Original article

A tooth preparation technique in fixed

prosthodontics for students and neophyte dentists

Daniele Rosella, DDS1 sonal experience with the novel technique. It

Giancarlo Rosella, MD, DDS2 could helps dental students and neophyte denti-
Edoardo Brauner, DDS, PhD1 sts in their learning curve.
Piero Papi, DDS1
Luca Piccoli, DDS, PhD1 Key words: tooth preparation, fixed prosthodon-
Giorgio Pompa, MD, DDS1 tics, dental education, prosthodontics.

Introduction
1 Department of Oral and Maxillofacial Sciences,
“Sapienza” University of Rome, Italy Tooth preparation for fixed prosthesis is a common pro-
2 Private Practitioner, Italy cedure in clinical practice, which all general dentists
should perform correctly. However, it could be difficult to
obtain always a predictable result, especially for dental
students or young doctors: they could make mistakes in
Corresponding author: their learning curve leading to inadequate results.
Daniele Rosella Unlike other human substance, dental tissues don’t
Department of Oral and Maxillofacial Sciences, have regenerative capacity. Therefore, the removal of
“Sapienza” University of Rome dental biological material should be planned and exe-
Via Caserta 6 cuted with maximum attention (1).
00161 Rome, Italy The purpose of a fixed prosthodontic therapy may
E-mail: [email protected] vary from the restoration of a single tooth to the reha-
bilitation of the complete occlusion. A single tooth can
be fully restored both functionally and aesthetically. A
missing tooth can be replaced by a fixed prosthesis,
Summary increasing patient masticatory competence and main-
taining or improving dental arches function, often ele-
Purpose. The aim of this study was to evaluate a vating patient’s self-image (2).
novel technique of tooth preparation in fixed Tooth preparation should have specific geometrical cha-
prosthodontics suitable for dental students and racteristics to provide necessary retention and resistance
neophyte dentists. to the vertical and lateral forces acting on the restoration.
Materials and methods.Twenty-four dental stu- The most important element of retention is the presence
dents of the sixth-year class were recruited to ve- of two opposing vertical surfaces. The axial walls of the
rify the predicibility of this technique. Each stu- preparation should taper slightly to allow the cementation
dent prepared two mandibular second premolars of the artificial crown. The more parallel are the axial wal-
on a typodont for a dental crown with a 90° shoul- ls the greater is the retention. However, it is impossible to
der finishing line. One tooth was prepared using obtain parallel surfaces without producing undercuts.
standard procedures taught in the prosthodontic Goodacre et al. (3) suggest an angle of convergence be-
dental course; the other tooth was prepared with tween 10 and 20°. Moreover, the occlusocervical length
the new technique. Three Professors of Prostho- is another fundamental factor for both retention and re-
dontics of the same University evaluated the re- sistance. The longer is the preparation the greater is the
sult on the basis of 10 criteria. retention. Teeth with larger diameter need a greater
Results. A statistically significant difference be- length to prevent dislodgement (4). Proper occlusal and
tween the two techniques was found in 8 out of 10 axial reductions are essentials to provide enough space,
criteria. The new technique showed higher values allowing a good functional morphology and structural
(p<0.05) in 7 criteria, while the conventional tech- durability. Moreover, no more than necessary dental tis-
nique had better results in just 1 criterion. More- sues should be removed in order not to jeopardize tooth
over, the total sum of values was higher for the structure and retention of the restoration (2).
new technique (total 41.2±3.98, p<0.05) compared Preston (5) and Miller (6) suggest starting the tooth prepa-
to the conventional technique (total 38.12±5.18, ration producing depth-orientation groves on the vestibu-
p<0.05). lar and incisal surfaces, with a round-end tapered dia-
Conclusions. This study showed that the results mond as reference for removing tooth structure. The oc-
were less dependent on manual abilities and per- clusal reduction is performed by removing the tooth por-

104 Annali di Stomatologia 2015; VI (3-4): 104-109

A tooth preparation technique in fixed prosthodontics for students and neophyte dentists

tions between the orientation groves with the same bur. • Bur N°2: diamond-coated depth marker of 2 mm
After the functional cusp bevel is made, a no. 17L bur is with a round and angled stopping surface;
used to smooth the planes of the occlusal reduction. • Bur N°3: cylindrical diamond of 1 mm with no dia-
Three vertical groves are performed in the vestibular sur- mond head;
face with a flat-end tapered diamond. All tissues between • Bur ANT: football diamond bur. It is the only one
the depth-orientation channels are removed. The proximal conventional bur of the kit;
reduction is performed with a needle narrow diamond, • Bur N°4: cylindrical bur with the only 2 final mm
avoiding damage to the adjacent teeth. The lingual and diamond-coated;
proximal surfaces are then cut with a torpedo diamond • Bur N°5: truncated cone diamond bur with no dia-
(2). Different finishing line may be created. A chamfer is mond head.
considered the preferred choice for veneer metal restora- The innovation of this technique is the easier control
tion. Several Authors have shown how this finishing line of depth and direction of the removing procedures. In-
exhibits the least stress, with the lowest failure rates (7). A deed, due to flat and no diamond-coated stopping
shoulder finishing line is used for all-ceramic crowns, mini- surfaces, the dentist can dominate easier the bur du-
mizing stresses with its wide and preventing the possibility ring tooth reduction. Every bur tracks a guide for the
of the porcelain fracture. However, it is the more destruc- following one. There are less variables to consider,
tive finishing line for the tooth tissues. On the other hand, so the error-probability is lower.
the knife-edge is the more conservative finishing line, but The technique consists in four phases (Fig. 1):
it may results in an over-contoured restoration. 1. First phase: axial and occlusal reduction depths
The most demanding challenges for prosthodontists 2. Second phase: reduction
are the control of depth and direction of tissue remo- 3. Third phase: finishing line preparation
val. None of the Authors in the current literature had 4. Fourth phase: tooth surface refining.
proposed a systematic procedure in which every bur
of the previous step produces a stopping surface on
the tooth for the next one. 1. Axial and occlusal reduction depths
The aim of this paper is to present a novel technique
of tooth preparation in fixed prosthodontics, capable Depth-orientation grooves are placed with the N°1 bur
to decrease the importance of dentist’s manual skill in along the vestibular and oral gingival margin of the
order to obtain a proper result. tooth (Fig. 2A). The round and flat stopping surface of
the bur doesn’t allow to go beyond a depth of 1 mm.
Anterior teeth: two or three grooves are completed on
Methods the incisal surface with the N° 2 bur.
Posterior teeth: following the tooth occlusal anatomy,
Novel technique the dentist creates longitudinal and trasversal deep
guide channels on the occlusal surface with the N° 2
The new technique consists of six burs (Fig.1): bur (Fig. 2B). The angled stopping surface of the bur
• Bur N°1: diamond-coated depth marker of 1 mm makes it easier between the cusps. It doesn’t allow
with a round and flat stopping surface; the dentist to go deeper than 2 mm.

2. Actual reduction

2.1 Incisal/occlusal reduction

Anterior teeth: the tooth incisal reduction is made

between the grooves with the N° 3 bur.
Posterior teeth: the no diamond head of the N° 3 bur
Figure 1. Burs and phases of the novel technique. is placed at the bottom of the central sulcus on the

Figure 2. A, Depth-orientation
groove placed with the N°1
bur along the vestibular gingi-
val margin of a mandibular
second premolar. B, Longitu-
dinal and trasversal deep
guide channels on the oc-
clusal surface made with the
N° 2 bur.

Annali di Stomatologia 2015; VI (3-4): 104-109 105

D. Rosella et al.

Figure 3. A, Vestibular view of a deep guide grove made with the N° 3 bur. B, Interproximal reduction made with the N° 3
bur orientated perpendicularly to the major axis of the tooth. C, Circumferential axial reduction.

occlusal surface. The occlusal reduction is made convention way, it could be practicable to start using
using as reference the trasversal deep guide chan- a normal flame bur.
nels. An uniform reduction of 2 mm is easily obtained The N° 3 bur could now easily remove the axial cir-
just moving the bur in the mesiodistal way. cumferential surface through the reference of the
axial and the cervical grooves (Fig. 3C).
The ANT bur is used in the anterior teeth only to re-
2.2 Axial reduction duce the occlusal area between the cingolum and the
incisal margin.
An axial deep guide grove is made with the N° 3 bur. It
should be directed in a perfectly vertical way and in pa-
rallel with the tooth major axis. The no diamond head 3. Finishing line preparation
doesn’t allow to remove dental tissue beyond the 1
mm depth of the gingival margin groove (Fig. 3A). The N° 4 bur is used to prepare the finishing line. The
The same bur is used to separate the tooth from the smooth proximal portion of the bur allows to use the
proximal one. The interproximal cut is made with the axial surfaces of the cast to guide the dentist in the
N° 3 bur orientated perpendicularly to the major axis preparation (Fig. 4).
of the tooth (Fig. 3B). If it isn’t possible, or the dentist
prefers an approach to the interproximal cut in the
4. Tooth surface refining

The N° 5 bur refines the tooth surface. It is used to

round the line angle of the stump and eliminates any
undercut (Fig. 5A, B).

Study sample selection

Twenty-four students of the 6th years dental school

were recruited to test the novel technique. They vo-
lunteered for the study by responding to an email
sent to the sixth-year class. All participants gave ver-
bal and written consent to take part of the study, ac-
cording to the World Medical Association’s Declara-
Figure 4. Vestibular view of the 90° shoulder finishing line
tion of Helsinki.
made with the N° 4 bur.

Figure 5. A, Refining proce-

dures made with the N° 5 bur.
B, Final vestibular view of a
mandibular second premolar
prepared with the novel tech-
nique.

106 Annali di Stomatologia 2015; VI (3-4): 104-109

A tooth preparation technique in fixed prosthodontics for students and neophyte dentists

Each student prepared two mandibular second pre- 33). It also facilitate pouring impressions and in-
molars (#4.5) on a typodont for a dental crown with a vesting wax patterns without trapping air bubbles
90° shoulder finishing line. One tooth was prepared and to ease removing casting modules.
using standard procedures (1, 2) taught in the pro- 9. Surface texture:
sthodontic dental course; the other tooth was prepa- The restorations fitting appears better in smooth
red with the new technique. Prior to the beginning of tooth preparation (34, 35). The retention of zinc
the study, the students were given a thirty-minute phosphate cement is increased by surface rough-
training session on how to use the novel technique ness (35-41); its effect has not been as definitely
with the first Author, DR. determined with adhesive cements.
Three Professor of Prosthodontics (SDC, GP and LP) of Another criterion was added for the assessment:
the same University evaluated the result on the basis of 10. Lesion of the proximal teeth.
9 scientific principles described by Goodacre et al. (3).
1. Total occlusal convergence (TOC): The grading sheet contains ten criteria above-mentio-
TOC is the angle of convergence formed between ned, associated with a specific point value and added
the two opposite axial surfaces of the preparation; together to generate the total score. These criteria
it should vary between 10 and 20°. appear in rows, while the associated letter grades (A,
2. Occlusocervical dimension: B, C, D and F) appear in columns. There are point
The minimal size of incisors and premolar pre- values for letter grades on each criterion: A=5, B=4,
pared with 10-20° of TOC is 3 mm (8). 4 mm is C=3, D=2, F=0. The total score is the sum of the all
the minimal dimension of molars prepared within points in the columns.
10-20°of total occlusal convergence (9). After each student completed the first tooth, perfor-
3. Ratio of occlusocervical/incisocervical dimension med with a standard procedure, the second Author
to faciolingual dimension: (GR) has given to everyone an identification number
For all teeth it should be 0.4 or higher (4). and each tooth was placed into a sealed envelope.
4. Circumferential morphology: The identification numbers were assigned progressi-
Everytime is possible, facioproximal and linguo- vely from the first student to finish (id n° 1) to the last
proximal corners of the teeth should be preserved one (id n° 24). After each student completed the se-
(10). cond tooth, performed with the new technique, the sa-
5. Finish line location: me Author has given to every student an identification
Whenever possible, a supragingivally finish lines letter and each tooth was placed in a different sealed
should be preferred (11-19); when subgingival fin- envelope. The identification letters were assigned pro-
ish lines are required, they should preserve the gressively from the first student to finish (id letter A) to
epithelial attachment (20-22). the last (id letter X) in the same way for the identifica-
6. Finish line form and depth: tion numbers above-mentioned. Therefore, every stu-
A chamfer finish lines of 0.3 mm is deep enough dent had a double code with a number and a letter
for all-metal crowns (23, 24). The different finish (i.e. 1F). Next, the typodonts were given to the eva-
line chosen for use with metal-ceramic crowns luator, who was blinded to the student’s identity.
should not be related to marginal fit but on per-
sonal preference (25, 26). Although metal-ceram-
ic finish line depths of 1.0 mm or more is recom- Statistycal analysis
mended, the optimal depth has not been deter-
mined. Both chamfer and shoulder can be used A specific statistical software (IBM SPSS V10 Statis-
with all-ceramic crowns bonded to the prepared tics, IBM, Armonk, USA) was used to analyze the da-
teeth (27, 28). A greater depth than 1 mm is not ta. Descriptive statistics (mean, frequency, range,
necessary when a semitranslucent type of all-ce- standard deviations) were computed for each group
ramic crown is used (29). of students, a T test was performed with a significant
7. Axial and occlusal reduction depths P value < 0.05.
All-metal crowns should be reduced at least 0.5
mm on the axial surface and 1.0 mm on the oc-
clusal surface. For metal-ceramic crowns, axial Results
reductions beyond 1 mm can prejudice the resid-
ual tooth structure external to the pulp (30); a 2.0 A statistically significant difference between the two tech-
mm of occlusal reduction is generally possible niques was found in 8 out of 10 criteria: only “surface tex-
even on a young tooth (2, 23, 24, 31). With all-ce- ture” and “line angle form” had p value > 0.05.
ramic crowns, it is not required a greater depth The new technique showed higher values (p<0.05) in
than 1 mm of axial reduction and 2 mm incisal/oc- 7 criteria, while the conventional technique had better
clusal reduction with semitranslucent systems results in just 1 criterion (“lesion of the proximal
(29). teeth”).
8. Line angle form: Moreover, the total sum of values was higher for the
Line angles of tooth preparations should be new technique compared to the conventional tech-
rounded to reduce stress in the restoration (31- nique (p<0.05). Data were summarized in Table 1.

Annali di Stomatologia 2015; VI (3-4): 104-109 107

D. Rosella et al.

Table 1. Assessment criteria.

Assessment criteria Conventional technique New technique P value

Total occlusal convergence 3.82 ± 0.43 4.23±0.78 <0.05
Occlusocervical dimension 3.67 ± 0.67 4.04±0.75 <0.05
Occlusocervical / faciolingual dimension 3.87 ± 0.54 4.12±0.67 <0.05
Circumferential morphology 3.64 ± 0.78 4.25±0.6 <0.05
Finish line location 3.84 ± 0.77 4.21±0.56 <0.05
Finish line form and depth 3.77 ± 0.69 4.33±0.63 <0.05
Axial and occlusal reduction depths 3.93 ± 0.52 4.37±0.62 <0.05
Line angle form 3.83 ± 0.63 4.08±0.65 >0.05
Surface texture 3.81 ± 0.83 3.78±0.81 >0.05
Lesion of the proximal teeth 3.94 ± 0.57 3.79±0.56 <0.05
Total 38.12 ± 5.18 41.2± 3.98 <0.05

Discussion cularly for neophyte dentists: they can use it as a trai-

ning procedure in their learning curve. It could be also
According to our results, the new preparation techni- possible the use of the technique in combination with
que is more predictable than the conventional techni- other methods. Hence, due to the small size of the
que for no experienced doctors. The reason is that re- sample (N students = 24, N teeth = 48), which could be
sults are less dependent on manual abilities and per- affected by selection and information biases, these da-
sonal experience. This study has shown benefits in ta need to be evaluated carefully, however the novel te-
control of depth and direction of tooth tissue removal chnique is a valid alternative in the landscape of fixed
as well as a better definition of the tooth finishing line. prosthodontic preparation techniques.
The total occlusal convergence (TOC) is an essential
criterion to be considered in tooth preparation. Okuya-
ma et al. (42) made a quantitative evaluation of axial Conflict of interest
wall taper in artificial teeth prepared by pre-clinical stu-
dents. After a fixed prosthodontics course, they have No potential conflict of interest relevant to the study
been instructed to reduce 54 artificial teeth for comple- was reported.
te cast restorations. Statistically significant higher TOC
than required have been detected. The greatest diffe-
rences were produced in the vestibular region with a References
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