Interview with Dr. Gary DeWood By Lauren Krzyzostankiak
Some dentists might argue that provisional restorations don’t matter as much as the final restoration, but Gary DeWood, DDS, would disagree. Dr. DeWood serves as the executive vice president of Spear Practice Solutions and is a fierce proponent of producing functional, durable, and — most of all — esthetic temporaries, every time. They affect the health of the dental practice a lot more than one might think.
We sat down with him to go over the ins and outs of producing a quality provisional. Below, he outlined the eight ways your provisionals might be costing your practice money.
1. Not making temporaries thin enough
See if the material can be done thin and trimmed easily without chipping. To mimic the restoration that you’re going to be using, it needs to be fabricated thin enough. If I’m doing minimal-reduction veneers and decide that I want to put provisionals on them for this case, it has to be a material that I can work with when it’s very thin, getting down to half a millimeter by the gingival margins. Obviously, there are times when you need them to be thicker for stability, but a good provisional material can be trimmed thin without losing its strength.
Other than that, the reason they fail in the posterior is because they aren’t thick enough. However, that’s usually not the fault of the provisional, it’s the fault of the preparation, which is under-reduced.
2. Not creating esthetic temporaries
I would argue that temporaries have to look exactly like you want the final restorations to look. I built a practice by having temporaries that brought referrals to my practice. If I’ve done a wax up, I will use a model of my wax up to create a former to build my provisionals in. I can either take an impression of the preps and build them on a model, or I can go directly in the mouth. The most efficient of those two is to go directly to the mouth and make the provisionals there based on a guide that you’ve created.
I could also use the guide as a reduction guide, which now means I can make better provisionals because I prep correctly.
You also want to use a provisional that gives you a nice shade range to choose from. You want to be able to mix them and use different colors in different parts of the teeth, depending on how much detail you want to include. All of that plays into building provisionals that people say, wow, those are just the temporaries? That’s the way to build the practice. I think that’s the most significant way that provisional restorations cost you money. The better your provisionals, the better acceptance you get for your final restorations. You have to make them functional and durable, but the way to build a practice with them is through esthetics. It costs you money both at the chair and in patients if they don’t look good.
3. Not using adequate cements
If you don’t make nice temporaries and they keep falling off or getting lost, that will cost you a lot of money.
There’s a line you have to walk, because I would like to use a cement that would hold my provisionals on, but I have to be able to remove them easily. The more minimal I prepare, the harder it is to hold that on, because I don’t have tooth form to hold those provisionals in place. You want a temporary cement that sets hard enough to hold things on well, but you can still get it off, like TempoCemID.
4. Fabricating chairside
If you’re doing all of the teeth, the extra time does cost you money. That’s when having the lab make a shell ahead of time would be useful. If I have an extensive case with a lot of stuff going on, it’ll go to my laboratory. My lab technician will wax it based on me taking photographs and designing what I want and then showing him that. I always have them make me a putty impression of that so that I can get a solid stone model of the ideal. That becomes my guide and serves as my model for making any guides that I want to make. My favorite would be a flexible plastic material like a copyplast guide to make provisionals with. In some cases, such as a full-arch restoration, making them outside the mouth is more fun. However, doing them on a model usually takes longer, unless you do it with your assistant. If you have a guide and plans for the provisionals and you snap an impression of the preparations as soon as you prep, you can have an assistant go to the lab and make those. They can pour a model and a mold that shows them what the provisionals should look like. I can keep moving at the chair, placing a retraction cord and making an impression or scanning or whatever I’m going to do. That can be more efficient if you’re going to work with an auxiliary. But if you’re working alone, it’s usually faster to do it directly in the mouth.
5. Not sending images to lab
Not sending images will make it harder for the lab to design the final outcome. They need to see what you’re thinking. What do you want it to look like? That’s going to cost you money in your provisionals, because you’re not going to like the provisionals. It’s about communication between you and your lab technician, either in the wax up stage or in the shell creation stage. 6. Using inadequate impression material If you’re going to do your provisionals built from an impression of your ideal outcome or an impression of the teeth as they are now (if the tooth is cracked and you don’t need to change the form to restore it, for instance), then you can use an impression to build your provisional. In that case, using a good impression material is important.
If the lab is building the provisionals for you and the impressions were inaccurate, that would be a problem. If you are sending for wax ups and shells, you should use a bite registration material that is both highly accurate and highly stable, like LuxaBite.
7. Not using the right materials for the case
The better the provisional material is at holding tooth position, the less adjustment I’m going to have. Using a high quality provisional material like Luxatemp is important. It’s one of the best ones out there, by far. I’ve been using it for 25 years. You can get bis-acryl materials that are way less expensive, but they don’t set as hard or as thoroughly. A lot of them have an oxygen-inhibited layer that just stays on there like a gel. When you wipe it off with alcohol, the surface is harder to maintain.
8. Not using a core material that can be polished
If you use a good core material that can be polished, it makes it easier to make nice provisionals. Ideal prep form helps you make way better provisionals. Using smooth, flowable materials are going to help you get a better prep design. And a good prep design makes you fabricate better provisionals.