Case Report

Use of Protemp 4 in Pediatric Patients: A Novel Approach to Make

Bitter Smiles Better
Pratibha Krishnan, Sakshi Singh, Priyanka Biswas, Niharika Sharma

Department of Pedodontics Early childhood caries is a multifactorial chronic disease affecting the general
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Abstract
and Preventive Dentistry,
Kothiwal Dental College and
life of a child. Functional along with esthetic rehabilitation of decayed primary
Research Centre, Moradabad, teeth should be the main focus of pediatric dentists. The advent of new restorative
Uttar Pradesh, India materials and techniques has helped to create beautiful smiles for children. As
the retention time of primary teeth is short, hence using temporary material for
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/10/2024

primary teeth restoration could be a good alternative. This case series depicts
a novel clinical technique of using a temporization material –Protemp 4 for
intra‑ and extracoronal restorations in primary teeth.

Keywords: Early childhood caries, protemp 4, strip crown, temporization

material

Clinical Relevance to Interdisciplinary Dentistry

Received: 01 December 2022 • The present case report describes the use of Protemp 4 in primary dentition
Revised: 20 February 2023 • Esthetic rehabilitation was done for anterior primary teeth using Protemp 4
Accepted: 23 February 2023
Published: 28 April 2023 • Protemp 4 was used as a restorative material along with strip crowns.

Introduction This case series represents the rehabilitation of primary

teeth using novel Protemp 4 as intracoronal and
E arly childhood caries is a significant chronic
disease of childhood leading to loss of structural
integrity of primary teeth affecting esthetics, causing
extracoronal restorative material.

poor phonetics, compromised masticatory system along Case Reports

with difficulty in social and physiological adjustment.[1,2]
Various restorative materials such as miracle mix,
composites, glass ionomer cements (GICs), resin‑modified
glass ionomers, and polyacid‑modified resins are good
intracoronal treatment options in primary teeth.[3,4]
Conventionally, strip crowns are used with light‑cured
composites.[4] In this series, a new bis‑acryl group
composite resin and temporization material are used.
This is ideally used for temporary crowns[5] but here, we
have used it as a restorative material for intracoronal and
extracoronal restoration considering shorter time span of
primary teeth in the oral cavity.
Protemp 4 is a chemically cured resin of the bis‑acryl
group, consisting of an organic matrix and inorganic
fillers having low polymerization shrinkage, reduced
tissue toxicity, good wear resistance, and strength.[6,7]
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Patients with dental caries in primary tooth were selected
for the case series from the Outpatient Department
of Pedodontics and Preventive Dentistry, Kothiwal
Dental College and Research Centre, Moradabad, Uttar
Pradesh, India. Informed consent was taken from the
parents. Classification of International Caries Detection
and Assessment System II (ICDAS II) was specified
for each tooth.[8] This scoring system was developed tp
allow the standardized caries detection and diagnosis in
different situations.
Address for correspondence: Dr. Sakshi Singh,
Department of Pedodontics and Preventive Dentistry, Kothiwal
Dental College and Research Centre, Moradabad ‑ 244 001,
Uttar Pradesh, India.
E‑mail: sakshi.s380@gmail.com
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as
appropriate credit is given and the new creations are licensed under the identical
terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

DOI: How to cite this article: Krishnan P, Singh S, Biswas P, Sharma N. Use of
10.4103/jid.jid_31_22 Protemp 4 in pediatric patients: A novel approach to make bitter smiles
better. J Interdiscip Dentistry 2023;13:39-42.

© 2023 Journal of Interdisciplinary Dentistry | Published by Wolters Kluwer - Medknow 39

 Krishnan, et al.: Use of Protemp 4 in pediatric patients: A novel approach to make bitter smiles better
Case selection
Inclusion criteria
• Teeth having dentinal and enamel caries
• Children with Frankl behavior score – 3 or 4.
Exclusion criteria
• Teeth with pulpal involvement or showing mobility.
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Case 1
A 4‑year‑old child reported to the department with
chief complaint of dirty anterior teeth for few months.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/10/2024
On intraoral examination, decayed teeth in relation
to 51, 52, 61, and 62 [Figure 1a]. ICDAS II code was
assigned 5 in relation to 51, 52, 61, and 62. 51, 61 were
rehabilitated with strip crown using Protemp 4. 52, 62
were restored with GIC.
Steps for restoring maxillary central incisors using
Protemp 4:
• Step 1: Caries were excavated in relation to 51, 61
• Step 2: Crown cutting was done, ~1.0 mm from all
sides [Figure 1b]
• Step 3: The mesiodistal dimension of the tooth was
measured, accordingly, a correct size of strip crown
was selected for the crown [Figure 1c]
• Step 4: The teeth were air‑dried and isolated using
cotton rolls
• Step 5: Shade A3 was selected for the following
cases. Strip crowns were loaded with Protemp 4 with
the help of automix syringe. Loaded strip crowns
were placed on the prepared teeth, and the celluloid
portion of crowns was removed as the material set.
• Step 6: Finishing of the restoration was done using
finishing burs [Figure 1d].
Case 2
A 5‑year‑old child reported with the chief complaint of
blackish discoloration in the upper front teeth region
for 1 year. Clinical examination revealed decayed tooth
in relation to 53, root stumps in relation to 51,52,61,
and 62 [Figure 2a]. ICDAS II code 3 was assigned in
relation to 53.
a c
b d
Figure 1: (a) Carious 51, 52, 61, 62, (b) Crown preparation of 51, 61, (c)
Checking the size of Strip Crown, (d) Strip crowns in 51, 61 and GIC
restoration in relation to 52, 62
40 Journal of Interdisciplinary Dentistry ¦ Volume 13 ¦ Issue 1 ¦ January-April 2023
Protemp 4 was manipulated according to the
manufacturer’s instructions using an automix syringe
followed by the restoration of the decayed right
maxillary canine [Figure 2b].
Case 3
A 5‑year‑old child reported with chief complaint of
decayed teeth in the upper anterior region for few
months. On intraoral examination, decayed teeth in
relation to 51, 52, 53, 61, 62, and 63 [Figure 2c]. ICDAS
II code was assigned 5 to all the teeth. GIC restoration
was done in relation to 51 and 52, whereas 61 and
62 were rehabilitated using strip crown with Protemp 4
in place of conventional composite material [Figure 2d].
However, the parents were not willing to the restoration
of 53 and 63 during the same appointment.
Case 4
A 6‑year‑old child reported with the chief complaint of
food accumulation in posterior teeth for several days.
On clinical examination, occlusal caries in relation to
74 and 84 [Figure 2e]. ICDAS II code was assigned 3 in
relation to 74 and 84. Caries excavation was done using
small round bur followed by restoration with Protemp 4
in relation to 74 and 84 [Figure 2f]. High points were
trimmed with diamond burs.
Discussion
Bis‑acryl composites consist of bifunctional substrates
to provide cross‑linkage with one another and form
monomer chain cross‑linkage leading to increase in
impact strength and toughness. They have overcome
the disadvantages of polymethylmethacrylate (PMMA)
resins.[9] Young et al. claimed that bis-acryl composite
resin were superior to PMMA with respect to contour,
occlusion, fit, and finish because of increased filler
content.[10] A new variant of bis‑acryl composites,
Protemp 4 having flexible monomer chain unlike
rigid intermediate chain of other bis‑acryl resins.
This creates balance between high mechanical
strength and limited elasticity allowing it to
withstand higher stresses.[7] Protemp 4 (3M ESPE,
Seefeld, Germany) comprises catalyst paste: ethanol,
2,2‑[(1‑methylethylidene) bis (4,1‑phenyleneoxy)]
bis‑diacetate, benzyl‑phenyl‑barbituric acid, silane‑treated
silica, tert‑butylperoxy‑3,5,5‑trimethylhexanoate, base
paste: dimethacrylate (BISEMA6), silane‑treated
amorphous silica.[11]
Protemp 4 has a working time of 40 s. It chemically
binds to the tooth. In uncured state, it acts like wax or
clay. In the wax stage, material can be easily adapted to
the tooth. The earliest point of removal from the mouth
is 1:40 min. Latest point of removal from the mouth
 Krishnan, et al.: Use of Protemp 4 in pediatric patients: A novel approach to make bitter smiles better
a c
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b d
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Figure 2: Case 2‑(a) Carious in relation to 53, (b) Restoration done using Protemp 4, Case 3‑(c) Carious in relation to 51, 52, 61, 62; (d) Strip crown
in relation to 61.62 and GIC in relation to 51, 52, Case 4‑(e) Carious in relation to 74,84; (f) Restoration done using Protemp 4
is 2:50 min. A study stated that Protemp 4 contains
dimethacrylate polymer and bisphenol A glycidyl
methacrylate resins with fillers and stabilizers and rigid
central structure of bis‑acryls reduces the dissolution of
the resin‑filler particles, rendering it with better hardness
than heat cure acrylic resins.[12] According to Khajuria
et al., Protemp 4 on comparison to other provisional
materials, it showed less intrapulpal temperature change
and exothermic heat release.[13] Protemp 4 has good color
stability due to the fact that it utilizes modified Bowen
resin, which is a derivative of the bis‑acryl compounds,
rendered hydrophobic in nature causing major reduction
in water absorption.[11] Protemp 4 has reduced cytotoxic
effects due to its free radical defense system. Reactive
oxygen species (ROS) are generated from these resins
which have direct scavenging effect and promotive effect
on the glutathione system – a direct ROS scavenger.[14]
The value for flexural strength of Protemp 4 material
was measured to be 110 ± 12 MPa. The flexural strength
of Protemp 4 increases when cured at 60°C.[13]
Other findings of Protemp 4 were, change in optical
characteristics, after storage time of 30 days. It may
be seen due to water sorption, swelling effect, and
unreacted monomers being oxidized. Swelling leads to
relaxation of polymer, making the polymer chain more
mobile and causing removal of unreacted monomers,
pigments, and fillers. Hence, it interferes with the overall
polymer strength.[15] A study conducted by Vignesh et al.
comparing fracture toughness of packable composite
resin versus Protemp 4 when used inside a strip crown
to restore primary incisors and concluded that the
fracture toughness of both materials was comparable and
Protemp 4 can be used as an alternative.[16]
In the present case series, GIC was used in some teeth so
as to compare its esthetics and longevity with Protemp
4 temporization material. To the best of our knowledge,
a few in vitro studies have been conducted using
Protemp 4 in the primary teeth; however, no clinical
studies have been reported to date. Hence, to check the
Journal of Interdisciplinary Dentistry ¦ Volume 13 ¦ Issue 1 ¦ January-April 2023
e
f
applicability of this material in primary teeth, a few
cases were carried out. Protemp 4 has been proved to
be cost‑effective owing to its multiple usage in primary
dentition in the form of restoration, strip crowns, and in
permanent dentition as fabrication of temporary (inlays,
onlays, bridges, veneers, and crowns).
The follow‑up of cases one, three, and four was done
at 6 months, whereas case two did not show up on
recall appointment. In case 1- Strip crowns made using
Protemp 4 were intact along with the GIC restoration
irt 52 with no color change, however the GIC
restoration done irt 62 chipped off. In case 3 and case
4- Restorations done using Protemp 4 were intact with
color stability.
Overall, Protemp 4 has proved to be superior in its
properties. However, its effect on primary teeth is yet to
be evaluated properly, due to paucity of literature.
Conclusion
The use of temporization material, as a restorative
material and as a strip crown material for permanent
rehabilitation of primary teeth is a good treatment
alternative than using conventional restorative materials.
Protemp 4 chemically bonds to the tooth and with its
advanced properties, it could be a good recommendation
in pediatric dentistry.
Declaration of patient consent
The authors declare that they have obtained consent
from patients. Patients have given their consent for their
images and other clinical information to be reported in
the journal. Patients understand that their names will not
be published and due efforts will be made to conceal
their identity but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
41
 Krishnan, et al.: Use of Protemp 4 in pediatric patients: A novel approach to make bitter smiles better
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