Details Of The Provisional Appointment
by Allison Watts, DDS
Here we go! We are going to walk through provisionalization in detail.
We have a wax-up done, it has been duplicated and putty matrices have been fabricated for reduction guides and for provisional stents. We will start with the upper arch for purposes of clarity in walking through this process.
Let’s assume we are opening the vertical via both arches and the waxup reflects the new vertical.
We have already chosen the type of restoration and prep design we are planning on doing on each tooth based on the esthetic (including patient expectations), occlusal, structural and biological findings — veneers, crowns, or partial coverage restorations such as inlays or onlays. We have a good idea of the materials we will be using as well based on all the parameters.
The patient is in the chair, anesthetized and sedated (if applicable, most all-day appointments they will be). We are going to prep and provisionalize the maxillary 6 anterior teeth first. I have had the lab (when I remember) make a duplicate and/or stent with the 6 anteriors waxed up but not the posteriors so that I have a matrix with posterior stops (even though the palate works pretty well).
Under magnification (either loupes or microscope), prep the teeth using depth-cutting burs and check with reduction guides. In general, 2mm off the incisal edge and the rest of the reduction depends on the restoration you are doing. Once you have them prepped the way you like, I recommend polishing the preps with a white stone and a brownie.
Now I would make the provisionals for these 6 teeth. Use the matrix that has the unprepped posteriors if you have it. Before you fill the matrix with temporary material in the appropriate shade (we use luxatemp), make sure to trim it around the second premolars and mark the midline and distal to the cuspids with a pen so that you can orient the matrix when it’s full.
Fill the matrix with provisional material and seat it. Leave it in for 1.5-2 minutes and remove matrix and temporaries. The more accurate your putty matrix is, the less flash you will have to trim (some people reline their matrix with light body PVS). Trim the flash and get the temps pretty close to finished (I always check the length of each tooth with my Boley gauge to make sure it matches the waxup and alter it in the mouth if it needs tweaking).
Get the occlusion pretty much done (when patients are sedated, this is difficult so we usually have them come back in the next day or two to show them how to floss and check their occlusion). To verify the vertical, measure from the gingival of the upper left cuspid to the gingival of the lower left cuspid on the waxup and then compare to the mouth; change as necessary.
Now you can prep the posteriors on one side for the appropriate restoration and temporize with a new matrix that’s made from the full waxup and has been trimmed from the lateral or cuspid back on each side. It will not fit perfectly over your temps, but it will be close! Adjust the occlusion on this side until anteriors contact. Then repeat on the other side.
An alternative is to make the temps outside of the mouth. Take an impression of the prepped teeth (this can be done in alginate)and pour up to make the model. Then place die spacer and separator on and around the teeth and fill the matrix with temp material and adjust margins, embrasures, length, etc outside the mouth. Then try in the mouth. We used to do this a lot and while my assistant made the anterior temps in the lab, I was prepping one of the posterior quadrants.
Another alternative is to have lab-fabricated provisionals, which a lot of people like. I haven’t used them in a while, but the lab can make really nice shells. It’s important to try them in after prepping to make sure they seat all the way (passively), then reline with whatever material and protocol the lab specifies. Measure vertical and adjust occlusion just like you would with temporaries fabricated in the mouth.
Another alternative is not to provisionalize the posteriors at all, but to build them up with composite to the correct vertical.
If there is any question about prep design, such as depth of prep for particular materials, you can take digital photos of the prep color or post or whatever you’re seeing and communicate that to the lab to alter your prep so the results are exceptional. This can be done today but doesn’t have to because we are not final impressing today. I have a friend who regularly (I’ve done it a few times if I have a question or concern) takes an impression of her preps at this appointment and sends it to the lab for direction/refinement. Regardless of what you decide to do at this stage, communication with the laboratory is critical. Photography is very valuable throughout the case to document and communicate with lab.
I will almost never impress this day. I will usually have the patient wear the provisionals for 3-6 months to test occlusion.
The next appointment will be exactly like today but with the lowers and we will usually try to schedule it within a week or so because the occlusion will likely be pretty off until we do the lowers.
As I shared last time, no matter how the case is provisionalized, I generally final impress and finish the case in this order:
1. Impress lower anteriors
2. Deliver lower anteriors, impress upper anteriors
3. Deliver upper anteriors, impress lower posteriors
4. Deliver lower posteriors, impress upper posteriors.
5. Deliver upper posteriors, impress nightguard
6. Deliver nightguard, final equilibration
7. Final photos and celebration
One of my motivations for writing these articles is to help other dentists avoid some of the challenges I had figuring out how to execute these large cases. I didn’t take a single course or even a series of courses that I felt walked me through it step by step. I’ll never forget my first full mouth rehab. As I shared in the last article, I had to figure it out as I went—so stressful! Let me know if you have any specific comments or questions or if there’s something you want to hear about. You can connect with me on my Facebook Page or send an email to insights [at] transformationalpractices.com.
I will be more than happy to assist in any way that I can!
Rock the rehab,
