluoride release of glass iono-mer-based luting cements in vitro. J Prosthet Dent. 1999;82:172-6.

27. Haddad MF, Rocha EP, Assunção WG. Cementation of prosthetic restorations: from conventional cementation to dental bonding concept. J Craniofac Surg. 2011 May;22(3):952-8.

28. Lürhs AK, Guher S, Günay H, Geurtsen W. Shear bond strength of self-adhe-sive resins compared to resin cements with etch and rinse adhesives to enamel and dentin in vitro. Clin Oral Investig. 2010;14(2):193-9.

29. Pegoraro TA, da Silva NR, Carvalho RM. Cements for use in esthetic dentistry. Dent Clin North Am. 2007;51(2):453-71.

30. Vargas MA, Bergeron C, Diaz-Arnold A. Cementing all-ceramic restorations. Recommendations for success. J Am Dent Assoc. 2011;142(4 Suppl):20S-24S.

31. El-Mowafy O. The use of resin cements in restorative dentistry to overcome retention problems. J Can Dent Assoc. 2001;67:97-102.

Acknowledgement:Case 2 courtesy of Dr. Chris Salierno

DENTAL LEARNING

14


CEQuiz

1. Temporary/provisional restorations are required to prevent ___________.a. movement of adjacent or opposing teethb. damage to the preparationc. damage or irritation to the adjacent gingivad. all of the above

2. Temporization may be used to ___________.a. help define tooth shape and estheticsb. assess function when multiple units are plannedc. assess phoneticsd. all of the above

3. Pre-fabricated temporary/provisional crowns ___________.a. allow for more customizationb. require more chairside timec. allow for more shade optionsd. none of the above

4. Metal provisional pre-fabricated crowns include those fabricated from ___________.a. stainless steelb. aluminumc. goldd. a and b

5. Prefabricated composite resin provisional crowns ___________.a. are available for anterior teethb. are only available for posterior teethc. are an outmoded solutiond. a and b

6. ___________ can be used to create an index for the fabrication of provisional restorations chairside.a. Silicone b. Waxc. Polyetherd. all of the above

7. An advantage of an alginate index is that it is ___________.a. multiple useb. less expensive than some other optionsc. quick and easy to taked. b and c

8. ___________ is a high-strength ceramic material.a. Aluminab. Zirconiac. Lithium disilicated. all of the above

9. Compared to each other, for provisional restoration resins the least exothermic setting reaction occurs with ___________.a. polyethyl methacrylateb. polymethyl methacrylatec. bis-acrylated. a and c

10. Polymerization shrinkage ___________.a. is higher with bis-acrylate than with polymethyl methacrylateb. is lower with polyethyl methacrylate than with bis-acrylatec. is not relevant for provisional restorationsd. none of the above

11. The color retention and color stability of ___________ are high-er than for ___________.a. polymethyl methacrylate and bis-acrylate; polyethyl methacrylateb. polyethyl methacrylate and bis-acrylate; polymethyl methacrylatec. polymethyl methacrylate and polyethyl methacrylate; bis-acrylated. none of the above

12. Nanofillers in bis-acrylate contribute to ___________.a. greater polishb. strengthc. a smooth finishd. all of the above

13. ___________ cement has been found to interfere with bonding and materials used for definitive restoration placement.a. Glass ionomer b. Eugenol-containingc. Zinc phosphate d. all of the above

14. ___________ is a primary goal for a permanent luting cement. a. Sealing the tooth against microleakageb. Filling the microgap between the tooth and the restoration c. Securing the definitive restorationd. all of the above

15. ___________ is an important consideration for a luting cement.a. The coefficient of expansionb. Strengthc. Biocompatibilityd. all of the above

16. Feldspathic porcelain is ___________ .a. a glass-ceramicb. a high-strength ceramicc. only suitable for diastema closured. a and c

To complete this quiz online and immediately download your CE verifica-tion document, visit www.dentallearning.net/UOT-ce, then log into your account (or register to create an account). Upon completion and passing of the exam, you can immediately download your CE verification docu-ment. We accept Visa, MasterCard, Discover, and American Express.


15April 2015

17. ___________ can be used for metal and metal-based indirect restorations.a. Glass ionomer/resin-modified glass ionomer cementb. Resin luting agentsc. Conventional luting cementd. all of the above

18. Depending on which material a crown is fabricated from, its intaglio surface can be pre-treated with either ___________.a. sand blasting or periacetic acidb. sand blasting or hydrofluoric acidc. alkali solutions or hydrochloric acidd. none of the above

19. Zinc phosphate can be used for ___________.a. metal crownsb. ceramic veneersc. ceramic inlaysd. b and c

20. A low pH setting reaction is observed with ___________.a. polycarboxylate cementb. zinc phosphate cementc. resin luting cementd. all of the above

21. Ceramic veneers and inlays should be luted using ___________.a. glass ionomer cementb. resin luting cementc. polycarboxylate cementd. a or b

22. Excellent clinical outcomes for provisionals requires ___________.a. a careful technique b. use of a suitable adhesivec. use of a suitable luting technique d. all of the above

23. When cleaning preparations prior to using resin luting ce-ment, the preparations should be cleaned using ___________ and a rubber cup.a. fluoridated pumiceb. a desensitizing liquidc. non-fluoridated pumiced. none of the above

24. For crowns that do not permit the transmission of light, a ___________ cement must be used.a. self-curedb. dual-curedc. light-curedd. a or b

25. If a tooth preparation has a non-retentive form and a crown will be placed, ___________ should be used for luting.a. zinc phosphate cementb. glass ionomer cementc. resin luting cementd. all of the above

26. Glass-ceramic crowns and low-filled ceramics ___________.a. have low strengthb. have low fracture resistancec. mandate the use of a resin adhesive cement to aid strength d. all of the above

27. If a total-etch technique is being used, the dentin can be etched for ___________.a. 5 secondsb. 15 secondsc. 25 secondsd. 35 seconds

28. First tack-curing resin luting cement after placement of the restoration aids ___________.a. shade selectionb. removal of excess cementc. prevention of sensitivity d. all of the above

29. ___________ aids placement of a thin film thickness of resin luting cement.a. Small particles/nanofillersb. Careful applicationc. Air-thinning of the adhesived. all of the above

30. A resin luting cement may be ___________.a. self-curedb. light-cured c. dual-curedd. any of the above

16

A Clinical Update on Temporization and Definitive Restoration Placement

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EDUCATIONAL OBJECTIVES1. List the reasons for providing single-unit temporary restorations;2. Review the types of materials and cements that can be used to provide temporary restorations;3. Delineate the step-by-step process for the chairside fabrication of tooth-colored temporary restorations;4. List and describe the types of luting cements that are available and which cements should be used

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