Nisrine Elouard

1. Fundamentals of fixed prosthodontics

Concept and aim
• Definition: The branch of prosthodontics concerned with the replacement and/or restoration of teeth by
artificial substitutes that cannot be removed from the mouth by the patient
• Fix: to make firm, stable, or stationery, to attach to another object so that separation of the parts cannot be
accomplished without breaking of the mechanical and/or chemical bonds that hold the parts in spatial
relationship with each other, to repair
• Fixed dental prosthesis: the general term for any prosthesis that is securely fixed to a natural tooth or teeth,
or to one or more dental implants/implant abutments; it cannot be removed by the patient
• Fixed prosthesis:
◦ The prosthesis cannot be removed (the dentist must cut it)
◦ It requires a previous prep of the tooth to be set
◦ It requires a cement between the tooth prepared and the restoration
◦ Materials: ceramics, composites, hybrids or metals
◦ More resistant and abrasive
◦ Better hygiene
◦ More comfortable and psychological acceptance
• Removable prosthesis
◦ The prosthesis can be removed by the patient
◦ Does not require any previous preparation (bof)
◦ It does not require any cement
◦ Materials: acrylic and/or metals
◦ More resilience elastica
◦ Less hygiene
◦ Foreign body sensation
• Missing teeth can be replaced with fixed prostheses (and small gingiva defects)
• It does not cause any biological aggression
• The retention of a fixed prostheses is achieved by the friction between the two surfaces
• Therapeutic
◦ Missing tooth
◦ No prosthetic antagonist space
◦ Corrects occlusal alterations and consequences from partial edentulism
◦ It will render an optimal occlusion that also improves orthopaedic stability (TMJ)
• Preventive: maintain the health and integrity of the dental arches
• Function restoration: patient comfort, masticatory, and phonetic ability

Indications and contraindications

• General
◦ Indications • Contraindications
‣ Psychological ◦ Psychologic (non reversible)
‣ Systemic diseases ◦ Systemic diseases
‣ Orhodontic reasons ◦ Deficient hygiene, multiple cavities
‣ Periodontal reasons ◦ No patient cooperation
‣ Esthetic ◦ Macroglosia & advanced periodontitis
‣ Functional ◦ Age
‣ Early age: voluminous pulp that can be injured during teeth
preparation
‣ Use provisional Maryland bridge before definitive treatment
‣ Elder patients: less collaboration due to physical condition
• Local
◦ Indications ◦ Contraindications
‣ Dental protection ‣ Health of the abutment
‣ Replace missing teeth ‣ Crown-root ratio
‣ To alter shape, size or inclination of teeth ‣ Prosthetic space
‣ Appearence ‣ Gap length
‣ Trauma ‣ Previous patology

• General indications
◦ Psychological
‣ Aesthetic requirement: immediate provisional FPD
‣ Good acceptance
‣ Integration of the dental prosthesis in between 24h
‣ In case of implant rejection

◦ Systemic diseases
‣ Epilepsy
• Avoid long appointments and situations that lead to seizures
• No removable prosthesis
• Metallic occlusal surface
‣ Cardiovascular disease
• Blood pressure, coagulation disorders
• Be careful with anaesthetics
‣ Diabetes
• Predisposition for periodontal situations
• Make sure they are controlled and have eaten
‣ Xerostomy
• Frequently associated with other pathologies (Sjögren Sd, medication, arthritis…)
‣ Special patients
• Compromised oral higiene
• Less retention of plaque in fixed prosthesis
◦ Orthodontic reasons
‣ To avoid ortho treatment
‣ To maintain occlusal stability
◦ Periodontal reasons
‣ To create and/or correct axial forces
‣ To correct occlusal trauma
◦ Esthetics
‣ Bone and gingiva limitations
◦ Functional
‣ Restoring occlusal stability can help solve TMJ disorders (correcting interferences and prematurities,
restoring missing guidance)
‣ To restore the masticatory function
‣ To restore phonetics abilities

• Local contraindications
◦ Crown root ratio
‣ Crown Root
• The longer height, the better prognosis • Radiolucent images
• Endodontic treatment = worse prognosis • Rhizolysis
• Mobility = absolute contraindication • Hypercementosis
• Number, shape
• Root crown proportion = 1:2, 2:3, 1:1
 ◦ Prosthetic space: non prosthetic space can be caused by:
‣ Dental movements (extrusion, inclination)
‣ Gingival enlargement
‣ Trauma
◦ Gap distance and shape
‣ Length:
• Maximum two absence
• Exception the 33 to 43 bridge 4 lower incisors
‣ Shape
• The greater the curvature, the worse the prognosis
• Never splint the entire arch

Types of restorations

• Inlay: partial indirect restoration without cusp covering

• Onlay: partial indirect restoration, covering at least one cusp
• Partial coverage: restoration that require less destruction of tooth structure, used to reinforce the remaining
dental structure in cases of caries and fractures
• Veneers: a thin bonded ceramic restoration that restores the facial surface and part of the proximal surfaces of
teeth requiring esthetic restoration
• Full coverage: restoration that covers completely one single tooth, restoring its morphology and function
• Intraradicular: fiber glass post
◦ Teeth that have short clinical crown, which are notlongalone enough to support the definitive restoration can
be treated using a post
• Bridge: a prosthesis that is used to replace a missing tooth/teeth, the artificial tooth (pontic) of an FPD replace
the lost natural tooth, restores its function, and usually occupies the space previously occupied by the natural
crowns

Workflows

• Conventional
◦ 1. Impression taking = casting the impression
◦ 2. Waxing
◦ 3. Investment
◦ 4. Casting
◦ 5. Veneering porcelain build-up
• Partial digital
◦ 1. Impression taking = casting the impression
◦ 2. Digitalization of the master cast or the waxing (extraoral scanning)
◦ 3. Design of the structure CAD computer aided design
◦ 4. Manufacturing of the structure CAM computeraided manufacture
◦ 5. Veneering porcelain build-up
• Complete digital
◦ 1. Digitalization intraoral scanning
‣ Different technologies (photographic tech. or video tech)
‣ Different techniques
‣ Some are more sensitive to saliva, humidity, or light
◦ 2. Design of the structure CAD
◦ 3. Manufacturing of the structure CAM
◦ 4. Veneering porcelain build-up

• CAD/CAM concepts
◦ CAD = Computer Aided Design = Prothesis design
‣ The dentist or the lab technician can use diverses design software where they design all he parts of the
restoration, check occlusal contacts, interproximal contact, etc...
‣ Specific software for each system
‣ Design of the prosthetic structure
◦ CAM = Computer Aided Manufacturing = Manufacture
‣ Mechanized or milling technique
• The manufacturing process takes place mainly in the lab
• With all the information provided by the design software, the structure is milled
• Subtractive technique, the restorations are milled/carved from a solid block of the material
‣ Laser sintering
• Once the design is performed, the information is sent by the design software to the machine so
can prepare different structures at the same time
• Laser sintering: is a 3D printing technique (additive)

Introduction to tooth preparation

• What is it?
◦ Process of removal enamel and dentin and cementum to shape a tooth to receive a restoration
• How much structure should I remove?
◦ It will depend on the type of restoration
• What will the preparation require?
◦ Enough space for the material
◦ Good shape and retention
• Mechanical principles to achieve
◦ Retention = conicity
◦ Stability
◦ Structural strength of the restorations
◦ Path of insertion
• Silicon key
◦ Polyvinylsiloxane = putty silicon
◦ Respect the quantities of each
◦ Mix it homogeneously
◦ Prepare it moulding it on top of the teeth that are going to be prepared, including the adjacent for stability
◦ Used as a preparation guide
• Before starting
◦ Protect the adjacent teeth and soft tissues with:
‣ Metallic matrix
‣ Wood wedges
‣ Retraction chords
‣ Position of the bur
‣ Cotton roll
 ◦ Protect the pulp
‣ High-speed turbine
‣ Cooling water
‣ New burs
‣ Without pressure over the tooth and intermittently
◦ Tooth preparation burs
‣ Each bur has a different purpose
‣ Different types, sizes, grit
‣ The one you use will depend on the final restoration you are preparing
◦ Commonly used burs
‣ 856-016
• Round end tapered diamond
• 1.6mm at the base
• 1mm at the tip
‣ 856-012
• 1.2mm at the base
• 0.8mm at the tip
‣ 847-016
• Flat end tapered diamond
• 1. 6mm at the base
• 1.1mm at the tip
‣ 847-016 KR: more rounded angle
‣ 837: occlusal and incisal reduction
‣ 858: needle shape, proximal reduction to break contact points
‣ 368: rugby bur, lingual or palatal concavity anterior teeth

• Remember
◦ Don’t remove more than you should
◦ Check the available space: all the surfaces including the prosthetic space
◦ Polish angles and finish lines
◦ Rounded shapes, never sharp angles
◦ Volumes will depend on the type of restoration
Nisrine Elouard

2. Tooth preparation in fixed prosthetics

Concept: the process of removal of diseased and/or healthy enamel, dentin and cementum to shape a tooth to
receive a restoration

Tooth preparation
• Irreversible removal of tooth structure
• Usually with high speed diamond burs
• The fixed restoration goes over the prepared tooth
• Double purpose
◦ Provide space for the restoration, so it complies with esthetics and function
◦ Achieve a shape that provides to the restoration:
‣ Retention
‣ Stability
‣ Mechanical strength

Preparation principles

Biological: conditioning the future health of the surrounding tissues

• Objective:
◦ 1. Prevent harm to the surrounding oral structures, during the tooth preparation
◦ 2. Preservation of as much tooth structure as possible
• The preparation has to comply with the following principles in order to preserve the health of the surrounding
tissues
• During tooth preparation:
◦ A. PROTECTION OF THE ADJACENT TEETH
‣ Use metal matrix and wood wedge
‣ Important not to tilt the bur into the neighbouring tooth when removing contact areas

◦ B. PROTECTION OF THE PERIODONTUM

‣ Not touching the gingiva and avoid the bleeding
‣ Start doing the preparation supragingivally and only at the end take it to the desired height
‣ Use retraction cord when necessary and working near the gingiva

◦ C. PROTECTION OF THE PULP

‣ TERMAL HARM
• Copious water cooling
• Sharp burs
• Gentle and intermittent techniques
• Use of provisional
‣ MECHANICAL HARM
• Getting into the pulp with the bur
• Knowledge of the anatomy (tooth, age, Rx)
• Diameter of the burs

◦ D. PROTECTION OF THE SURROUNDING SOFT TISSUES

‣ Tongue, lips, cheeks
‣ With the help of the mirror, ejector, cotton rolls

• After tooth preparation:

◦ A. BIOLOGICAL SEAL
‣ The fit between the margins of the restoration and the margins of the preparation
‣ It impedes the cement from dissolving, and the penetration of bacteria's into the space between them
 ◦ B. ADEQUATE EMERGENCE PROFILE
‣ The restora6on must have and reproduce a contour similar to the natural tooth
‣ Otherwise dental plaque gathers and caries and/or periodontal diseases may occur

◦ C. RESPECT FOR THE BIOLOGICAL WIDTH

‣ Margins of the preparation should be at least 2mm away from the crest bone
‣ The finish line should never be more than 0.5 to 1mm under the sulcus
‣ The consequence of not respecting the biological width will be a chronic inflammation of the gingiva
(periodontal disease and bone resorption)
‣ Sulcus = 0,5-0,6mm
‣ Epithelial attachment = 1mm
‣ Connective tissue attachment = 1mm

• Preservation requirements
◦ Main principle: to preserve as much tooth structure as possible
◦ Specially important when vital teeth: not harm the pulp
‣ With the heat from the high speed burs
‣ Chemical irritation produced by certain cements
◦ Non-vital teeth: avoid fractures
◦ Preserve tooth vitality
◦ Not weaken the tooth
◦ Every restorative materials have it’s own ideal thickness
◦ The amount of preparation will vary depending on the material desired
◦ ≠ Diameter of burs

• Preservation requirements for FCC

1. Preparation of the interproximal surfaces (M,D) with a slight convergence towards occlusal
◦ The less conicity leads to less occlusal convergence but also more preservation of dental structure
◦ The buccal and lingual (palatal) surface also requires a minimal degree of conicity

2. Anatomical reduction of the occlusal surface

◦ Basic inclined planes must be respected
◦ When too flat, there will be
‣ Areas too close to the pulp (fossae)
‣ Areas with a lack of space for the material (cusps)

3. Uniform reduction of the axial surfaces

◦ Buccal, lingual (palatal), mesial and distal
◦ It needs to be parallel to the long axis of the tooth
◦ It shouldn’t be perpendicular to occlusal plane
◦ Anterior convex teeth, with a convex surface, require from a two plane preparation to avoid the pulp
chamber

4. Selection of the correct margin or finish line for the restoration

◦ Depending on:
‣ The type of restoration
‣ The restorative material
‣ The width/length proportion

5. Avoid apical extension of the FL

◦ Only when required (esthetics, to increase length)
◦ Requires more structural removal
Mechanical: conditioning the behaviour of the restoration

« The form of prepared teeth and the amount of tooth structure removed are important contributors to the
mechanical, biologic, and aesthetic success of the overlying crown or fixed partial denture »

A- RETENTION

• « That quality inherent in the dental prosthesis acting to resist the forces of dislodgment along
the path of placement »
• The essential element of the retention is two opposing vertical surfaces in the same preparation
• It’s not provided by the cement (except for non retentive restorations such as veneers, inlays and onlays)
• The cement only seals the interface between tooth and restoration

External retention Internal retention

• Factors that influence retention

◦ Magnitude of dislodging forces
‣ Magnitude of the vertical forces = occlusal direction
‣ Factors that minimize crown retentiveness
• Short teeth
• No marginal adaptation
• Cementation technique
• Sticky food
◦ Marginal adaptation
‣ A proper adaptation between both surfaces is essential to obtain sufficient friction and retention
‣ Quality of impressions and lab procedure
◦ Cements
‣ They increase the retention because they increase friction
‣ Provide micro mechanical bonding
‣ No chemical bonding (when PFM)
◦ Morphology of the preparation
‣ Together with the adaptation it’s the most important factor to obtain retention
‣ It depends on the clinical criteria and manual ability

• Tooth preparation
◦ 1. Slight conicity of the prepared tooth
‣ Slight conicity of the tooth is required
‣ The conicity of the preparation is inversely proportional to retention
‣ Ideal situation: no conicity: // walls = the most retentive preparation but no insertion
‣ Allows the insertion and complete seating of the restoration
‣ Provides an adequate retention: friction
‣ Tooth preparation should be kept minimal:
• Adverse effect on retention
• Preservation of as much tooth as possible
• Limits the number of paths along which a restoration can be removed
 ‣ Using a tapered diamond bur if the shank of the instrument is held parallel to the intended path of
insertion
‣ The two opposing external walls must gradually converge in the occlusal direction
‣ Conicity is inversely proportional to retention
• The more conicity the less retention
• Less conicity leads to higher retention
‣ Ideal taper:
• 6°
• 3° per wall given by the tapered bur

◦ 2. Volume directly proportional to the retention

‣ The more surface the more friction the more retention
‣ Height: the more height the more retention
‣ If a tooth is short, height can be maximized by:
• Moving the finish line apically
• Preparing the occlusal surface as little as possible, but respecting the required prosthetic space
• Build boxes and guiding grooves
‣ Diameter: more diameter, more friction, more retention
‣ If a tooth is too narrow, you can build boxes and guiding grooves in the proximal surfaces

◦ 3. Type of restoration
‣ We differentiate between an external and an internal retention
‣ External takes place btw external walls of the preparation and the internal surface of the restoration
• Ex: PFM crown, full ceramic crown
‣ Internal takes places btw internal walls of the preparation and the external surface of the restoration
• Ex: inlay, onlay

◦ 4. Unique path of insertion

‣ The specific direction in which a prosthesis is placed

B- STABILITY

• « The quality of a dental prosthesis to be firm, steady or constant to resist displacement by

functional horizontal or rotational stresses »
• Factors that influence stability
◦ Magnitude and direction of the force
‣ Tangential forces
‣ Forces due to interferences and/or prematurities
◦ Geometry of dental preparation
◦ Physical Properties of the cement
• Tooth preparation
◦ 1. Adequate conicity
‣ The more conical is the preparation, the more probability for the restoration to rotate
‣ Less retention
‣ Less stability
‣ More removal paths

◦ 2. Lateral boxes and grooves

‣ Used to reduce the freedom of displacement of the restoration when the conicity, height or
diameter cannot be the appropriate
‣ Boxes: when there is not enough height on M and D surfaces
‣ Grooves: when there is a lack of height and a wide MD distance, parallel to the insertion path
• Lower molars = buccal
• Upper molars = palatal
 ◦ 3. Length to mesio-distal width ratio
‣ The length must be great enough to interfere with the arc of displacement
‣ Short teeth:
• Boxes/grooves
• Crown lengthening
• Moving the finish line apically
• Lowering MD width

◦ 4. Length to faciolingual width ratio

‣ A ratio of 0.4 is necessary
‣ Meaning at least 4mm height for 10mm wide
‣ That avoids movements in a bucco-lingual sense
• Ex: lateral movements of the jaw in a group function situation

C- PATH OF INSERTION

• « The specific direction in which a prosthesis is placed on the abutment teeth or dental implant »
• It’s an imaginary line along which the restoration will be placed onto or removed from the dental preparation
• It’s determined mentally by the dentist before starting the preparation
• It must be unique in order to obtain retention and stability
• The ideal path of insertion must be determined by the long axis of the tooth and must be parallel to it
• It is given by the preparation of the axial walls
• Respect the 3º taper per wall.
• The path of insertion must be considered in two dimensions
◦ Bucco-lingually
‣ Buccally inclined = under or overcontouring
‣ Lingually inclined
• Short preparations
• Pulp chamber invasion
• Too aggressive with the remnant tooth structure

◦ Mesio-distally: the path of insertion must be parallel to the adjacent teeth, so they do not interfere
with insertion

• When for bridges (fixed partial denture) it is of special importance to create a good path of insertion
◦ All the abutments are parallel between each other
• Direct vision
◦ With one eye we must see the whole finish line, the four axial walls with a slight conicity
◦ Not having a correct visual will mean that there is retentive areas to correct.
• Indirect vision
D- STRUCTURAL STRENGTH

• A restoration must contain a bulk of material that is adequate to withstand the forces of occlusion
• This bulk must be confined to the space created by the tooth preparation
• The occlusal surface must have the correct thickness (depending on the material we are working with)
to not break nor distort
• Must support all the occlusal forces
• The needed space will depend on the type of restoration and on the type of material
• This will be given by the tooth preparation
• We need to first have a treatment plan before starting with the preparation of a tooth
• To have a correct structural strength of both the tooth and the restoration we must respect and remove the
correct volumes
• Parameters to achieve structural strength
◦ 1. Occlusal reduction
‣ Must have the correct volume, respecting the anatomy of the tooth
‣ Must provide enough space for the material
‣ Remember to respect the anatomy of the occlusal surface, do not flatten
‣ When too flat: there will be areas too close to the pulp and other areas with a lack of space for
the material
‣ Metal crowns
• Functional cusp: 1,5mm
• Non-functional cusp: 1mm
‣ Metal-porcelain crowns (PFM)
• Functional cusp: 2mm (= incisal border)
I • Non-functional cusp: 1,5mm
‣ All ceramic, with stratification
• Functional cusp: 2mm (= incisal border)
• Non-functional cusp: 2mm
‣ Monolithic crowns
• Average of 0.8-1mm on functional, non-functional cusps and incisal border
• Differences can be found depending on the material

◦ 2. Functional cusp bevel

‣ Bevel the external surface of the functional cusps to gain volume and structural strength
‣ 45º inclination 2mm thickness for a PFM crown and full ceramic crowns
1.5mm for gold crowns
‣ Consequences
• Not enough restoration material thickness:
◦ Perforation in metallic crowns, fracture in porcelain-fused-to metal crowns 2
• Restoration with correct thickness but not enough prosthetic space
◦ Prematurities and interferences
• An attempt to obtain an adequate bulk in a normally contoured casting without
bevel: overcontoured restoration

◦ 3. Axial reduction
‣ Enough structure must be removed to create enough space for the restoration
‣ Axial reduction is key to obtain an adequate thickness of the material
‣ To respect the periodontium
‣ To give to the restoration enough strength to resist occlusal forces
‣ If it’s not prepared enough, often there is an attempt to compensate by overcontouring the
axial surfaces, it strengthens the restoration but it has disastrous effect on the periodontium
‣ Lack of axial reduction:
• Thin and fragile restorations
• Overcontoured restorations
• Both are incorrectly prepared
E- FINISH LINE

TOOTH PREPARATION

• 1. Location of the margin of the preparation

• 1.1 NON-GINGIVAL MARGIN
◦ Easy to work with
◦ No gingival fluid, no blood
◦ Only for posterior teeth = onlay, overlay…

• 1.2 GINGIVAL MARGIN: neighbouring the periodontium

• 1.2.1 Supra-gingival margin
◦ Located 0.5 to 1mm from the surrounding gingiva
◦ Indicated when
‣ No esthetic is needed
‣ Enough height of abutment to have adequate retention
◦ More hygienic
◦ Easier to prepare
◦ Over enamel
◦ More conservative
◦ Easier impression
◦ Easier to identify by the dental technician
◦ Easier to assess at check-ups (with a probe and visually)
◦ They should be first choice for the many advantages except esthetics

• 1.2.2 Yuxta-gingival margin

◦ At the level of the gingiva

• 1.2.3 Sub-gingival margin

◦ Hinder hygiene
◦ Risk of biologic width invasion
◦ Located maximum 0.5-1 mm under the gingival margin
◦ More difficult to prepare
◦ More difficult to copy at the impression
◦ The use of cords or retraction materials is necessary
◦ More difficult to assess at check-ups, no direct visual
◦ Requires cast preparation
◦ Main advantage: esthetics (the margin of the restoration is hidden under the gingiva)
◦ Main disadvantage: high rish of BW invasion
◦ Besides the esthetic factor, also used to gain retention and resistance by increasing the occluso-
cervical dimension, to extend the FL beyond caries, fractures
◦ We have to consider:
‣ Esthetics expected
‣ Height of the die (short)
‣ Caries location
‣ Caries propensity
‣ Height of tooth fracture
◦ Indications of the subgingival margin
‣ Aesthetic reasons:
• Mainly buccal FL, and posterior buccal surface in patients with a wide smile
‣ Short clinical tooth, to increase the height and gain retention
‣ Subgingival caries
‣ Subgingival composites, the FL should always be over healthy structure
‣ Subgingival fractures of the tooth
‣ Caries over the roots
 • 2. Marginal integrity
◦ « The restoration can survive in the biologic environment of the oral cavity only if the
margins are closely adapted to the cavosurface finish line of the preparation »
◦ « The configuration of the preparation finish line dictates the shape and bulk of restorative
material in the margin of the restoration »
◦ High accuracy marginal integrity: 20-40 microns
◦ Maximum clinically acceptable: 100 microns
◦ Checked at the lab with a microscope
◦ Checked at the office with an explorer and X-rays
never ◦ Space will be occupied by the cement (thin layer)
7100M ◦ Over 100 µm discrepancy = bad survival
◦ A 100 microns discrepancy should never be exceeded
◦ At the office: the tip of the dental probe should not be able to fit between the finish line and the
restoration at the level of the margin
◦ Marginal fit: finish line should be neat and clear & transferred correctly to the working cast
‣ Horizontal
‣ Vertical
◦ Marginal strength: Adequate thickness and shape of the restoration
—> Strength to the restoration, good morphology
◦ To sum up: a correct finish line will and must provide the following basic requirements
‣ Marginal integrity
‣ Strength to the restoration
‣ Adequate localization
‣ Correct emergency profile
‣ Healthy periodontium

• 3. Characteristics
◦ Its design will depend on the kind of restoration
◦ Neat and clear (no irregularities)
◦ Deep and wide enough to be identified easily
◦ Lay over healthy tooth tissue, never over caries
◦ Follow the gingival scallop
◦ Conservative with tooth tissue
◦ Its thickness will have to be adequate for the material of the restoration
◦ Adequate shape for the material of the restoration
◦ The type of restoration decides what type of finish line is required
◦ Important to know the diameter and geometry of the burs
◦ The FL must have the correct shape and size so the restoration can fulfil the following requirements:
‣ Marginal integrity
‣ Structural strength
‣ Localisation
‣ Adequate emergency profile

• 4. Types of burs
◦ High speed hand-piece
◦ Always with water
◦ Medium grit for the tooth preparation
◦ Fine grit, red stripe = for polishing
◦ Different diameters
◦ Tapered/conical shape
◦ The bur designs the finish line while removing tooth structure
◦ The bur we use will depend on the result we want to achieve depending on the type of restoration
◦ While working we must not incline the bur, and respect the parallelism with the long axis of the tooth
and the parallelism with the adjacent teeth
◦ Recommended to start with a supragingival FL and then take it to the decided level
 ◦ Commonly used burs
‣ 856-016
• 1.6mm at the base
• 1mm at the tip
‣ 856-012
• 1.2mm at the base
• 0.8mm at the tip
‣ 847-016
• 1. 6mm at the base
• 1.1mm at the tip
‣ 847-016 KR: more rounded angle
‣ 837: occlusal and incisal reduction
‣ 858: needle shape, proximal reduction to break contact points
‣ 368: rugby bur, lingual or palatal concavity anterior teeth

• Types of finish lines

◦ CHAMFER
‣ Curved shape
450
‣ Depth: 0.5-0.7 mm
‣ Very conservative
‣ Prepared with a torpedo-shape bur
‣ 856-016 bur = base 1.6mm, tip of 1mm
‣ Half the bur works = 0.5mm
‣ Needs metal at the end of the restoration O
round
‣ With smaller angles, the margin increases fit
‣ Less stress at the cement area
‣ Indications
• Metal-end restorations (metal collar)
• Lingual or palatal metallic surfaces of PFM crowns (metal collar)
• When there is no aesthetic needs
• Periodontal teeth (metallic finishing over cementum)
• Feldespathic veneers (856-012 RK, for a 0.3 to 0.5mm FL)
• Can also be used for preparations for monolithic zirconia restorations

◦ DEEP CHAMFER (rounded chamfer)

‣ Angle at the margin of 90º approx
‣ Inner shape has a smaller radius than that of the normal chamfer
‣ Its depth depends on the material of the restoration
◦ BUTT SHOULDER
‣ Prepared with a flat-tip cilindrical bur
‣ Angle of 90º at the margin
‣ Was used for all-ceramic crowns, creating enough space, but destroying too much structure
‣ DISUSED

◦ ROUNDED SHOULDER
‣ Angle at the margin is 93º
‣ Inner angle is rounded, as opposed to butt shoulder
‣ Creates an angle of 93º between the axial wall and the gingival wall
‣ The rounded angle reduces the tension and stress concentra;on over the tooth
‣ Prepared with 847-016 KR bur
‣ Reduces the stress at the inner angle
‣ Allows the scanning of most of CAD/CAM scanners
‣ Provides good space for porcelain
‣ More conservative than butt shoulder
‣ Prepared with a cylindrical bur with rounded edge at the tip
‣ Indications:
• Full ceramic crowns (1 mm around all the perimeter)
• Labial surface upper ant PFM crowns & post when esthetics are jeopardized
◦ 1 to 1.5 mm
• Porcelain fused to metal anterior crowns/bridges
‣ Facilitates laboratory fabrication and procedures
‣ Facilitates restoration fit
‣ Reduces stress concentration
‣ Easier to take impressions
‣ Less air bubble trapping while pouring
‣ Less air trapping when investing the die with wax pattern
‣ Better capture when working digitally (CAD-CAM)

◦ CERAMIC SHOULDER
‣ Porcelain labial shoulder
‣ Used for the anterior sector when PFM restorations
‣ High aesthetic
‣ Allows yuxtagingival finish lines
‣ The metal only covers the axial wall
‣ It’s the best option from a esthetic point of view
‣ Acceptable fit (45 µm in vivo and 15-25 µm in vitro)
Nisrine Elouard

3. Material in fixed prosthetics

I. Requirements
◦ Biocompatibility ◦ Easy
◦ Resistance to fracture ◦ Not porous
◦ Esthetics ◦ Easily polished
◦ Abrasion resistance ◦ Color stability
◦ Relative cost to patient ◦ Accurate adaptation
◦ Low coefficient of thermal expansion ◦ Suitable hardness

II. Selection criteria

1- Resistance
2- Adhesive capacity
3- Preparation (conservative/invasive)

4- Abrasivity/wear
The performance or zirconia polishers was better than that
• Diagnosis and etiological treatment for wear of diamond-impreganted porcelain polishers. The use of
◦ Assessment of caries risk zirconia polishers is thus recommended for polishing zirconia
◦ Saliva tests prostheses after clinical and laboratory adjustments.
◦ Buffer capacity of saliva
◦ Diet analysis
• Relationship between hardness and abrasivity
◦ Directly proportional:
‣ Acrylics
‣ Composites
‣ Metal alloys: Zirconium is the hardest but if correctly polished, the least abrasive.
◦ Inversely proportional:
‣ Ceramics: they lack plastic deformation and their surface is not homogeneous.

5- Esthetics
6- Cost/benefits
III. Acrylics Use to make provisional restorations

Uses:
• Protection of abutment teeth
• Occlusion maintenance
• Esthetics
• Gingival maintenance
• Mock up: try-in of the final treatment in order to see before doing the invasive treatment (take an impression of
the patient, on the cast we block the diastema with wax, we take an impression with silicone, we pour acrylic and
we try the acrylic on the patient)

PMMA: old, cheap Bisacrylics: new, expensive

• Advantages: • Advantages:
◦ Fracture resistance ◦ Dimensional stability
◦ Ability to reline ◦ Low polymerization shrinkage
◦ Layering ◦ Low heat output
◦ Low cost ◦ Easy to use
• Disadvantages: ◦ No need for glazing
◦ Polymerization shrinkage ◦ Can be repaired with composite
◦ Heat output ◦ Automix system
◦ Long working time • Disavantages:
◦ Hard to use ◦ No relining
◦ Polishing

Relining: you take an alginate impression of the tooth not prepared and you send it to the lab, the lab tech makes
the preparation on the cast as if he was the dentist, he makes a thin prep and adapts the crown on top of this prep.
But this prep is different from the one we did, so it won’t fit so we add material for it to be adapted = PMMA

• Selection of the most appropriate temporal material and production technique to fulfill many different functions:
◦ Protection of the underlying tooth structure
◦ Maintenance of function and esthetics
◦ Conditioning of the gingival tissues
◦ Mock-up for the final restoration
◦ Therapeutic clinical test drive
If you use PMMA: 6 months/1 year
• Mechanical (strength) Biacrylic: less time
◦ Bear masticatory load
◦ Retention PFM: core of metal and layers of porcelain
◦ Resist its removal without breaking —> 3 tries on the tooth
—> provisionals need to bear at least 3 removal
• Aesthetic:
◦ Look like natural teeth, specially for front teeth
◦ Sometimes they are a test of what the final aesthetic result will be

• Technical:
◦ Easy to polish
◦ Easy to trim and adjust
◦ Easy to handle
◦ Should be able to reline
◦ Non-porous: all of them are porous because they are organic
◦ Easy to clean
◦ Cheap
Acrylic classification:

• Conventional technique: impression + cast sent to the lab

◦ Metacrilates: PMMA (monomer + polymer)
‣ High heat output
‣ Rigid
‣ Allows relining
‣ Clinic and or laboratory
‣ High fracture resistance
‣ Low material cost
‣ AKA: conventional (methacrylate resins)

◦ Bisacrylic resin (pistol)

‣ Bis-GMA ‣ High dimensional stability
‣ Lower heat output ‣ Superior esthetics: no need of glazing
‣ Shorter working time ‣ Better mixing quality (automix)
‣ More rigid ‣ Low polymerization shrinkage
‣ More fragile ‣ Lower setting temperature
‣ Difficult to reline ‣ Ease of use
‣ High mechanical strength

◦ Prefabricated: acetate, polycarboxylate, protemp…

—> like pediatrics, all same colors but possibility of relining with different shades

• Digital technique: (full: intraoral scanner, partial: impression + cast + extraoral scanner = most used)
◦ Substractive techniques: taking out material from block (waste)
‣ Acrylic blocks for milling: PMMA, acetalic resin (≠ biacrylic)
◦ Additive techniques: add layers until you create the prosthesis —> cheaper
‣ Light curing resins for 3D printing (stereolithography: many layers of polymerized acrylic)
‣ Estrusion of melted material
‣ Sintering…
IV. Metals

Classification:
• High noble alloys: > 40% gold + 60% other noble metals
• Noble alloys: > 25% noble metals + no limit for gold content
◦ Cr-Ni
◦ Cr-Co
◦ Ti
• Base metal alloys: > 75% base metals + < 25% noble metals

GOLD
• Advantages:
◦ Strength (but not hard)
◦ Longevity
◦ Good biocompatbility
◦ Hypoallergenic
◦ Minimal wear to opposing teeth: but opposing teeth is going to perforate it
◦ Fit: easy to adjust because soft
◦ Less tooth reduction required
• Disadvantages:
◦ Esthetics
◦ Expensive cost
◦ Can’t be fused with ceramics (no PFM)

Noble alloys advantages

• Compared to gold
◦ Increased strength
◦ Increased hardness
◦ More resistant to abrasion
• Compared to base metals
◦ Less corrosion
◦ Less abrasion
◦ Easier to adapt and polish
◦ More accurate

Noble alloys disadvantages compared to base metals

• More expensive
• Less rigid: disadvantage in long bridges (softer = bending)
• More tooth reduction required = more invasive

Uses:
• Gold inlays (gold type I and II), full coverage crown (gold type III) —> Not commonly used
• Full coverage crown totally metallic
• Full coverage PFM crowns
• Metal ceramic bridges: highly or noble alloys —> if long: Cr-Ni
• Metallic pin-cast: with noble or highly noble alloys

Summary:
• High noble: no use
• Noble: use with conventional technique
• Metal: use with digital technique
V. Ceramics

Porcelain: pressed, fired, polished or milled materials containing predominantly inorganic refractory compounds,
including porcelains, glasses, ceramics and glass-ceramics.

Dental ceramics properties:

• Inert
• Metallic oxides
• No liberation of ions into the mouth
◦ Unlike metals
◦ No corrosion
• Highly biocompatible

Types of ceramics:
• Vitreus ceramics: very translucent and very breakable
◦ Feldespathic
◦ Feldespathic reinforced with crystals
‣ Leucite
‣ Lithium disilicate: once cemented with adhesive technique, it becomes more resistant
• Oxide cristalines: pure cristals, very hard, very resistant but less esthetic
◦ Zirconium oxide

ask.fiaxeuss forBroxist MwÉ

wax Leucite wax
mint xmill cADkAM
Filtering

Classification (regarding chemical composition): The higher the resistance, the less esthetic

1- Glass-matrix ceramics = Vitreus

• Feldespathic: used for layering, very esthetic, not resistant
• Feldespathic with synthetic reinforcement crystals
◦ Leucite based
◦ Lithium disilicate and derivatives
◦ Fluorapatite based
• Glass-infiltrated = we add crystals of Al and Zr to feldespathic but doesn’t make it polycrystalline
◦ Alumina
◦ Alumina and magnesium
◦ Alumina and zirconia

2- Polycrystalline ceramics —> only crystals of aluminium or zirconium

• Alumina
• Stabilized zirconia = Z-YTP
• Zirconia toughened alumina
• Alumina toughened zirconia

3- Resin-matrix ceramics = Hybrid material

• Resin nanoceramic
• Glass-ceramic in a resin interpenetrating matrix
• Zirconia-silica ceramic in a resin interpenetrating matrix
Classification (regarding chemical composition):

1- Low strength feldespathic porcelains Use for LAYERING

• The first that appeared The lab technique with a brush and adds some powder with water and apply
• Composition: it on the tooth. Every layers have to be baked in an oven. Really time
◦ Feldspar: translucency consuming and depends on the skills of the technician (differents shades etc)
◦ Quartz: crystalline phase
◦ Kaolin: plasticity
• Important glass phase
• Main current use: Veneering porcelain
• High esthetic but high fragility
• Mirage, Optec, Duceram

2- High strength feldespathic porcelains

• Leucite reinforced
◦ High esthetic demand, but not resistant
◦ Leucocite microcrystals: more resistant than feldespathic alone
◦ Fracture strength: 120Mpa
◦ Only use for veneers (carillas)
◦ Empress
• Lithium disilicate reinforced
◦ Reinforced with a higher percentage of lithium disilicate = 75%
◦ Resistance of 360 to 400 Mpa = more than leucite
◦ Can be one in 2 ways:
‣ Monolithic: full block of material = can be done with e.max Press and CAD
‣ Layered: core of lithium dislilicate then layering with feldespathic (—> done with Press or CAD)
◦ e.max Press:
‣ First the crown is done with wax then the wax is melted and the porcelain is pressed inside
‣ Varies from HT to HO: depends on the colour of the tooth underneath
◦ e.max CAD:
‣ Varies from HT to HO
‣ Blocks used for milling
‣ Typical blue initial color: metasilicate (softer) = after oven, it becomes hard and white.
‣ Gives the option for monolithic restorations. (Also possible with e.max press)

3- Aluminous porcelains DISUSED

• Aluminium oxide instead of quartz in its composition

• Good mechanical properties
• Low translucency
• For full cast crown copings (FCCs)
• In-ceram alumina + Mg —> In-ceram Spinell + Zirconia —> In-ceram Zirconia
• High general porosity but more flexural strength
• Disused due to better properties and survival of LDS and Zr
4- Zirconia based porcelains
• ZrO2
• 95% zirconium oxide + 5% yttrium oxide Y2O3
• Totally crystaline structure

• Phases of Zirconia: tetragonal, monoclinic and cubic = transition related to temperature changes

• Zirconia + Yttrium oxide = Y-TZP (yttrium stabilized tetragonial zirconia polycrystals)

—> Zr is stabilized in tetragonal phase at room temperature
◦ High tensile strength
◦ Fracture toughness
◦ Most used in dental restorations

• Transformation toughening: Zirconia changes from tetragonal to monoclinic (when trauma)

• Evolution of zirconia:
◦ At first: Zirconia at the core of the crown but too opaque so feldespathic layering was needed
‣ Chipping: the feldespathic layering falls down due to a bad chemical union = death of zirconium

◦ Layered zirconia porcelains

‣ Aging (low temperature degradation)
‣ Chipping in 15% of the cases after 24 months
‣ 25% fractures and chipping after 31 months
◦ Monolithic zirconia porcelains
‣ Newly developped zirconia
‣ Monolithic zirconia: more translucent
‣ No need of layering: no chipping complications
‣ Stability structure
‣ High biocompatibility
‣ Mono-blocks previously stratified
‣ Even if hard and resistant, it is not abrasive if correctly polished
‣ Tooth structure reduction between 0,5 and 1,5mm
‣ 0,5mm chamfer line (0,3-0,8mm)
‣ Lava Plus, Lava Esthetic
‣ Limitations:
• The size of connectors: place where most fractures happen, especially when more than 1 pontic
• Anterior: 7mm2
• Posterior: 9mm2
• 2 pontics bridges: central connectors 12mm2 The limitations of
• Needs more prothestic space than PFM (4mm2) zirconium is only for bridges
VI. Porcelain fused to metal

• Gold standard for now

• Core made of metal, feldespathic porcelain surrounding
• Very resistant treatment
• We need more space for PFM = more invasive
• Less resistant than zirconium and more aggressive for the antagonist
• Can’t use feldespathic porcelain alone, not resistant enough —> (feldespathic 10

1- Parts
• Metal coping
◦ 0,5mm for noble alloys = more invasive
◦ 0,3mm for non-noble alloys
• 3 layers of veneering porcelain = 1mm
◦ Opaque porcelain (opaquer)
‣ Hides the color of the underlying metal framework
‣ Joins and links the metal to the rest of porcelain layers
Every layer is baked in the oven
◦ Dentin porcelain
Very esthetic and manual work
‣ Main part of veneering porcelain Depends on the hand of the technician
‣ Provides the shade to the restoration
◦ Incisal/enamel porcelain
‣ Provides translucency
‣ Can be stained
‣ Last layer

2- Margin
• Metal margin
◦ Metal collar at lingual surface
◦ 0,3 - 0,5 mm thick: chamfer lingual and buccal
◦ 2-3mm high
◦ Good fit and hygiene
• Metal-porcelain margin
◦ Most commonly used
◦ Metal coping gets thinner as it gets near the margin
◦ Contraction of porcelain can put the coping out of fit
• Ceramic shoulder/chamfer
◦ Low fusing ceramic in contact with margin
◦ In buccal aspect: the metal is cut before the finish line so there is only feldespathic porcelain
◦ Good esthetic
◦ Requires adhesive technique cementation where the porcelain is: better adhesion
◦ Requires a preparation with enough thickness to avoid fracture: chamfer lingual, shoulder buccal

• Even if PFM is still the gold standard, monolithic zirconium crowns show:
◦ More conservative preparation
◦ Less abrasion for antagonist
◦ More biocompatibility with gums
◦ More esthetic (altough it depends on the lab technician)
◦ Less working time in the lab —> cheaper

• But for single anterior cases, it is still necessary to do a layering of feldespathic porcelain
(—> feldespathic alone)
VII. Hybrid materials —> Resin Matric ceramics

1- Resin nanoceramic
• Mainly resin with particles of ceramic
• Resist chipping and cracking during the milling
• No post firing step needed (baking in oven)
• High luster (éclat)
• Easily abraded
• Lava Ultimate:
◦ Pros: Elastic modulus similar to dentin
◦ Cons: High rates of wear = loss of contacts and guidance

2- Glass-ceramic in a resin interpenetrating matrix

• Mainly ceramic with particles of resin
• Hybrid ceramic
• Ceramic strenghtened by a polymer
• High load capacity after bounding
• High elasticity module
• Vita Enamic:
◦ More esthetic because if its ceramic composition
◦ Composite filling suffers high level of wear = exposition of the ceramic crystals
—> Abrasive restoration
◦ Requires fluorohydric etching and silane

3- Zirconia-silica ceramic in a resin interpenetrating matrix

• LDS + 10% Zr
• Slightly harder than LDS
Nisrine Elouard

4. Laboratory techniques conventional and digital workflow

I. Tooth supported prosthesis

Traditional workflow:
• Impression technique
• Casting
• Casts
◦ Trim the cast where there are the abutment teeth = dice
◦ Wax up: the technician add wax on top of the preparation to produce the shape of the crown
‣ Time consuming and depends on the skills of the technician
• Lost-wax technique
◦ Once the waxing of the core is over, rods are attached to the non-functional cusps
◦ Investment:
‣ Powder and liquid mixture, 30 min setting time
‣ Pouring over the wax up with the rods
‣ Can bear the oven = wax is melted = negative obtained
◦ Oven: when molten the metal is cast through the sprue inside the negative left by the wax
◦ Centrifuge
‣ Casting step: step where the wax pattern is converted to his metal replica
◦ Removal of the coping
◦ Trimming and finish
◦ Solutions for volume changes during casting:
‣ Unpredictable process: the investment expands like plaster when it sets
• If cylinder resistant: internal expansion = the preparation will be too small
◦ For pin cores (post) —> we make sure it will fit inside the root (external wouldn’t fit)
• If cylinder is not resistant: external expansion = the preparation is going to be too big
◦ Oversized wax pattern
◦ For crowns: correction of the crown, manually
• Layering
◦ Layering of opaquer over the metallic core
◦ Layering of feldespathic porcelain over the metallic core

Partial digital workflow

• Impression technique
◦ Contraction of impression material
◦ Dragging
◦ Disinfection
◦ Discomfort
◦ Storing and transport
◦ Soft tissue retraction
◦ Impression material separated from tray
◦ Expiration date
◦ Not immediate quality control
• Casting
◦ Higroscopy
◦ Bubbles
◦ Fractures of the cast
◦ Contact points altered in dyes
◦ Storing and transport
• Casts
• Extraoral scanning
◦ Optical scanners
‣ More widely spread
‣ Quicker
‣ Indicated for more organic anatomies (natural tooth)
◦ Contact scanners
‣ Indicated for more accuracy
‣ Renishaw
‣ Procera started with contact and changed to optical
◦ STL File: Standard Tesselation/triangle language
‣ Cloud points that the software joins together in triangle.
‣ No butt shoulder = the software won’t be able to form a triangle so it will be round
• 3D Digitalizing: CAD/CAM
• Layering

1- Porcelain fused to metal: 3 ways to do the metal core of PFM

• 1) Lost wax: not used
• 3D Digitalizing:
◦ CAD: in the lab or chairside
◦ CAM: 2 ways to print
‣ 2) Additive: Sintering
• Laser is joining the powder of CrCo of many layers
• Material is re-used + we can do many restorations at
the same time
• Cheaper
• Easier for feldespathic to attach = rugosity on the surface
‣ 3) Substractive: Milling (fresado) With this system there’s a big waste of the material —> very accurate —> long process
• It takes time and waste material
• Only one restoration can be done at a time
• Most precise technique
• Polished and shiny results
• We don’t need to do milling for tooth supported prosthesis, sintering is sufficient
• Not the same for implant supported prosthesis
We can use milling for IMPLANTS

2- Full porcelain
• Possibilities to obtain FPD in the lab
◦ Milling (CAD/CAM) The core is made by lithium disilicate and the final
external crown is made off porcelain
‣ Lithium disilicate (e.max) —> can be etched = partial restorations
‣ Leucite (Empress)
‣ Zirconia:
• Resistance, more conservative, more esthetic than PFM
• Only used for full coverage crown because can’t be etched
‣ Hybrid material
‣ Wax to be milled and then pressed (digital wax up instead of manually)
◦ Pressing (Conventional)
‣ Lithium disilicate
‣ Leucite
‣ Hybrid and zirconia can’t be pressed
• Layering over a core
◦ Cut back technique
◦ Monolithic technique Cheaper / quicker / less abrasive —> the preparation is much more conservative (we just obtain more aesthetic in
the Incisal edge —> monolithic restorations can be made by Milling or pressing
• Materials
◦ Layered composites
◦ Full porcelain
◦ Hybrid materials
Full digital workflow
• Intraoral scanning: Trios 3 shape, Omnicam, True definition
◦ 1973: F. Duret « Empreinte optique »
◦ 1983: Mormann and Brandestini Cerec I
• Advantages: • Disadvantages
◦ Immediate quality control ◦ Only for partial
◦ Process standardization ◦ Up to 3 implats
◦ Predictability ◦ Initial investment
◦ Accuracy and marginal fit ◦ Learning curve
◦ Comfort ◦ Soft tissue retraction
◦ Less crossed infection ◦ Adaptation to technology
◦ No storing and less transport ◦ Limited scanning time
◦ Less visits ◦ Maintenance fee
◦ Lab communication ◦ Compatibility with other
◦ Marketing CADCAM systems
◦ Matching by overlapping

II. Implant supported prothesis

• Conventional workflow: impression with transfer —> never

◦ Lost wax is not predictable = forbidden with implant supported because we need accuracy
◦ Passive fit: perfect adaptation of the framework of the prostheses on the implants = no tension
‣ Much more important than natural teeth because implants don’t have axial or lateral mobility
• We will always work with partial digital workflow at least
• CAD: implant angulation correction
• CAM:
◦ Milling:
‣ Device with 5 axis for implants
‣ More accurate but waste and expensive
‣ Connectors obtained is smooth —> less bacterias
‣ Materials:
• Zirconia: monolithic zirconia crowns on Ti base
• Acrylic: for temporaries
◦ Laser sintering:
‣ Connectors obtained is rough but cheaper and time saving
◦ Milling-sintering (sinterofresado): mix of the two techniques
‣ Full framework obtained with sintering
‣ Connectors obtained with milling
◦ Summary:
‣ For tooth supported: sintering is enough
‣ For implant supported: milling or milling-sintering
• Digital workflow: don’t always need a working cast
◦ We mill or press the final result directly on the computer
◦ Sometimes we still need cast if we do a layered technique

1- Implant supported fixed partial denture

• Conventional impression : customized coping
• 3D Digitalization: True definition
◦ Scan bodies = impression transfer for digital
◦ Titanium oxide powdering = improve scanning
• CAD: STL file
◦ Upper, lower, bite registration
◦ Design of the framework
◦ Zirconia framework
2- Implant supported fixed full arch

Full digital workflow:

• Advantages:
◦ Immediate quality control
◦ Process standardization
◦ Predictability
◦ Accuracy and marginal fit
◦ Comfort
◦ Less crossed infection
◦ No storing and less transport
◦ Less visits
◦ Lab communication
◦ Marketing

• Disadvantages
◦ Only for partial
◦ Up to 3 implats
◦ Initial investment
◦ Learning curve
◦ Soft tissue retraction
◦ Adaptation to technology
◦ Limited scanning time
◦ Maintenance fee
◦ Compatibility with other CAD/CAM systems
◦ Matching by overlapping:
‣ Head of the pistol is small and is scanning a small part of the mouth
‣ When moving, it adds up all the images scanned by stitches
‣ The farthest we go from the begining of the scanning = the more mistakes, the less accuracy
‣ Not enough accuracy for more than 3 implants
• New digital scanner = up to 8 implants
Nisrine Elouard

6. Veneers
1- Concept

Definition: A thin bonded ceramic restoration that restores the facial surface and part of the proximal surfaces of
teeth requiring esthetic restoration.
Concept: Extracoronal partial-coverage singe-tooth restoration made of ceramic materials.

2- History

• 1938, Charles Pincus. The “Hollywood Veneer”

• 1955, Buonocore (acid etch of the enamel).
• 1963, Bowen (BIS-GMA resins and resin composites).
• Acrylic veneers
• Porcelains---no bonding capacities.
• 1983, Simonsen y Calamia (adhesion to porcelain)
◦ Porcelain etching + silane.

3- Characteristics

• Highly esthetic restorations

◦ Highly translucent (if dentin is yellow = more opaque)
◦ Takes advantages of the optical properties of the underlying
dentin

• Highly conservative restorations

◦ Minimal preparation
◦ Into enamel whenever possible
◦ Chamfer 0,3-0,5mm thickness
◦ Excellent bond to enamel

• Low geometrical retention (very low friction)

◦ Adhesive bond

4- Indications

When we seek: maximal long term esthetic results (buccal) or restoration of anterior guidance (palatal)
And we have: healthy tooth structure, minor color, shape or position alterations
For anterior teeth and premolars (not in molars)

Depending on the material and the case:

• Feldespathic porcelain
◦ Moderate modification of the colour (max 2 shades)
◦ Slight differences with the colour of the substrate
◦ No more than 2mm lenghtening of the incisal border
◦ Low mechanial load
◦ Contraction of the cement = breakage (very fragile bc very thin)
 • E.max + veneering
◦ Modification of the colour of 3 shades or more
◦ Non-homogeneous colour of the substrate
◦ More than 2mm lengthening of the incisal border
i ◦ Bruxism, overbite, high mechanical load no falso
• Monolithic e.max
◦ When the mechanical needs are higher than the esthetic ones (ex: bruxism)
• Cut back technique

Can’t use zirconia (never!!) because it can’t be etched (only sand-blasted)

so does not have adhesive cementation.

• Color alterations
◦ Tetracycline stains (opaque LS bc dark substrate)
◦ Dental fluorosis
◦ Hypoplasia stains
◦ Tooth resistant to bleaching

• Shape and size alterations

◦ Microdontia / conoid teeth
◦ Primary teeth
◦ Tooth fractures
◦ Broad cervical embrasures
◦ Dental erosion

• Position alterations
◦ Diastema
◦ Mild crowding (if ortho is refused)
◦ Minor malpositions (rotations)

• To restore anterior guidance (palatal)

5- Contraindications
• Inadequate occlusion or position
◦ Deep overbite
◦ Parafunctional habits (bruxism)
◦ Severe crowding
• Multiple restorations
• Inadequate anatomy
◦ Short clinical crowns
◦ Thin incisal portion of the tooth
◦ Highly triangular crowns
◦ Little quantity of enamel
• Caries and/or bad OH
• Erupting teeth
• Untreated periodontal disease
• Angle’s class III
6- Types
• Type I
Breaks Best
◦ The most conservative
◦ Requires a thick incisal edge
◦ Allows less shape change
◦ Less thoughness = more fractures

• Type II
◦ Thicker at the incisal edge: 1,5mm
◦ Tougher: same as type III
◦ Allow greater shape changes
◦ Design of choice

• Type III
◦ Increases support of incisal porcelain
◦ Tougher under horizontal compressive forces Type II not type III
◦ Increased retention and stability
◦ Increases adhesion surface
◦ More complicated fit
◦ Pascal Magne: againt this type = type II more adequate

• Palate veneers
◦ Quite recent technique
◦ Lithium disilicate palatal veneers
‣ Election material = 0,8-1mm thickness
‣ Always monolithic (layered doesn’t make sense)
◦ Cases of erosion or attrition
◦ To avoid placing a full coverage crowns
◦ Re-establish occlusal schemes

• Sandwich veneers
◦ More expensive
◦ More time consuming (bc done separately) but more conservative
◦ Attrition dental: construction with composite then veneer
◦ Erosion dental: directly veneer

7- Preparation
• Minimal possible preparation
• Over enamel whenever possible, especially at the margin = better adhesion and less marginal leakage
• Always conditioned by the diagnostic wax-up and mock up
◦ We do a wax up and try-in then we do a silicon index
• Reduction average: depends on chosen material
◦ 2/3 incisally : 0,5mm
◦ 1/3 gingivally : 0,8mm
• Guide grooves:
◦ Special bur with 1,6-2mm depth
◦ Preserve buccal curved morphology
• Buccal preparation
◦ Deep chamfer, chamfer or rounded shoulder
◦ Maintain buccal curvature
◦ Finish line 0,3-0,5mm deep
◦ Height of finish line
‣ Yuxtagingival: if bad OH or low smile line
‣ Slight subgingival: more esthetic
‣ Recommended bur: 856
 • Proximal preparation
◦ Contact points
‣ Pascal Magne: preserve them (more conservative)
‣ Sidney Kina: opens them
• Impression doesn’t tear
• Easier to individualize dies at the lab
• Can be removed with polishing stripes
◦ The interproximal finish line should end far from visible areas
◦ We can’t see the transition between the tooth and the veneer

• Incisal preparation
◦ 1,5-2mm
◦ It’s a high stress area
◦ Be careful with lower incisors (sometimes type II-III preparation are needed)

• Variations from the standard preparation

◦ Premolars:
‣ We don’t go until central fossa —> biting with antagonist
‣ We go until the middle of the internal incline
◦ Diastema

• Lingual/palatal preparation
◦ Round tapered bur
◦ Thickness 0,5mm
A ◦ Located in incisal third
◦ Continuity with the interproximal preparation

• Finish of the preparation

◦ Remove edges/angles
◦ Open contact points with polishing strips

• Preparation of the silicone guides:

◦ Start with a regular alginate impression
◦ Wax up: over the cast obtained from the alginate impression and poured with type IV plaster
◦ The putty silicon is shaped over the wax up cast
◦ Uses for the silicon keys
‣ Mock up: show the patient the results
‣ Preparation guide
‣ Preparation of the temporary veneers: we fill the silicon index with acrylic
‣ The margins are cut with a blade to create the key that will be used for the temporary veneers to help
the material flow or for the mock up

8- Impression
• Conventional = pouring the cast with plaster • Digital = CAD/CAM
◦ Layering
◦ Pressing
◦ Extraoral scanning
‣ CAD/CAM —> Milling or Sintering

• Double retraction cord

◦ The placement of two retraction cord is needed to displace the gingiva
◦ The second chord is removed right before taking the impression
◦ The first chord stays into the gingival sulcus to keep the gingiva away from the tooth
◦ The purpose is to create a better access and reproduction of the FL
• « Pastelike » retraction materials: astringent, retraction paste
• Single step technique
◦ Taken with PVS (polyvinylsiloxane) : light body + putty silicone at the same time
• Two steps technique
◦ 1) Putty silicone impression
◦ Necessary to create space for the second step
◦ 2) light body silicone (over impression taken with putty)

9- Provisionals
• Technique is complex (low retention of provisional and low
adjustment)
• Sometimes it is not necessary (rare)
◦ All the preparation is over enamel
◦ Esthetics is not affected Acrylic resin direct provisionals
• Types:
◦ Resin composite direct provisional
◦ Acrylic resin direct provisional
◦ Acrylic resin indirect provisional

10- Laboratory procedure

• Master cast is duplicated with investment material
• Individualization of dies
• Porcelain layered veneers:
◦ From the inside to the outside
◦ Mimics the different layer of the tooth
◦ It allows the veneer to be natural
◦ May have different opacities to cover underlying color
◦ Reproduction of natural aspects of the teeth
◦ 2-3 firings and glazing

• Procera laminate veneers:

◦ Zirconia coping
◦ Doesn’t allow etching with hydrofluoric acid NOT USED !!!!
◦ Different cementation technique
◦ Feldespathic veneering porcelain

• Lithium disilicate veneers (e.max)

◦ Pressed or CAD/CAM
◦ LS copings
◦ Allows acid etching
◦ Feldespathic veneering porcelain

11- Verification
• Individual fit
• Collective fit = contact points
• Color verification = modification if needed
• Use try-in pastes or glycerin
• General appearance
12- Cementation
• Types of main veneers: feldespathic, high leucite, lithium disilicate
• Important: enamel substract is needed for good adhesion
• Final shade: also depends on the colour of the cementing agent
• Tooth and veneer: need they own preparation process
• Different material requires different cementation protocols
• Layers:
◦ Etched enamel surface
‣ Orthophosphoric acid
◦ Dentin-enamel adhesive
◦ Composite luting agent
◦ Dentin enamel adhesive
◦ Silane coupling agent
◦ Etched porcelain veneer
‣ LS: Hydrofluoric acid 10% for 20 seconds

13- Post-op instructions

• In the next 24-72h:
◦ Avoid alcohol
◦ Avoid hard food
◦ Avoid food that can stain: coffee, wine, tea
◦ Careful mastication
• Check-up after two weeks

14- Maintenance
• Check-ups every 6 months
• Thorough hygiene
• Avoid parafunctional habits
• Mouthguard for sporty people
• Night mouthguard

15- Failures
• Fractures
• Marginal leakage
• Loss of cementation
• Gingivitis
Nisrine Elouard
7. Partial coverage restorations
1- Concept

• Conservative restoration that requires less destruction of tooth structure

• Used to reinforce the remaining dental structure in cases of caries and fractures
• They are considered minimally invasive restorations
• The retention depends on the final adhesive cementation
• Types of indirect restorations:
◦ Inlay: without cusp covering
◦ Onlay: covering at least one cup
◦ Overlay: covering all cusps

2- Conventional direct restorations

• Many advantages when restoring cavities but also limitations:

◦ Specially due to polymerization contraction
◦ Even when ≠ techniques are used
‣ Slow start curing
‣ Flowable liner
‣ Incremental placement

• Consequences:
◦ GAP, due to curing contraction
◦ Secondary decay
◦ Crack propagation
◦ Cusp fracture
◦ Postop sensitivity

• Factors influencing the polymerization shrinkage

◦ Cavity size
◦ Cavity shape
◦ Adhesive technique
◦ Material application: type of light, intensity, time, material used…

• Light curing: 2 phenomenons

◦ Light curing: when applying the light, there is a 50% of polymerization
◦ Dark reaction: after light curing, between 10min and 48h, the material still polymerize to 100%
◦ That is why the ideal is to wait 48h before the polishing of the surface, or ideally 10 min so the
polymerization process reaches a 75%
◦ The thickness reached by the light is 2mm
◦ The distance between the lght and the composite should be 1-2mm = minimal distance without touching
◦ The emission spectrum is very important for the result:
‣ Halogen: 350-400 NM = covers and cure the 3 catalizers
‣ Plasma: 460-480 NM = only activates the camphorquinone compound
‣ Laser: No use
‣ LED, 2° gen: 430-490 NM = only activates the camphorquinone, not all the photoinitiators
‣ New LED, 3rd gen: works with all different activators, covers […] spectrum
◦ Recommendation for light curing unit:
‣ Wavelength: 400-500 NM
‣ Max wavelength: 460-480 NM = in order to activate the camphorquinone
‣ Light output 800-1000mW/cm2, to reduce timings
‣ Periodical verification of the light density: halogen and plasma
‣ The LED type bulb: practically no power loose with the time
3- Types of partial coverage restorations

• Inlay
◦ Used for smaller cavities
◦ No cusp coverage
◦ It can result more aggressive during the preparation than a direct composite filling
◦ Still comme controversy for class II MO/OD
◦ Porcelain, resins, hybrid materials
• Onlay
◦ Onlay
‣ Includes cusp coverage
‣ At least one cusp is covered
‣ Indicated for the restoration of big cavities with remaining axial surfaces
‣ Porcelain, resins, hybrid materials
◦ Overlay
‣ A type of onlay
‣ Full cusp coverage = all cusps
‣ Also used in cases of full arch rehabilitation with VD increase
◦ Veneer onlay / overlay
‣ Same as onaly and overlay
‣ But covering the buccal surface
‣ High esthetic demands
• Endocrown
◦ Exclusive option of endo teeth
◦ Full coverage cusp
◦ No post nor pin
◦ Uses the pulp chamber for:
‣ More adhesive surface
‣ More macro-retention
◦ More conservative option than FCC
◦ Materials properties
‣ Elasticity modulus similar to the tooth
‣ High mechanical strength
‣ Bonding strength to the underlying structure
• Indications:
◦ Medium to large sized cavities with one or more cusps missing
◦ Cavities where the cusp coverage is advisable for a better prognosis
◦ Morphological modification and/or raising the posterior occlusal vertical dimension
◦ Cracked tooth syndrome, when the symptomatology needs to be managed with the aim of maintaining the
vitality of the tooth.
• Recommendation for a full coverage of the cusps: more indicated when
◦ Parafunction
◦ Upper endo premolars
◦ Less than 2mm thickness of the wall
4- Preparation steps

1) Remove the pathological and decayed tissue

2a) Build-up
• Filling the missing or inadequate areas
• With a nanohybrid composite
• Purpose
◦ Reducing the bur reduction
◦ Eliminate retentive areas
◦ Lift cavity floor = floor is higher
◦ Create better access to the curing light
◦ Strengthen the cavity

2b) Relocation of the margin if necessary

• Consist in elevating the margin of the preparation
• During the build-up step, and with the same nanohybrid composite
• Indications:
◦ If no good insulation is possible
◦ If a good impression can’t be taken (conventional, digital)
• Use of a rubber damn to control and isolate the working area
• Dry environment for proper adhesive techniques
• Use of a matrix for a good emergency profile
• If the biological width was invaded, consider crown lengthening / ortho extrusion

3) Preparing the cavity for the final restoration

• In this type of restoration = retention depends on the adhesion
• The shape of the preparation must be expulsive to admit a good adaptation of the restoration (≠ retentive)
• The adhesion is between the internal surface of the tooth and the external surface of the restoration, opposite to
the crown
• The shape and size is mainly related to the pathological tissue
• Minimal occlusal thickness for the restoration of 1,5mm
• Thickness at the base of the cusp : 1,5-2mm, if not enough = remove
• Residual surfaces of at least 2mm, if not enough = remove

• Buccal cusp coverage

◦ Ultraconservative preparation
◦ Conventional buccal cusps coverage
◦ Full buccal cusp coverage

• Minimum width of the isthmus of 2,5mm

◦ To avoid fractures of the restoration
◦ Rounded angles

• Expulsive shape of the cavity for a good insertion and settlement

◦ Taper of the internal walls 6-10°
◦ Rounded angles
• The anatomical contour of cusps and sulcus must be respected, always with smooth transitions
• Enough prosthetic space
◦ 2mm of restorative material is needed in the cusps areas
◦ With LS: 1,5mm sufficient
• Contact points must be open
• Recreate a good anatomy and new contact point with the restoration
• The bigger the distance with the adjacent tooth, the bigger the interproximal box
should be to recreate correctly the anatomy

• When no remaining walls during the preparation and build-up step, create indexations : to gain retention
◦ Puzzle making : we make grooves on the tooth so it doesn’t move
• Preparation far from pulp
• Criteria for cavity approval:
◦ Detailed sharp margins
◦ Absence of undercuts
◦ Accessibility of subgingival margins
◦ Absence of contact between the cavity and the adjacent teeth
◦ Adequate interocclusal space in centric and during lateral movements.

5- Materials

• Composites
◦ Layering: semidirect or indirect
◦ Milled: more resistant than layered
• Ceramics

I
◦ LS: choice = etch + resistance + esthetic
◦ Leucite and feldespathic: not for posterior teeth
• Hybrids
◦ Nanoceramic resin: Lava Ultimate
‣ Resin nano-ceramic material
‣ Resists chipping and cracking during the milling
‣ No post firing step needed
‣ High luster
‣ Easily abraded
‣ Pro: elastic moduluc similar to dentin
‣ Cons: we can loose easily our contact and guidance
◦ Ceramic with resin: Vita Enamic
‣ Hybrid ceramic
‣ Ceramic strengthened by a polymer
‣ High load capacity after bonding
‣ High elasticity module
‣ More aesthetic because of its ceramic composition
‣ The composite filling suffers a high level of wear
‣ The result is the exposition of the ceramic crystals creating a more abrasive restoration
‣ Requires hydrofluoric acid etching and silane

• Selection criteria
◦ Mechnical properties
‣ Flexural strength: capacity to withstand forces in the longitudial axis between to support points
‣ Hardness: hard materials are more difficult to polish
‣ Modulus of elasticity: the closer to the natural structure, the better
◦ Optical properties
‣ Must reproduce the natural colour of the restored tooth
‣ Translucency: materials with different translucencies
• Low translucency materials
• High opacity materials
• More thickness of the preparation leads to more opacity
‣ Fluorescence: spontaneous emission of light after exposure to an UV light source, more vital result
• Ceramic vs hybrid materials = LS better than hybrid (adhesion is not that good)
6- Impressions
• With addition silicon, PVS
• Putty and light body silicone for details
• The antagonist is needed for the occlusion
• No gingival retraction is needed because of the supragingival margins

7- Provisionalization
• Complicated technique because we have no retention from the cavity
• We provisionalize to: protect the tooth and avoid non-desirable movements
• Option A: Acrylic provisional —> Direct provisional technique with silicon key
◦ Prepare a silicon key before the preparation
◦ With putty silicon over the unprepared tooth
◦ Once we have the preparation and the impression
◦ Place bis-acrylic resin into the needed area of the silicon key
◦ Place it into the mouth and wait for it to dry
◦ We can gain some retention with one point of adhesive in the middle of the preparation
◦ Time consuming technique
◦ Complicated to achieve retention
• Option B: Provisional composite
◦ Apply in the center of the preparation one point of adhesive
◦ Shape a bulk of composite over the preparation
‣ Semi-rigid specific light curing materials for provisional restorations
‣ Telio CS Inlay (Ivoclar): used for provisional in class I and II

8- Laboratory procedures
• Layering
◦ Inherent errors similar to the direct technique
◦ The lab heat curing process provides better extraoral properties
• Milling: CAD CAM
• Pressed

9- Cementation

1) Isolation: control of the operative field, humidity, security, optimization of the adhesion, real 4 hands work
2) Surface conditioning
• Preparation of the cavity
• Dentin sealing Conditioning —> we seek for:
• Cavity building and marginal relocating • Micromechanical retention
• Final dental preparation • Chemical adhesion
• Substrate conditioning:
◦ Enamel
‣ Selective enamel etching with orthophosphoric acid 37% 30sec
‣ Rinse with water
‣ Absolute drying
‣ Adhesive (bonding) = last step before the bonding
◦ Dentin
‣ Much more sensitive to the technique = isolation
‣ Follow instructions
‣ Self-etching adhesive, 2 steps = less sensitive to the technique and good results
◦ Composite
‣ 1) Sand blasting to create micromechanical retention: AlOx 30-50 microns
‣ 2) Etching
‣ 3) Application of bonding: the one that comes with adhesive
• Restoration conditioning: ceramic, hybrid materials
• Cements requirements:
◦ Marginal fit
◦ Low solubility in the oral cavity
◦ Radiopacity
◦ Working time
◦ Viscosity
◦ Aesthetic properties
• Types of resin cement
◦ Microhybrid composites: preheated up to 55° (Z-100, tetric basic, Herculite XRV)
◦ Light curing resin cements (VarioLink Esthetic, Relyx Veneer…) —> Watch out for lamps /!\
◦ Dual curing cements
Nisrine Elouard

8. Bridges I
1- Partially edentulous patient characteristics

• Etiology
◦ Traumatisms
◦ Caries
◦ Peridontal disease
◦ Orthodontic
◦ Prosthodontics
• Multiple clinical situation with different circumstances in each patient
• Indications and contraindications (general and local) of fixed prostheses

A) Treatmeent planning of FPP

• Key to success
• It must be based on a perfect diagnosis of our patients:
• Clinical history
◦ Exploration
◦ Radiology
◦ Diagnostic cast on the articulator
• Justification
◦ Anterior sector: esthetics
◦ Posterior sector: mastication
◦ Occlusal stabilization or archs
• Advantages
◦ Firm union
◦ Esthetic
◦ Comfortability
◦ Splitting action To restore lower incisors = only C
◦ Physiological transmission of forces To restore upper incisors = C & 1PM
◦ Better hygien than PPR (longest bridge allowed to do)

2- FPP Concept

• Fixed dental bridge: fixed dental prosthesis used to replace a missing tooth/teeth by using abutment teeth on
both sides of the edentulous space.
• Other rehabilitation options for partial edentulism
◦ RPD
◦ Maryland bridge (not long-term)
◦ Implant fixed partial prosthesis

A) Bridge elements

• Abutment
◦ Primary
◦ Secondary
• Retainer
◦ Standard: PFM crown or high strength ceramics (monolithic or veneered)
◦ Know well all the materials
◦ Know unitary crowns indications
◦ Same retention on each abutment
◦ Secondary abutment: same or greater retention than primary
 ◦ Intracoronal retainers: Inlay/onlay
‣ Less retentive and resistant
‣ More conservative
‣ Esthetic better in full coverage
◦ Extracoronal retainers:
‣ Partial coverage crown ‣ Advantages
• Low retention • Firm attach
• Low stability and esthetic • High stability
• In disuse • Comfort for the patient
‣ Adhesive bridge = Maryland • Aesthetics
• Provisional • Better load transfer to abutment than RPDs
• Also definitive but not good ‣ Disadvantages
‣ Full coverage crowns • Less conservative preparation
• Metallic ‣ Indications: Full coverage crowns (most common)
• PFM ‣ Retentive requirements:
◦ Complete veneered • Large bridges
◦ Partially veneered • Short preparations
• All ceramic
◦ Monolithic
◦ Complete veneered
◦ Partially veneered

• Pontics: « The pontic or artificial tooth constitutes the reason to be of a fixed partial prosthesis »
◦ An artificial tooth on a fixed dental prosthesis that replaces a missing natural tooth, restores its function,
and usually fills the space previously occupied by the clinical crown maintaining the tissues health of the
edentulous area
◦ Depends on the correct design
‣ Correct anatomy in terms of shape and contour that ensure correct function
‣ Permit proper hygiene
‣ A relationship with the gingival mucosa that keeps it in constant health
◦ Not a simple replacement:
‣ Dental loss
‣ Alveolar ridge resorption
‣ Morphological changes in hard and soft tissues
‣ Pontic adaptation to the alveolar ridge shape
◦ Purposes:
‣ Restore masticatory function
‣ Restore esthetic
‣ Facilitates hygiene and health of surrounding tissues
‣ Comfort
‣ Restore phonetics
◦ Types of pontics:
‣ Ridge lap: old one, provokes gum swelling
‣ Conical pontic: so thin so not good for phonetics
‣ Modified ridge lap: removal of palatal aspect
‣ Hygienic pontic: food gets stuck, not used anymore
‣ Ovoid pontic: most commonly used

◦ Anterior sector: Ovoid

◦ Posterior sector: Ovoid or modified ridge lap
 • Connectors:
◦ Part that joins the different parts of the bridge
‣ Pontic - retainer
‣ Pontic - pontic
‣ Retainer - retainer
◦ Rigidity
‣ Adequate diameter and minimum surface according to material used
• Metal: 4mm2 (2x2mm)
• High strength ceramic: 16mm2 (4x4mm)
• Zirconia: from 7 - 9 - 12mm2
‣ Correct shape: the more resistant is the triangular shape, where the vertical axis is the bigger
◦ Width
‣ 1/3 to 2/4 of the B-P diameter
‣ Also depends on the FPPM length and alloy material
◦ Height
‣ Joins at the medium third, slightly below the fossae of the retainers
‣ Far from the papilla to create embrasures for the hygiene (adecuadas troneras)
◦ Fixed-fixed: PFM or porcelain
◦ Fixed-Removable: Interlock
‣ Only PFM
‣ Patrix in the pontic
‣ Matrix in abutment
‣ When they come from the lab they are separated = dentist place them together
‣ Indicated in long bridges and very curved arch

3- Factors to assess in FPP

A) Indications and contraindications (general and local) of fixed prosthesis —> review lesson 1
B) Occlusal pathologies from a prosthetic point of view —> review occlusion

C) Assessment of abutment teeth

• Pulp vitality
◦ Optimum situation: vital tooth, without caries or restorations
◦ If endo treatment: can be used for FFP if asymptomatic and perfect X-RAY
‣ Ferrule effect: very important
‣ FPP abutments with endodontic treatment fail twice as much than when teeth are vital, even with
ferrule effect —> if more than 1 pontic: not consider as abutment tooth
A ‣ Some people state that every abutment teeth has to undergo endo when bridges = FALSE!!!
‣ Indications:
• When it can be foreseen that preparations will get into pulp
• Accidental pulp exposure
• Assessment of the clinical crown
◦ Integrity
‣ Ideally: no caries, no abfractions, erosions, abrasions or restorations. If not good resto: repeat them
‣ Not leave caries in a tooth destined to be an FPP abutments = will need endo in the future
‣ Teeth with large reconstructions can be abutments and if previous endo = preferable to put a post
◦ Morphology
‣ Should not be expulsive
• Because no survey line
• Survey line below the gingival margin
◦ Ex: gingival hyperplasia, not complete eruption (consider crown lengthening)
◦ Size or volume
‣ The clinical crown must be with an adequate volume to provide good retention and stability
‣ Height of the crown must be equal to or bigger than the width
 ◦ Position
‣ Ideally, abutment teeth shouldn’t be inclined, with no rotation and parallel to the other, existing or
allowing a correct path of insertion to the bridge
‣ Tooth preparation can correct inclination to a certain degree

• Assessment of the anatomical crown

◦ The ideal fixed prosthesis abutment is one whose anatomical crown (enamel) is identical or similar to the
clinical crown
◦ Finish line over enamel whenever is possible
◦ Generally, amelo-cemental union is within the gingival sulcus. In this way, the finish line, even in cases
where it is indicated subgingivally, will be carried out on enamel

• Periodontal condition
◦ Radiological assessment should yield images with:
‣ Even periodontal ligament
‣ No bone resorption
• Slight horizontal resorption due to periodontal disease is tolerable if disease controlled
• Slight vertical resorption due to occlusal trauma is tolerable if is removed with new restoration
‣ Support bone in sufficient quantity and normal quality, with a well inserted root surface
‣ No periapical radiolucencies, no root resorptions, no cementomas or hypercementosis
ok
◦ Crown to root ratio
‣ Must be assessed radiographically, measure from bone crest level
yes
‣ Ideally 2:33
‣ Minimum acceptable: 1:1
‣ Has to be considered together with
• Antagonist arch (CD, FD) yes ok if curved
• Periodontal condition of antagonist arch roof
• Length of the edentulous space (assess secondary pillars)
‣ Single rooted teeth
• Oval section ones (PM) are better than round (I)
• Conical and straight can be used as an abutment but roots with a certain curvature in the
apical third are preferable
‣ Multirooted teeth yes No
• Divergent roots and separated are better than fused ones
—> Better perio support

◦ Root surface areas (Jepsen)

Upper : 1M > 2M > C > 1PM > 2PM > CI > LI

Lower : 1M > 2M > C > 2PM > 1PM > LI > CI
D) Assessment of edentulous spaces

• Number of abutment teeth necessary for the retainers

◦ Depends mainly on the length of the edentulous space and the support condition of the retainers
• Appropriate morphology of the pontics in the underneath surface
◦ Depends mainly on the alveolar ridge of the edentulous space
• Bridge biomechanics characteristics (alloy, thickness of the pontics and connectors, type of connectors)
◦ Depends on the length and location of edentulous space and disposal of the abutments
• Length
◦ The longer the greater the load
‣ Ante’s law: « The total periodontal membrane area of the abutment teeth must equal or
exceed that of the teeth to be replaced »
‣ Cantilever bridge: replace upper LI with C = only bridge with one abutment

◦ 1 tooth missing: very good prognosis

◦ 2 teeth missing: good prognosis
◦ 3 teeth missing: unfavorable prognosis
◦ 4 teeth missing: not indicated, except 4 lower incisors
‣ Canines as abutments = enough
◦ Failure of long bridges:
‣ Periodontal ligament overload
‣ Failure of the materials
‣ Biomechanical failure: excess of lever or torque

• Shape
◦ Straight spaces: more favorable —> posterior sectors
◦ Curved spaces: unfavorable —> anterior sector
‣ Ex: Upper front teeth = require using more teeth
◦ In cases of ridges with notable deformities, periodontal pastic surgery is usually necessary to correct
the defect before installing the bridge
◦ Siebert alveolar ridge classification:
‣ Class I: horizontal, width loss
‣ Class II: vertical, height loss
‣ Class III: combination
◦ Occlusal load = behaviour is different between both arches
‣ Upper: occlusal load will tend to spread abutment teeth (buccal)
‣ Lower: occlusal load will tend to gather abutment teeth (lingual)
• More favorable: better prognosis
• Better bone quality, better support

◦ Sometimes it is necessary to gain prosthetic space by modifying antagonists and/or removing part of the
gingival tissue from the edentulous space
‣ Mounting models for previous study and diagnosis is required
◦ Other times the prosthetic space may be excessive, making aesthetics difficult in the anterior sector
‣ Periodontal plastic surgery
E) Biomechanical considerations

• Occlusal load will bend the bridge towards the ridge

◦ Deflection
• Tension over retainers of the pillars which result in torque over abutments
◦ Affects retainer-pillar joint (cement)
• Lever effect consequences: luxation of the abutment teeth (on curved edentulous spaces: 4 incisors)
◦ Affects pillars-bone joint (luxation)
• Minimize deflection to preserve the health of abutment teeth, how ?
• Factors that condition how much the bridge bends:
◦ Length of the bridge
‣ The greater length of the bridge, the greater the deflection
‣ Longer pontics are less rigid
‣ Bending is directly proportional to the cube of the length
‣ 1 length pontic = 1P^3 = 1x
‣ 2 length pontics = 2P^3 = 2x2x2 = 8x
• Eight more time deflection if the span length is doubled
‣ 3 length pontics = 3P^3 = 3x3x3 = 27x
• The deflection is 27x bigger if the length is 3x longer

◦ Thickness of the bridge

‣ The less thick the bridge, the more deflection
‣ Deflection is inversely proportional to the cube of the thickness
‣ A pontic that is half as thick as another will deflect 8x more

How to minimize torque over abutments ?

‣ Pontic design
• Greater thickness of the internal structure
• Monolithic
‣ Materials with greater rigidity
• More resistant ceramics (polycrystalline)
• For long = base metals (CrCo, CrNi)
‣ Using more than one abutment tooth, whenever necessary (without overtreatment)
• The secondary abutment will have to support tensile forces when the pontic flexes
• Crown to root ratio: equal or bigger than primary
• Bone support: equal or bigger than primary
• Periodontal health: better or equal
• Retentive capacity: higher or equal
 ◦ Curvature of the bridge
‣ When pontics are away from the line that joins the retainers = more lever arm, more risk of torque
‣ The longer the lever arm, the more torque and luxation
‣ To counteract these lever forces we must use additional retainer

◦ Materials (lesson 3 and 4)

4- Prosthetic diagnostic index

A) Location and extension of edentulous areas

• Ideal edentulous area or minimal compromised = one arch with

◦ Anterior sector maxilla : loss of no more than 2 incisors
◦ Anterior sector mandible : loss of no more than 4 incisors
◦ Posterior sector : no larger than 2 premolars or 1 molar + 1 premolar

• Moderately compromised edentulous area = both arch with

◦ Anterior sector maxilla : loss of no more than 2 incisors
◦ Anterior sector mandible : loss of no more than 4 incisors
◦ Posterior sector : no larger than 2 premolars or 1 molar + 1 premolar
◦ Loss of an upper or lower canine

• Edentulous area considerably compromised = both arch with

◦ Posterior sector: more than 3 teeth or 2 molars
◦ Edentulous area with more than 3 absences in a row
◦ In post sectors: no larger than 2 premolars or 1 molar + 1 premolar
◦ Loss of upper or lower canine

• Severely compromised area

◦ Any edentulous area or combination of them where the care is critical for the patient

B) Condition of abutment teeth

• Ideal edentulous area or minimal compromised

◦ Do not require pre-prosthetic treatment
• Moderately compromised edentulous area
◦ Insufficient tooth structure to retain intracoronary restorations in 1 or 2 sextants
◦ Abutment teeth require pre-prosthetic treatments in 1 or 2 sextants:
‣ Periodontal treatment
‣ Endodontic treatment
‣ Orthodontics
• Edentulous area considerably compromised
◦ Insufficient tooth structure to retain intracoronary or extracoronary restorations in 4 or more sextants
◦ Ortho, perio, endo treatments in 4 or more sextants
• Severely compromised area
◦ Uncertain prognosis of the abutment teeth

C) Occlusal scheme

• Ideal edentulous area or minimal compromised

◦ They do not require pre-prosthetic treatment
◦ Angle class I
• Moderately compromised edentulous area
◦ Trata. Coadyuvante localizado (ejm. Tallado selectivo contactos prematuros).
◦ Angle class I
• Edentulous area considerably compromised
◦ Modification of the occlusal scheme without changing the OVD
◦ Angle class II
• Severely compromised area
◦ Modification of the occlusal scheme changing the OVD
◦ Angle class I division 2 or class III

D) Alveolar ridge remaining

• Class I: horizontal, width loss

• Class II: vertical, height loss
◦ Hard to treat
◦ Bone graft from mandible or soft graft
◦ Or pink porcelain = bad hygiene
• Class III: combination
◦ Most frequent

E) Classification system

• Class I
◦ Ideal cases or minimal compromised
◦ All 4 criteria are favorable:
‣ Location and extension of edentulous area: ideal or minimum compromised
‣ Condition of abutment teeth: idea or minimum compromise
‣ Occlusal scheme: iral or minimum compromised
‣ Alveolar ridge: class I
• Class II
◦ Location and extension moderately compromised (both arches)
◦ Abutment teeth require treatment
◦ The occlusal scheme requires treatment
◦ The 4 criteria:
‣ Location and extension of edentulous areas: moderately compromised
‣ Condition of abutment teeth: moderately compromised
‣ Occlusal scheme: moderately compromised
‣ Alveolar ridge : Class II
• Class III
◦ Significantly compromised in location and extension (both arches)
◦ Abutment teeth require treatment
◦ Occlusal scheme require treatment without OVD modification
◦ 4 criteria:
‣ Location and extension of edentulous areas: significantly compromised
‣ Condition of abutment teeth: significantly compromised
‣ Occlusal scheme: significantly compromised
‣ Alveolar ridge : Class III
• Class IV
◦ Severely compromised in location and extension with uncertain prognosis
◦ Abutment teeth require large treatments
◦ The occlusal scheme require treatment with OVD modification
◦ 4 criterias:
‣ Location and extension of edentulous areas: severely compromised
‣ Condition of abutment teeth: severely compromised
‣ Occlusal scheme: severely compromised
‣ Alveolar ridge: Class III
Nisrine Elouard
9. Bridges II

I. Abutments and materials in FPP according to location and nb of absences in the arches

ONE INCISOR MISSING

A) Healthy abutments

• Most common used retainers: crowns

• Exceptionally: Maryland
• One retainer on each side of the pontic
• Materials: CrCo maximum rigidity
• Biomechanical tips
◦ Pontics without contacts in eccentric movementss
◦ Contacts in M bc it avoids extrusion of the antagonist
◦ If the resistance requirements increase by small teeth, parafunctions…
‣ Select more resistant materials (Zr + monolithic)
◦ LS bridges: 3 tooth maximum = anterior only (never post !!!)
◦ Zirconia = anterior and posterior

B) Abutments with affectations and special situations

• If the first abutment is compromised we use a secondary abutment

◦ Lack of retention (short abutment, too much conicity)
◦ Periodontal health not at 100%
◦ Parafunctions (overload)
• Secondary abutments characteristics
◦ All the abutment must have the same retention, when it is not homogeneous, it is used a secondary
abutment, located immediately next to the first abutment to increase retention on that side of the bridge
◦ More healthy or equal than primary abutment
‣ Crown to root ratio
‣ Retentive capacity
◦ Together, the capacity of one sector of the bridge abutment must be homogeneous with the other sector
• Not necessary on both side, only when the primary abutment needs help

• Adhesive retainers: undamaged teeth and without malposition —> Maryland bridge
◦ Only anterior sector
◦ Wings: Metal
◦ Crown: PFM
◦ Not long term treatment : 3-6 months
• Cantilever bridges with only one abutment: to replace LI and avoid preparation of CI
◦ Bad prognosis
◦ Not definitive
◦ Wait for implant placement
◦ Replace LI with canine as abutment
• Cantilever bridges with several abutments
◦ To minimize problems in cases of intermediate abutments
◦ Treatment with implants is an alternative
◦ All cantilever bridges generates a high load on abutments = always avoid if possible
◦ Always place cantilever in the mesial side of pontic = avoid lever effect
◦ Width M-D pontic (d) = half of width M-D retainer (D)
‣ This principle must be accomplished in all cantilever bridges
• Biomechanics tips in cantilever bridges
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
◦ High resistance demand
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials is difficult to achieve aesthetics, especially in teeth with great characterization
‣ Veneered even only in vestibular
◦ Assess substrate color
UPPER LATERAL AND CENTRAL INCISORS MISSING

A) Healthy abutment: Central incisor and canine

• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
◦ Having two pontics: greater demand on the material
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials is difficult to achieve aesthetics, especially in teeth with great characterization
‣ Veneered even only in vestibular
◦ Assess substrate color

B) Abutments with affectations and special situations

LOWER CENTRAL INCISORS MISSING

A) Healthy abutment

• Most common used retainers: crowns

• Retainers on each side of the pontic
• Maryland bridge in LI = exceptional
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
◦ Having two pontics: greater demand on the material
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials is difficult to achieve aesthetics, especially in teeth with great characterization
‣ Veneered even only in vestibular
◦ Assess substrate color

B) Abutments with affectations and special situations

ALL LOWER INCISORS MISSING

A) Healthy abutment

• Most common used retainers: crowns in loveronly

• Retainers on each side of the pontic = Canines enough if healthy (≠ upper = C + PM)
• Maryland bridge in LI = exceptional
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
◦ Having four pontics: greater demand on the material
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Only if a lot of thickness and no parafunctions
‣ Difficulty to achieve aesthetics, especially in teeth with great characterization
‣ Veneered even only in vestibular
◦ Assess substrate color

B) Abutments with affectations and special situations

abutment
secondary

weak
1ST UPPER/LOWER PM MISSING

A) Healthy abutment

• Most common used retainers: crowns

• Retainers on each side of the pontic
• When there is no adequate canine guidance and we want to provide it with the new bridge
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp

B) Abutments with affectations and special situations

1ST UPPER/LOWER PM MISSING IN CANTILEVER

• Retainer: crowns
• Healthy abutments
• Ideal abutment in perfect condition
• If it is correctly restored, it is possible with a greater risk (slide 31)
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp
2ND UPPER/LOWER PM MISSING

A) Healthy abutment

• Most common used retainers: crowns

• Retainers on each side of the pontic
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp

B) Abutments with affectations and special situations

1ST UPPER/LOWER MOLAR MISSING

A) Healthy abutment

• Most common used retainers: crowns

• Retainers on each side of the pontic
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp

B) Abutments with affectations and special situations

1ST AND 2ND UPPER/LOWER PM MISSING

A) Healthy abutment

• Most common used retainers: crowns

• Retainers on each side of the pontic = first molars and canine
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp

B) Abutments with affectations and special situations

Secondary abutment needs to be better or equal than the primary abutment = not the case of LI not worth it
2ND PM AND 1ST MOLAR MISSING (UPPER & LOWER)

A) Healthy abutment

• Most common used retainers: crowns

• Retainers on each side of the pontic = 1st premolar and 2nd molar
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp

B) Abutments with affectations and special situations

1ST, 2ND PM AND 1ST MOLAR MISSING (UPPER & LOWER)

A) Healthy abutment

• Most common used retainers: crowns

meanie
• Retainers on each side of the pontic = 1st premolar and 2nd molar
• The clinical crowns of the abutments must be long, perfectly aligned with peridontal status
optimal
• One of the most complicated bridges
• The occlusion will be canine guidance
• The rigidity will be maximum (CrNi)
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp

B) Abutments with affectations and special situations

FPP that require more than 2 abutments
• In complex FPP, the dynamic commitment of the teeth to replace makes the demand higher on the abutment
teeth
• We increase their number to two on each side or one side

LOWER LATERAL AND CENTRAL INCISORS MISSING

A) Healthy abutment

• Most common used retainers: crowns

• Retainers on each side of the pontic = central, lateral incisors and canine
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
◦ Canine guidance can be given
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp

B) Abutments with affectations and special situations

UPPER AND LOWER CANINE MISSING

A) Healthy abutment

• Most common used retainers: crowns

• Retainers on each side of the pontic = central incisor, lateral incisor and 1st premolar
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
◦ NO CANINE GUIDANCE
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp

B) Abutments with affectations and special situations

• The position of the arch is conflictive

• The occlusal scheme to be restored will be a group function, never canine guidance !!!
• It is not recommended to use 2 premolars and one lateral incisor, since the crown to root ratio of the lateral is
less and will be overloaded
• Bridge with special difficulty due to biomechanical aspects
UPPER CENTRAL INCISORS MISSING

A) Healthy abutment

• Most common used retainers: crowns

• Retainers on each side of the pontic = canine and lateral incisors on each side
• For lower central incisors missing = only lateral incisors would be enough
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
◦ Canine guidance can be given
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp
◦ Not LS = more than 3 teeth
UPPER/LOWER LATERAL INCISOR AND CANINE MISSING

A) Healthy abutment

• Most common used retainers: crowns

• Retainers on each side of the pontic:
◦ Upper: both central incisors + 1PM + 2PM
◦ Lower: both central incisors + 1PM
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
◦ NO CANINE GUIDANCE = group function
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp

B) Abutments with affectations and special situations

UPPER/LOWER CANINE AND 1ST PM MISSING

A) Healthy abutment

• Most common used retainers: crowns

• Retainers on each side of the pontic:
◦ Upper: CI + LI + 2PM + 1M
◦ Lower: CI + LI + 2PM
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
◦ NO CANINE GUIDANCE = group function
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp

B) Abutments with affectations and special situations

MISSING IN THE UPPER ANTERIOR SECTOR

A) Healthy abutment

• Most common used retainers: crowns

• Retainers on each side of the pontic
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
◦ Canine guidance can be given
◦ Forces from palatal
‣ Beware patients with bruxism
• Materials
◦ CrCo: maximum rigidity
◦ With monolithic materials:
‣ Veneered even in vestibular only if there is esthetic demand
◦ If you doubt about the prosthetic space or parafunctions, go safe and use the more resistant ceramic
‣ Zirconia for cores 1200Mp
‣ Remember that the monolithic (translucent) less resistance 800Mp
‣ If made of zirconia = only milling (pressing only for leucite and LS)

B) Abutments with affectations and special situations

(≠ than lower incisors missing where only canine enough if healthy)

1ST PM AND 1ST MOLAR MISSING = INTERMEDIATE ABUTMENT

• If the canine is healthy and provides a canine guidance —> CANTILEVER

◦ Abutment: 2PM and 2M without preparation on the canine
• Width M-D pontic (d) = half of width M-D retainer (D)
◦ This principle must be accomplished in all cantilever bridge

• If there is no canine guidance —> INTERLOCK

◦ 5 pieces bridges with interlock in distal of 2PM (intermediate abutment)
• Concept
◦ Primary element: MATRIX = Distal surface of the retainer
◦ Seconday element: PATRIX = Mesial surface of the pontic
◦ Can’t be removed, it is fixed
◦ Two parts joined, a certain lability or resilience = stress breaker
• The retainer attached to the matrix is the one that will intrude
◦ It will not transmit vertical forces to the other retainer
• The connector therefore acts as a stress breaker
• Frequent complication is the intrusion of one of the parts, usually the matrix
• Indications:
◦ Intermediate abutment
‣ Fulcrum, great strength
‣ Ex: 17 — 15 (distal) — 13
◦ Unparalleled abutment teeth = 3 solutions
‣ Best: ortho
‣ 2nd: very invasive preparation with RCT to make teeth less inclined
‣ Or interlock
◦ Separate straight section from curved section
◦ Teeth with different periodontal resilience
• Where is the interlock placed ?
◦ The forces have an oblique component with an anterior direction during mastication, so the patrix impacts
and fixes on the bridge.
◦ Otherwise, it would tend to separate and decement

• Most common used retainers: crowns

• Retainers on each side of the pontic
• Biomechanical tips
◦ Pontics without contacts in eccentric movement
◦ Contacts in MI: bc it avoids extrusion of the antagonist
◦ Canine guidance if the canine is present
◦ Group function if the canine is absent
• Materials
◦ CrCo: maximum rigidity —> only choice due to attachments (LS and Zr never !!!)
‣ Casting: lost wax technique
‣ Milled
FPP WITH PONTICS IN EXTENSION IN DISTAL (CANTILEVER)

• 1 pontic + 2 retainers = lever (beware occlusion)

• Nowadays they are obsolete —> implants
• Usually 6 and 7 missing and absence of bone for implants —> very bad prognosis
• Indications:
◦ Kennedy class II
‣ Abutment 4 and 5 + pontic 6
‣ Abutment 4, 5 and 6 + pontic 7 = better to not restore 7

Good cantilever = replace LI with only canine as abutment

SPLINTING

• Rigid joint of two ore more teeth which may be adjacent (splinting two continuous teeth) or not (splinting several
abutment teeth with multiple edentulous spaces in the arch)
• Splinting may be more or less extensive, the greater the extension, the more difficulty
• Indications are very limited:
◦ Crown in 2 adjacent teeth, one of them presents unsuitable conditions regarding the future
retention of the restoration. It is recommended to use adhesive cementation
◦ Crown in 2 adjacent teeth, one of them has a unsuitable periodontal support in relation to the
occlusal loads that it will have to bear. Typical case of LI
◦ Splinting of adjacent teeth in cases of combined prosthesis in free-ended endentulous space
‣ Biomechanics similar to a cantilever
‣ If the attachments is on 1PM: canine as secondary abutment
‣ If the attachment is on a C:
• Canine is perfect periodontally and intracoronary attachment = without splinting
• Canine has not 100% support or extracoronal attachment = splint with LI and CI
• When the two attachments are placed on the canines: splint all anterior teeth
◦ Temporary crowns: not very retentive —> always splinting

When?

• Mobility grade I with good perio

• Short crowns not retentive
• In implants = always splint
• Free ended for combined
• Temporary crowns

FULL MOUTH SPLINTED REHABILITATIONS

Indications:
• When mobility present, in very well selected cases and with experience
◦ Certain cases of periodontal disease due to loss of support and mobility grade I
◦ In mobility due to occlusal trauma
◦ In combination of the previous two
◦ In certain and very rare cases it is possible to consider the prosthetic treatment of the whole arch with a
semi-rigid splinting of all the abutment teeth
• To earn retention between them
• To achieve suitable occlusal surfaces with the objective of not causing occlusal trauma
• These cases are highly risky and can only be carried out if the periodontal disease if perfectly
controlled

• No degree subject
• Avoid whenever is possible
◦ Difficult to achieve path of insertion
◦ Different resilience of the teeth
◦ If a problem appears in one tooth it means raising the rest
II. Clinical sequence in FPP

Case 1

• Bridge from 13 to 15 decemented

◦ Abutments: 11-12-14
◦ Cantilever pontic 15
◦ 11 and 12 decapitated
• Take a silicone key with the old bridge in the mouth for a direct provisional
• Reconstruction with post and composite
• The abutment teeth are prepared with the BOPT technique
• Provisional with bisacrylic resin, it is removed the 15 of the provisional
• Final impression (stable tissues) one step impression with polyvinylsiloxane
• Casting to obtain master cast
• Scanning of the cast with an extraoral scanner —> partial digital workflow
◦ Digital model is obtained in STL format
• With the software « EXOCAD », design of FPP is made
◦ Monolithic Zr veneered with make up
◦ A bio copy is made from 21 to 24 with the software so they are symmetric
‣ Occlusion is adapted (MI)
• Software sends design to CAM phase
• The structure is milled, sintered and make up
• It is checked in the physical cast
• In the final design, it is eliminated the pontic in extension
• Adhesive cementation is made for Zr : Sandblasting and dual curing resin cement with MDP
Case 2

• Patient treated with crowns of 15 to 25 (FPS of 12-11-21) and partial restorations in posterior sectors
◦ Mounting in CR because increase of OVD
• Lithium disilicate veneered in vestibular —> cut back technique
• Indirect provisionals with veneered PMMA

• Two steps impression with polyvinylsiloxane

• Geller cast in CR at final OVD
• Scanning of both models in this position with an extraoral scanner —> partial digital flow
• CAD design of disilicate cores for milling
• Veneering of feldespathic ceramic in vestibular on the physical cast in articulator —> cut back
• Adhesive cementation with etching of hydrofluoric acid 20 seconds and dual curing resin cement
Nisrine Elouard

10. Treatment of the endodontically treated tooth

1- Introduction

• A great amount of severely destroyed teeth can be treated with fixed prosthetics
• Alternatives for ETT
◦ Removable denture
‣ Tooth overdenture
‣ RPD
◦ Fixed denture
‣ Large restoration with prefabricated post
• Cheaper
• Elastic modulus similar to the tooth
• 1 appointment only
‣ Cast post and core
• Can’t be done with metal base, only noble
• At least 2 appointments = impression + placing
• Lab: lost wax technique
• Internal expansion better
◦ More conservative
‣ Fiber post
‣ Build-up (with composite)
‣ FCC
◦ Extraction
‣ Implant
‣ Bridge

When to extract and when to maintain?

• Criterias: multidisciplinary approach

• Considerations for the case evaluation
◦ Extent of previous dental restorations
◦ Previous and present signs and symptoms
◦ Significant radiographic changes
◦ Periodontal disease: presence and extension
◦ Predictability of the perio outcome
◦ Patient information of results and needs
◦ Patient’s expectations
◦ Feasible treatment plan

• Factors considered to influence tooth maintenance versus tooth replacement

◦ Periradicular pathology
◦ Extent of canal filling
◦ Type of tooth: anterior, posterior
◦ Age
◦ Sex
◦ Quality of filling
◦ Time of filling
◦ Tooth type: maxillary, mandibular
◦ Pulp status: vital or non vital
◦ Use of intra-canal medication
◦ Filling material
• Impossibility to perform the root canal treatment
◦ Calcified root canal
◦ Anatomy of the root canal
◦ Impossibility to retreat the tooth
‣ Removal of an old post
‣ Broken endodontic files
‣ Silver tips
‣ Previous failed retreatments

2- Characteristics of endodontically treated teeth

• Dentin modification
◦ The dentin has inherent properties that helps inhibits the crack progression
◦ It has fracture toughening mechanisms
‣ Dentin dehydration (increases the fragility)
‣ Collagen fibers reduction and degeneration (also increased fragility)
‣ Consequences: dentin is less fatigue resistant
◦ ETT or older teeth:
‣ Less collagen fibers and more minerals
‣ Higher brittleness
‣ Higher fracture risk

• Reduction of structural integrity

◦ Due to caries / old restorations / fractures
◦ Loss of the pulp chamber roof
◦ Due to the effects of the endo treatment
◦ Due to the effects of the endo irrigants over the dentin (NaOCl, EDTA, Ca(OH)2)
◦ Always try to avoid unnecessary removal of tooth structure
◦ Opposing teeth tend to separate cusps of ETT
◦ Chance of vertical fracture
‣ Probing very deep at one point
‣ Not visible in X-RAY = CBCT scan
‣ Lower M and upper PM with MOD restorations and endo = 50% of fractures after 5 years
‣ With cusps coverage = 94% success
‣ Without cusps coverage = 56% success

• Reduction of sensitivity
◦ Reduced proprioception
◦ Higher pain threshold
◦ Lowered capability of recording stimuli
◦ Less control of the applied forces over it = needs twice the forces to react
◦ It leads to inadequate behaviour under high occlusal loads

3- Assessment of endodontically treated teeth

• Must be healthy tooth

◦ Clinically
‣ No fractures that extend beyond the boundaries of the restoration
‣ Periodontal health
‣ No infection = no fistulas, no oozing …
◦ Radiographically —> Always need to do X-RAY before post
‣ No root fractures
‣ No internal or external resorption
‣ Good apical seal
‣ No radiolucent periapical areas = must be assessed 6 months after the endodontic therapy
• Quantity and quality of remaining tooth structure
◦ Big caries
◦ Amount of tooth structure lost
‣ No post just regular reconstruction when small destructions
‣ Prefabricated post: smaller and medium to big destructions
‣ Cast post and core: great destructions

• Anatomy of the pulp canal

◦ Cylindrical: cast post and core or prefabricated post
◦ Oval: cast post and core or prefabricated post
‣ More retentive
‣ Does not rotate
◦ Pulp canal diameter: always in the largest and straightest canal
‣ Upper molar: palatal
‣ Lower molars: distal
‣ Premolar: palatal
where
you place the post
‣ The post has to adapt to the canal, not the other way around !!
◦ Direction of the canal relative to the occlusal plane
‣ If there is a great inclination: prefabricated post
‣ If not, depending on the canal
• Prefabricated or cast post and core

• Biomechanical needs for the restoration

◦ The position and type of tooth
◦ The function of the future restoration: unitary or abutment for a bridge
◦ Determine the flexural and compressive forces the tooth will bear
◦ Every posterior ETT will need a restoration that covers the cusps
◦ Ideally: onlay or crown = to reduce risk fracture

• The ferrule effect

◦ The crown has to embrace at least 1,5-2mm of healthy dentin all around the contour of the tooth
◦ 360° of healthy cervical dentin surrounding the tooth
◦ Why? To optimize the biomechanical behaviour of the restored tooth
◦ It is important and mandatory to respect it
◦ Better biomechanical behaviour
◦ Elevated the resistance of the crown
◦ Reduces and transmits better the stress
◦ Dissipates the forces that concentrate at the circumference of the tooth
◦ Stabilizes the restored tooth
◦ Optimizes the resistance form
◦ The more ferrule height, the better prognosis
◦ The more uniform the ferrule in the whole circumference, the less risk of failure
◦ Non uniform ferrule is better than none: more important on the palatal and buccal surface
◦ In case of no ferrule: evaluate the situation
‣ Crown lengthening: makes the crown to root ratio worse
‣ Ortho extrusion
‣ Post
‣ Extraction
◦ Not so long ago, the option was CP&C
◦ Today many authors prefer prefabricated post
◦ If not viable, extract and restore with an implant or a bridge
• Crown to root ratio
◦ The proportion between the length of the crown and the length of the root
◦ Minimally acceptable proportion is 1:1 to resist lateral forces always and only if
‣ Healthy periodontium
‣ Controlled occlusion
◦ 1:2 proportion will have a better prognosis

• Subgingival destructions
◦ Depending on the amount and depth of the subgingival destruction, solutions will be
‣ Crown lengthening
• Increases the crown/root ratio
• Reduces effective root length
• Increases effective crown length
• Reduces the volume of root dentin
• Evaluate the esthetic outcome if its an anterior tooth
• Good option for molars
• Delays the treatment to 3 to 6 months
‣ Ortho extrusion
• Reduction of the bone support
• It should be considered before the surgical option because
◦ More favorable mechanical behaviour
◦ Preferable for pm and incisors
• Delay the final treatment
‣ Tooth extraction
◦ Minimum of 4,5mm of supra-alveolar tooth structure required
‣ 1,5-2mm for ferrule effect
‣ Respect of 3mm of the biological width

• Balance between the tooth reconstruction vs value of the tooth in the treatment plan
◦ If the tooth has to act as an abutment for removable or fixed prosthesis
‣ Evaluate the higher risk of fracture
◦ If the tooth is in a strategic position in a wider restoration plan
‣ Consider extraction
◦ If the tooth to restore is in between two implants
‣ Consider extraction and restore with implants

• Successful clinical outcome of ETT

◦ Adequate RCT
◦ Adequate restorative treatment
‣ Good post and core system
‣ Luting agent and techniques
‣ Restoration type, full or partial coverage crown

4- Treatment planning

What are posts used for ?

• The retention of the core
• Optimization of the resistance
• Transfer and dispersion of the loads into the root
• Even if still controversial: strengthen the totality of the tooth and restoration
General indications for the placement of a post
• Large defects requiring crowning
• Large defects requiring partial coverage
• Narrow abutment diameter
• Immature root with a large root canal
« Guttapercha, MTA and composite are materials that do not have a reinforcing effect over the
tooth or the restoration »

Anterior teeth
• Intact tooth
◦ Sometimes no post is needed = ex: only minor proximal cavities
◦ Upper central incisors is 3x thougher is it doesn’t have a cast post and core (CP&C)
◦ When there is no crown destruction, only the cavity access
◦ Anterior teeth suffer more from flexural stress, the post helps increasing the ridigity and biomechanical
properties

• With loss of tooth structure

◦ Always take into consideration the translucency of the final restoration to choose the restorative material
◦ Possible alternatives:
‣ Prefabricated post and composite resin restoration = for the abutment reconstructio and after crown??
‣ CP&C: disused

For anterior teeth = we place a post in anterior teeth with RCT

that are going to receive a crown only !
If no crown = no post

Posterior teeth
We don’t place post as often in
• Shillinburg recommends cusp coverage posterior teeth, only if loss > 50%
• Minor tooth structure loss
◦ Cavity just to access the canal
‣ Composite resin
‣ Onlay
‣ Endocrown: use the pulp chamber to increase the retention and adhesion

• Moderate tooth structure loss (<50%)

◦ Big occlusal or proximal caries
◦ Increased severity if there are also cervical lesions
◦ Treatment: prefabricated post and composite resin restoration (PP&CRR) and crown
◦ Onlay, overlay, endocrown

• Severe tooth structure loss (>50%)

◦ If more than 50% of the structure is compromised
◦ Two or less walls left
◦ The post is recommended
◦ Ex: MOD caries or cusp loss
◦ Options:
‣ Prefabricated post and crown
‣ CP&C and crown = disused

• Always with ferrule effect

• If no ferrule effect:
◦ Prefabricated post + composite resin + cusp coverage
CONTROVERSIA
◦ Crown lengthening + CP&C + crown
◦ CP&C with additional post for more stability
• Premolars
◦ Smaller teeth means less structure
◦ Smaller pulp chamber to use to increase retention and adhesion
◦ Subject to lateral forces during mastication
◦ The post is usually indicated

• Molars
◦ The post is more indicated when
‣ The coronal structure is totally missing
‣ Small pulp chamber that will not allow us to gain retention and adhesion

Considerations for teeth that will be abutments of dentures

• ETT must not be abutment teeth of free-ended RPDs

◦ Four times more risk of fractures

• ETT must not be used for cantilever bridges

◦ Higher risk of fracture or failure

• ETT used as abutments of bridges suffer fractures twice as often as teeth without endodontic
treatment or single tooth FPDs
◦ Even with ferrule effect
◦ Not to be used as single retainers = need of secondary abutments

• The use of ETT as abutments for bridges with more than one pontic is questionable
◦ Use secondary abutment

5- Prefabricated posts

Classification depending on
• Material
◦ Metal posts
‣ Very rigid = elastic modulus ≠ from dentin
‣ Low resistance to rotational forces due to its cylindrical shape
‣ Indicated more for posterior teeth and/or crowns
‣ No esthetic is required
‣ PFM as final restorative treatment
‣ Stainless steel
• Still used successfully but don’t recommend
‣ Ni-Cr alloy
‣ Titanium alloy
• Appeared to avoid corrosion
• Low radiopacity
• Low toughness when small diameter
 ◦ Esthetic posts
‣ Carbon fiber
• 8 µm fibers parallel to the axis of the post
• Epoxy resin matrix
• Radiolucent
• Biocompatible
• Elasticity 21 GPa (dentin 18GPa)
• Disadvantages = black color
‣ Glass fiber —> the one we use
• Translucent
• Favorable color
• Transmits light = dual curing cements
• Similar elasticity to dentin
• Some authors state that their flexibility can lead to microleakage and fracture if there is not an
adequate ferrule effect
‣ Quartz fiber
‣ Zirconia
• Prefabricated or custom-fitted
• High compression strength
• Very rigid
• Almost impossible to remove in case a retreatment is required
• Require more pulp canal preparation
• Cannot be etched, low retention to the composite
• Better not to be used
• Shape
◦ Cylindrical
‣ Greater retention (more friction)
‣ Creates a weaker area of the root at the tip of the post
◦ Tapered
‣ Fit better the pulp canal
‣ More respectful with the shape of the canal
‣ Less weakening of the root
‣ Lower retention
‣ Wedge effect if not deep enough
• Surface
◦ Threaded
‣ Rish of fracture
‣ Created high tension over the residual walls = really retentive
‣ Don’t use
◦ Unthreaded
‣ Lower risk of fracture of the root
‣ Election surface type

Purposes

• Intraradicular retention
• Better dispersion of the forces
• Doesn’t reinforce the tooth perse
• Nowadays we can find in the literature authors that states that the post helps with the reinforcement of the tooth
• The crown is what really reinforces the tooth
• Retention will depend on the design of the post and cement (mostly)
◦ Length
‣ Minimum: crown height
‣ Minimum: +/- 8mm canal
‣ 2/3 of the length of the tooth root length
Ann
‣ Leave at least 4-5mm of apical seal
• Ex: 23mm long root canal = post of 18-19mm
• If longer = bacteria
◦ Shape and surface
‣ Best shape: tapered
‣ Most retentive surface = threaded but high risk of fracture —> unthreaded better
‣ Prefabricated post are usually fluted
◦ Diameter
‣ The greater the diameter, the greater the retention
‣ Not greater than 1/3 of the diameter of the root
‣ At least 1mm of root wall thickness
‣ Always try not to weaken the tooth
‣ The post must be adapted to the canal, not the other way around!!

Procedure

• Drills are coded according to the shape and size of posts

• General sequence

• First, make a radiograph of the tooth = always !!

• Confirm apical seal and performance of the endodontic treatment
• Calculate working length: 4-5mm of apical seal
• Removal of endodontic sealing material (gutta-percha) with Gates Glidden drills
◦ Better without water = if pain because of heat —> anesthesia
• Shaping of the pulp canal with drills
◦ Increasing diameter
◦ Contra-angle hand piece
◦ Up to the desired width
• Get the post into the canal and make a radiograph
◦ Fit of the post
◦ All the gutta percha has been removed
• Check that there is enough space to the antagonist tooth
• Cement the post
◦ We use = dual curing self adhesive resin cement
◦ Fiber posts are cemented with composite resin cement
‣ Translucent post: dual cure cements
‣ Opaque: self cure cements
◦ Metal posts are cemented with
‣ Zinc phosphate cements
‣ Glass ionomer cements
• Build-up the core = orthophosphoric acid + adhesive + compo
• Crown preparation
• Impression taking
• Provisional restoration
• Cementation of the crown
To sum up

• The use and indication of the post placement and the type of post is still a controversial subject
• Analysing all the determinant factors will help increase the good prognosis to our restoration

• No post and composite core building

◦ Molars and small destructions. It is enough taking advantage of the anatomy of the pulp chamber

• Fiber post
◦ When at least 50% of the structure is lost
◦ Two surfaces or less are present
◦ Incisors and premolars
◦ Studies on pm demonstrated less fractures when posts are placed
◦ Molars, if crown structure is missing and insufficient pulp chamber

• Need of pre-restorative treatment

◦ Crown lengthening, ortho extrusion

• Cast post and core

◦ Big destruction
◦ Bad or complicated isolation
◦ No ferrule
◦ Patients insisting on trying to save the tooth
◦ Acceptable results

• Extraction
◦ When the tooth has no viability
◦ Because of the planification the extraction makes more sense

Summary
Nisrine Elouard

11. Pre-prosthetic treatments

1- Concept and aim

• Procedures designed to facilitate fabrication of a prosthesis or to improve the prognosis of prosthodontic care
• The purpose of it is to eliminate pathological conditions, uncertainties and risks:
◦ Urgent treatments
◦ Tooth extractions
◦ Periodontal treatment:
‣ Initial periodontal treatment
‣ Surgical periodontal treatment
◦ Orthodontic treatment
◦ Endodontic treatment
◦ Restorative treatment
◦ Occlusal equilibration
◦ Treatment of TMDs

2- Medical history and examination

• Reason for consultation (chief complaint)

◦ What happens to you?
◦ Since when?
◦ What do you think the reason is?
• Personal data
• Medical condition
◦ General diseases that might influence the treatment
◦ Pathologies that might make us modify the treatment
‣ Epilepsy = metal occlusal surfaces and short appointments
‣ Allergies = Ni, acrylic resins, alginate
‣ Xerostomy = higher caries incidence
‣ Diabetes = higher incidence of periodontal decease
‣ HIV = higher incidence of periodontal decease
‣ Hydantoin treatment = gingival hyperplasia
‣ Sjögren syndrome = xerostomy

Intraoral examination Extraoral examination

• Count teeth: horizontal and vertical migrations may occur • Muscular hypertrophy
• Assess migrations carefully: pre-prosthetic treatments may have to be done • Scars
• Re-evaluate previous dental treatments • Old traumatisms
• Evaluate pulp vitality • Paralysis
• Periodontal assessment: crown lengthening may be required • VD (decreased, maintained)
• Dental pathology (may indicate parafunctional habits): • Facial examination:
◦ Wear facets, abrasion, erosion ◦ Facial fistulas
• Soft tissue assessment ◦ Areas of alopecia
◦ Soft tissue lesions ◦ Facial profile
◦ Exostosis (torus) ◦ Lip support
• Assess aesthetics: color, shape, position ◦ Smile line
• Assessment of edentulous space ◦ Lip seal
◦ Morphology If you anticipate a pulp • Cranio-cervical palpation
◦ Extension invasion, schedule an ◦ Adenopathies
◦ Date of last tooth extraction endodontic treatment prior ◦ Tyroid gland
◦ Relation with near teeth to the dental preparation ◦ Salivary glands
• Assessment of occlusion, to see if the present occlusion is correct and can be kept
◦ Static occlusal relationships:
‣ MI is it stable?
‣ Overbite, overjet
‣ Cross bite
‣ Cusp-to-cusp occlusion
‣ Uniformity of the occlusal plane
‣ Midline
◦ Dynamic occlusal relationships (disocclusions, prematurities and interferences)
‣ If the occlusion is correct = keep it
‣ If the occlusion is wrong = modify it with the treatment or modify the occlusion before the treatment

Muscular examination
• Some patients may show muscular pain
• Sometimes related to parafunctional habits
◦ Stress
◦ Occlusion
• Parafunctinal habits may lead to :
◦ Muscular pain
◦ Spasm
• Muscular examination can reveal problems that can be otherwise unnoticed
• Palpation = find pain
◦ TMJ, temporal, masseter, lateral pterygoid, medial pterygoid, sternocleidomastoid, post belly of digastric
◦ Know origin and insertion
• Functional examination
◦ Muscular pain occurs either at:
‣ Maximal stretching of the muscle
‣ Maximal contraction
◦ Maximum mouth opening
◦ Protrusion against a resistance
◦ Clenching
◦ Laterality against a resistance
◦ Biting a saliva ejector laterally
◦ Protrusion against a resistance with a unilateral saliva ejector
• Apart from painful muscular points, assess:
◦ Muscle hypertrophy
◦ Face asymmetries
◦ Muscle hypertonicity
◦ Spasm
• Functional limitation of muscular movements:
◦ Maximum mouth opening:
‣ Less than 40 mm interincisal opening
‣ Due to pain and spasm of elevator muscles
◦ Protrusion and lateralities
‣ Usually not limited (8mm) due to muscles
‣ Unless lower lateral pterygoid is highly affected
◦ Soft “end-feel”:
‣ Muscles allow 2 mm stretching
‣ The opening can be increased when applying some force over the jaw
‣ Painful
◦ Hard “end-feel”:
‣ Articular problem, not muscular
‣ The mandible can’t be opened more, even when a gentle force is applied
‣ The opening can not be forced
 ◦ Opening closing path
‣ More than 2 mm deflection
‣ When it’s a muscular problem: variable deviated path
‣ When it’s an articular problem: always the same path

Joint examination
• Articular pathology is less frequent than muscular pathology
• Most frequent articular pathology is intracapsular pathology
• Articular pain:
◦ Usually not from the articular surfaces, but from the surrounding tissues
• Articular sounds:
◦ Clicks: single explosive noise
‣ During opening —> DISPLACEMENT
• Indicate anterior functional displacement of the disc
• Milder stage the nearer the MI point
‣ During opening and closing —> DISLOCATION
• Reciprocal click (or clicking)
• Indicate disc dislocation with reduction
• Disc dislocation without reduction = opening limitation, deviation towards blocked side
• Early on opening, late on closing usually
• More advanced stage
‣ During mediotrusion
• Indicate medial disc dislocation
◦ Crepitus: continuous “grating” noise
‣ Due to wear of the articular surfaces
‣ TMJ osteoarthrosis
‣ Rx to see this: Schüller’s transcranial radiography
◦ Heared with the bell of the phonendoscope
◦ While performing opening-closing or eccentric movements
◦ Are the most frequent sign
◦ Can also be noticed during lateral palpation
• Movement limitation:
◦ Max mouth opening of less than 40 mm with hard-end feel
‣ Articular problem
‣ Probably an anterior disc dislocation without reduction
◦ Mediotrusion of less than 8 mm
‣ Probably an anterior disc dislocation without reduction
◦ Lateral deflection of the mandible during protrusion
‣ Deflection towards the affected side
• Deflection during opening-closing movement
◦ More than 2 mm deflection is considered a pathological sign
◦ If there is reduction:
‣ The deflection ends again at the midline
‣ Deflection during the opening path
◦ If there isn’t reduction:
‣ The deflection doesn’t get back to the midline

3- Urgent treatments
• Urgencies are pathologies that require immediate treatment ≠ from emergencies = risk to life
• In general, every process that presents pain or infection
• Pathologies that require urgent treatment:
◦ Acute pulp diseases (pulpitis)
◦ Periodontal abscesses
◦ Tooth fractures
◦ Acute TMDs (trismus)
4- Tooth extractions

• We extract when the tooth is:

◦ Too damaged to be restored
◦ High degree of mobility or too extruded
◦ For a better treatment planification
• If an anterior tooth or teeth needs to be extracted = a provisional immediate denture (fixed or removable)
has to be prepared in advance —> helps gingiva to adapt
◦ Removable denture
◦ Maryland bridge
◦ Provisional bridge
• Regarding third molars:
◦ Hardly ever have attached gingiva at buccal and lingual surfaces
◦ Tend to produce periodontal problems to the 2nd molars
◦ Usually fused or conical roots
◦ Tend to have inadequate positions, inclination or lack of eruption
◦ Can produce root resorptions to the 2nd molar
• Extract 3rd molars next to bridges, UNLESS:
◦ They’re in perfect condition
◦ Risk to inferior alveolar nerve
◦ When extracting 3rd molars, possible extrusion of the antagonist can cause prematurities, inadequate
contact point: food impaction = when extracting a 3rd molar: extract opposing one too
• How long should we wait after a tooth extraction ?
◦ From 6 months to 1 year
◦ Less = possible bone resorption can still happen:
‣ Gingival level migration
‣ Separation between pontic and gingiva
◦ More than 1 year:
‣ Tooth migrations
◦ Meanwhile:
‣ Temporary RPD
‣ Immediate provisional bridge

5- Periodontal treatment

• Periodontal assessment:
◦ Probing, bleeding, calculus, tooth mobility, plaque index, attached gingiva around teeth, percussion
• Initial treatment
◦ Hygiene instructions
◦ Motivation
◦ Dental prophylaxis
◦ Scaling and root planing
◦ Correction of overcontoured margins of restorations and other iatrogenic irritants
• Surgical treatment (if needed)
• Maintenance
• Having done the initial treatment has these advantages:
◦ No plaque, no calculus = better visibility
◦ No inflammation = better handling of tissues
◦ Less posterior inflammation
◦ Patient already motivated
• Patients with bad plaque control:
◦ May have to consider other treatment options and/or prosthetic designs
• Surgical treatment:
◦ For esthetic purpose
◦ For periodontal reason
◦ Revaluation after 2 months
◦ Important to obtain a good stability and healing of the periodontal tissues
• How long should we wait after a periodontal treatment ?
◦ Two months after SRP, reevaluation and decision:
‣ Surgical treatment
‣ More SRP
‣ Prosthetic treatment
◦ During these 2 months
‣ Evaluation of the commitment of the patient with its oral health
‣ Stabilization of the gingival tissues
‣ Very important for any prosthetic treatment to succeed
◦ If surgery (approx. times):
‣ Only gingiva have been touched: 1 to 3 months
‣ Gingiva and bone: 6 months

6- Orthodontic treatment

• Objectives:
◦ Improve periodontal health
◦ Improve occlusion
◦ Remove and prevent occlusal trauma
◦ Ease prosthodontic treatment (inclinations, extrusions)
• Options:
◦ Distalize teeth Inconvenients:
◦ Extrude teeth to increase ferrule effect • Crown-to-root ratio
◦ Align crowded teeth • Time consuming
◦ Achieve a good anterior guidance (overjet, overbite)

7- Endodontic treatment —> Only when needed, required and justified

• Endo therapy when necrotic tooth

• Fistula and abscess treatment
◦ Wait 6 months before performing the prosthodontic treatment
◦ Be sure of the remission of the pathology
• Endo therapy of vital teeth:
◦ When fiber post or cast post-and-core is needed (retention)
◦ Extrusions
◦ Great tooth inclination
◦ Wait 1 month
• Apicectomy:
◦ Evaluate crown-to-root ratio
◦ Wait 6 months for a full healing
◦ Disadvantages:
‣ Low crown-to-root ratio
‣ Unaesthetic scar
‣ Sometimes increases tooth mobility
8- Restorative treatments

• Remove and restore any caries

• Trim and polish overcontoured restorations
• Repeat any restorations that are not in optimum conditions over abutment teeth
• In case of doubt, repeat the restoration

9- Occlusal equilibration

• Irreversible and non-conservative treatment

• Consists in the elimination of prematurities and interferences
• First of all: occlusal analysis on the articular mounted in CR and eliminating the contacts on the casts
• If > 4 contacts to eliminate: not recommended and hard to reproduce in the patient´s mouth
• Eliminating one contact can lead to the apparition of another one
• Not recommended
• When?
◦ Only for occlusal contacts clearly harmful to the patient
◦ Fremitus
◦ Extrusions that might interfere with the denture
◦ Unevenness of the occlusal plane
◦ Lack of occlusal stability

10- Treatment of TMDs

• “The more complex is a system, the more probability of breakdown” (Okesson)

◦ Disturbances of the masticatory system can be as complicated as the system itself
• How TMD symptoms develop?
◦ Normal function + the event (local alterations or systemic alterations)
‣ Physiologic tolerance is surpassed
‣ In response: signs and symptoms of TMD
• Etiologic considerations of TMD
◦ 1. Occlusal condition
‣ Only occlusion problem that can cause TMJ pb = discrepancy from CR to MI bc of prematurities
◦ 2. Trauma over structures of the masticatory system
◦ 3. Emotional stress
◦ 4. Deep pain input
◦ 5. Parafunctional activities
◦ A good diagnosis of the etiological factor is basic for therapeutic success
• Dental signs tooth and periodontium
◦ Dental wear
◦ Cervical erosion
◦ Tooth mobility
◦ Gingival recessions
◦ ental migrations
◦ Parafunction
◦ Alveolar bone exostosis
• In general TMDs treatment consists of:
◦ Education of the patient and home care
◦ Relaxation and stress control
Should be:
◦ Physiotherapy
• Reversible whenever possible
◦ Pharmacotherapy
• Conservative
◦ Psychological support
—> Because occlusion is not proven to be the cause
◦ Occlusal splints
• Physiotherapy
◦ Massages: increases the heat and helps eliminating toxins during the contraction
◦ Therapeutic exercises: to help recover the function; limiting the movements, opening and closing,…
◦ Transcutaneous electrical nerve stimulation: to reduce pain and stimulate the tone of the muscles
◦ Infrared light: creates heat that improves the blood-flow, the oxygenation and relaxes the muscles
• Pharmacotherapy
◦ Purposes:
‣ To reduce the psychological tension
‣ To relax the muscles
‣ Allow manœuvres needed during the treatment
◦ Types:
‣ Muscle relaxants: Robaxisal®, Myolastan ®
‣ Sedative and tranquilizer: Benzodiazepines = can help the doctor reduce the pain
‣ Analgesic: Paracetamol = not very useful to relieve acute pain
‣ Anti-inflammatories
‣ Vasoactive drugs: for vascular migrains
‣ Infiltrations in the affected areas
• External agents: as a contributing factor for the treatment
◦ HEAT: can creates changes over the neuromuscular system, increase of the blood-flow and the
capillary permeability
‣ When muscular tension, pain and rigidity of the joints
◦ COLD: anaesthetic effect, reduces spasms and the blood-flow, reducing the local
inflammatory response, oedema, haemorrhage.
‣ When jaw movements are limited associated to active therapy
• Psychological support
◦ Stress and anxiety are a cause and consequence of TMDs
◦ Psychologist
◦ Psychiatrist
• Education of the patient:
◦ Soft diet
◦ Voluntary avoidance; disengage teeth contact
◦ Avoid parafunction and other oral habits
◦ Avoid stressful activities
• Occlusal splint:
◦ “Any removable artificial occlusal surface used for diagnosis or therapy affecting the
relationship of the mandible to the maxilla”
◦ It alters the mandibular position and contact pattern of the teeth
◦ It hasn’t been proved what makes them work
◦ It has been stated that it’s because it resets neuromuscular patterns
◦ Synonymous of occlusal device
◦ We take the MI into CR with the splint = simulating a THIOP without being invasive, then when the
pain stops, the patient stops wearing the splint and if the pain comes back = it is an occlusal problem = we
can do invasive treatment
◦ Might be used for:
‣ Occlusal stabilization
‣ Treatment of TMDs
‣ To prevent wear of the dentition
◦ Therapeutic objectives:
‣ Relax muscles of the stomatognathic system
‣ Provide orthopedic stability to TMJs
‣ Lower grinding/parafunctional activity
‣ Protect periodontium from occlusal trauma Flat, rigid
‣ Prevent wear of the dentition Reversible treatment
‣ Very effective at reducing muscular pain
‣ Poorly effective to reduce joint sounds
◦ Indications:
‣ Relaxes the muscles
‣ Helps reducing the pain
‣ Allow to handle the patient during the treatment
‣ Treatment for TMD’s
‣ Occlusal stabilization
‣ To prevent the occlusal trauma
‣ Reduce tooth wear
‣ As a provisional to increase VD
◦ Characteristics:
‣ Must cover all teeth (prevent extrusions)
‣ Should provide occlusal stability at CR
‣ Should increase VD (1.5 - 2 mm)
‣ Flat and polished occlusal plane (freedom of movements)
• Only occlusal contact points at MI/CR
Thiop
‣ Occlusal scheme = MUTUALLY PROTECTED ARTICULATION
◦ Sometimes physiotherapy and pharmacotherapy are needed before doing the splint:
‣ To be able to handle the patient
◦ When it’s impossible to record CR:
‣ Approximate CR
‣ Posterior adjustments to the splint or new splint
◦ Procedure:
‣ Craneomaxillary transfer and upper mounting
‣ Intermaxillary transfer and lower mounting:
• At final VD (thickness of record)
• In CR position
• The purpose is to take the condyle-disc-fosssa to an optimum position
‣ Manufacturing:
• Heat-curing acrylic resin
◦ Good mechanical properties
◦ Allows adjustments
‣ For night-time bruxism: upper splint
‣ For day-time bruxism: lower splint
‣ Anyway: arch where it’s more stable or stabilizes more the dental arches = usually upper
‣ Design:
• Retention: survey line (middle of the tooth)
• Avoid contact with periodontium (plaque gathering)
• Flat occlusal surface
• Mutually protected articulation
• Soft canine and anterior guidance
• Even contacts
• No tooth without occlusal contact
◦ To prevent extrusions
• Minimum possible VD (not making the splint weak)
◦ To prevent myotatic reflex
◦ Time of use:
‣ Will depend on the pathology of the patient
‣ Bruxist patient: forever
◦ MI at CR:
‣ Rarely achieved the first time
‣ Adjustments to the splint
◦ Monthly appointments
◦ Avoid soft splints: increase parafunction and stimulates chewing