June 1, 2000
by Thomas E. Hughes, DDS
Pre-cemented instant temporaries are exactly what the name implies. These are temporaries that are quickly fabricated directly over a fully cured temporary cement placed on the prepared teeth after the final impression has been taken. I have utilized this technique in my practice on hundreds of patients for more than three years, and I can attest to its success. It is phenomenal in terms of time savings for me and satisfaction for my patients.
The story began several years ago when Dr. Ray Bertolotti shared with me a technique for temporaries that he called “speed temps”. For this technique he took a pre-operative polyvinylsiloxane double bite impression and then used that impression to form the temporaries with either Turbotemp or Luxatemp. The “speed temps,” as with all previous temporary techniques, were removed from the prepared teeth prior to final set, trimmed, polished, finished, re-cemented back onto the prepared teeth and adjusted for patient bite comfort. Dr. Bertolotti’s “speed temp” technique is indeed a good technique. However, I would like to now share with you the latest and most advanced account of this technique, namely: pre-cemented instant temporaries.
The long-standing rule of temporary fabrication; that the “time saved during the fabrication of temporaries at the prep appointment will be spent two-fold at the final restoration delivery appointment” has now been re-written: “The time saved with pre-cemented instant temporaries will be met with greater time savings at the final restoration delivery appointment.” The time saving quality of this technique is magnified at the delivery appointment by the fact that the teeth, although temporized, remain seemingly undisturbed and virtually identical to their condition prior to treatment. This means that the inter-proximal contacts as well as the occlusal relationships are precisely as they were prior to treatment and remain constant during the provisional phase of treatment. This technique has proven to produce temporaries that are reliable for the provisional phase of crown and bridge procedures with predictable serviceability and comfort for all patients.
The Following Photographs Depict the Technique in Detail:
1. The pre-operative condition. Three teeth with large amalgams for which the patient desired restorations that favor greater function, appearance and longevity.
2. The pre-operative impression of the teeth prior to preparations. The use of a polyvinylsiloxane impression material (Star VPS Danville; Splash Half-Time Discus; or Imprint II 3M) in a disposable double-bite tray will produce the necessary detail and bite-index for accurate relocation at the time of re-insert of this impression to form the temporaries. It is important to note that a polyvinyl and a double-bite tray are essential elements for the success of this technique. In addition, it is recommended that missing cusps and fractured areas of the teeth be blocked-out with a highly visible block-out composite (L.C. Block-Out Resin from Ultradent (800) 552-5512) prior to the pre-op impression. Also, for you economy minded colleagues, alginate will not provide the pre-op tooth detail and positive, inter-arch bite index needed for this technique. Again, the cost of the polyvinlysiloxane pre-op impression in a disposable double-bite impression tray will pay for itself four-fold in the time saved with this technique.)
3. The teeth with amalgam removed, preparations complete and ready for the final impression.
4. The final impression is taken with a polyvinylsiloxane(Star VPS Danville; Splash Half-Time Discus; or Imprint II 3M) stiff/heavy body tray material in a disposable rimless double-bite tray plus an ultra light-body syringe material applied directly on the teeth. The stiff heavy-body tray material in the rimless double- bite tray will produce a rigid impression that will resist distortion and inaccurate models. The ultra light-body syringe material will be expressed beyond the gingival margins (without use of retraction cords) when the heavy-body tray material is inserted and the patient is instructed and assisted to bite in centric occlusion into this double bite impression.
5. The prepared teeth are covered with temporary cement immediately following the final impression. (note: the cement is placed before the temporaries are fabricated… this is the point where this technique becomes distinctively different from all other provisional techniques!) Use of Nogenol with 10% Vaseline (Nogenol will not adversely affect future bonding of adhesive materials). The inclusion of 10% Vaseline will reduce the viscosity of the cement, retard the set, permit placement of cement with a disposable brush and permit air thinning (thinner is better). After air thinning, the cement is set instantly with a blast of air and water from your three-way air/ water syringe. It is important that the cement be completely set prior to the placement of the temporary composite to prevent displacement of the Nogenol/Vaseline cement when the temporary material is seated. It is also suggested that additional cement be placed (i.e. dabbed onto the inter-proximal papillae from the side of an explorer or plastic instrument) as needed to block-out the inter-proximal gingival areas and prevent “locking” the temporaries into these “undercut” inter-proximal sites.
6. The temporary “adhesion spot.” If the preparations are extremely non-retentive or you are concerned about the retention of the temporaries, use a Microetcher intraoral sandblaster with 50 micron aluminum oxide abrasive (Danville Engineering Inc. (800) 827-7940) or any air abrasion system to lightly abrade off a 3mm “adhesion spot” of the temporary cement from the pulpal floor of one or all of the preparations. The temporary composite will adhere nicely to this “adhesion spot” without acid etching and will still permit you to remove the temporary at your command.
7. The pre-op impression (seen previously in figure #2) is first lubricated with a thin oil (handpiece spray lubricants work well) and the preparation sites are filled with an auto cure, low viscosity, temporary composite (Luxatemp, TurboTemp, ProTemp, SmarTemp or Perfect Temp). A small amount of this material is also expressed onto the prepared teeth to insure complete tooth-preparation coverage.
8. The “filled” pre-operative double bite impression is then seated first on the opposing teeth and the patient is instructed and assisted to bite into the double bite pre-operative impression, seating the double bite tray and the temporary material onto the prepared teeth. Remember, the temporary cement (Nogenol plus 10% Vaseline) has already been applied and fully set on the prepared teeth… (step 5). The patient is instructed to comfortably hold the double bite impression tray (and temporary material) in place for three minutes while it completely polymerizes.
9. After three minutes the auto cure temporary material is fully polymerized. The pre-op double bite impression can now be removed by gently “rolling” it off the temporized teeth to either the buccal or the lingual. The excess “flash” is teased off from the teeth and gingiva in a gingival direction with a stiff instrument (Sickle scaler; Hu-Friedy).
10. The finished pre-cemented instant temporaries with the gross material excess (flash) removed are polished with a slow speed “yellow cup” (Ultradent) and/or Moores Discs to remove excess cement and any small excesses of the temporary material. This will produce a very smooth and comfortable provisional restoration.
11. Occlusion check. Because the polyvinlysiloxane pre-op double bite impression captures such accuracy prior to treatment, the pre-cemented instant temporaries are essentially exact replicas of the pre-treatment condition in every detail. Adjustments of tooth contour, inter proximal contacts and the usual “high” occlusion typical of temporary techniques of the past are therefore unnecessary.
12. Delivery. At the delivery and seat appointment, it is suggested that after removal of the provisional, the temporary cement be removed from th
e teeth with a Microetcher intraoral “sandblaster” (Danville) or by any air abrasion system set at low pressure (Air Abrasion cement removal and clean-up will also enhance the adhesion of bonding materials to enamel and dentin). Minor gingival hemorrhage may occur with air abrasion methods of cement removal, and it is recommended that a non-sulfide containing hemostatic agent [Tissue Management Gel, Kottler Research (877) 480-6097] be placed for three minutes prior to adhesion techniques to insure predictable and reliable hemorrhage control near bonding sites. Incidentally, this hemostatic material works well for all hemostatic requirements you may encounter where hemostasis and dry-field are necessary for predictable adhesion dentistry.
13. The final restorations ten days post-operative, bonded in place with Clearfil Liner Bond 2 V (Kuraray) with Variolink II Vivadent (both products are available through local suppliers).
The benefits of pre-cemented instant temporaries are obvious and numerous. The technique is “quicker, cheaper and better” than all provisional techniques previously described or employed. No longer is it necessary to remove, trim, finish, polish, cement and correct “high” occlusion of provisional restorations for any lab-fabricated dental procedure. This single technique improvement can save the dentist and staff between fifteen to thirty minutes per patient, which multiplied by hundreds of lab-fabricated procedures per year can result in significant savings of time and therefore greater profits.
But there is more value with this procedure than the immediate and distinct economic impact. The predictable success, comfort and satisfaction for the patient are just as important. Leaky, loose, ill-fitting and rough-to-the-tongue temporaries are uncomfortable and serve as constant reminders of a perceived “low quality” service. In addition, poor quality temporaries can lead to costly (non-profitable) appointments in the office for unwanted and unnecessary adjustments or re-cementations.
Pre-cemented instant temporaries have proven to be faster, more economical and better in every way for the doctor, the staff and the patient. The time savings for patients and doctors are self evident, and therefore the economic and marketing benefits of using superior materials in your practice can no longer be ignored.
Dr. Tom Hughes and his wife, Barbara, founded High Impact Marketing to develop, test and provide an array of promotional materials to support their vision for dentistry well into the 21st Century. For information contact: High Impact Marketing at (719) 488-0808 or (888) SMILE-IS. Fax (719) 488-0805.