May/June 1998	Jorge Pinero, DDS
Contemporary Esthetics
The Revolution Technique

Today’s dental practice is undergoing an evolution and revolution from the methods of practice 10 years ago. Today, the clinician has an array of different materials that can be used to restore teeth that were not available several years ago.

One of the most important facets of esthetic dentistry is to provide a predictable outcome to any cosmetic or complete oral rehabilitation. The placement of provisional restorations will enable the patient and clinician to view the final desired outcome predictably. Placing provisional restorations not only protects the teeth prepared for a prosthesis and allows greater patient comfort, but it also provides an avenue to market the practitioner’s clinical services to patients outside the practice.

This article discusses the technique of provisional placement for two cosmetic rehabilitations using veneer restorations. It also demonstrates the application of this technique to more complex rehabilitations, and the associated benefits for the patient and clinician.

Challenges for the Restorative Dentist

What is the most difficult aspect of esthetic restorative dentistry? This is a highly debated question. Many clinicians might say treatment planning or patient management is the most difficult. Still others might say designing the restorations is the most complex aspect. Others think final placement and tissue management of the final prosthesis are the most challenging. All are valid concerns of esthetic dentistry, and all are an integral part of the final picture. The most frequent problems encountered by the restorative dentist are in the area of provisional restorations. This aspect of treatment alone can stir up many emotions in individual practitioners.

Fabricating Provisional Restorations

Whether you call them provisionals, temporary restorations, interim restorations, or just temporaries, provisional restorations can be fabricated with many techniques. For fixed prosthetic restorations, the variety of techniques is almost endless.

In esthetic dentistry, where laminate veneers are often used, provisional restorations are not used by many clinicians.1 Preparation of teeth is often minimal and does not compromise the integrity of the dentinal junction. The patient might have slightly shorter, rougher, and more unesthetic teeth after preparation and before placement of the final veneers, but this is not thought to be a major problem because the final restorations can be finished within a reasonable time.

It is precisely this thought that is one of the biggest mistakes esthetic dentists can make. Provisionals are one of the most important keys to a successful treatment outcome. Using them demonstrates a dentist’s commitment to excellence in the treatment of his or her patients.

The Initial Design

What is the correct design for a provisional restoration? Begin with the end in mind! This is the answer to all great rehabilitations. The process begins with a thorough and complete gathering of diagnostic information and the keeping of proper diagnostic records. We should begin with a comprehensive examination. In addition, the evaluation should include a determination of the final result desired by the patient and practitioner. This can be done by using video imaging or a catalog of smiles, such as the one in William Dorfman’s book The Smile Guide.2 This publication is a must for restorative and esthetic dentists.

Benefits of the Provisional Restoration

Provisional restorations offer many benefits. Provisionals are a map to your destination, guiding you to the final results. The design of these temporary restorations shows you and your patient what can be expected. If modification is necessary, it will be discernible at the preparatory visit.

Provisional restorations are also an excellent marketing tool. The author uses them to market esthetic services to the patient’s acquaintances. There is always a story to tell when someone visits a dentist. It can be a pleasant “Wow! Look what my dentist did for me” story, or it can be a boring “I had a dental appointment today” kind of story. Take advantage of the immense opportunity offered by esthetic provisional restorations to communicate to others your ability to provide a greatly appreciated service to your patients.

The author requests that patients ask their friends, coworkers, and family members how they like their provisional restorations. This enables the patient to enter a dialogue with a person about the esthetics and harmonious results. It also serves as a marketing instrument, because many people will be consulted and involved in the treatment process. Many times, these “smile consultants” have come into the author’s practice for the very same results. The key is to ask during the provisional phase. When the final restorations are completed, it is difficult to ask the patient to get multiple opinions from their friends because the treatment has already been completed.

Getting several opinions during the provisional phase results in two benefits for the patient and the dentist. First, the esthetics (and sometimes the color) can be reviewed before completion. Second, the provisional restorations serve to tell the world of the world-class treatment the patient is receiving from his or her dentist.

The following cases demonstrate the Revolution Technique™ the author uses to provide provisional restorations for his patients.

Case Studies

Case 1

Figure 1 Preoperative smile appearance. Figure 2 Preoperative dental and periodontal esthetics. Figure 3 Preoperative view showing rotations and gingival defects.

Her initial examination revealed healthy periodontal tissues, a healthy occlusion and temporomandibular relationship, and a meticulous oral hygiene regimen. The smile analysis revealed crowding of her maxillary and mandibular arch. The lower right central incisor was severely rotated and posed a problem for proper esthetics.

An evaluation with intraoral imaging and a reference from The Smile Guide allowed the selection of the proper shape, length, and esthetics for her final teeth. After much discussion of the varieties of veneers that could be fabricated, IPS EmpressΠ(Ivoclar Williams) veneers were selected because of their inherent quality and ability to produce extremely translucent esthetics.

The patient’s main concerns were:

The patient had been advised that provisionals would be fabricated to the ideal proportion and final shape. She would have these in place for 2 to 3 weeks while her final restorations were fabricated at the laboratory. The laboratory prescription is a custom, detailed description of the proposed result, which often takes longer than usual laboratory time.

Preparation for Provisionals

Before preparing the teeth for veneers, it was observed that the gingival height of several teeth was improper for maximum esthetics. Crown lengthening was accomplished with a Luxar CO2 laser (Luxar Corporation) for the maxillary left central incisor and the mandibular left central incisor.

The teeth were prepared in the usual fashion for veneers with lingual shoulders and lapped incisals (Figure 4).

Figure 4 Preparations for veneers on maxillary and mandibular teeth.

A chamfer margin was placed supragingivally because the optical quality of the veneers would facilitate proper esthetics.4 Tissue retraction was not necessary because of the proper visualization of the gingival margins.

Impressions were taken with Extrude™ PS (KERRŒ Corporation). Occlusal and protrusive bite registrations were taken with Stat BR™(KERRŒ Corporation) to facilitate proper mounting. A facebow transfer was taken to facilitate mounted models on a quality articulator.

Properly mounted models give the technician the correct incisal guidance, which is critical to a balanced anterior occlusion. Also, considerable time is saved because the clinician has fewer chairside adjustments to make.5

In addition to the impressions, bite registrations, and other information described above, a shade diagram and smile profile from The Smile Guide were sent to the laboratory. Intraoral and extraoral photographs of the patient also were sent.

The overall design of the restoration is the responsibility of both the clinician and the laboratory technician. With detailed information supplied by the clinician to the technician, there is little doubt about a satisfactory and predictable outcome.

Fabricating the Provisionals

Now comes the time we all dread--the provisionals! Provisional restorations can be made in a variety of ways. They can be made from self-curing acrylic and an Omnivac shell, from laboratory-processed provisionals, or from freehand composite placement spot-bonded in place. The technique described here is a modified freehand technique that can be cemented or bonded.

The Revolution Technique™

The Revolution Technique™ evolved from years of working with provisional fabrications that were time-consuming, expensive, and did not withstand the trial of provisionalization. This technique is simple, fast, and economical. In addition, patient response is favorable, because the technique produces provisionals that give a true feeling of the final restorations. This technique has proved effective for a wide variety of reconstruction situations. Steps in the Fabrication Process As soon as the teeth have been prepared, they are cleaned with a slurry of pumice to remove any debris from the preparation sequence. A flowable composite (Revolution™, KERRŒ Corporation) was used to fabricate the provisionals. The teeth were lubricated with a water-soluble lubricating jelly, which was air-thinned. A layer of A2 shade resin was applied to the prepared surfaces directly from the syringe tip. Great care must be taken in this step to ensure very little flash on the gingival tissues (Figure 5). The result is similar to a preliminary wax-up covering the prepared surfaces.

Figure 5 Application of gingival shade A2 Revolution resin. Figure 6 Photopolymerization of gingival and body A1 Revolution resin. Figure 7 Photopolymerization of incisal B1 Revolution resin.

The resin layer was photopolymerized with a Demetron Optilux 500™ (KERRŒ Corporation) curing light for 30 seconds per tooth.

Next, a thin layer of A1 shade resin was applied on the gingival third of each tooth and photopolymerized for 5 seconds per tooth (Figure 6).

The final step consisted of placing an A1 shade on the body of the teeth, polymerized for 5 seconds per tooth, followed by application of a B1 incisal shade (Figure 7) polymerized for a full 60 seconds per tooth.

At this point, the provisionals have a rough surface texture and need refinement. It is important to note that the final body and incisal resin must be overbulked to allow for final shaping. Medium- and fine-grit diamonds (Brasseler USAŒ) were used to shape the provisionals and create the desired texture. The provisionals were polished to a bright luster with Lustreshine™ Polishing Paste (Accurate Set, Inc.) (Figures 8 and 9).

Figure 8 Maxillary provisional restorations before seating. Figure 9 Mandibular provisional restorations before seating.

The provisionals were carefully removed and then cemented with Temp-BondŒ NE (KERRŒ Corporation). The provisional restorations were cemented on in case they needed to be replaced. The excess cement was removed, and the restorations were polished again with Lustreshine™. The final step was the application of OptiGuard™ (KERRŒ Corporation) surface sealant on the provisionals to enhance their luster and esthetic appearance (Figure 10).

Figure 10 Application of OptiGuard resin to cemented provisional restorations. Figure 11 Completed provisional restorations.

The Patient's Reaction

The patient’s reaction to these restorations was ecstatic; they exceeded her expectations beyond anything she had envisioned (Figure 11). The provisionals were held in place for 2 weeks until the final veneers were placed.

The esthetics of the final restorations are very important. The laboratory you work with must be able to deliver final restorations that meet or surpass the esthetics of the provisionals. Often, the patient likes the provisionals better than the final restorations. This problem can be eliminated with precise communication and a good working relationship between the clinician and the laboratory technician.

Placing the Final Veneers

After receipt of the restorations from the laboratory and preinsertion approval, the provisionals were removed with a Cooly Pick (Hu-FriedyŒ), and the preparations were cleaned with a slurry of pumice, acid etched, and rinsed. The final veneers were placed with NexusŒ (KERRŒ Corporation) as the luting agent.

Before the primer placement, wetting solutions were applied. Tubulicid Red (Global Dental Products) and AQUA-PREP™ (Bisco Dental Products) were used to enhance the structural cohesive bond and to prevent postoperative dentinal hypersensitivity.

The final restorations were photopolymerized and finished with 12- and 36-fluted finishing burs (Brasseler USAŒ). The marginal junction of the veneers was acid etched with 37% phosphoric acid and rinsed, and OptiGuard™ was placed to reduce microleakage.

The final restorations proved to be a life-changing experience for this patient. She felt that she had a reason to smile again (Figures 12 through 14).

Figure 12 Final IPS Empress restorations on maxillary and mandibular teeth. Figure 13 Preoperative full smile view. Figure 14 Full smile view of completed Empress restorations.

Case 2

A 35-year-old professional man presented to our office dissatisfied with his unesthetic smile (Figure 15). Previous attempts to bond, laminate, bleach, and rebond his teeth had produced poor results (Figure 16).

Figure 15 Preoperative full-smile view. Figure 16 Preoperative esthetics showing delaminated veneers and staining.

The patient’s original request had been for total smile improvement. However, previous clinicians advised him to treat only the maxillary central incisors and bleach the remaining anteriors. He was concerned with the narrow look of his premolar area, but was told the only remedy was orthodontic therapy.

The Smile Analysis

A smile analysis was performed on this patient, as in Case 1, along with comprehensive evaluations of his occlusion, periodontium, and oral tissues. Examination revewaled a health oral environment with the exception of an unesthetic maxillary arch and teeth discolored from tetracycline staining (Figure 17).

Figure 17 Preoperative view of esthetics and poorly aligned lower teeth. Figure 18 Preparations of the maxillary teeth. Figure 19 Preparations of the mandibular teeth.

Proposed Treatment

The proposed treatment was to place veneers on all anterior maxillary and mandibular teeth, as well as the first premolars on both arches. The preparations, impressions, and occlusal records were accomplished as described earlier (Figures 18 and 19).

For fabrication of the provisional, the plan was to do a Revolution Technique™ modified from the one previously described. The technique for this case involved the use of an Omnivac shell and freehand provisional placement of Revolution™ resin. The modification was to spot-bond the restorations directly to the preparations, avoiding cementation of the provisionals.

Cementation of provisionals often results in an opacious quality to the provisionals. The cements used are opaque and allow “bleed-through” coloration of the interim prosthesis.

Spot Etching

Figure 20 Spot etching of maxillary teeth with 37% phosphoric acid. Figure 21 Spot etching of maxillary teeth before provisional fabrication. Figure 22 Application of OptiBond Solo.

The prepared teeth were pumiced, and a small dot of 37% phosphoric acid was placed on the center of the labial surface of the teeth (Figures 20 and 21). The teeth were then conditioned with wetting solutions and with OptiBond™ Solo (KERRŒ Corporation) (Figure 22).

Note: The only aspect that will adhere to the teeth are the areas that were conditioned with the etchant.

Resin Placement

Placement of Revolution™ resin was accomplished in the manner described previously (Figure 23). The patient specifically wanted to match his original color of dentition to avoid causing suspicion about the nature of treatment. The shade selected was a B3, B2 combination and was layered on the teeth in incremental fashion as in the previous case (Figures 24 through 26).

Figure 23 Photopolymerization of OptiBond Solo. Figure 24 Freehand application of gingival B3 and body B2 Revolution resin. Figure 25 Photopolymerization of gingival and body resins.

The final incisal shade and contours of the teeth were accomplished with an Omnivac shell used as a mold for the flowable resin (Figure 27). Shade B1 Revolution™ resin was placed on the labial surfaces of the Omnivac shell and then seated on the maxillary dentition (Figures 28 and 29).

Figure 26 Application of incisal resin (freehand) Figure 27 Model of maxillary teeth with Omnivac shell. Figure 28 Application of Revolution incisal B1 resin in Omnivac shell. Figure 29 Seating Omnivac shell with incisal resin in maxillary arch.

Photopolymerization of the incisal resin was accomplished through the acrylic shell (Figure 30). The shell was removed easily because flowable resins do not adhere to the Omnivac shell after polymerization (Figure 31).

Figure 30 Photopolymerization of Revolution resin through Omnivac shell. Figure 31 Removal of Omnivac shell showing gingival detail.

Final Contouring, Finishing

The final contouring and finishing of the provisionals was accomplished with finishing burs and diamonds as in the previous case study (Figure 32). The patient’s occlusion was evaluated, teeth were polished, and OptiGuard™ resin was placed (Figures 33 and 34). Laboratory fabrication of the IPS EmpressŒ veneers was accomplished within 2 weeks.

Figure 32 Final contouring and finishing of provisional restorations. Figure 33 Evaluating the occlusion of the provisionals. Figure 34 Final polishing of provisional restorations.

The provisionals held up remarkably well during the laboratory interval (Figures 35 ). Removal of the provisionals was accomplished with a Cooly Pick prying at the gingival and incisal margins. The provisional fractured in two sections.

Figure 35 Detail of gingival adaptation of the Revolution Technique.

The small spot bonds remained on the tooth structure. The excess provisional material on the teeth was removed with a diamond instrument, and the final restorations were tried in. The restorations were now ready to bond in the manner described earlier.

Before this step, however, the provisionals were placed back on the teeth out of curiosity and repaired with Revolution™ resin. The result was a perfectly fitting provisional that could have been reused in the same manner described in the previous case with the use of provisional cement.

Final Restorations Placed

Figure 37 Final maxillary and mandibular restorations. Figure 38 Preoperative full-smile view. Figure 39 Postoperative full-smile view of Empress restorations.

The restorations were placed with NexusΠluting cement. The patient was extremely pleased with the results (Figures 37 through 40).

When treatment was completed, he was asked what facet of treatment most impressed him. The patient said he liked the use of the provisionals because they allowed him to view the changes before finalization. Also, no one ever suspected he had undergone a Smile Lift Procedure™ until the final results were completed. He was secretive about this because his new smile was a surprise for his bride on their wedding day. Talk about a sensational ending to this esthetic rehabilitation!

Conclusion

The techniques described above are used on a continual basis in the author’s private practice. They illustrate what can be accomplished with a quick, efficient, and effective method. The technique takes 20 to 30 minutes for cases like the 2 described in this article.

This technique can also be used for complete crown-andbridge fabrication. The latter requires an Omnivac shell, where the flowable resin is injected and placed over the corresponding teeth and polymerized with a curing light (Figures 27 through 32). The quality of this type of provisional restoration surpasses that of laboratory-fabricated provisionals at a substantial reduction in cost and time to the practitioner.

Figure 27 Figure 28 Figure 29 Figure 30 Figure 31 Figure 32

The appearance of provisionals made of flowable resins is identical to enamel because they do not have the opacity of methylmethacrylate provisionals. Another advantage is the absence of free methylmethacrylate resin, which can cause thermal and chemical irritation to the pulpal and periodontal tissues. Free-flowing composites such as Revolution™ do not have this inherent problem.

Flowable resins are more expensive than other provisional material; however, the overall cost of the procedure is lower because of the speed and durability of this technique.

Revolution™ is the flowable composite of choice for these applications because of its ease of handling. It also includes the complete VitaŒ shade selection, plus gingival shades for placing pink gingival collars in dentition with gingival recession or embrasure areas of provisionals.

Join the Revolution™ and start enjoying the benefits of custom, chairside, freehand provisionals!

Acknowledgment

The author would like to express gratitude to MicroDental Laboratories and Carol Schweizer, Master Technician, in the realization of these cases, and to the cooperative patients who allowed our team to change their smiles and their lives.

The “Smile Lift Procedure™” and “The Revolution Technique™” were developed by the author.

References

Back to top

1. Goldstein RE: Diagnostic dilemma: to bond, laminate or crown? Int J Periodontics Restorative Dent 5:9-29, 1987.

2. Dorfman W: The Smile Guide. Phoenix, Ariz, Smart Practice, 1990.

3. Pinero J: The smile lift procedure. Contemporary Esthetics and Restorative Practice. In press.

4. Rufenacht CR: Esthetic management of the dentogingival unit. In: Rufenacht CR (ed): Fundamentals of Esthetics. Chicago, Ill, Quintessence, pp 229-235, 1990.

5. Dawson PE: Evaluation, Diagnosis and Treatment of Occlusal Problems, ed 2. St. Louis, Mosby, pp 1-2, 1989.