Types of abutments

Jepson’s pericemental area

What are the indications, contraindications, advantages and disadvantages of porcelain jacket
crowns? Describe the steps in the preparation of an upper central incisor tooth to receive a porcelain
jacket crown.

7/8th crown

½ crown

Interocclusal clearance

Electroformed dies

Die trimming

Luting cements

Discuss briefly the diagnosis and treatment planning for fixed partial denture treatment
Case history and examination, radiographs and the mounted diagnostic casts are the three
important diagnostic aids [Diagnostic Triad] for FPD evaluation

Diagnostic data sheet

Age

Young age- Provision should be made for growth in young people. Eruption is still not complete.
Pulp chambers are large. They may require space maintainers or temporary FPD.

Elderly individuals may not be able to undergo long procedures. Tooth structure is more brittle.
Periodontal condition may not be good. But if all conditions are favorable and the prosthesis is
going to help the patient, then there is no reason why they should not be treated with a FPD.

Sex: females usually will have small teeth compared to males. They are more concerned about esthetics.
Teeth shape and form need to be given based on the sex of the individual.

Occupation: economic status, time, importance to esthetics etc.

Chief complaint- chewing, appearance, speech or the patient has no complaint but desires replacement
for the lost tooth
Examination

General oral examination: for oral hygiene, periodontal condition, exploration of all associated teeth
and other teeth with questionable restorations and carious lesions.

Teeth missing and Span length: depending on which are the teeth missing and how many are missing, it
may be possible to treat with FPD with 1 or 2 teeth missing. If 3 teeth are missing, it requires careful
assessment of all the factors. If 4 teeth are missing, FPD may not be possible, except sometimes in
anterior region provided the occlusion and other factors are favorable.

Alveolar ridge form: too large space as in cases of trauma may favor RPD treatment. It also
decides the gingival form of the pontic.

Phonetics: the prosthesis should offer resistance to the flow of air. RPD may be better
sometimes.

Esthetics: Has the missing teeth and the abutments esthetically important? We need to decide about full
or partial coverage, metal or tooth colored restoration.

Occlusal forces: favorable or unfavorable.

Depends on the relationship between the upper and the lower teeth, alignment of the teeth, no of teeth
missing, bone support to the abutment teeth, the condition of the opposing teeth and if artificial,
whether fixed of removable, muscular activity, patient’s habits- clenching, bruxism, food habits, etc.

Radiographs

Disclose the presence of osseous disease, location and approximate depth of carious lesions, widths and
lateral positions of the pulp, C: R ratios, root size and form, lamina dura, quantity and quality of bone
including trabecular pattern, widths of periodontal ligament, quality of restorations, presence of root
fragments and foreign bodies, character of bone in index areas [areas of added stress such as tipped
teeth, traumatic occlusion, bridge abutments etc.], bone density and surface character of alveolar ridge,
and evaluation of the abutments [described below]

Articulated diagnostic casts

Diagnostic casts should include all teeth and surrounding soft tissue and should be accurately mounted
on an articulator in order to analyze the occlusion. The casts provide information about the size, shape,
form, alignment of the abutment teeth, occlusion, pontic space, inter abutment axis, etc

Survey analysis: the path of insertion should assume a direction in which the prosthesis will be
simultaneously seated on all abutment teeth.

After assessing all the above factors, a decision is to be made whether the teeth can be
replaced with a fixed partial denture or not.

What is an abutment? Enumerate the types of abutments and describe the criteria for the selection of
an ideal abutment for a FPD patient.

Abutment: a tooth, a portion of a tooth or that portion of a dental implant that serves to support and or
retain a prosthesis.

Types of abutments

Tooth abutment

Implant abutment

Requisites for an ideal abutment:

1. Crown length: adequate crown length is necessary to obtain sufficient retention. The more the
length, the better the retention. Short teeth require full coverage preparations, crown
lengthening procedures or subgingival margins.
2. Crown form: the bulkier and well calcified the tooth, the better. It will have more of enamel and
dentin and less of pulp chamber. Tapered teeth do not provide parallelism and require full
coverage. Peg shaped and hypoplastic teeth make questionable abutments. Thin teeth will have
less of tooth structure. Anterior teeth may be thin with poorly developed cingula and short
proximal walls. Mandibular premolars may have poorly developed lingual cusps and short walls.
3. Degree of mutilation: the lesser the better. Grossly destructed teeth make questionable
abutments and may require removal or full coverage.
4. Root length and form: Roots with parallel walls and developmental depressions have more
surface area. Long roots are favorable unlike short and conical roots. Multi rooted teeth are
better abutments than single rooted teeth.
5. Crown :Root ratio: it is the physical relationship between the portion of the teeth within the
alveolar bone compared with the portion not within the alveolar bone, as determined
radiographically. 1:2 is ideal, 1:1.5 is satisfactory, and 1:1 is the minimum necessary.
 6. Ante’s law: the combined pericemental area of all abutment teeth supporting a FPD should be
equal to or greater in pericemental area than the tooth/ teeth to be replaced. It is employed
along with other factors.
The pericemental area of a tooth depends on the no of roots, root length, cross section, and
the bulk. Jepson has given the approximate pericemental areas of all the teeth.

------------

7. Periodontal health: abutment teeth should be periodontally healthy. If not good, then
periodontal treatment is done and evaluated. Examination of periodontal ligament space,
lamina dura, height of the bone, bone quality, the magnitude of mobility and its cause provides
information about the periodontal condition of the tooth. If the teeth are weak, treatment may
include extraction, RPD prosthesis, or FPD with multiple abutments. If FPD is done, it should
promote hygiene and cause no damage to the periodontal health of the tooth.
8. Axial alignment: abutment teeth ideally should be vertical to the horizontal plane. They should
be in correct alignment and relation with respect to the adjacent and opposing tooth [not
rotated or out of the arch]. Mal aligned teeth may require full coverage, devitalization-
prophylactic endodontic treatment or orthodontic treatment.
9. Arch form: if pontics are placed away from the fulcrum line [Inter abutment axis i.e line joining
the abutment teeth and the pontics should form a straight line.] resulting in longer lever arm, it
results in tipping forces on the abutment teeth. Counterbalancing retention in the form of
multiple abutments may have to be given to offset the longer lever arm length. FIG
10. Pulpal health: should be good or endodontic treatment may be necessary, followed by full
coverage with or without post and core.
11. Should be an active tooth [teeth that are inactive for a long time cannot be used as abutments-
there maby be negative bone reaction and such teeth need to be gradually loaded]
12. Long term abutment prognosis: should be good enough.

All these factors need to be assessed based on which are the teeth missing, the adjacent teeth
present, occlusals factors etc and their relative importance defined.

Define tooth preparation. Explain the bio-mechanical principles [considerations] of tooth preparation.

Tooth preparation is defined as the mechanical treatment of dental disease or injury to hard
tissues that restores a tooth to its original form.

Teeth don’t possess the regenerative ability found in most other tissues. Therefore
once enamel or dentin is lost as a result of caries, trauma or wear, restorative materials
must be used to establish form and function.
An ideal tooth preparation should satisfy biologic, mechanical and esthetic requirements.
Biologic principles- affecting the health of the oral tissues.
Mechanical principles- affecting the integrity and durability of the restoration.

Esthetic principles- affecting the appearance.

BIOLOGIC PRINCIPLES
 Prevention of damage during tooth preparation:
 Conservation of tooth structure
 Adequate axial reduction
 Margin placement and adaptation
 Providing harmonious occlusion
 Protection against tooth fracture

PREVENTION OF DAMAGE DURING TOOTH PREPARATION:

During tooth preparation the structures easily damaged are the adjacent teeth, soft tissues and
the pulp of the tooth being prepared.

If the proximal tooth is damaged in the contact area, the surface layer containing high fluoride
concentration is lost and even if it is reshaped and polished, it becomes more prone for plaque
collection and caries. To prevent this damage, thin tapered diamond bur or safe sided disc can be used.
The next tooth can also be protected by metal matrix band.

The damage to the tongue, cheeks, and lips can be prevented by careful retraction using mouth
mirror, aspirator tip, saliva ejector etc.

Extreme temperature, chemical irritation and microorganisms can cause pulpal injury.
Pressure, rotational speeds and type, shape and condition of the cutting instrument all
determine the amount of heat generated. Water spray is to be directed at the area of contact between
the tooth and the bur. This will also remove debris and improves cutting efficiency. Sharp instruments
need to be used and reduction should be performed intermittently in study, controlled manner.

Certain chemical agents used for cleaning preparations and some dental materials [bases,
resins, luting agents] can cause damage to the pulp especially when applied on freshly cut dentin. Pulpal
damage can also occur due to the action of bacteria, which were either left behind or gained access to
the dentin because of microleakage. So all caries dentin should be removed before restoration.

CONSERVATION OF TOOTH STRUCTURE

One of the basic rules is to preserve as much of tooth structure as necessary in consistent with
the mechanical and esthetic factors of tooth preparation. This will reduce the harmful pulpal effects of
various dental procedures and materials used and particular care must be taken when preparing the
vital dentin. This can be achieved by,
- use of partial coverage whenever full coverage is not indicated
- minimum taper
- preparation of occlusal surface in anatomic planes
- conservative margin preparation
- orthodontic repositioning of the tooth
- Supragingival margins etc.

CORRECT AXIAL REDUCTION

Incorrect axial reduction results in over or under contoured restoration. Over contoured restoration
results in plaque accumulation and gingival inflammation. Undercontouring can result in injury to the
gingival margins by the food.

MARGIN PLACEMENT

The termination of the preparation is called the finish line. The part of the restoration that adapts to
the finish line is called the margin.

Whenever possible the margins of the restoration should be supragingival, unless there is a definite
indication for subgingival margins. The subgingival margins have been identified as a major factor in
periodontal diseases particularly when they encroach on the epethelial attachment.

Advantages of supra gingival finish line:

 It is easier to prepare without soft tissue trauma

 It is situated on the hard enamel whereas the subgingival finish line is on soft dentin or cementum.
 Easy to finish
 Easy to keep them clean
 Impression can be easily made
 The margin can be easily evaluated during recalls.

Indications for sub gingival finish line:

 When dental caries, erosion or restoration dictates

 Need for additional retention [cervico occlusal length]
 Esthetics dictates [to hide the margin of the restoration]
 When proximal contact area extends to the gingival crest
 When root sensitivity is present

Margin adaptation

Margins should be short, smooth and well adapted. Rough, irregular, and open margins cause
caries by dissolution of the cement
OCCLUSAL CONSIDERATIONS

Adequate and uniform occlusal reduction is necessary to prevent potential harm from a traumatic
occlusion. This also allows for sufficient space to develop functional occlusal scheme in the finished
restoration.

PREVENTING TOOTH FRACTURE

The likelihood that a restored tooth will fracture can be lessened if the tooth preparation is
designed to minimize potentially destructive stresses. This can be achieved by conservation of tooth
structure, rounding of all line and point angles etc

It is necessary that the biological principles of tooth preparation are not compromised or if very
much necessary, only minimally compromised with adequate precautions, when compared to the
mechanical and esthetic principles.

MECHANICAL PRINCIPLES
The design of the restoration must follow certain mechanical principles to avoid dislodgement,
distortion or fracture of the restoration during service.

It is important to understand the types of forces commonly present in the mouth and to study
those aspects of preparation form and prosthesis design that allow restorations to possess adequate
retention and resistance form to resist these forces.

Three types of forces can be directed against a prosthesis during function.

Tipping- bucco-lingual, mesio-distal

Twisting of rotational

Path of insertion- apically and occlusally [sticky food].

 The mechanical factors can be divided into:

1. Providing retention form:

The quality of a preparation that prevents the restoration from dislodgment by the forces along
the path of withdrawal is known as retention.

2. Providing resistance form:

Involves features of a preparation that prevent dislodgment of a restoration when it may be

subjected to horizontal or oblique forces [tipping or rotational forces].

3. Geometry of the finish line

4. Preventing deformation of the restoration- rigidity

1. PROVIDING RETENTION FORM

The tooth preparation should be such that the restoration must have a single path of withdrawal
and the tooth is shaped to restrain the free movement of the restoration. The cement grains prevent
sliding by providing frictional resistance between two surfaces. This depends on

Taper: parallel walls provide best retention. But to prevent undercuts and to ensure complete
seating of the restoration around 6 degrees taper is given. The tapering diamond points usually come
with this taper.

Surface area: depends on the length of the axial walls and the size of the preparation. It is more
important if it results in increased axial height. There is increased retention in increased axial wall height
and larger preparations.

Stress concentration: sharp angles lead to cohesive failure in the cement. So all the line and
point angles of the preparation are rounded off.

Type of preparation: A complete coverage restoration will have better retention than a partial
coverage restoration. In a partial coverage preparation, grooves and boxes increase the retention by
limiting the path of withdrawal.

Retention of the restoration also depends on factors like surface roughness, the alloy used, type of
luting agent used etc.

Surface roughness: roughening restorations like cementing ‘as cast’ after sand blasting prevents
retentive failure, which most often occurs at cement- restoration interface.
Materials being cemented: high reactive base metal alloys are better retentive than less reactive gold
alloys.

Type of luting agent: the cements that bond chemically with the tooth structure provide better
retention. Glass ionomer and resin cements provide good retention. The film thickness of the cement
should be minimal [25 to 40 microns] but sufficient to enable complete seating of the restoration.

2. PROVIDING RESISTANCE FORM

In the normal occlusion, the biting forces are usually axially directed and well tolerated. However, in
patients with malocclusion and habits such as pipe smoking, bruxism etc, it is difficult to prevent a large
amount of oblique forces from being applied on the restoration. Eccentric influences in occlusion and
the type of occlusion [group function, canine protection] influence the magnitude of forces.

Resistance form of a preparation depends on

Axial wall height: an abutment tooth must have an adequate occluso-cervical crown dimension. The
height required depends on:

Magnitude of occluding forces

Span length

Type of preparation

Length of the lever arm

Bone support

The minimal acceptable height is that which allows the tooth structure to interfere with the arc
of rotation as tipping forces attempt to cause rotation around a fulcrum located at the finish line on
the opposite side of the tooth.

On short teeth, adequate axial wall height may be achieved by subgingival extension of the
finish line. The other alternative is to prepare the tooth with minimal taper.

Taper: Increased taper lessens the ability of a restoration to interfere with the arc of rotation as
tipping forces act to unseat the restoration.

Ratio of preparation diameter to axial wall height: if the axial wall height and the taper are
the same for both the teeth, the smaller diameter tooth interferes more effectively with the arc of
rotation because of a smaller fulcrum line.
 Circumferential irregularity: the circumference of a tooth is usually irregular in form and
when the tooth is uniformly reduced, an irregular shape is formed, which enhances the ability of
a restoration to resist both tipping and twisting forces. When a tooth is encountered that is round,
short or overtapered, intentionally formed irregularities such as boxes and groves may be used to
produce areas that interfere with dislodgment of a restoration.
Boxes placed in the middle of the proximal surface resist bucco-lingual forces and those
on the middle of buccal or lingual surface resist mesio-distal forces.

Occlusal irregularity: occlusal reduction following anatomic form produces an irregular

surface that aids resistance to dislodging forces. Auxillary occlusal irregularities such as pinholes
can be used to enhance resistance to dislodgment in anterior teeth when partial veneer crowns are
used.

The resistance of a restoration to horizontal forces also depend on the rigidity of the material, its
adaptation, surface area and physical properties of the luting agent [compressive strength and
modulus of elasticity]

3. GEOMETRY OF THE FINISH LINE

An ideal finish line should

- be easy to prepare without over extension

- be readily identified in the impression and on the die
- give a distinct margin to which the wax pattern can be finished
- provide for sufficient bulk of material [to avoid distortion of wax pattern and for esthetics in
porcelain]
- be as conservative of tooth structure as possible

The various types are

Feather edge:

Adv

Conservative of tooth structure

Disadv

Inadequate bulk - chances of pattern distortion and overextension, chances of distortion

and over contouring of the restoration margin.

Not clear,

Not advised [only sometimes on distal surface of second molar]

Chisel edge:

Similar to featheredge but larger angle between the axial surface and unprepared tooth
structure.

Indicated occasionally on tilted teeth, where excessive axial reduction is done.

Chamfer:

Prepared with tapered diamond having a rounded tip. It is indicated in cast metal restorations
and lingual margin of porcelain fused to metal restorations. Care is needed to avoid unsupported lip of
enamel.

Adv

Distinct margin, adequate bulk and easier to control.

Bevel:

Removes unsupported enamel and allow finishing of metal. It is indicated in cast restorations
and facial margin in partial coverage restorations [buccal cusp bevel or reverse bevel]

Adv

It allows burnishing of metal, minimizes marginal discrepancy if the crown doesn’t seat
completely, protects unprepared tooth structure by removing unsupported enamel.

Shoulder, sloped shoulder or heavy chamfer:

Indicated for PFM, and full ceramic restorations.

Adv- Allows bulk of restorative material at the margin

Disadv- Less conservative.

Shoulder with bevel:

Has an advantage of bevel and shoulder. It is indicated in PFM restorations, when metal collar is
given.
 4. PREVENTING DEFORMATION OF THE RESTORATION:
A restoration must have sufficient strength to prevent it from being permanently deformed during
function. Other wise it will fail at the restoration-cement or metal-porcelain interface. This may be a
result of

Inadequate tooth preparation: even stronger alloys need sufficient bulk if they are to withstand
occlusal forces [1.5 and 1 mm]. In addition, anatomically prepared occlusal surface will give rigidity to
the crown because of corrugated effect.

Functional cusp beveling is done on the buccal cusps of the lower posteriors and the palatal surface
of the upper posteriors in order to increase the bulk of material over these cusps. This enables
additional strength and rigidity for the restoration over the functional cusps, which have to bear more
forces compared to non functional cusps. In this way, functional cusps are reduced about 0.5 mm more
for metal and about 1mm more for ceramic and metal ceramic restorations.

Improper finish line design: distortion of the restoration margin is prevented by designing the
preparation outline to avoid occlusal contact in this area and by providing sufficient bulk of metal at the
margin.

Inappropriate alloy selection- type III and IV gold alloys are usually chosen for crowns and FPDs. Ni-
Cr alloys are considerably harder and may be indicated when large forces are expected such as long span
FPDs.

ESTHETIC FACTORS
A dental restoration should look as natural as possible but not at the expense of the patient’s
long term oral health or functional efficiency.

Esthetic requirements dictate

 Material metal or porcelain

 Adequate preparation for porcelain
 Margin placement- Subgingival

Define crown and write its indications. What is the difference between a crown and a retainer?

A crown is an artificial replacement that restores missing tooth structure by surrounding part
or all of the remaining structure with a material such as cast metal, porcelain, acrylic, or a
combination of materials such as metal with porcelain or acrylic. It is a single unit restoration
and is not attached to any artificial tooth.
A crown is an extra coronal or post retained fixed restoration and may be either full coverage
or partial coverage.
 Indications for crowns
- Grossly destructed teeth
- Root canal treated teeth
- Discolored teeth
- To close spaces in between teeth
- To alter the contour of the teeth
-
When crown becomes a component of fixed partial denture, it is called a retainer. A retainer
will always have pontic attached to it and provides retention to the prosthesis. Hence, all
retainers are crowns but all crowns are not retainers.

Define and classify bridge retainers. Explain briefly the different types of retainers.

A retainer is the portion of a FPD that unites the abutment to the remainder of the restoration.
Cemented on to the abutment, this device is used for the stabilization or retention of a prosthesis.

It is that part of the FPD which is fixed on the prepared abutment teeth and which is responsible
for retaining the bridge in position.

A crown or a retainer may be

Extracoronal- extra coronal restorations are the commonly used bridge retainers. They may be either

Full coverage crown/retainer- the restoration covers all the coronal surfaces of an abutment,

Partial coverage crown/retainer- it is an extra coronal cast restoration that usually covers the
occlusal and all but one of the axial surfaces of a tooth. The facial surface is often not involved.

Intraradicular/ Radicular/Post retained/Dowel crown]- If the remaining coronal tooth structure present
is inadequate, the retainer has to gain retention from the root canal in an endodontically treated tooth.

Note- Intra coronal restorations are not advisable to be used as retainers for a FPD.

A crown or a retainer may be of all-metal, all- ceramic, or metal with acrylic or porcelain facing.
What are the requirements of an ideal bridge retainer? Write the factors to be considered in selecting
a retainer?

Ideal requirements of a retainer: It should

- retain the bridge to the abutment teeth.

- transmit the occlusal load from the prosthesis to the abutment tooth and thereby makes it a
tooth borne fixed partial denture. It should ideally transmit pressure along the long axis of the
tooth. Such forces are distributed over a large area and well tolerated.
- prevent the transmission of occlusal load to the soft tissues.
- take part in occlusion which is in harmony with the remaining natural teeth.
- take part in mastication.
- be esthetically acceptable.
- maintain proper relationship between the pontic and the adjacent teeth

Factors for selection of retainer:

- Age
- Caries index
- Amount of tooth structure lost
- Edentulous span
- Alignment of the tooth in the arch
- Vitality of the abutment
- Periodontal condition
- Occlusion
- Oral hygiene

Write the indications, contraindications, advantages and disadvantages full coverage [veneer]
crown/retainers. Describe the preparation of a tooth to receive a full veneer metal crown/retainer.

Indications for full coverage crown/retainer:

- Extensive caries, cannot be restored by other means

- Existing large defective restoration
- Root canal treated teeth
- Fractured teeth
- Discolored teeth
- Need to change contour as for RPD retention.
Additional indications when used as a retainer

- Short teeth
- Long edentulous span
- Greater occlusal forces
- When tooth alignment demands full coverage for adequate retention.
Contra indications

- When a more conservative restoration can serve the same purpose

Advantages
- Affords the most effective retention and resistance form of all the extra coronal restorations
- Can be used when tooth form and alignment are not ideal and less than ideal preparation
results
- Can be used to make relatively extensive alterations in tooth form and occlusion
- Strongest bridge retainer
- Provides more protection from caries.

Disadvantages:

 Preparation is extensive – non conservative

 Long finish line adjacent to gingiva
 All metal crown lacks esthetics- so cannot be used in areas readily visible
 Difficult to wax back proper axial contours
to obtain accurate cervical fit

to detect gingival caries

to seat completely during preparation

to conduct vitality tests.

Tooth preparation to receive a full veneer metal crown/retainer

Caries or damaged tooth is restored first before preparation.

Proximal reduction:

Tapered round end diamond bur

3-5 ° taper is given to the proximal walls compatible with path of insertion,

Chamfer finish line- 0.3 –0.5 mm wide, depending on the tooth form and alignment. The finish
line should terminate on enamel and supragingivally [unless sub gingival is indicated]

Care is taken to avoid damage to adjacent teeth

Facial and lingual reduction:

 Tapered round end diamond

Buccal surface of lower and palatal surface of upper are reduced in two planes

Chamfer- 0.3 – 0.5 mm terminates on enamel or supragingivally

Occlusally- 0.7 –1.0 mm reduction

Cervical 2/3rds will have 3-5 °s taper

Depth cuts can be used as guides and joined.

Occlusal reduction:

Tapered round end diamond

Follows anatomical contour

1-1.5mm [determined with the patient biting on a strip of wax]

Sufficient reduction for adequate bulk.

Smoothen the preparation and round off all the line angles with fine grit round end diamond
carborundum stone.

Auxiliary retention can be provided if required, in the following ways.

Boxes-.5-1mm X 2- 2.5mm and parallel to the path of insertion

Grooves-0.5mm

Pinholes

Mal aligned teeth:

Tipped side- knife edge margin, limit the extension cervically

Endodontic treatment enables getting correct path of insertion

Orthodontic uprighting of the tooth can be done

What are the indications, contraindications, advantages and disadvantages of porcelain jacket
crowns? Describe the steps in the preparation of an upper central incisor tooth to receive a porcelain
jacket crown.

Indications:

When optimal esthetic results are desired i. e. in anterior teeth [incisors only]

Contraindications:

Conditions that tend to promote premature fracture of porcelain. i. e.

- short clinical crowns

- shovel shaped inisors, teeth with small cingula with insufficient lingual wall length
- incisors thin labio-lingually
- peg shaped incisors [no resistance to rotation]
- when there are abnormal occlusal relationships and forces [centric occlusal contacts occuring
incisally or cervically and not in the middle thirds]
- strong, active oral musculature, bruxism, clenching.

Jacket crown porcelain:

Aluminus procelain with 40-50% alumina crystals.

Newer ceramic jacket crowns {CJC]: include

- leucite crystal reinforcement feldspathic porcelain

- castable porcelain- Dicor glass ceramic
- glass infiltrated dental ceramic
- injection molded ceramic
- cerestore

Porcelain fused to metal restorations

Full coverage ceramic restorations have been used in dentistry since the late 1800’s and early 1900’s
when the porcelain jacket crown was developed. The all ceramic restoration proved to be the most
esthetic full coverage restoration available in dentistry.
 However, the need for greater strength and versatility lead to the development of a restoration
having porcelain fused to a metal sub-structure. Metal helps the porcelain to resist fracture and a
stronger restoration is produced. PFM is the currently widely used restoration. [ with the advancement
in all-ceramic restorations, they are again replacing the PFM restorations]

Porcelain fused to metal restorations:

Consist of a metal casting onto which a veneer of porcelain is fused. A thin layer of opaque
porcelain is fused over the casting to mask the metal and porcelains designed to match dentin and
enamel subsequently are fired over the opaque porcelain.

Metal- ceramic porcelains are similar to conventional glasses except for increased alkali content
[soda and potash] to lower the fusion temperature below that of the alloy and to increase the thermal
expansion to a level compatible with the metal.

Indications:

Esthetics is required but occlusal forces donot indicate all-ceramic restoration.

Even teeth with abnormal form can be given PFM restorations because additional retention and
resistance can be achieved through metal sub-structure adapted to auxillary grooves and pinholes.

They can also be used as cast RPD retainers.

Contraindications:

When a more conservative restoration is possible.

What are the indications, contraindications, advantages and disadvantages of partial veneer crowns?

In general, because of its conservative design a partial veneer crown / retainer should be used instead of
full veneer, whenever possible. But since it does not cover all the surfaces, it results in less than
optimum retention form and hence is indicated in the following situations.

Indications:

 Coronal tooth structure is intact or minimally restored

 Normal crown form and size [not conical]
 Average or greater crown length
 Good axial relationship to the abutment tooth [path of insertion]
 Short edentulous span
 Average or below average occlusal forces.
Contra indications:

A partial veneer crown is contra indicated when it cannot provide enough protection to the
tooth, and when there is a definite indication that only a full veneer crown can serve the
purpose in that particular situation.

Advantages:

 Conservative
 Periodontal response to the restoration is good, because the facial periodontal tissues which do
not respond favorably to the undesirable stimuli are left untouched.
 Esthetically superior, because the facial surface is left untouched
 It may be used as a single unit restoration in place of MOD inlay or onlay [an Inlay has wedging
effect and may cause fracture]

Disadvantages:

 There is some display of metal [requires skillful execution]

 Retention and resistance less than full veneer
 Less rigid compared to full veneer [when used as retainer]

Describe the steps in the preparation of a maxillary premolar tooth to receive a ¾ partial veneer
crown.

Proximal

Tapered round end diamond

3-5 ° taper,

Chamfer 0.3 –0.5 mm. Ideally terminates on enamel and supragingivally [unless sub gingival is
indicated]

Proximally extends into proximal contact areas. Avoid facial [esp.mesial] overexension. When
properly done there should be a lip of enamel remaining lingually to the facio-proximal line angle, which
can be blended to the proximal box.

Lingual
 In two planes in the upper

0.7-1 mm occlusally ending as chamfer 0.3-0.5mm

Supragingival but with adequate length

Lingual reduction joins the proximal reduction.

Occlusal

1-1.5 mm following the tooth anatomy

Tapers as buccal cusp is approached, avoid over reduction of buccal cusp

Proximal boxes

Located on the facial half of the proximal surface

Aligned along the path of insertion [with 3-5° taper]

Facio-lingual angulation must be compatible with lingual surface

Box-0.5mm, flaring to 0.8-1mm and 1.3-1.7mm.

Facial flare of proximal box

Facial aspect of proximal box is flared to blend with the lip of enamel and meets the unprepared
tooth surface at 90° angle. Flare extends just past the proximal contact area [to a cleansable area].

Facial cusp bevel

Facial aspect of buccal cusp is bevelled at 45° relative to the facial surface to terminate the
preparation and allows a thickness of metal sufficient to protect the facial cusp against fracture. Bevel
width is 0.5-0.8 mm and mesio-distally it joins the facial flare of the proximal box.

Smoothen the preparation and round off all the angles.

Difference in the preparation of a mandibular premolar 3/4th crown.

- The facial cusp is the functional cusp. Hence, more of reduction and beveling is required.
Reverse 3/4th crown

Explain in brief about an anterior ¾ partial veneer crown.

The popularity of the metal-ceramic crown and the importance of esthetics, has decreased the usage of
anterior partial veneer crowns.

Indications: Similar to posterior partial veneers

Advantage:

Conservative, Favorable periodontal response, Esthetic.

Disadvantages:

Similar to posterior partial veneers +

Anteriors, particularly thin teeth become darker when the crown is cemented.

Thinness of anteriors also makes retention difficult [limited bulk for placing grooves and boxes]

PREPARATION

Proximal

Tapered round end diamond

3-5 ° taper, 0.3-0.5 mm wide chamfer finish line.

Length adequate for retention and ideally supragingival

Facial extension- upto midway of proximal contact leaving a lip of enamel i. e. in contact with
the adjacent tooth [avoid overextension]

Lingual

Cingulum: chamfer-0.3-0.5mm
 Joins two proximal reductions

Vertical surface is produced with 3-5° taper and compatible with the path of insertion.

The remainder of the lingual surface is reduced for clearance in centric relation with wheel or
foot ball shaped diamond. Uniform reduction of 1 mm following anatomical concavity of the lingual
surface.

Incisal

Place incisal bevel at about 60° to the incisal 2/3rds of the facial surface or at 45° to the long
axis.

Bevel is flat facio-lingually and terminates at the labio-incisal angle.

Incisal groove

Increases resistance form by providing bulk

Located 1/3rd the distance from the lingual extent of the incisal reduction [bevel]

0.3-0.5 mm deep and at 90°s to the lingual surface. tapers out facially.

Proximal grooves

Located in the facial half

Parallel to the path of insertion with 3-5° angulation

0.3-0.5mm deep and 1mm wide

Cingulum ledge and pinhole

To increase retention in an anterior partial veneer crown, pinholes [1 to 3] may be formed

on a ledge. Ledge is half moon shaped, 2 X1 mm.
Pinhole is centered on the ledge to a depth of 1.5 to 2 mm parallel to the path of insertion.

Facial flare of proximal grooves

Meets unprepared tooth surface at 90°s

Include proximal contacts to cleansable area

 Terminates lingual to facio-proximal line angle.

Smoothen and round off the line angles.

7/8th crown

½ crown

Interocclusal clearance

Temporary protections of a prepared tooth

What are temporary restorations? Write the requirements and uses of temporary restorations.

INTERIM, TEMPORARY OR PROVISIONAL PROSTHESIS: A fixed or removable prosthesis, designed to

enhance esthetics, stabilization and/or function for a limited period of time, after which it is to be
replaced by a definitive prosthesis.

Prepared abutment teeth must be restored temporarily while the final prosthesis is being fabricated.
This is done with the help of temporary or provisional restoration. The process is also referred to as
temporization.

Sometimes provisional restorations have to function for extended periods of time due to things
like laboratory delays, patient unavailability etc. At times it may be deliberate due to correction of
etiological factors of temporo-mandibular disorders or periodontal disease or till the tissues heal.

Functions/ Requirements:
Protection:
 It should protect dentin and pulp from unnecessary exposure to oral fluids and temperature
changes, thus avoiding hypersensitivity.

It should prevent damage or fracture of the preparation and of the critical margins [it should be
strong enough and well adapted to the tooth to accomplish this].

Positional stability:

Should restore and maintain occlusal relationship and function,

Should prevent supra eruption of the prepared tooth and/or the opposing tooth.

Should restore proximal contacts thus preventing drifting and loss of space and protecting the
integrity of the papillae.

Should maintain the normal esthetic position of the lip or the cheek.

Should maintain the health of gingival tissues by providing well adjusted margins [neither short
nor impinging], proper axial contours and a surface, which is highly polished and easily cleansable.

Mastication:

Should allow for reasonable mastication of food while the final restoration is being fabricated
[depends on the material]. It should have proper occlusal relationship with the opposing teeth.

Esthetics:

It should restore esthetics [esp. with anterior teeth], thus providing for patient acceptability.

Diagnostic information:

To try out for biological and psychological acceptance of alterations in occlusion, contour,
materials, color etc

Decisions relating to lip support, phonetics and arrangement of teeth can be made.

The prognosis of the abutment teeth, the periodontal response and response to additional
occlusal forces can be evaluated.

Treatment restorations can evaluate the acceptability of the new mandibular position, new
occlusal interdigitation and an increased vertical dimension of occlusion.
 The treatment restoration can then be used as a blueprint for the fabrication of a definitive
restoration.

In general a temporary restoration should be easy to fabricate, easy to alter and not break during use
and removal.

List the temporary tooth protection materials. Explain the techniques of temporary tooth protection.

Types of interim coverage:

- ZnOE restorations, for intracoronal restorations mainly inlays.
- Preformed temporary crowns

- Custom made restorations

Prefabricated crowns
These crowns can be luted directly to the prepared teeth after adjustment or they may be relined with a
plastic material prior to cementation.

The various options available are

- Polycarbonate crowns- described below

- Clear plastic crown forms: Similar to polycarbonate crown [anterior teeth]
- Aluminum shells, Stainless steel and Ni-Cr crowns: these metal crowns are used on posterior
teeth. Size is selected and contoured with pliers. Cervical extension is cut with scissors to follow
the finish line and occluso cervical dimension is adjusted. Axial surfaces are contoured and
occlusal surface is adapted with ball burnisher. Margin smoothened. Aluminum shell can also be
relined with self-cure resin.
- Temporary repair of existing restoration- When an existing restoration is being replaced it can
often be used as a temporary restoration. It may require to be relined.

Custom made restorations

Original tooth morphology and the relationship with the opposing and the adjacent teeth can be
more accurately reproduced with custom made crowns as compared to prefabricated ones. Custom
made fixed partial dentures can also be made of temporary materials. Pontic may be connected to the
individual temporary restorations to form a temporary FPD.

They can be fabricated by any of the following techniques

 Direct technique – usually indicated for single crowns only

Indirect technique – fabricated on a cast of the prepared teeth. Single crowns or fixed partial
dentures can be made and produce better contour and fit.

Direct- indirect technique -

Materials used

PMMA and PEMA - cold cure resin

PMMA- heat cure resin- more durable and stain resistant

Cast temporary restorations:

Needed when temporary restoration is required for an extended period of time.

- when orthodontic realignment is being done

- during extensive rehabilitation
- to promote healing during periodontal therapy

Temporary restorations for endodontically treated teeth:

If an endodontically treated tooth has sufficient tooth structure, than any of the previous
method is used.

If tooth structure is insufficient, than additional retention is gained from the post space, while
the post and core is being fabricated. A sufficiently stiff orthodontic wire or a plastic post is used as a
temporary post and joined to the temporary crown with the resin being allowed to flow partially around
the post into the root canal. Restoration is removed and reinserted several times before the resin
hardens to prevent locking into mechanical undercuts.

Cementation of temporary restorations:

The restoration is well finished and polished. Temporary restorations are usually cemented with
ZnOE cement [soothing to the pulp] or non eugenol cements [EBA cements, because eugenol has
softening effect on resins]

Because the crowns are well adapted after relining only a thin layer of cement is required.
Polycarbonate crowns

Temporary restorations can be fabricated using thin walled tooth colored polycarbonate
crowns, which are manufactured in an assortment of sizes and molds.
The technique involves measuring the mesio-distal width needed and selecting an appropriate
crown from the available. The cervical form is achieved with an acrylic cutter until it follows the contour
of the finish line and the desired inciso-cervical dimension is achieved.

Self-cure resin is mixed to a flowable consistency, placed inside the polycarbonate crown and
the crown is seated over the prepared tooth to create an intimate adaptation of the axial walls and
finish line. It is removed before complete hardening and excess resin is cut off. Form and occlusion
adjusted and the crown is cemented.

Polycarbonate crown may also be adapted indirectly on a stone cast.

Gingival retraction and impression procedures

Gingival retraction and its importance in fixed prosthodontics.

Gingival retraction or displacement is the deflection of the marginal gingiva away from the
tooth. The gingival sulcus is temporarily enlarged.
Gingival retraction is done to evaluate the finish line and refine it without soft tissue trauma. It
also enables us to record the finish line and the form of the tooth cervical to the finish line.

Methods of gingival retraction

The method used should cause the least amount of trauma to the gingiva while providing good access to
the finish line.

1. Mechanical
Cotton thread around gingival margin

Gutta percha- absorbs fluids and swells

Temporary crowns for some time

Rubber dam, matrix band etc. for 10-15 minutes only.

 2. Chemical- vasoconstrictors, astringents for15-20 minutes. Al2So4, Alcl2[hemostatic drug],
adrenaline 8%, alum[aluminium potassium sulfate], ZnSo4 etc. Epinephrine is C/I in patients
with cardio vascular disease and hyper thyroidism and in patients on epinephrine
potentiating drugs.

3. Chemico-mechanical- commonly used method. Retraction cards impregnated with

chemicals are available.

4. Surgical: Electrosurgery- when tissue is to be removed

Periodontal surgery- when more tissue is to be removed, when apical
repositioning is to be done.

Takes 1-2 mins, but avoided unless hyperplastic tissue is present.

Retraction cord technique:

Cord selection depends on the bulk of tissue and adaptation. Select thin cord for less bulky and
well-adapted tissues.

Dry the operating area. Cut to encircle the tooth with about 5-mm excess

Loop formed and held with cotton pliers

Dipped in water, hemostat or chemical- softens it for easy placement.

Hold around the tooth, begin interproximally where more loose tissue is available, and continue
around the tooth

Use periodontal probe, bladed instrument [cord packer]

Spray water, dry with compressed air and isolate the area.

Ask the patient to bite on the cotton after removing the cord, when impression material is being
readied.

Impression making in fixed prosthodontics

The indirect technique of fabricating restorations will require an accurate, undistorted impression of the
prepared teeth so that the cast is an exact duplicate of the prepared teeth.
An acceptable impression in fixed prosthodontics

- Should be an exact negative replica of prepared teeth including the margins, [bubble free
recording of the prepared teeth esp. the finish line area is very critical].
- Must include sufficient unprepared tooth structure cervical to the finish line to blend the
contour of the restoration with the tooth
- Should record the adjacent teeth of the arch and tissue to enable articulation of casts, and to
develop contours of the restoration,
- An impression of the opposing teeth is required to develop occlusion after articulation.

Note - The health of the adjacent tissues should be optimum before impression making. The impression
area should be clean and well isolated.

Impression materials available

 Low fusing impression compound- copper band technique [not used now]
 Reversible hydrocolloid
 Irreversible hydrocolloid- cheaper and easy to manipulate, but dimensionally not stable and not as
accurate as elastomers
 Elastomer- gives good details, dimensionally stable, duplicate casts can be made. They can be used
with
- Single impression [multiple mix] technique
- Double impression [putty wash] technique
- Single mix technique

Isolation procedures during FPD therapy

Isolation procedures involve cleanliness and moisture control of the area around the prepared teeth,
surrounding teeth and the soft tissue.

Fluid control is necessary during the preparation of teeth, impression making and during cementation of
the restoration. It is done with

 Rubber dam [most effective isolation device]

 High volume vacuum- very useful during preparation phase when large volume of water
is to be evacuated and also makes an excellent lip retractor.
 Saliva ejector- effective without an assistant also
 Cotton rolls
 Anti-sailagogue is required when no device is effective and
 Local anesthesia- can control moisture. to some extent.
 Construction of dies and working casts

What is a die? What are the requirements of dies?

A die is a positive replica or an accurate reproduction of the prepared tooth both in dimensions and
surface details.

Requirements

 It must represent all prepared surfaces, including the finish line and a reasonable amount of the
uncut apical portion of the tooth. This is to develop the wax form and contour for acceptable
esthetics and periodontal health.
 It should be made made of a dense hard material to resist fracture, abrasion etc during the
production of the wax pattern and fitting of castings
 A die should allow easy handling during waxing and other procedures and must permit
accessibility to the finish line. These can be achieved by die trimming.
 A working cast should have an accurate reproduction of the adjacent and the contra lateral
teeth for proper alignment, creation of contours, and proximal contacts.
 Residual ridge contour in the pontic area should be well recorded
 Occlusal surface of the opposing teeth should be accurately produced for interdigitation
Note- preparation of die and its trimming needs to be monitored by the dentist.

Die materials

The materials used to prepare dies are

- Type IV and V gypsum- die stone and high expansion die stone
Advantages- It is inexpensive, easy to use, compatible with all the impression materials,
reproduction of detail and dimensional accuracy is good, setting expansion is 0.1%

Disadvantages- abrasion resistance is not very good. So gypsum hardeners like colloidal silica or
soluble resin is used during mixing. The surface can be treated with the resins like epoxy, acrylic,
styrene or cyanoacrylate. These resins penetrate and polymerize.

Water powder ratio is 0.2. hand /mechanical mixing can be done.

- Epoxy Resin
 Advantage- good abrasion resistance

Disadvantage- contraction, not compatible with all the impression materials.

Acrylic and Polyester resins are also used.

- Silico phosphate cement

- Metallic dies
Amalgam dies, electroformed [silver and copper] dies

- Refractory dies- divestment and DVP [divestment phosphate]

The die material is gypsum bonded or phosphate bonded investment material. As the wax pattern is
invested along with the die, there are less chances of distortion in the wax pattern.

Electroformed dies

Describe the die preparation techniques / systems used in fixed prosthodontics.

Die preparation techniques

- Multiple pour intact cast technique:

Impression is made of elastomer. Prepared teeth in the impression is filled with die materials,
roots made and removed. Dental stone is then poured to the entire impression and an intact cast got.

Advantages: separate die and an intact cast got with this technique.

- Removable die technique:

The prepared tooth is part of the cast and can be removed from the cast and reseated whenever
required.
Advantages- this technique can be used with any impression material, there is better accessibility and
evaluation of the pattern contour and adaptation is easier.

Disadvantages- die may not be accurately reseated and stabilized in position.

Removable dies can be prepared by the following techniques

Dowel pin technique- dowel / die pins are made from brass, tapered for easy removal, flat on
one side for accurate reseating and interdigitation. Two pins are also available.

Dilok tray technique- A dilok tray is an interlocking device that holds all the parts of a sectional
working cast. It is a multiple piece interlocking plastic form. When the form is disassembled, the cast can
be removed and dies separated by cutting them out with a saw. Then the stone parts can be replaced
and held securely in position by reassembling the plastic form.

Die trimming

Die spacer

Resins, model paint, nail polish etc can be coated on the die to within 0.5 mms of the finish line. The wax
pattern is than prepared. This compensates for the shrinkage of the alloy and helps to create space for
the cement.

Altering die dimensions:

Increased expansion-larger die is got by adding silica to the liquid

Pontics and Connectors

Define pontic. What are the requirements of pontics?

A pontic is an artificial replacement on a FPD that replaces a missing tooth, restores its functions and
usually fills the space previously filled by the natural crown.

It is a suspended member of the bridge attached to the retainer by means of connectors and transmit
the occlusal stress to the abutment through them.
Requirements of pontics

- should restore function [mastication, speech]

- provide esthetics and comfort
- be biologically acceptable
- permit effective oral hygiene
- protect the underlying residual alveolar ridge and preserve it by deflecting food and maintaining
continuous stimulation below
- maintain tooth relationships

Classify pontics and discuss the principles of pontic design.

Designing a pontic consists of constructing a substitute tooth that favorably compares with form,
function, and appearance with the tooth it replaces. The design is affected by changes in the

- contour of the residual ridge

- occluso cervical space available [depending on ridge resorption, supra eruption of the
opposing dentition]
- mesio distal width available [tilting, drifting] etc.

Gingival surface

It is the most important aspect of the pontic design. The material, the shape and the degree of tissue
contact affect the choice of approach.

Material

Based on the material used:

- all metal
- all porcelain
- metal + porcelain
- metal + acrylic
Glazed porcelain is the material of choice to contact the tissues. However, the finish of the material is
more important and a dense, smooth surface that can be polished to a high luster does not accumulate
plaque.

Shape and tissue contact

The tissue contact of the pontic with the ridge should be only minimal. Increased pressure will cause
inflammation and proliferation in the tissues.

Based on the shape of the surface contacting the ridge and tissue contact

- hygienic or sanitary
In this design, at least 2 mms of space exists between the gingival surface and the ridge so that the
patient can maintain hygiene. The embrasures between the pontic and the abutment teeth are kept
wide so that the bristles can pass in between and clear the food particles. As they are not esthetic
looking, they can be given only in case of mandibular posteriors

- spheroidal or egg shaped, also hygienic

The pontic contacts without pressure the tip of the ridge or the buccal surface depending on the
relationship of the residual ridge to the opposing occlusion.

- ridge lap, not used as it creates an uncleansable concave surface

- modified ridge lap

This type of pontic is both esthetic and hygienic. It contacts the buccal surface of the ridge. A slight
bucco-lingual concavity is created along with mesio-distal convexity

- conical
- ovate or root extension [?] indicated in immediate FPDs, prepared before extraction is done.

Occlusal surface

A reduction of occlusal table can be done bucco-lingually to decrease the forces on the abutment
teeth[?]. The table is decreased only to create favorable relationship with the opposing teeth and in case
of less space for the pontic.

The reduction is done at the cost of functional cusps. Maxillary buccal [effect esthetics and prevent
cheek biting] and mandibular lingual [protect the tongue] are not reduced.

Interproximal surface

The proximal surface should not impinge upon interproximal tissues. Interproximal embrasures are open
to permit access for cleaning. [maxillary anterior embrasures are minimal but still without impingement]
Buccal and lingual surfaces

The contour of the buccal and the lingual surfaces depend on esthetic, functional and hygienic
requirements. Lingual embrasures are wider than the buccal.

The facial surface will have normal contour, axial alignment and length. Lingual contour harmonizes with
adjacent teeth from the cusp tip to the height of contour, then sharply recede convexly to the facial or
buccal contact area.

The hygienic and the spheroidal designs result in tapering of both the buccal and lingual surfaces from
the height of contour.

Pontics can also be

- prefabicated – flat backs, trupontic, long pin facings, pontifs, reverse pin facings [protected by
thickness of metal]
- custom made- [PFM]

What are the factors that influence pontic selection?

Pontic selection: is determined by

- retainers
PFM retainer- PFM pontic

Partial retainers- prefabricated facings

Complete metal retainer- all metal pontic

- esthetics
maxillary anterior and posterior- modified ridge lap

mandibular posterior- sphroidal or hygienic

- Occluso-gingival height and mesio-distal width

decreased height- metal pontic or porcelain fused to base metal for extra rigidity

- ridge resorbtion and contour

increased resorption- hygienic pontic

Define and classify connectors in FPDs.

Connector is a part of FPD, which connects the pontic to the retainer. It transmits the occlusal loads
from the pontic to the abutment tooth through the retainer.

May be

Rigid – connector can be made rigid by casting in one piece or by soldering. Rigid joints are
indicated when abutment teeth are satisfactory, and for splinting together additional
abutments.

Non rigid

Requirements for a connector

Mechanical- strength, smooth and rounded surface

Biological- should occupy the normal proximal contact areas to ensure cleansable embrasures.

Esthetic- should be acceptable

What are the advantages of soldered connectors? Explain the technique of soldering.

Soldered connectors can help

- compensate for the shrinkage of metal

- avoid distortion
- compensate for the release of stresses
- make the occlusal corrections easier

Requirements of a dental solder:

Soldering technique:

Non rigid connectors

Non rigid connector is given in a FPD in order to provide movement of the prosthesis in between the
abutment teeth. This decreases the amount of load brought to bear upon a particular abutment.

It may be either

Non precision type – Flexible connector or stress breakers, key and key way, lock and key-
movement at the joint can be controlled.

Precision type- these are ready made connectors or attachments. They have a slot and stud. These
two portions can be separated only vertically and not horizontally and allows only vertical
movement. One portion is attached to the retainer and other portion to the pontic. They are every
precise and allow only limited movement. They require skill and are expensive. Repair is difficult.

Precision attachments. [April 01] Explain the advantages and disadvantages of precision attachements

Non precision fixed bridges.

Stress breakers.

Finishing, cementing and maintenance of crown and bridge

Method of intra oral evaluation of fixed partial denture.

The tooth must be completely clean and free of all foreign material prior to evaluation. The prosthesis is
then seated on the prepared teeth for final evaluation.

Proximal contacts

Casting should seat completely with the application of finger pressure. A properly adjusted contact
allows the floss to snap through with resistance but without tearing.

Incomplete seating may be due to unduly tight or heavy proximal contacts. Heavy contact is adjusted by
placing thin articulating paper.

Marginal fit

Marginal fit is evaluated by moving a sharp explorer occluso-cervically perpendicular to the margin.
Improper marginal fit may be due to
 - heavy proximal contact- incomplete seating
- temporary cement on the prepared tooth
- defective individual unit- inaccurate impression, damage to prepared tooth finish line, faulty die
trimming, poor lab technique
- defective assembly

Stability and ridge adaptation

Form- cervical under and over contouring is to be avoided

Occlusal adjustment

There should be simultaneous contact of restored and unrestored teeth. Teeth not being restored [teeth
just in front of the restored teeth] should contact in the same manner with or without the prosthesis
present. This is checked visually and with the help of articulating paper and cellophane sheet.

Final finishing and polishing is done after evaluation of the prosthesis and found correct.

Luting cements
Comparison between ZPC and GI cements
Ideal requirements for a luting cement

- insolubility
- adhesion to tooth structure
- sufficient strength
- biocompatibility

resin cements- 2 types

a. chemically activated direct filling resins- PMMA, BIS-GMA

adv- insoluble in water, chemical bonding

Cementation of a fixed partial denture.

The casting and the tooth surface must be clean and free of foreign materials. Casting is ultrasonically
cleaned and dried with compressed air.

Methods to ensure complete seating of the restoration

 - Film thickness – 18-22 microns
- Venting
- Die spacer
- Vertical groove
- Larger die- expansion of die material, larger impression
- Over sized casting

Steps

- The abutment teeth are isolated, and haemostatic agents and retraction cord used if necessary
- varnish applied over prepared teeth if necessary
- thin layer of properly mixed cement is applied to the internal aspect of the casting with a small
instrument without air entrapment
- casting is seated with forceful finger pressure and facio-lingual tipping motion
- margins checked for complete seating
- patient is asked to bite on the wooden stick or cotton roll
- excess cement removed after set
- if seating is incomplete, the casting should be removed immediately.

Instructions and post insertion problems in fixed prosthodontics

Instructions

Proper brushing

Flossing

Interproximal brush, under the pontic and the connector.

Post- insertion problems

Thermal sensitivity

Reasons

- proximity to pulp
- inadequate water spray
- prolonged dry cutting
- faulty temporary- inadequate coverage, loose with seapage, high occlusal forces
Some sensitivity to cold following insertion of a metallic restoration is considered to be a normal
response. The duration ranges from few days to several months before it ceases. An insulating base
material [varnish] can be placed.

If sensitivity does not decrease or there is development of acute pain, it may necessitate endodontic
treatment.
Discomfort during function

- premature centric contact and/or excessive eccentric contact- needs correction

- pulpal damage
- sudden loading of tooth that was nonfunctional- becomes normal

Gingival inflammation

Gingival irritation is minimal, if all the procedures are correctly executed. Inflammation may be due to

- faulty cervical contour, marginal fit and embrasures

- soft tissue damage, excessive retraction, faulty temporary
- inadequate oral hygiene

Retention of food

- improper proximal contact and occlusal relationships

- improper hygiene below pontic and connectors

Trauma to the tongue and cheeks

- sharp, poorly finished and polished prosthesis

- improper horizontal overlap
- temporarily in the region of pontics

Sensitivity to sweets

- improper marginal fit and extension

- dissolution of luting agent
- loose retainer
- marginal caries

Tooth mobility

- increased loading
- heavy contact
- poor abutment [case selection]

Neuro-muscular discomfort

- improper occlusion
Types of clinical failures

Biological failures

- caries- at the margins require early detection and restoration

- pulp degeneration
- periodontal breakdown, due to poor hygiene maintenance or due to faulty restoration that
hinders maintenance.
- Occlusal problems- cause tooth mobility and neuromuscular problems
- Tooth perforations, during making pin holes, endodontic treatment
Mechanical failures

- Looseness of the prosthesis due to long span, heavy occlusal forces, no retention form[faulty
preparation], improper cementation
- connector failure
- occlusal wear
- tooth fracture
- porcelain fracture
Esthetic failures

- faulty shade selection and matching

- faulty design- metal display
- facing failures

What are resin bonded bridges? Write their Indications, contraindications, advantages and
disadvantages.

Resin bonded FPDs are those that are held in place by composite resin that locks mechanically into
chemically etched enamel and into microscopic undercuts in the casting. [as contrasted with
conventional FPDs, which depend on the geometric shape of the prepared teeth for retention]

Resin bonded FPDs [Adhesive bridge] have gained considerable popularity since the technique of
splinting mandibular anterior teeth was described by Rochette in 1973. The restorations consist of a
pontic supported by thin metal retainers placed lingually and proximally to the abutment teeth.

The conventional FPDs have the disadvantage of requiring considerable preparation of the natural tooth
structure. The development of acid etching of enamel to improve retention of resin [ first described by
Buonocore in 1955] has proven to be a means of attaching FPDs by less destructive means.
Indications:

- anterior teeth replacement in children, where conventional FPDs are contraindicated because of
management problems, inadequate plaque control, large pulp size and participation in contact
sports
- anterior and posterior teeth in adults, with advanced techniques

Contra-indications:

- above average occlusal forces

- retention depends on having adequate surface area of enamel. So avoided in damaged or
largely restored teeth and teeth with short crowns
- thin crowns, because of darkening of teeth.

Advantages:

- minimal tooth preparation

- no anaesthesia required
- supra gingival margins
- reduced cost
- can be converted to full crown, if it fails

Disadvantages:

- irreversible
- uncertain longevity
- no space correction- if edentulous space is wide
- no alignment correction
- difficult temporization
- requires skillful preparation

Explain the different types of resin bonded bridges.

1. Rochette bridge

- wing like retainers with funnel shaped perforations

- combined mechanical retention with a silane coupling agent to produce adhesion to the metal

2. Maryland bridge [Maryland school of dentistry]

- micromechanical retention
- acid etching of metal with 18% Hcl for 10 mins or 10% H2So4 for 3 mins
- electro chemical etching
- electrolytic etching
3. Cast mesh FPDs:

- net like mesh on the lingual surface

4. Verginia bridge:

- lost salt tehnique

Resin cements:

- unfilled resins- PMMA

- Filled resins- 4- META [4-Methacryloxyethyl trimellitate anhydride], can adhere to metal and
BIS-GMA

All the four types of Resin- bonded FPDs use wing-like retainers on the lingual surface of abutments.

Procedure:

Preparation of abutment teeth:

- creating occlusal clearance

- removing proximal undercuts
- giving ledges and grooves for resistance form[for single path of withdrawl]
- definite margins

design of the restoration- 4 designs

bonding:

- etching of metal
- etching of enamel
- seating with composite resin cement

Laminates, facial veneers

Laminates: They are veneer restorations that restore facial surface of a tooth for esthetic
purposes. Fabricated with resin or porcelain and bond to etched enamel with a composite resin
luting agent.[micro retention]
Indications:

For superficial stains

Laminates can be

Direct- composite resin used

Indirect [when multiple teeth are involved]- composite resin

Porcelain

Tooth preparation

- 0.5mm reduction [preserve proximal contacts]

- long chamfer margin
- do not reduce incisal edge [for resin]. But porcelain veneer can be carried out on to the lingual
surface for improved esthetics.

Preparations for extensively destroyed and endodontically treated teeth

Most individual teeth requiring crowns or FPD retainers have been damaged enough to require
modification of a classic preparation design.

It depends on the amount of tooth structure destroyed and the location of the destruction, whether
central, peripheral or combined. Many times such teeth are already root treated or may need to be
treated.

A tooth that is properly endodontically treated should have a good prognosis. It can resume full function
and if necessary serve satisfactorily as an abutment for a FPD or a RPD. However, special techniques are
needed to restore such a tooth as it usually has lost a considerable amount of tooth structure because of
caries, endodontic treatment and/ or previous restoration. The loss of tooth structure makes retention
of a subsequent restoration more problematic.

Anterior teeth
Endodontic treatment may cause the teeth to become weak and brittle. Although some people argue
that there is similar resistance to fracture between vital and non vital teeth, clinically fractures does
occur. However, they do not always need complete coverage when plastic restorative materials can
successfully restore the tooth. Many function with composite resin restorations.

Indications for complete crown

Discoloration that cannot be bleached

Extensive loss of tooth structure

Teeth to serve as FPD/ RPD abutment

Crowns can be made with or without posts depending on the amount of tooth structure remaining.

Disadvantages of metal posts

Additional procedure

Removal of additional tooth structure

Prevents future endodontic treatment

Trauma can lead to root fracture.

Posterior teeth

Posterior teeth are subjected to more loading because they are closer to the insertion of masticatory
muscles. The biting forces can wedge the cusps apart and hence need to be protected with full veneer
restorations with a access cavity restoration or a post core. But, mandibular premolars and first molars
with intact marginal ridges and conservative access cavities need not be given full crowns.

Principles of preparation

1. Conservation of tooth structure

Root canal

- minimal tooth structure to be removed from the canal

- Over enlargement can lead to perforation of the canal or can weaken the root.
- Enlarged to 1 or 2 additional file sizes beyond that used for endodontic treatment.
Coronal tissue

- As much of the coronal tooth structure should be conserved as possible because this helps
reduce stress concentration at the gingival margin.
- Just remove the intracoronal undercuts and round off sharp points. If more than atleast 2 mm of
tooth structure remains than it is more favorable.

2. Retention form
Anterior teeth

Preparation geometry

Parallel walls with minimum taper increase the retention [but there is danger of perforation]

Threaded posts increase retention [but are not recommended routinely]

Post length

As length increases retention increases. It should be equal to the length of the crown. But care is to
be taken not to damage the apical seal or perforate the root. A short post may fail.

Post diameter

?, because increased diameter may weaken the root.

Post surface texture

Serrated or roughened post provides better retention than a smooth walled post.

Luting agent

Zinc phosphate and glass ionomer cements provide better retention than polycarboxylate and resin
cements.

Posterior teeth

- short posts in divergent canals

- cast core can be made in sections
- Use the widest root.
3. Resistance form
Stress distribution

- conserve tooth structure

- long posts
- parallel sided posts distribute stresses evenly
- avoid sharp angles
- Avoid stress generation during cementation- tapered posts and posts with vent holes are better
than parallel or threaded posts.

Rotational resistance

- conserve as much coronal tooth structure as possible [axial walls]

- groove in the canal for anti rotational effect [where root is bulkiest]

Ferrule principle

Procedure

1. Removal of root canal filling material to the appropriate depth

- It is better to obturate completely and then remove [dense and lateral canal obturation got]
- Silver point cannot be used
- Use warmed endodontic plugger [if removed immediately] or rotary instrument with or without
chemicals like chloroform [be careful]
- Calculate the approximate length to be removed. Post length should equal the anatomical
crown. Leave atleast 3-5mms of guttapercha.
- Shape the canal with endodontic instruments or low speed drill.

2. Enlargement of the root canal

It depends on the type of the post.