Removing Provisionals for Anterior Teeth Restoration

In anterior teeth restoration, also known as the "esthetic zone," a significant amount of thought, planning, and communication with the patient is necessary. At Spear Education, we accomplish this through the flagship workshop at the campus, known as Treatment Planning with Confidence (previously known as FGTP (Facially Generated Treatment Planning)), followed by the second workshop, Occlusion in Clinical Practice. The fundamentals learned in this educational journey form the basis for linear planning and determining the most sensible style of anterior restorations for each individual case. This article is designed to complement and cement the lessons learned in those workshops.

Let’s get started!

Factors that Affect Outcomes in Anterior Teeth Restoration

When planning a case using porcelain veneers to fulfill the final outcome, there are plenty of factors to consider.

Some include.

What is the size, shape, and contour of the veneers? What degree of shade change is anticipated from the pre-operative state to the envisioned outcome, as agreed upon by both the doctor and the patient? Are the teeth rotated? Is there any pre-prosthetic orthodontic treatment?

Are there functional considerations for the patient? If so, What does their mandible do when it moves? Are there parafunctional concerns? Should the palatal finish line wrap over the incisal edge or be a butt finish line?

Does the papillae need to be managed? If so, Does the veneer play a role in sculpting and enhancing the embrasures? Where then should the interproximal finish line be? Middle of the contact? Just past the contact moving palatally? Wrapping all the way to the mesiopalatal and distopalatal line angles per tooth?

 

This case called for this style. I like to use a polarized lens as it allows me to see a great deal more detail in the preparations themselves.

All the above will influence what you do to the teeth during the preparation stages and will more so influence the position of the provisional veneers and the definitive veneers, and the responsibility of each in:

• Airway


• Esthetics


• Function


• Structure


• Biology

The intent and purpose of this article are to provide you with a reliable, predictable, low-stress method for removing provisional veneers from your beautiful preparations without altering them in the process.

There wasn't much time saved for the removal of provisional crowns and veneers, especially the latter, which is the most straightforward. A curved hemostat or Kelly clamp can be used to apply pressure to the acrylic and wiggle them off one at a time or many at once if they are fused or splinted. But removing provisional veneers is a different story altogether, isn’t it? Provisional veneers are often placed more than once during a case, meaning you are often charged with fabricating more than one set during the case process.

As a side note, part of the principles of beautiful and long-lasting, predictable ceramic restorations involves linear planning and thinking, utilizing the principles of what you might have learned at the Spear Education campus. We always emphasize the importance of provisionalization with the intent to try out all the variables considered in acrylic form. I often tell patients, "We need to hash out all the potential challenges in the pretend phase. Any necessary changes should be made there so that we are all on board. This approach ensures the final outcome will be predictable and without disappointment."

Several considerations, such as shade change, parafunction, and management of the papilla, may definitely affect the thickness and retention of the provisional restorations. And if we have the responsibility of preparing the teeth in a way that makes sense for the plan, then we do not want to make any unexpected changes to the preparations when removing the provisionals, especially on the delivery date.

Honestly, with all the hours of workshops at Spear Education and long before at my time at The Pankey Institute, I cannot remember significant time spent on the art of the demolition of our "temps" and a way to do this with the least resistance. I write this knowing, sure, someone along the lines, maybe my first doctor I rented space from told me to cut the crown or veneer off midway through the "temp." However, there wasn't comprehensive guidance on considering all possibilities and the consequences of not paying attention to what can go wrong. So, how do we do this in a way that is not stress-free, just less stressful? Stick to a game plan and protocol you can use and follow consistently. Believe me, even after practicing for 30 years, there is always stress, and I am sure all of you reading this feel the same. Why? It is only because we care so much, isn’t it?

Preparing Your Armamentarium

Having the right tools can make all the difference as you embark on your anterior teeth restoration process.

Here are some to remember.

1. 1:5 high speed electric handpiece


2. 0.016F tapered diamond bur from the Restorative Design bur block


3. OS 2 Brasseler Esthetic Trimming bur


4. Crown separator – CRCH2 Hu-Friedy


5. Spoon excavator


6. Kelly clamp (curved hemostat)


7. Favorite Isolation – Optragate, for example, sometimes just cotton rolls


8. Loupes! The highest magnification you have. The more the merrier!

Whether you're removing the initial or final set of provisionals, it's crucial to avoid damaging your preparations. This means avoiding any cuts, notches, or defects on the facial surface, but more importantly, ensuring there are no alterations at the incisal-palatal and interproximal margins. That is why you need to remember the principles of restorative design and what your goals were from the start as the thickness of the provisional will differ greatly, thus your depth of vertical cuts will also differ greatly.

 

1. After administering proper anesthesia, start with the tapered diamond bur. Score and make depth cuts at a comfortable speed, beginning at the mid-facial of the prep, the thickest part. Proceed vertically, cutting from cervical to incisal, removing at least half of the thickness. This portion can be done wet.

2. Next, using the diamond bur again, take a moment to re-familiarize yourself with the thickness of your provisionals. You may not have seen them for approximately five weeks. Carefully cut facially over the incisal edge, ensuring not to expose the tooth. Use a mirror to identify the location of your incisal finish line. Make sure to stop cutting halfway short of it.

Now do the same thing at the interproximal area. There is a lot more acrylic here so your time and depth of cuts will take longer, keeping in mind what your preps look like.

3. This is a good time to slow down the handpiece and turn off the water supply. Having an electric handpiece is crucial because it provides a level of precision not achievable with an air-driven handpiece. While air-driven handpieces were used from 1992 to 2009, they lack the exceptional control and torque of electric handpieces. Change your bur to the Brasseler OS2 and slowly move in the same direction and motion facially from cervical to incisal. If it becomes dusty, clean, and dry it, as you now want to look for the "windows." These are the first sites of your preparation as you slowly peel away to expose what you do not want to alter. This is why the movement facially from cervical to incisal is critical. Stop at this site and continue to peel away moving incisally.

The next image is what it can look like, organized, and clean.

Precision in Provisionalizing Veneers

Now it is time to remember how you put your provisionals on in the first place. As a Moderator of Spear Talk, I field numerous questions regarding methods of provisionalizing veneers. Some still use temporary cement, making them chairside in the mouth. However, for veneers, this method is fraught with path of draw challenges, especially if your preparations break proximal contact.

Personally, I prefer to use an absolutely precise and detailed putty matrix from the wax-up. This technique requires minor spot bonding on the preparations. The essence of this method is to lock the provisionals into place, especially if your case involves breaking contact. Spot bonding involves applying a minimal amount of Scotchbond Universal, for example, mid-preparation, providing some chemical retention. For instance, when treating teeth 5-12, I would apply bonding to teeth 6, 11, and one central. That's it. Your micro brush should be barely wet.

With this removal technique, you can reach a certain point and score the remaining temporaries slowly until you see a fine line. However, complete exposure everywhere is not necessary with this technique, as the provisionals are locked in place. Removing the crown separator takes care of the rest.

 

4. Demolition time. After cutting through plenty of acrylic, it's time to use the crown separator. First, place it into the deeper interproximal areas and apply light pressure. Turn off suctions and listen for mild cracking sounds. Make sure to set your patient up ahead of time to expect this, as it's part of the show. Move around and repeat the process with the rest of the acrylic. You should find chunks coming off or loosened interproximally that can be teased off with a curved hemostat and/or a spoon excavator.

 

Notice how healthy the tissue is with this technique. These provisionals often remain on for 5-6 weeks for me to address any aesthetic or functional issues.

Getting from here…

To here…

To here…

Full disclosure: 5 and 12 are resin bonded veneers using the direct/indirect contact lens technique without preparation, made intentionally with a higher value in color.

This is manageable and highly predictable as long as you adhere to the protocol and maintain thorough case notes on the technique utilized for your provisional anterior teeth restoration. It's essential to use all the thinking and planning tools provided by Spear Education, which complement each other seamlessly. With the support of our curriculum and online resources, along with the assistance of like-minded colleagues, you can achieve virtually any goal in anterior teeth restoration. Thank you for reading this article and allowing me to share some pearls gathered along this remarkable journey.

David St. Ledger, DDS is a Visiting Faculty member, a Spear Moderator, and a Contributing Author to Spear Digest.