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DDS
YEAR 4
Fixed Prosthodontics
The scope of fixed prosthodontic treatment can
range from the restoration of a single tooth to the
rehabilitation of the entire occlusion.
Single teeth can be restored to full function, and
improvement in cosmetic effect can be achieved.
Missing teeth can be replaced with fixed
prostheses that will improve patient comfort and
masticatory ability, maintain the health and
integrity of the dental arches, and, in many
instances, elevate the patients self-image.
A crown, is a cemented restoration that
covers or veneers the outer surface of
the clinical crown.
If it covers all of the clinical crown, the
restoration is a full veneer crown.
If only portions of the clinical crown are
veneered, the restoration is called a
partial veneer crown.
TERMINOLOGY
A full veneer crown covers all of
the clinical crown of the tooth
It may be fabricated entirely of a gold
alloy or some other untarnishable
metal, a porcelain fused to metal
(PFM), or an all-ceramic material.
A partial veneer crown covers
only portions of the clinical crown
of the tooth.
E.g., Three-quarter crown, covers
the clinical crown except for the
facial portion.
Intra-coronal cast restorations are those that
fit within the contours of the clinical crown of
a tooth.
Inlay may be used as single-tooth
restorations for proximo-occlusal lesions
with minimal to moderate extensions.
Onlay may be used as single-tooth
restorations for restoring more extensively
damaged posterior teeth when modified with
an occlusal coverage.
TERMINOLOGY
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Inlays made of gold alloy (A), or
ceramic material (B)
Onlay is an intra-coronal restoration
with an occlusal coverage.
The all-ceramic laminate veneer, is
a cemented restoration consists of
a thin layer of dental porcelain that
is bonded to the facial surface of
the tooth to improve cosmetic
appearance.
TERMINOLOGY
A laminate veneer is bonded to the
facial surface of a tooth with resin
The fixed partial denture is a prosthetic
appliance replaces one or more
missing teeth which is attached by a
cementing medium to natural teeth,
roots, implants. This type of restoration
has long been called a Bridge
TERMINOLOGY
The abutment is a is any tooth, root or
implant which gives attachment and support
to the fixed partial denture.
The retainers, are extra-coronal restorations
that are cemented to the prepared abutment
teeth.
A pontic, is the artificial tooth replacing the
missing tooth in the fixed prosthesis. Pontics
are attached to the retainers
TERMINOLOGY
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The connectors are the portions of the
bridge uniting the individual parts of the
bridge (pontic and retainer).
They may be rigid (solder joints or cast
connectors) or nonrigid (precision
attachments or stress breakers).
Connector
Retainer
Retainer
Pontic
A cantilever bridge is a fixed partial
denture that attaches to adjacent teeth
on one side of the bridge only.
Simple Cantilever Spring Cantilever
A Fixed-Movable bridge is a prosthesis
where the artificial tooth or teeth is rigidly
supported on one side, usually the distal end
by one or more abutment teeth and includes
a minor retainer on the other side with a
movable joint.
Resin-bonded bridge
Or Minimal-Preparation Bridge, consists of a
metal framework including a pontic with wing-like
extensions coming from the proximal sides.
For example; Maryland bridge
These metal wings are prepared to have a porous surface
so that they can receive a bonding agent, and then the
wings are bonded to the back sides of the teeth on either
side of the missing tooth.
Pontic
Indications for Crowns
Badly broken-down teeth.
Primary trauma.
Tooth wear.
Hypoplastic conditions.
To alter the shape, size or inclination of teeth.
To alter the occlusion.
As part of another restoration.
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Indications for Crowns
Badly broken-down teeth
Teeth may have suffered secondary caries or parts of the
tooth or restoration may have broken off.
Before crowns can be made, the lost dentine will usually
need to be replaced by a suitable core of restorative
material.
Indications for Crowns
Primary trauma
Tooth may have a large fragment broken off without
damaging the pulp and leaving sufficient dentine to
support a crown.
Indications for Crowns
Tooth wear
The processes of erosion (damage from acid), attrition
(mechanical wear of one tooth against another) and
abrasion (mechanical wear by extraneous agents) may
occur in patients.
If tooth wear is excessive or occurs early in life, crowns or
other restorations may be needed.
Indications for Crowns
Hypoplastic conditions
Can hereditary or acquired defects .
Examples of the former are amelogenesis imperfecta,
dentinogenes imperfecta and hypodontia (for example
peg-shaped upper lateral incisors).
Examples of acquired defects are fluorosis, tetracycline
stain and enamel hypoplasia resulting from a major
metabolic disturbance (usually a childhood illness at the
age when the enamel was developing).
Peg-shaped lateral incisor
Amelogenesis Imperficta
Dentinogenesis Imperficta
Enamel Hypoplasia
Indications for Crowns
To alter the shape, size or inclination of teeth
Minor changes in appearance of teeth can be achieved by
'crowns. Teeth can be made larger but not usually
smaller. For example. a diastema between teeth which
the patient finds unattractive can be closed by means of
oversized crowns.
Before Treatment
After Treatment
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Indications for Crowns
To alter the occlusion
Crowns may be used to alter the angulation or occlusal
relationships of anterior and posterior teeth as part of an
occlusal reconstruction either to solve an occlusal
problem or to improve function.
Indications for Crowns
As part of another restoration
Crowns are made to support bridges and as components of
fixed splints. They are also made to alter the alignment
of teeth to produce guide planes for partial dentures or to
carry precision attachments for precision attachment-
retained partial dentures.
Combined indications
More than one of these indications may be present, for
example, a broken-down posterior tooth that is over-
erupted and tilted may be crowned as a repair and at the
same time to alter its occlusal relationships and its
inclination , providing a guide plane and rest seat for a
partial denture.
Indications for anterior crowns
Caries and trauma.
Non-vital teeth.
When a pulp becomes necrotic the tooth often discolours due to the
haemoglobin breakdown products. This discoloration may be such
that it can only satisfactorily be obscured by a crown.
Tooth wear.
Hypoplastic conditions.
To alter the shape, size or inclination of teeth.
As part of other restorations.
The alternatives to anterior
crowns?
Bleaching.
Some teeth discoloured by a necrotic pulp can be bleached with
hydrogen peroxide.
Restorations with composite materials or glass
ionomer cements.
It is clear that no absolute rules can be given on whether crowns or
fillings are indicated other than to say that in general the more
conservative procedures are to be preferred.
Veneer restorations.
Composite or porcelain veneers can be used after simply acid etching
the enamel, or some preparation of the enamel may be first carried
out.
Indications for posterior crowns
Restoration of badly broken-down teeth.
Restoration of root-filled teeth.
There is a strong clinical impression and some scientific evidence that root-
filled teeth are more likely to fracture than teeth with vital pulps.
Endodontically treated teeth are thought to be more brittle because of water
loss and loss of collagen cross-linking.
Together with the original damage that necessitated the root filling and the
access cavity, follows that some thin and undermined cusps of root-filled
teeth need to be protected.
This means that many, but by not means all, root-filled posterior teeth are
crowned.
To alter the occlusion.
As part of another restoration.
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The alternatives to posterior
crowns?
Pin-retained amalgam restorations.
Tooth-colored posterior restorations.
Gold or ceramic inlays and onlays.
Choosing the right posterior
restoration
The decision depends upon three factors:
Appearance.
Problems of retention.
Problems of strength of the remaining tooth
tissue and the restorative material.
Can be treated with pin-retained
amalgam restoration
Can be treated with gold/ceramic inlay
or GIC/Composite layered restoration
to strengthen the cusps
Can be treated with a core build-up
(Composite or Amalgam) and
Partial coverage crown.
Can be treated with a core build-up
(Composite or Amalgam) and
Complete coverage crown.
Indications for
fixed Prostheses (Bridges)
1. Short span edentulous areas (one or two teeth).
2. Presence of sound teeth that can offer sufficient
support (abutment teeth).
3. Patients preference.
4. The patient has the skills and motivation to
maintain good oral hygiene.
5. Mentally compromised and physically
handicapped patients.
Contraindications for
Fixed Prostheses (Bridges)
1. Long span edentulous spaces, bilateral edentulous
spaces, and distal extension edentulous areas.
2. Necessary supportive tissues are diseased or
missing. Suitable abutment teeth are not present.
3. Very young patients where teeth have large pulp
chambers.
Construction of a definitive crown (full-veneer crown) for a tooth of a patient
under 18 years of age should be postponed until full eruption finishes to the
tooth.
3. The patient is in poor health.
4. The patient is not motivated to have the prosthesis
or have poor oral hygiene habits.
5. The patient cannot afford the treatment.
HISTORY TAKING
AND
CLINICAL
EXAMINATION
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To achieve predictable success in this technically
exacting field, there must be meticulous
attention to every detail-from the initial patient
interview and diagnosis
Making the correct diagnosis is prerequisite to
formulating an appropriate treatment plan. This
requires that all pertinent information be
obtained.
HISTORY
A patient's history should include all
pertinent information concerning the
reasons for seeking treatment, along with
any personal information, including
relevant previous medical and dental
experiences.
The chief complaint
The chief complaint should be recorded,
preferably in the patient's own words.
This may be just the tip of the iceberg,
and careful examination will often reveal
problems and disease of which the patient
is unaware.
Chief complaints usually fall into one of the
following four categories:
Comfort (pain, sensitivity, swelling)
Function (difficulty in mastication or speech)
Social (bad taste or odour)
Appearance (fractured or unattractive teeth or
restorations, discoloration)
PERSONAL DETAILS
The patient's name, address, phone
number, sex, occupation, work schedule,
and marital and financial status are noted.
MEDICAL HISTORY
An accurate and current general medical
history should include any medication the
patient is taking as well as all relevant
medical conditions
If necessary, the patient's physician(s) can
be contacted for clarification.
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The following classification may be helpful:
1. Conditions affecting the treatment methodology
(e.g., any disorders that necessitate the use of antibiotic
premedication, any use of steroids or anticoagulants, and any
previous allergic responses to medication or dental materials).
2. Conditions affecting the treatment plan
(e.g., previous radiation therapy, hemorrhagic disorders, extremes of
age, and terminal illness).
3. Systemic conditions with oral manifestations.
For example, periodontitis may be modified by diabetes, menopause,
pregnancy, or the use of anticonvulsant drugs.
4. Possible risk factors to the dentist and auxiliary
personnel
(e.g., patients who are suspected or confirmed carriers of hepatitis B,
acquired immunodeficiency syndrome, or syphilis).
DENTAL HISTORY
Periodontal History:
The patient's oral hygiene is assessed, and
current plaque-control measures are
discussed. Any previous periodontal
surgery should be noted.
Restorative History:
The patient's restorative history may include
only simple composite resin or dental
amalgam fillings. The age of existing
restorations can help establish the
prognosis and probable longevity of any
future fixed prostheses.
DENTAL HISTORY
Endodontic History:
Patients often forget which teeth have been
endodontically treated. These can be
readily identified with radiographs.
Periapical health can be monitored and any
recurring lesions promptly detected.
DENTAL HISTORY
Orthodontic History:
Root resorption (detected on radiographs) may be
attributable to previous orthodontic treatment. As the
crown/root ratio is affected, future prosthodontic
treatment and its prognosis may also be affected.
Occlusal adjustment (reshaping of the occlusal surfaces of
the teeth) may be needed to promote long-term
positional stability of the teeth and reduce or eliminate
parafunctional activity.
DENTAL HISTORY
Removable Prosthodontic History:
The patient's experiences with removable
prostheses must be carefully evaluated.
DENTAL HISTORY
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Oral Surgical History:
Information about missing teeth and any
complications that may have occurred
during tooth removal is obtained.
DENTAL HISTORY
Radiographic History:
Previous radiographs may prove helpful in
judging the progress of dental disease.
In most instances, however, a current
diagnostic radiographic series is essential
and should be obtained as part of the
examination.
DENTAL HISTORY
TMJ Dysfunction History:
A history of pain or clicking in the
temporomandibular joints (TMJs) or
neuromuscular symptoms which should
normally be treated and resolved before
fixed prosthodontic treatment begins.
DENTAL HISTORY
EXAMINATION
An examination consists of the clinician's
use of sight, touch, and hearing to detect
conditions outside the normal range.
To avoid mistakes, it is critical to record
what is actually observed rather than
to make diagnostic comments about the
condition.
GENERAL EXAMINATION
The patient's general appearance is assessed.
EXTRAORAL EXAMINATION
Special attention is given to facial asymmetry
because small deviations from normal may hint
at serious underlying conditions.
Cervical lymph nodes are palpated, as are the
TMJs and the muscles of mastication.
Temporomandibular Joints (TMJs).
The clinician locates the TMJs by palpating
bilaterally just anterior to the auricular tragi while
having the patient open and close. This permits
a comparison between the relative timing of left
and right condylar movements during the
opening stroke.
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Tenderness, or pain on movement, is noted
and can be indicative of inflammatory
changes in the retrodiscal tissues, which are
highly vascular and innervated.
Clicking in the TMJ is often noticeable
through auricular palpation.
A maximum mandibular opening resulting in less
than 35 mm of interincisal movement is
considered to be restricted, because the
average opening is greater than 50 mm
any midline deviation on opening and/or closing is
recorded.
The maximum lateral movements of the patient
can be measured (normal is about 12 mm).
Muscles of Mastication:
The masseter and temporal muscles, as well as
other relevant postural muscles, are palpated for
signs of tenderness.
Muscle Palpation
A, Masseter.
B, Temporal muscle.
C, the trapezius muscle.
D, The sternocleidomastoid
muscle.
E, The floor of the mouth.
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Lips:
The patient is observed for tooth visibility during
normal and exaggerated smiling. This can be
critical in fixed prosthodontic treatment planning
especially for margin placement of certain metal-
ceramic crowns.
Smile analysis is an important part of the
examination
The "negative" space between the maxillary
and mandibular teeth when the patient laughs
INTRAORAL EXAMINATION
The intraoral examination can reveal considerable
information concerning the condition of the soft
tissues, teeth, and supporting structures.
The tongue, floor of the mouth, vestibule, cheeks,
and hard and soft palates are examined, and
any abnormalities are noted.
Gingiva:
The gingiva should be lightly dried before
examination so that moisture does not
obscure subtle changes or detail.
Color, texture, size, contour, consistency,
and position are noted and recorded.
Periodontal Examination:
Because long-term periodontal health is
essential to successful fixed
prosthodontics, existing periodontal
disease must be corrected before any
definitive prosthodontic treatment is
undertaken.
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The periodontal probe is one of the most
reliable and useful diagnostic tools
available for examining the periodontium.
It provides a measurement (in millimeters)
of the depth of periodontal pockets and
healthy gingival sulci on all surfaces of
each tooth.
CLINICAL ATTACHMENT LEVEL
Documenting the level of attachment helps the
clinician determine the amount of periodontal
destruction that has occurred and is essential when
rendering a diagnosis of periodontitis.
The clinical attachment level (CAL or AL) is
determined by measuring the distance between the
apical extent of the probing depth and a fixed
reference point on the tooth, most commonly the
cementoenamel junction (CEJ).
CAL- Continued
When the free margin of the gingiva is located on
the clinical crown and the level of the epithelial
attachment is at the CEJ, there is no loss of
attachment, and recession is noted as a
negative number.
When the level of the epithelial attachment is on
root structure and the free margin of the gingiva
is at the CEJ, the attachment loss equals the
probing depth.
Dental Charting
An accurate charting of the state of the dentition
will reveal important information about the
condition of the teeth and will facilitate treatment
planning.
Adequate charting must show presence or
absence of teeth, dental caries, restorations,
wear faceting and abrasions, fractures, and
malformations.
Occlusal Examination
Occlusal analysis should be an integral part of the
assessment of a postorthodontic dentition.
The objective is to determine to what extent the
patient's occlusion differs from the ideal and how
well the patient has adapted to this difference.
Special attention is given to initial contact, tooth
alignment, eccentric contacts, and jaw
maneuverability.
Initial Tooth Contact:
The relationship of teeth in both centric
relation and the intercuspal position should
be assessed.
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General Alignment:
The teeth are evaluated for crowding,
rotation, supra-eruption, spacing,
malocclusion, and vertical and horizontal
overlap.
Lateral and Protrusive Contacts:
The degree of vertical and horizontal overlap
of the teeth is noted.
The patient is then guided into lateral
excursive movements, and the presence
or absence of contacts on the nonworking
side and then the working side is noted.
Jaw Maneuverability:
The ease with which the patient moves the
jaw and the way it can be guided through
hinge closure and excursive movements
should be assessed.
RADIOGRAPHIC
EXAMINATION
Detailed knowledge of the extent of bone
support and the root morphology
of each abutment tooth is essential for
establishing a comprehensive fixed
prosthodontic treatment plan.
VITALITY (sensibility)
TESTING
Before any restorative treatment, pulpal
health must be assessed, usually by
measuring the response to
percussion and thermal or electrical
stimulation.
Diagnostic Casts
Diagnostic casts are an integral part of the
diagnostic procedures necessary to give the
dentist as complete a perspective as possible of
the patient's dental needs.
To accomplish their intended goal,
they must be accurate reproductions
of the maxillary and mandibular arches,
made from alginate impressions.
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To gain the most from the diagnostic casts, they
should be mounted on a semi-adjustable
articulator.
Articulated diagnostic allow an unobstructed view
of the edentulous spaces and an accurate
assessment of the span length, as well as the
occlusogingival dimension.
The length of abutment teeth can be accurately
gauged to determine which preparation designs
will provide adequate retention and resistance.
The true inclination of the abutment teeth will also
become evident, so that problems in a common
path of insertion can be anticipated.
A further analysis of the occlusion can be
conducted using the diagnostic casts.
A thorough evaluation of wear facetstheir
numbers, size, and location is possible
when they are viewed on casts.
Occlusal discrepancies can be evaluated and the
presence of centric prematurities or excursive
interferences determined.
Diagnostic the wax-up will help the dentist
plan and execute the preparations
and the interim, or provisional, restorations.
DIAGNOSIS AND
PROGNOSIS
When the history and examination are
completed, a differential diagnosis is
made.
The practitioner should determine the
most likely causes of the observed
condition(s) and record them in order of
probability.
A typical diagnosis will condense the information
obtained during the clinical history taking and
examination.
For instance, a diagnosis could read as follows: 28-year-old male, no
significant medical history; vital signs normal. Chief complaint:
Mesiolingual cusp fracture on tooth # 46. Teeth # 18, # 16, #
17, # 38, and # 48 missing. High smile line. Caries: # 14, mesial; # 26,
distal; # 35, mesio-occlusal; and # 46, mesioocclusal-
distal. Generalized gingivitis four posterior quadrants.
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PROGNOSIS:
The prognosis is an estimation of the likely
course (outcome) of a disease.
The prognosis of dental disorders is
influenced by:
General factors (age of the patient,
lowered resistance of the oral environment
or caries risk); and
Local factors (forces applied to a given
tooth, access for oral hygiene measures,
individual tooth mobility, root angulation,
root morphology, crown-to-root ratios).
Overview of a
Fixed
Prosthodontic
Procedures
History taking, examination and diagnosis,
primary impression
. Articulated Study casts, diagnostic wax-up
Shade matching
Tooth preparation
Gingival retraction and tissue management, Final
impression making
Bite registration
Provisional coverage (interim restoration)
Laboratory prescription
. Laboratory procedures include: definitive cast and die fabrication,
wax-Up, investing and casting, porcelain build-up (for PFM
restorations)
Clinical try-in and Adjusting
. Laboratory procedures include: Polishing and glazing for porcelain.
Cementation
Home care instructions
REFERENCES
Rosenstiel, S.F., Land, M.F., and
Fujimoto, J. (2006). Contemporary Fixed
Prosthodontics. 4
th
Ed. Mosby.
Shilingburg, H.T. (2003).Fundamentals of
Fixed Prosthodontics. 3
rd
Ed.
Quintessence Pub. Co.
Smith B.G. and Howe L.C.(2007).
Planning and making crowns and bridges.
4
th
Ed. Informa HealthCare.
Dr. Maan Ibrahim Al-Marzok 2012