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INTRODUCTIONThe ability to transform a patient’s smileand function could not be any more excitingand fun for a dentist than it is today. Themyriad of materials and treatment optionsavailable to clinicians and patients alikemakes the profession newer and more excit-ing every day. With numerous modernmaterials, we can be less invasive, more aes-thetic, and more creative with the treatmentoptions we offer to our patients. Creatingbelievable, lifelike restorations across differ-ent treatment modalities within the samedentition had often been challenging priorto the advent of many newer materials.

CASE REPORT Diagnosis, Treatment Planning, and

Prerestorative ProtocolA 38-year-old female presented for thereplacement of existing restorations on herfront teeth, in addition to a cosmetic reha-bilitation of the appearance of her smile.Upon evaluating the patient, it was notedthat she was missing the maxillary right lat-eral incisor and had a traditional PFMbridge that was deteriorating. The contralat-eral lateral incisor was present but it had apreviously placed crown that was also inneed of replacement. The existing positionsof the anterior teeth, as well as the crown-to-width ratios, were less than ideal when com-pared to contemporary aesthetic concepts.

Prior to restoring the teeth, the patientopted to see an orthodontist and a periodon-tist to reposition the root structure to makespace for the implant placement as well ascreating better tooth positioning for place-ment of restorations (Figure 1). The patientwas evaluated during orthodontic therapyto assist in tooth positioning for the bestsetup and outcome for restorative therapy(Figures 2 and 3).

The first step in any case is determiningthe final outcome prior to starting the case.This means a comprehensive exam of theoral cavity as well as the supporting struc-tures and temporomandibular joints need-ed to be performed to build on a solid foun-dation. Additional information that wasgathered for this case were photographs,radiographs, and 3 sets of models taken forevaluation. Photographic documentation

and evaluation of the smile-line, lip pos-ture, drape, and teeth position are critical toevaluate when creating a new smile.

Digital mockups were performed to fur-ther evaluate tooth shape and position,allowing for verification by the patient asto the direction the case would be heading.After drawing some conclusions on digitalmock-ups of the case, we proceeded to do acosmetic wax-up of teeth Nos. 6 to 11. Adiagnostic wax-up is extremely helpful notonly in determining what is possible, but italso acts as a template on which everythingthat follows is created (Figure 4). Varioustypes of stents can be created to assist in theaccurate placement of the implant. A reduc-tion stent was created to enable precisiontooth structure removal during the prepa-ration appointment along with a provision-al template to successfully replicate thewax-up. Templates were also fabricated forthe ceramist to use in creating the sameshapes for each restoration.

Once the wax-up is created, and all thereduction templates are fabricated, thenthe actual creation of the case becomesmuch easier. Having already worked outany potential problems with the treatmentplan and preparation designs allows foreasy duplication of the case intraorally. Thewax-up, along with a CBCT of the premaxil-la, enable easy conversations and treatmentplanning with the periodontist. The patienthad a pre-existing pontic for the temporaryreplacement of No. 7 to be used in herbraces after segmenting the bridge. Had shenot had a pre-existing tooth or restoration,then a provisional flipper would have beencreated for implementation during theimplant osseointegration. While wearingbraces, the patient had the implant place-ment (Nobel Biocare) performed with theperiodontist based on a surgical guide fromthe wax-up. An impression was taken of theimplant’s position so that a dental techni-cian could create a custom healing abut-ment and custom pickup impression cap.

Once the implant was osseointegrated,the focus turned to finalizing the braces aswell as uncovering the implant and place-ment of the custom healing abutment. Oncethe custom healing abutment was in place,the remaining teeth could begin their various

Todd C.Snyder, DDS

The Modern Aesthetic MixedRestorative Case

Figure 1. Preoperative smile. (Courtesy of Mark J.Redd, DDS, Laguna Hills, Calif.)

Figure 2. Orthodontic repositioning of the roots andcreating more ideal spacing between teeth to allowfor the best preparation design.

Figure 4. Diagnostic wax-up.

Figure 3. Retracted view of braces to evaluatetooth position.

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restorative treatments. Upon removingthe braces, the patient wore a Hawleywire retainer with a single denturetooth to replace No. 7 and maintain thetooth position while waiting to restorein the coming weeks.

Preparation AppointmentThe preparation appointment beganwith ASA infiltrations of Carbocaine(Cook Waite) and Lidocaine (CookWaite) (Figure 5). The crowns on Nos.6, 8, and 10 were sectioned off first toevaluate the amount of tooth remain-ing and document the prepared toothcolors. The preparations were thenrefined to a more ideal reduction,shape, and margin design. Teeth Nos. 9and 11 were then prepared for conser-vative veneers with the preparationlimited to enamel reduction for thebest long-term adhesion.

A small No. 00 retraction cord(Ultradent Products) was placed to dis-place tissues to refine the gingival mar-gins (Figure 6). No astringents wereused so as to minimize any irritants tothe tissues and remove any risk of con-taminating the impression materials.A customizable impression tray(HEAT WAVE Trays [CLINICIAN’SCHOICE]) was fabricated by immers-ing the tray in a cup of hot water forone minute, followed by adaptation ofthe tray to the diagnostic model. Next,the existing custom healing abutmentwas removed, followed by the place-ment of the custom impression ana-log. The top of the custom impressionanalog was painted with an occlusalindicator spray (Oc clude [Pascal]). Thecustomized im pression tray was thentried in to determine positioning of theimpression analog and to mark the

area to be removed inside of the tray.The tray was then perforated to allowaccess to the top of the analog whilethe impression was in place to facili-tate the removal of the analog from themouth without its removal from theimpression. This allows for a more pre-cise positioning of the implant analogin the final stone model. The modifiedtray was then coated with tray adhe-sive and allowed to dry. The top of theimpression analog had a small piece ofutility wax placed over the screw headto keep the impression material fromcovering it and minimizing cleanup.The tray was then filled with Panasil

Binetics Putty (Kettenbach LP), whilesimultaneously, the teeth were coatedwith Panasil initial contact lightimpression material (Kettenbach LP).Upon placing the impression tray overthe teeth, the excess impression mate-rial that came out of the tray accesshole was wiped, allowing access to thetop of the analog. The analog screwwas then loosened prior to removingthe impression so that upon removalof the impression from the mouth, thecustom analog would be capturedwithin the impression and the modelanalog could be attached (Figure 7).The custom healing abutment was

repositioned back into the mouthalong with a wax bite and photograph-ic documentation of the preparedteeth for color assessment (Figure 8).

If the diagnostic wax-up is thearchitectural template for what is tobe created, then the provisional is theworking prototype that needs toduplicate the appearance and func-tion of the wax-up and, at the sametime, it needs to be durable and aes-thetic. To fabricate a provisional, thediagnostic wax-up of the desired finalappearance for the case will be dupli-cated (Figure 4) using the beadlineover-impression technique.1 The pro-cedure entailed a 0.5 mm scribe linebeing cut into the gingival margins ofthe diagnostic wax-up model for all ofthe teeth and a millimeter of spacebeing created between the implantcrown wax-up and the custom healing

abutment. It is possible to see under-neath the wax-up of the implantcrown and the stone model since it isnow a millimeter away from the stonemodel reproduction of the customhealing abutment. Next, a piece ofTeflon tape (DuPont) was applied tothe lingual surface of the implantcrown wax-up extending down ontothe gingival tissues of the stonemodel. This was performed to blockthe over-impression material fromcommunicating from buccal to lin-gual underneath the diagnostic wax-up of the implant crown. An over-impression of the modified wax-upwas taken using Panasil initial contactlight-bodied impression materialsyringed around the teeth and Panasiltray soft (heavy-body) (Kettenbach LP)material loaded into a stock impres-

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Figure 5. Post-orthodontic therapy, prior tostarting restorative therapy.

Figure 6. Prepared teeth with retraction cordin place.

Figure 7. Customized HEATWAVE Tray (CLINI-CIAN’S CHOICE) and Panasil Binetics Putty(Kettenbach LP) with Panasil initial contact(Kettenbach LP) light body wash. The customimpression analog in place with the stonemodel analog attached.

Figure 8. Prepared tooth shade documentedwith shade tabs for the master ceramist atthe laboratory.

Figure 9. The beadline over-impression having been removed shows the VisalysTemp provisional material (Kettenbach LP) inplace with the Teflon tape (DuPont), makingspace between the custom healing abutment and the provisional to createspace to facilitate cleaning.

Figure 10. The aesthetically pleasing VisalysTemp after wiping with gauze and pulling theTeflon tape out.

Figure 11. The provisionals evaluated forshape after one week.

Figure 12. The provisional smile evaluatedafter one week.

Figure 13. Occlusal view of the uncut modelto evaluate the custom implant abutment aswell as margins, contacts, and occlusion ofthe final restorations.

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To fabricate a provisional, the diagnostic wax-up of thedesired final appearance for the case will be duplicated.

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sion tray. The buccal and lingualaspect of the implant wax-up alongthe gumline was only separated by apiece of Teflon tape, which created acut in the over-impression to allow forremoval off the model as well. Whenused in the mouth to create the finalprovisional, it was possible for re -moval of the impression from themouth while still leaving the provi-sional intact on the teeth.

Utilizing the beadline over-im -pression from the diagnostic wax-up, aone-piece provisional was to be createdusing the Visalys Temp provisionalmaterial (Ket tenbach LP). A small pieceof Teflon tape was placed on top of thecustom healing abutment to minimizeany risk of attachment or cleanup aswell as improving access for hygiene.The beadline over-impression was care-fully filled with Visalys Temp so as notto overfill any of the different types oftooth preparations. If too much of aprovisional material is placed within

the over-impression, then the tray can-not seat completely and more adjust-ments to the provisional will need to beperformed, as well as having moreflash to clean off the adjacent teeth.Upon placement, we maintained directpressure on the over-impression whilethe temporary material was setting,which can help minimize distortionfrom incomplete seating or move-ment of the tray while waiting forautopolymerization to finish. Afterwaiting for one and a half minutes, thebeadline over-impression was re -moved, showing one very precise,durable, and aesthetically appealingprovisional that was locked into placemechanically without any etching orbonding to tooth structure. Because ofthe various preparation designs, theprovisional was intentionally lockedin place so as not to necessitate anyprovisional cement. The minimalexcess flash that was found on thegingival portion of the tooth andslightly onto the tissue was removedquickly with an explorer, periodontalknife, and a spoon excavator. The pro-visional was intentionally not pol-ished to highlight the material’s aes-thetic capabilities after removing the

beadline over-impression (Figure 9).After removing the small amount offlash and the retraction cords, the tis-sues were allowed to relax back intoposition. The restorations were thenwiped with gauze to show the naturalappearance without requiring polish-ing (Figure 10). If adjustments areneeded, fluted carbide burs can beimplemented, followed by polishingwith various abrasive points andcups. If no adjustments had been per-formed, the material would not re -quire any polishing for aesthetic pur-poses but sometimes a quick buffingwith a bristle brush or fine abrasivepolisher can enhance the alreadypresent good appearance. If an accu-rate wax-up and beadline over-im -pression technique are implemented,the amount of adjustment can beminimized or avoided completely.The patient was evaluated one weeklater and was very pleased with theaesthetic appearance of her provi-sional teeth that were foreshadowingthe shape of the final restorations(Figures 11 and 12).

Delivery AppointmentThe final model work and restora-

tions were evaluated in comparisonto the original wax-up for fit, shape,and color prior to the patient’sappointment so that any additionaladjustments could be made (Figures13 to 17). Delivering the restorationswas simplified by not requiring anyanesthesia. The Visalys Temp provi-sional material was cut into 3 sepa-rate pieces and then removed manu-ally with a crown key and a hemostat.The custom healing abutment wasremoved, and the zirconia customabutment was torqued into place andverified via a radiograph. All of therestorations were then tried in toevaluate fit, contacts, occlusion, andcolor. To facilitate placement, the lay-ered zirconia crowns (KATANA [Ku -raray Noritake Dental]) were steamcleaned and cemented first with a newcalcium aluminate cement (Ceramir[Doxa]). All of the typical steps foundwith resin cementation that we usual-ly perform in our office (such as clean-ing the internal aspects of the zirconiacrowns and then using a universalprimer) are contraindicated whenusing the Ceramir cementation proto-col. The only requirement is for thearea to stay immobilized and some-what dry while the material is solidify-ing for 2 minutes, then after 4 minutes,the excess cement can be pulled awayeasily. The 2 feldspathic porcelain(Noritake) veneers were tried in,cleaned, silanated, and adhered to theenamel using a total-etch techniquewith a traditional 4th generation bond-

ing agent (ALL-BOND 3 [BISCO DentalProducts]) and light-cured resin ce -ment (CHOICE 2 [BISCO DentalProducts]) (per manufacturer’s instruc-tions). After placement, the final res -torations mimicked very closely theshape and color of the provisionals(Figures 18 and 19).

DISCUSSION The process of fabricating a provision-al restoration has undergone manychanges in the procedure, as well asthe materials available for use withinthe dental profession. The simplifica-tion of the provisionalization processcame from the modernization ofmaterials and their delivery systems.Traditional acrylic monomers andpolymers having to be mixed by handand then utilized in a direct, indirect,or direct/indirect fashion have longbeen replaced by much faster and eas-ier techniques and materials. The pro-gression in the development of mate-rial chemistries continues to makethe fabrication process easier, withbetter aesthetics and higher strengthproperties. There are many types ofprovisional materials available indentistry, and they all can create afunctional provisional restoration.3The differences among materials canbe extensive, based on ease of use,durability, staining, wear, and aesthet-ics. The setting time for a provisionalmaterial to harden is another veryimportant characteristic that shouldbe taken into consideration when

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Figure 17. The diagnostic wax-up and thefinal restorations were verified to be virtuallyidentical in their shape when evaluated.

Figure 18. The layered zirconia crowns(KATANA [Kuraray Noritake Dental]) cement-ed in place with Doxa’s Ceramir cement, andthe feldspathic porcelain (Noritake) veneerscemented with BISCO Dental Products’ ALL-BOND 3 adhesive and CHOICE 2 lutingcement.

Figure 19. The new aesthetic and pleasingsmile.

The Modern Aesthetic Mixed...

Figure 14. Occlusal view of the uncut modelwith the final restorations in place.

Figure 15. Facial view of the uncut model toevaluate the custom implant abutment aswell as margins, contacts, and occlusion ofthe final restorations.

Figure 16. Facial view of the uncut modelwith the final restorations in place.

The process of fabricating a provisional restoration hasundergone many changes in the procedure, as well as thematerials available for use within the dental profession.

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evaluating provisional materials. Theability to efficiently place a provision-al can save valuable time chairsideduring the provisional fabricationand placement technique. KettenbachLP has done an excellent job of creat-ing a newer material that sets in as lit-tle as 80 seconds while still maintain-ing little to no oxygen inhibitionlayer. An oxygen inhibition layer onthe internal surface of a provisionalcan cause inadvertent adhesion tocomposite build ups and prematuredisplacement of a provisional. Thiscan create the un wanted need for anadditional procedure and sometimesadditional recementing appoint-ments. The oxygen inhibition layercan also clog up the fluting of carbideburs when adjusting a provisionalthat can further complicate and slowthe provisional placement process.All of these criteria can point the den-tist toward a new multifunctional

monomer provisional ma terial that isefficient, durable, easy to use, and aes-thetically appealing. Visalys Temp isunique in that it is made from a 2-component, BPA-free multifunctionalacrylic composite.

Ideal characteristics that a dentistwould seek for a provisional materialwould be something that works wellfor any situation to minimize officeoverhead and inventory, is quick tofabricate, easy to use, and simple tofinish. The material would offer aquick setting time with low heatrelease and low shrinkage while hav-ing virtually no air inhibition layer.As dentists, we would like somethingto have an easy aesthetic outcomewith the least amount of effort toachieve the goal. Visalys Temp has allof these desired characteristics inaddition to its excellent physicalproperties, durability, great aesthet-ics, and high polishability.

CLOSING COMMENTSMany of our patients are seeking aes-thetically driven treatments. The ad -vent of stronger ceramics has allowedfor more appealing, aesthetic restora-tions where once only metal-basedrestorations could be used. The in -creased demand for elective dentistryby consumers has created an in -creased need for better provisionalrestorations.3 The emphasis from thedental practitioner is the need for pro-visional restorations that can be useduniversally across all types of restora-tive procedures and placed quicklywith a lifelike appearance while at thesame time being durable enough towithstand the harsh environment ofthe oral cavity for days, weeks, ormonths. The creation of moderncements that facilitate quicker proce-dure times and offer new and uniquephysical properties is a great improve-ment for the clinician and the patient.Traditional materials, like feldspathicporcelains, 4th generation bondingagents, and light-cured resin lutingcements, are still highly effective andproven to still be some of the best aes-thetic treatment options for ourpatients. The blend of new and old

technology has enhanced how we canpractice aesthetic dentistry to im -prove our patients’ smiles and overallappearances.�

References 1. Kurtzman G. Crown and bridge temporization.

Part 1—Provisional materials. Inside Dentistry.2008;4.

2. Snyder T. Bead line veneer provisional restora-tions. Pract Proced Aesthet Dent. 2009;21:E1-E7.

3. Spear F. An interdisciplinary approach to the useof long-term temporary restorations. J Am DentAssoc. 2009;140:1418-1424.

Dr. Snyder received his doctorate in dental sur-gery at the University of California at LosAngeles School of Dentistry (UCLA). He co-developed and co-directed the first and onlycomprehensive 2-year postgraduate programin aesthetic and contemporary restorative den-tistry at UCLA and has been on the faculty atUCLA’s Center for Esthetic Dentistry andEsthetic Professionals. He is a graduate of theFoundation for Advanced Continuing Education(FACE) Institute for complex gnathological dis-orders and an Accredited Member of theAmerican Academy of Cosmetic Dentistry. Alsoa member of the Catapult Elite Group, his pri-vate practice, Aesthetic Dental Designs, islocated in Laguna Niguel, Calif. He lecturesinternationally on dental materials, techniques,occlusion, equipment, business development,and marketing. He consults for numerous den-tal companies, and he has authored articles indental publications internationally. He can bereached at drtoddsnyder.com.

Disclosure: Dr. Snyder reports no disclosures.

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The increased demand for elective dentistry by consumers hascreated an increased need for better provisional restorations.

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