PROSTHESIS

I
NOTES

Candela de Fortuny
Prosthetic dentistry

Classic concepts
Artificial replacement of a missing part of human body in order to improve its
morphology and function, loss due to surgical treatment.
OBSOLETE

Updated concept
The prosthesis which aims to:
• Restore
• Reconstruct
• Rehabilitate
Besides trying to prevent further problems maintaining the health of the
remaining tissues. mid
centric

Ideal prosthesis
MI occasion
Therefore we can define the ideal prosthesis as: besides of repositioning teeth,
restores and rehabilitates the function maintaining the organs and structures
that remain in mouth and the other elements of the masticatory apparatus
healthy.

Prosthodontics
Branch of dentistry that aims to restore (from the restoration of the natural teeth
and/or replacement of missing teeth and oral tissue)
• Function (speech)
• Comfort
• Aesthetic appearance
• Health
By means of artificial appliances
• Prosthesis

Terminology
• Prosthodontics aka dental prosthetics or prosthetics dentistry
• Graduated dentist dedicated to the clinical prosthetics.
• Or graduated dentist who has completed a postgraduate degree in
prosthetics
• Dental technician, dental technologist or lab technician
• Laboratory activities only, never carry out clinical procedures
• Stomatognatic system:
Combination or structures involved in speech, reception, mastication
(chewing) and deglutition (swallowing)
• Components:
1. Teeth
2. Interdental articulation
3. TMJ
4. Masticatory muscles
5. Neuromuscular system
6. Tongue, lips, cheeks, mucosa
 7. Vascular system
• Stomatologic prosthesis:
Rehabilitates the stomatognathic system (oral cavity)
Mastication (chewing)
Phonation
Deglutition (swallowing)
Aesthetics

Prosthetics classification
1. By extension
a) Full
Muco-supported
Acrylic resin
b) Partial
Removable partial
According to support: muco-supported, tooth-supported, dento-
muco-supported
According to materials: metal framework casting (chrome), acrylic
resin
Flexible partial dentures: Valpast, flexite
2. For its ability to be removed by the patient
a) Fixed (tooth supported and fixed prosthesis)
Cemented crowns
Onlays and inlays
Cast pin-stump, fiber posts, veneer, bridge
b) Removable
c) Mixed
Partial removable attachment
Partial removable telescopic crowns
Overdentures
3. For its manufacture materials
a) Metallic (cast)
b) Acrylic resin
4. By type support
a) Muco-supported
b) Tooth-supported
c) Dento-muco-supported (retainer bearing abutment teeth)
d) Implant supported
Full
Partial

Future
See mouth as a whole
• Not only restore the missing teeth
• Fixed prostheses
• Soft tissue
• Aesthetic
• Occlusal pathology
• TMJ
Prosthetic relationship with other branches of dentistry
• Conservative dentistry (prior to carry out a crown)
Restorations (fillings) and reconstructions for later stump preparation
• Endodontics (pin and crown)
• Periodontics
Prior to carry out he prostheses
Restore health of periodontium
• Surgery
Exodoncy (extractions): it is necessary to replace the missing tooth
Pre-prosthetic surgery: torus, frenulum
• Orthodontics
Prior to carry out the prostheses. Complex malpositioned teeth cases
(class II and III Angle)
• Occlusion and TMJ
Restore the health of the TMJ by the acute treatment of symptoms and
carry out the prosthesis in order to have a proper maxilla-mandibular
relationship
Stomatognatic system

1. Stomatognatic system study
2. Cephalometric landmarks points and planes in prosthetics

Stomatognatic system. Concept.
It is the functional unit that is responsible for chewing and swallowing and is
also involved in phonation, taste and breathing.
Parts:
• Bones
• Joint and its ligaments
• Muscles
• Controlling nerves
• Teeth

Bones
• Mandible (lower jaw)
• Maxilla (upper jaw)
• Temporal
Glenoid cavity
Articular eminence

Temporomandibular joint (TMJ)
Dual joint between the skull and the jaw. It is a ginglimoarthrodial type.
Parts:
• Joint surfaces
• Disc (dense fibrous conjunctive tissue, avascular and without innervation
getting less degeneration and greater repair capacity). It is thinner in its
central part
• Upper and lower joint cavity
• Synovial fluid (provide nutrients and act as lubricant, less friction)
• Retrodical tissue
• Upper and lower retrodical lamina
• Ligaments

Temporomandibular joint. Ligaments.
The ligaments are composed of connective tissue collagen that does not distend,
act as passive limiting of the joint movements in order to protect the joint. They
are well innervated and vascularized.
Functional or intrinsic:
• Collateral or discal. Attach the disc to the condyle
• Joint capsule
• Temporomandibular. Limit the opening. (Outer oblique/Axis hinge
opening and Horizontal inner portion/avoid backwards displacement)
Accessory or extrinsic:
• Sphenomandibular (from sphenoidal spine to mandible)
• Stylomandibular. Limit the opening and protrusion (from styloid
apophysis to angle of mandible)
 • Pterygomandibular (from pterygoid hamulus to retromolar trigone)

TMJ function
• Lower compartment rotational movement (due to the strong union
between the disc and the condyle by collateral and temporomandibular
ligaments.
• Condylar position on the posterior part of the articular eminence
(temporal bone) with an imposed articular disc
• Opening, there is rotation and translation motion
• Closing, there is rotation and translation motion on an axis slightly lower
comparing to opening.

Muscles
Masticatory muscles. Main:
• Masseter. From zygomatic arch to mandible (outer part)
• Temporalis. From temporal fossa to coronoid apophysis
• Internal (medial) pterygoid. From pterygoid fossa to jaw angle
• External (lateral) pterygoid
o Upper head. From sphenoid ala major to capsule and condyle
o Lower head. From lateral pterygoid lateral lamina to condyle neck
Assistant or accessory muscles
• Supra and infrahyoid muscles: digastric and mylohyoid
• Head and neck muscles: sternocleidomastoid and trapezius

Elevators and Depressors muscles of mandible (stabilizers)
Elevators
• Masseter
• Internal (medial) pterygoid
• Temporal anterior and middle fibers
• External (lateral) pterygoid upper head. (disc stabilizer).
Depressors
• External (lateral) pterygoid lower head
• Milohyoid
• Digastric anterior belly

Mandible protrusion-retrusion muscles
Protrusion
• External (lateral) pterygoid lower head (bilateral)
• Internal (medial) pterygoid. (Also has some protusive action)
Retrusion
• Temporalis posterior fibers (also postural rest)

Mandible side-to-side movements muscles
• External pterygoid lower head (opposite side)
• Temporalis posterior fibers (same side).

Cephalometric landmarks points and planes in prosthetics
Points
 • Tragus
• Porion
• Infraorbital point
• Lateral palpebral commissure
• Anterior nasal spine
• Hinge axis
Planes:
• Frankfurt plane
• Axis-orbital plane
• Camper plane
• Interpupillary line

Cephalometric landmarks points in prosthetics

Frankfurt plane
• Join porion and infraorbital point
• Reference for mounting in semi-adjustable articulator

Camper plane
• Join the top edge of the tragus and the bottom edge of the wing (ala) of
the nose
• Clinical reference for setting the occlusal plane that will be as much as
possible parallel to this (reference for full dentures).

Interpupillary line
• Horizontal anterior line which joins both eye pupils
• Clinical reference for setting the occlusal plane on anterior teeth that will
be as much as possible parallel to this.

Axio-orbital plane
• Join the hinge axis with the infraorbital hole
• Reference for mounts in fully adjustable articulators.
Neuromuscular system function

Motor unit
• Is the one which transmit nerve impulse in order to make muscle fibers to
contract or shortening
• Conducts impulses from the brain and spinal cord to effectors à muscles
• Constituted by:
Postsynaptic motor neuron button at neuromuscular junction (motor
endplate)
• It comes from a motor neuron
• In the case of masticatory system à motor nucleus of trigeminal
All extrafusal fibers to which it stimulates
• The smaller the group of muscle fibers innervated more accurate will the
movement
• Function
Muscle contraction or shortening by depolarization of muscle fibers

Muscles (motor unit)
Formed by:
• Hundreds of thousand of motor units
• Vessels
• Nerves
• Joined by a bundle of connective tissue and fascia that surrounds them

Isotonic contraction
• The fiber is shortened and the length may vary
• It maintains the same muscle tone
• Contraction under constant load
• Chewing (masseter)

Isometric contraction
• Muscle contraction without shortening (worse for muscle producing
accumulation of catabolites)
• Maintains the same length
• Increase the tone
• Bruxism

Controlled relaxation
• Upon cessation of nerve stimulation in the muscle
• Muscle “resting tone”
• Normal length

Neurological structures
• All muscles have some type of innervation
Sensitive/motor
• Sensitive afferent neurons
• Sensory information: Musc à CNS
• Muscular tone
 • Pain
• Proprioceptive information: pressure, position and movement

Central Nervous System
• Receives and processes information (sens and own) and generates a
motor response
• Conscious
• Reflex

Motor neuron or efferent
• They act in response
• CNS à Muscle
Trigeminal motor nucleus à brainstem
Cervical and spinal cord

Sensitive receptors
• Neurological structures situated in the tissues that provides information
from them to the CNS
• Nociceptors
Specific to discomfort or pain at any injury: mechanical, thermal
Theet, muscle, TMJ, tendons
• Propioceptors
Report à position and jaw movements
Information processing CNS à motor response very accurate
Types:
1. Muscle spindles
• Sensitive receptors inside the muscle belly embedded in
extrafusal muscle fibers
• Composed by intrafusals muscle fibers
• Detect changes in mucle length
• The order of motor response comes from the trigeminal motor
nucleus
• Participate in the mytotatic reflex à maintenance of muscle
tone
2. Golgi tendon organs
• Proprioceptive sensitive receptor organ situated in the tendons
of skeletal muscles
• Compounds of tendon fibers surrounded by lymphatic spaces
wrapped in a fibrous layer
• Receptor à changes in pressure (tendons)
• Stimulation à stretch tendon/muscle contraction
• Inhibitory response of muscle contraction protective character
à avoid muscle strain (pulled mucle or torn muscle)
3. Periodontal mechanoreceptors
• They respond to occlusal forces that occur during tooth
contacts
• Thanks to them the masticatory force is controlled
• Influence on the dynamics mandibular control
 • Able to detect changes in occlusal morphology à reflex arc
adaptation in order to avoid undesirable contacts à
craniomandibular dysfunction
4. Pacini corpuscles
They are in the TMJ
Sensitive receptor that respond to rapid vibrations and the deep
mechanical pressure
They have a connective tissue capsule
In the center of each one there is a core which contains a nerve
fiber termination
They are responsible for the perception of joint movement and
intense pressure

Reflex action

Distention reflex (myotatic reflex)
• It is triggered by a muscle passive stretch (distension)
• Stimulates the muscle spindle
• Reflex action to protect themselves from a sudden stretch
• Use the monosynaptic via
• Prevents luxation
• Responsible for the state of small permanent contraction (tone) in the
elevator msucles to counteract the force of gravity
• This tone maintains the jaw at certain height (VDR)
• It helps us to find and keep the VDO in edentulous patients

Nociceptive reflex
• Teeth non contact protection against hard object
• Periodontal receptors perceive a painful stimulus
• Relaxes elevator muscles
• Contraction of depressant muscles
• It opens the mouth and avoids teeth contact by protective reflex

Tactile reflex
• Periodontal and muscle receptor
• CNS recognize the force to be applied in order to chew different types of
food (e.g. hard or soft)

Mastication
Phases
1. Opening
Mandible: up to 15-18mm distance from maximum intercuspation with 5-
6mm lateral movement displacement
2. Closing
Flattening
• 3mm distance from MI
• With lateral movement displacement of 3-4mm
Trituration
 • At the first à few contacts à fragmentation of alimentary bolus à
increase the frequency of contacts
• Slide movement (inclined cuspal planes)
• Simple (maximum intercuspation position)

Mastication
• Deglutition
• Closed lips, teeth at maximum intercuspation
• Condyles are in CR
• Alimentary bolus at back of the tongue

Deglutition
• Series of muscular contractions move the bolus of the oral cavity to the
stomach
• It consists of 3 phases:
1. Voluntary
Bolus formation
Tongue à pharynx
2. Pharyngeal
Pharynx à esophagus
The soft palate closes the nasal fossa
The epiglottis closes the trachea and occludes the oropharyngeal airway
3. Reflex or Somatic
Cardia is opened à stomach
It occurs in adults, as long as there are teeth (somatic).
When no teeth à visceral à tongue moves forward to seal (babies)

Phonation
• Air à lungs à diaphragm
• Contraction/relaxation of vocal cords creating sounds
Forms adapted by mouth à resonance and articulation

Articulation of sounds
Sounds formed by
1. Lips: M, B, P
2. Teeth: S
3. Tongue and palate: D
4. Combination:
• Tongue + Upper incisor: Z
• Lower lip + Upper incisor: F and V
• Tongue + Soft palate: K and G
When speaking there is no tooth contacts.
When there is malpositions:
• Sensitive stimuli à CNS à Alterations in patterns of phonation
• A new pattern is created à Unconscious à Learned reflex
Study of dental arches

Functional anatomy
• Anterior teeth
• Posterior teeth
Alignment of the teeth in the arch
• Horizontal plane
• Sagittal plane
• Frontal plane
Alignment between the two arches
• Anterior sector
• Posterior sector

Functional anatomy.
Anterior teeth
• Aesthetics
• Phonetics
• Initiates the mastication
• Anterior guidance. Incisal guidance. Canine guidance.
Posterior teeth
• Elevations: cusps, ridges and planes
Cusps:
1. Working: cutting, or functional, center or supporting: upper palatal
and lower buccal. (active cusp and support the VDO and stabilize
the arch)
2. Non working or protecting, non functional, non centric guiding: in
upper buccal and in lower lingual (non-active, cutting)
Cusp ridges
Each cusp has four cusp ridges extending in different direction (mesial,
distal, facial, lingual) from its tip
Normally, the cusp ridge which extends toward central portion of occlusal
surface is also a triangular ridge
Named by the direction they extend from the cusp tip
1. Marginal: in the mesial and distal areas of premoalrs and molars
(they should be at the same height)
2. Central: towards to the major fissure and buccal (which form the
buccal and lingual surfaces of the cusps)
3. Triangular: form the cusps
• Depressions: fossa and pits, fissures
Fossa and pits (those that receive the active cusps)
Functional. They receive the active cusp.
1. Upper: mesial pit
2. Lower: distal fossa
Sulcus (fissures) and grooves
Central or development (extend from mesial to distal and serves as an
escape for the protrusive movement
Supplemental groove: (provides supplementary anatomy and increases
masticatory effectiveness)
Working grooves: transverse main sulcus (fissure)
 1. Upper molars (from the center of the fossa to buccal)
2. Lower molars (from the center of the fossa to lingual)
Non working: oblique


Alignment of the teeth in the arch
Saggital plane: Spee curve
• Mesial inclination of the mandibular teeth and upper
double inclination, mesially in anterior and distally in
posteriors of the maxilla
• Spee Curve: imaginary line joining the incisal edges of
the teeth and the active cusps of molars and premolars
Concave in mandible
Convex in maxilla
Frontal plane: Wilson curve
• Buccal inclination of the maxillary teeth and lingual
mandibular teeth
• Wilson curve: imaginary line that resulting of joining the
buccal and lingual cusps on both sides of the arch
Horizontal plane: Occlusal plane
• Occlusal plane
• Imaginary plane joining the incisal edges of front teeth and cusps of
premolars and molars
• Almost parallel to Camper (5º open to posterior).

Alignment between arches
• Length of each arch
The mandible is slightly shorter because the incisors are narrower
• Width
The upper arch occludes buccaly (vestibular) and each tooth occludes
with two antagonists (opposing teeth)
Anterior teeth
• Overjet
Length in mm of incisal edge of upper incisor to the labial surface of
the antagonist lower incisor.
Normal value 1 to 2mm.
• Overbite
Part of the vestibular face of the lower central incisor that is
covered by the maxillary central incisor.
Normal value 1/3.
Posterior teeth
• Class I Angle. Ideal situation
Mv cusp of 16 to buccal fissure of 46
 Mp cusp of 16 to central fossa 46
Upper canine cusp between lower canine and first premolar
• Class 2 Angle
Mv cusp of 16 to mesial buccal fissue of 46
Mp cusp of 16 to marginal ridge 45-46
• Class 3 Angle
Mv cusp of 16 to distal buccal fissure of 46
Mp cusp of 16 to marginal ridge of 46-47









Alignment between arches
• Origin
Muscle strength: lips, muscles of the face and tongue
thrusting (pushing).
Habits or parafunctions.
• Long-term stability
Interproximal contacts (functional response of alveolar
bone and its gingival fibers)
Occlusal contacts (minimum functional tripod)

Planning and detailed study of each case
Mandibular positions and movements

Concept
Movements and positions
• Spatial relationships between Jaw and Skull
Craneomandibular
Static à positions
Dynamic à movements
• Determined by the normal operation of:
TMJ
Muscles
Neuromuscular system
Contact between arches

Postural rest position (VDR) Vertical Dimension at Rest
• Mandibular position
• Relaxed
• With head erect (upper right position)
• There is no tooth contact, teeth are separated
• 2-4mm IFS (interocclusal freeway space) between the arches from MI
(maximum intercuspation)
Muscle balance between elevator and depressor
Due to myotatic reflex our mouth is relaxed and teeth are not in contact.

Centric relation
• It is the most anterior superior position of the condyles in the glenoid
fossa
• Internal pterygoid, masseter and elevators in action
• 5-10% centric occlusion
• Physiological position
• 25mm opening motion
• Repeatable
• Mandibular dynamics
• No changes over the years

Maximum intercuspation
• Cusps of the teeth of both arches fully interpose themselves with the
cusps of the teeth of the opposing arch
• There is a maximum number of tooth contacts
• Position where all the teeth mesh
• VDO (vertical dimension occlusion)
• Changes throughout life
• Independent of the condylar position
• CR (central relation) in MI (maximum intercuspation) = CO (central
occlusion) or THIOP (LAURITZEN)

Lauritzen
• Maximum intercuspation à IOP: intercuspal occlusal position
 • THIOP (terminal hinge IOP): CR (centric relation) coincides with MI (5-
10%)
• When condyles are not in CR (centric relation) when there is MI
MIOP (condyles are forward) most common situation
LIOP (1 condyle is more forward than the other) pathological TMJ

Excentric relations
• Any position other than the centric relation
• Protrusion: anterior condylar position in relation to CR à mandible
forward
• Laterality: mandibular movement sideways in relation to the maxilla
• Lateroprotrusion: lateralization + protrusion
Canine guidance causing Kristiansund phenomenom (Exam)

Mandibular biomechanics
1. Dental contact
Contact: laterality/protrusive
No contact: opening/closing
2. Movement amplitude
Border: maximum movement
Intraborders: functional movmements
3. Main direction of movement
Opening/closing
Protrusion
Retrusion
Laterality
Combined or intermediate
4. Basic type of movement
Rotation
Translation
Combined

Mandibular dynamics
• Depending on whether or not there is tooth contact
• Canine guidance
• Anterior guidance
• Opening-closing
• In centric relation
• Usual opening and closing until MI (more frequent and unconscious)
• When CR and MI do not coincide
• Amplitude movements
• Border:
 Extreme positions of the mandible
• Intra-border
Functional (mastication)
They can be measured in the 3 planes of space
They can guide/inform us about the range of mandibular movement
• Movements of direction
• Opening-closing
• Protrusion
• Retrusion
• Laterality
• Combined
• Types of movement
• Rotation;
Lateral: rare
Op-close: Up to 35mm
• Translation
Opening: from 25 to 40mm
Advance and recoil
• Combined
• Direction of movement
• MI to MO 40-50mm
• <40 mm dysfunction
• >50mm luxation or subluxation of the TMJ

Posselt’s diagram (envelope)

Opening and closing movement
• From MI to MO (opening) à 4-5cm
• Posterior border opening
• From CR
• First arc
Up to 25mm
The condyles are still in CR
Allow to localize the axis of rotation à kinematic facebow
• Second arc
Rotation + translation
Plus 20mm
• Anterior opening and closing border movement
From MP to MO

Protrusion movement
• Both condyles go forward and desent by the articular eminence
• Protrusion à Christensen’s phenomenom
Posterior disocclusion guided by anterior teeth
• =/> 7mm (up to 15mm)
• Movements
Ripping and tearing food apart with incisors
Pronounce the “S”

Laterality movement
• Mandibular lateral translation
Lateral translation of the mandible
• Working side à WS
• Side to which the jaw moves
• Active
• Rotational/Pivoting
• Rotation + translation (outwards)
• No working side à NWS
• The condyle that moves the most
• Translational or orbiting
 • Laterality =/>7MM
• Guided by the canines


Postural rest position
• Clinical RP/Physiological
• Postural position with the head straight
• Balancing of the elevator and depressant muscles
• Condyles are forward and downward in relation to CR
• It is not easily reproduced (stress)
• In normal conditions à 2-4mm from MI

Interocclusal freeway space
• Space between MI and PRP
Thanks to the myotatic contraction of the elevator muscles in order to
compensate the gravity
• It may be altered
• Bruxism
• Edentulous with old prosthesies
• Head position
Forward: decreases
Backward: increases
• Bone class
Class III: decreases
Class II: increases
• Never invade IFS à muscular dysfunction and temporo mandibular
disfunction

Vertical dimension
• Height of the lower facial third
• Distance between two points in mm
• Vertical dimension of rest
Distance to the jaw at postural rest position
• Vertial dimension of occlusion
Distance to the jaw in MI
Should be 2-4mm < than VDR
• VDR – VDO = 1FS

Mandibular centric relation
• Most important position of the mandible
• Maxilo-mandibular relationship in which the condyles are found on the
thinnest area of the disks being both located in the most anterior superior
position of the glenoid cavity
• This position is
• Independent of the dental contact
• Perceptible
• Reproducible
 • Restricted to a movement of pure rotation round the terminal hinge
axis
• This position can occur at = degrees of opening up to 25mm à first arc à
pure rotation
• Measurable, reproducible and repeatable
• You can not get a good CR with TMD
First we have to sort the dysfunction out
• Starting point of the mandibular dynamics
• Musculoskeletal most stable position
• MI = CR in 5-5’% of patients
• Optimal position to rehabilitate a patient when presents no stable
occlusion/edentulous

Techniques for determining the CR
• Unimanual
1. Chin point guide
2. Before à strong pressure back on the jaw
3. Today à slight pressure
• Bimanual
1. Dawson technique
2. More complex for the beginner clinician
3. It is very accurate

Anterior deprogramming techniques
• Lucia JIG: Acrylic on anterior teeth
• Gauge sheets
• Techniques are based on muscle deprogramming, these guide the
mandible to CR by having no posterior teeth contact.

Centric relation and maximum intercuspation
• They are different in 95% of population. Discrepancy up to 0.2mm is
considered physiological
• Normally the discrepancy is 1.25mm. With greater discrepancy it is more
likely to have TMD
• Do not coincide because maximum intercuspation position is slowly
acquired and it varies over the years
• When we need to have central relation and maximum intercuspation
coinciding at the same point:
• Full dentures
• RPD free end
• Total rehabilitation with fixed prosthesis
 • When there is TMD

WH


Centric occlusion
• 5% MI = CR à THIOP
• Ideal position for TMJ and the neuromuscual system
• The most common: closing in CR à prematurity à MI
• Upper first premolar palatal cusp (mesialinternal slope)
• Distal internal slope of the lower cusp
• MIOP
• Both condyle are advanced forward and descended
• It is the most common situation
• The distance of the condyle movement is 1.5mm approx.
Mone
• LIOP
• One of the condyles is in CR and the other one is more advanced forward,
descended and moves medially à mandible lateral deviation in MI
• More pathological
• Less frequent
• Right LIOP: right condyle is in CR à the jaw diverts to the right to go to
MI
• Left LIOP: left condyle is in CR à the jaw diverts to the left to go to MI
• The condyle that is in CR is what gives the name to LIOP

MIOP
• Jaw closes in CR à 1st contact in one side of the arch à slides on the 1st
contact to search for the 2nd contact on the opposite side
• The jaw moves forward à MI
• Both condyles move from CR towards to MI position

LIOP
• There is a prematurity in CR à the contralateral condyle moves forwards
à jaw deviation towards the side which is in cr
• The contralateral condyle which moves medially à TMD

Excentric movements
• Protrusion
• The jaw moves forward and downward
Both condyles also move
• Sagittal condylar path in protrusive movement
• Trajectory describing the condyles during protrusion
• Usually has italics S form
• In each patient will have an inclination = with respect to the
horizontal plane à CPI in Protrusive
Average value 40-45º according to the Frankfurt plane
Very important when mounting the casts on an articulator
It is influenced by the anterior guidance à it is not a fixed factor
• Anterior Guidance (vary the CPI inclination)
 • The lower incisors slide forward and downward until reach the edge
to edge position
• Incisal guidance inclination à 5º greater than the CPI (50-45-55º) à
posterior disocclusion
• Laterality
• Mandibular movements is more complex
• Usually guidance by the canine à canine guidance
• It is produced by the contraction of the external pterygoid NWS
• NWS (non working side)
• It moves forward, downward and inward
• Despite the name it is the condyle which works more
• In the sagittal plane: goes forward and descends à Sagittal condylar
path in lateral movement and its inclination to the horizontal plane à
Condylar path inclination in laterally
• Bennett angle: average value 15º
• Angle formed by the condylar horizontal path and the parasagittal
plane
• Line connecting the initial and final position of non-working condyle
in lateral movement

Bennett Angle
The angle formed between the sagittal plane and the average path of advancing
condyle as viewed in the horizontal plane during lateral mandibular movements.
Average range is 7.5-12.8degrees.

Excentric movements
• WS (working side)
• It may only rotate à it is not frequent à mediotrusion
• On rotate and moves outward à laterotrusion
• Outward movement of the condyle in order to allow its rotation on a
vertical axis
• Bennet movmenet
Actually makes reference to the bodily lateral movement of both
condyles
It is generally considered that only refers to the movement of the WS
• The most frequent (laterosurretrusion)
• Outward
• Backward
 • Upward

Bennett movement
It is defined as “the bodily lateral movement/lateral shift of mandible resulting
from movementof condyles along lateral inclines of mandibular fossa during
lateral jaw movement”

Mandibular dynamics

Concept
It is the study of mandibular movements in three planes: sagittal, horizontal and
frontal
The objective is to have a diagnosis and it contributes in the process of carrying
out a prostheses

Mandibular dyanmics
Ideal Thiop patient or CO (5-10% population) with 2mm overjet and overbite.
Types of movements:
• Opening-closing.
• Protusion.
• Laterality.
According to amplitude:
• intraborder or functional movements.
• border movements or limits.
Movement measurements:
• Lower interincisal point.
• Mandibular condyle.
Interincisal point movements:
• Sagital Plane. Modified Posset anagram.
• Horizontal Plane. Modified Gysi gothic arch.
• Frontal Plane. Modified Hildebrand scheme.
Condylar movement point in:
• Sagital Plane
Condylar path inclination (CPI) (ITC in spanish).
• Horizontal plane.
Bennet angle. Bennet movement.
• Frontal plane.

Sagittal plane (opening and protrusion)
Modified Posset anagram.
1. Posterior opening border.
First arch: pure rotation without displacement of the condyle
with 25 mm opening.
Second arch: rotation with translation of the condyle with 20
mm opening.
Total opening 45 mm.
2. Upper border protrusion.
Descend 2mm, advances 2 mm (with contact) and upwards 1
mm. Again advances 10 mm (non-contact teeth).
Total protrusion 15 mm.
3. Anterior opening border. Maximum opening at maximum
protrusion.
In the usual opening there are condylar rotation and translation
from the beginning (intraborder movement)


Sagittal plane (opening and protrusion)
Condylar path inclination (CPI)
Angle formed by the line connecting the initial and final position of the condyle
in the opening movement with the Frankfurt plane.
Average value: 33º

Sagittal plane (opening and protrusion)
Condylar path inclination. CPI.
Condylar path inclination in protrusive. CPIP. Condylar path inclination in
laterality. CPIL.
Fisher angle.

Horizontal plane (laterality and protrusive)
Gysi gothic arch
1. Laterality
Contact-border. Made by the anterior guidance. 10mm (upper central
incisor width) If you move the incisors distally canines are in contact
Border laterality non-contact. Muscular 8mm (upper lateral incisor
width).
Total: 16-18mm
2. Protrusive. Maximum 16mm. First gothic arc.

Horizontal plane (laterality and protrusive)
Double Gysi gothic arch modified includes:
1. Maximum opening 45mm. The interincisal point moves 30mm backward.
Second gothic arch.
2. Lateral anterior border movement. Maximum laterality to maximum
protrusive.
3. Lateral posterior border movement. Maximum laterality at maximum
opening.


Horizontal plane (laterality and protrusive)
• Protrusive
Advance both condyles
• Laterality
Working condyle rotates
• Bennet angle
Formed by the line connecting the initial and final position on non-
working condyle in lateral movement.
Average value 16º
(Not to be confused with Bennet movement)

Bennet angle and Bennet movement

Frontal plane (opening and laterality)
Modified Hildebrand scheme
1. Opening. Straight path of 45mm
 2. Laterality. Border contacting and non contacting with descent.

Frontal plane (opening and laterality)
Condyles
1. Opening: advance and descent. It can’t be seen on this plane.
2. Laterality: rotates, goes outwards and rises slightly.
No working: descends and moves medially.

Functional movements
• Begin and end at the intercuspal position
• During chewing mandible drops directly inferior until desired opening is
achieved.
• It then shifts to the side on which the bolus is placed and rises up.
• In maximum intercuspation bolus is broken down between opposing
teeth.
• In the final millimeter of closure, the mandible shift back to the
intercuspal positon.

Optimal functional occlusion

Occlusion
Maintaining oral health depends on what occlusion refers to:
• Optimal joint position
• Optimal tooth contacts
Stomatognathic system dysfunction can be caused by alterations in dental
occlusion.

Optimal functional occlusion criteria
• Centric occlusion
Only 5-10% à THIOP
The rest MIOP or LIOP à there are prematurities in CR
o Compensated (mostly)
o CMD
o Only in some objective therapeutic cases:
Patients with moderate/severe CMD
Treatments of very extensive fixed prosthodontics
Treatments of two posterior quadrants in the same arch
Full dentures
• Optimal functional in MI contacts
Posterior teeth
o Simultaneous and uniform contacts
o It should lead to axial loads
o Tripod contacts (when the tip of the cusp goes
to the fossa at three points to be more stable)
Cusp/Fossa (pit)
o It should not exist contact between cusp slopes
No axial forces à harmful to the periodontium
(bone resorption)
Anterior teeth
o Soft contact
o They are not axial, are oblique instead because they are inclines
• Optimal functional contacts in positon and eccentric movements à anterior
guidance
Christensen Phenomenon
Protrusion: 4 incisors
o Adequate overbite
Incisors: 2-3mm
Canines: 3-4mm
o Slight overjet
Laterality: canines
No axial loads
o Support the loads better
+ far away from TMJ
>Capacity of proprioception
Longer roots
Functions
o Allow posterior disocclusion
 o Direct the mandibular biodynamics
o Masticatory, phonetics, aesthetics

Occlusal contacts during mandibular movements
Optimum
• Anterior guidance in laterality and protrusive
o Canine guidance
Conditioned by the overbite
Posterior:
o NWS: 1mm
o WS: 0.5mm
o Incisal guidance
Conditioned by the overjet and the overbite
1mm in posterior
Undesirable à interferences
• Two types
o Prematurities (usually in this area)

o
Mandibular closing from CR
Impede the CR and MI coincide
Contact between cusp ridges à shift
o Mesial of upper cusp and distal of lower cusp
Lead to:
o Wear facets
o Bone resorption
o External pterygoid pain on palpation
o TMJ click
o Interferences
In posterior sectors during eccentric movements

Protrusion
Desirable contacts à incisal guidance
• Mandibular movement forward from MI to edge to edge
 • Contacts in anterior teeth
Upper incisor à palatal surface
Lower incisor à buccal surface
• No posterior contacts (cristiansund phenomenon)
Undesirable contacts
• When there is no incisal guidance
Excessive overjet/slight overbite
Anterior open bite
Class III angle
Extruded upper posterior teeth
Posterior dental malposition
• They occur between the upper distal ridges against lower mesial ridges
• They can cause:
o Wear facets
o Bone resorption
o Temporal/pterygoid pain

Laterality
Desirable contacts à incisal guidance
• Canine:
Overbite: 3-4mm
Minimum overjet
• It should not exist posterior contact à escape grooves
Undesirable contacts
• WS
Contacts between homonyms cusps
They occur when the canine guidance does not work properly
Group function: they are not considered real interference, only when
generate
pathology
When this type of contact occurs only between a posterior tooth and a
lower tooth: real interference
o Wear facets
o Cervical erosions
o Gingival recessions
o Myalgia of elevators muscles
• NWS
 Mandibular posterior teeth NWS move medially on the maxilla teeth
They are potentially the more pathogenic interference
They appear between internal ridges of active cusps
They can lead to:
o Wear facets in cusp ridges
o Cervical erosions lower buccal
o Gingival recessions lower buccal level
o Gingival recession on palatal level
o Reabsorption in the palatal posterior area
o External pterygoid myalgia
o Pain and click
o Deviation of the mandible in opening towards the affected side.

Retrusion
• Interferences occur in subjects MIOP or LIOP
• Between upper mesial ridge and lower distal ridge
• Vertical bone loss

Balanced occlusion
• Contacts in all teeth in MI (anterior and posterior) during all eccentric
movements
Simultaneous
• Full dentures treatment
• Lateral forces are shared by all teeth and TMJ
Distribute forces
o Maximum contact of cusps in all movements
o Helps maintain oral health
• Very difficult to obtain


Mutually protected occlusion
• Posteriors protect the anterior and vice versa
• THIOP
• Stallard à molars support occlusal vertical loads
Protrusion à incisors
Laterality à canines
• Fixed prosthesis
• Organic occlusion
RC = MI
Post: cusp/fossa
Tripod contacts
Protrusion: 4 maxilla incisors
Laterality: upper palatal/lower distal slope

Group function
• In laterality (WS) the rest of the teeth help canines
Internal ridge of the upper buccal cusp with external ridge of lower buccal
cusp
o Provided they do not cause disease
 • If it is a single contact on back molars à interference
• Lower lingual cusp with upper palatal cusp à interference
Sometimes in RPD (removable partial denture)

Occlusal trauma

Working side interference (laterality)

Working side interference (balance)

Protrusive interferences

Etiology, pathology and exploration of the TMJ
TMJ pain-dysfunction syndrome

1.Concept:
• Painful picture of the mastication muscles with functional limitation of
mandibular mobility.
• 20-40% prevalence in population.

2.Etiology
• Emotional stress.
• Bruxism.
• Prematurity and interferences in normal occlusion with failure of the
muscular adaptation. (overloaded muscles in order to align the condyle-disc
complex)
• Difficult mastication in patients with malocclusion. (muscle protection)
• Ill-fitting prosthesis.
• Rheumatoid arthritis.
• Trauma.

Bruxism
Nonfunctional jaw movements of voluntary or involuntary character with grinding
or clenching teeth, either during the day or night-time.
They can affect up to 70% of the population with a peak of maximum incidence
between 35-40 years.
Characteristics:
• üDaytime (bruxomania) or habits (nails, pencil...)
• Night time.
• Magnitude of the force is five times higher.
• Overloaded muscles
• üPredominance of the horizontal forces.
• Isometric contraction.
• Protection reflex disappears
• Prematurity and interferences (in parafunctional activity causing muscular
hyperactivity and in functional activity cause inhibitory effect
• Arthrosis due to cell proliferation causing shape alterations (adaptation
capacity is surpassed)

Occlusal trauma (different diagnosis)
• Occlusal trauma is one of the terms used to describe the pathological
changes or adaptation occurring in the periodontium as a result of
excessive forces produced by the muscles of mastication.
• According to Ramfjord and Ash, occlusal trauma is an injury that occurs
anywhere in the masticatory system as a result of an abnormal occlusal
contact and / or function thereof; manifesting either on the periodontium,
teeth, pulp tissue, TMJ or neuromuscular system.
• Glossary of Periodontal Terms, defines occlusal trauma as an injury on
insertion apparatus which is the result of excessive occlusal forces
 exceeding its tolerance limit, thus characterizing a traumatogenic occlusion.


Malocclusion
Emotional stress + malocclusion leads to muscle hyperactivity and pathology
(surpassing the capacity of adaptation).

3.Clinical
Teeth
• Mobility
• Recessions
• Tooth wear
Muscles
• Spliting: increased muscle tone with pain and weakness when It is working
but without functional limitation. (poorly adjusted restorations, stress)
• Spasms: increased tone with episodic pain due to nonfunctional continuous
contraction-relaxation and functional limitation by shortening. (opening
limitation)
• Myositis: inflammation of the muscle which might be due to prolonged
spasm or infection thereof with continuous pain irrespective of the muscle
use and significant functional limitation. (mandibular opening and
movement)
Joint
Muscular hyperactivity pulling the disc forward (pterygoid contraction) stretching
the ligaments and the retrodiscal lamina
The disc moves forward and the condyle is positioned in the posterior part of the
disc insted of being in the center causing a click
If the situation persists may lead to luxation with elonged ligaments causing
limitation and locking
1. Opening click. Without disc luxation (incoordination).
2. Double click on opening and closing or reciprocal (luxation).
• At the beginning of opening and end of closing. 20% (young people and
treatable)
• In the middle of the opening and closing. 80% of the population
• At the end of the opening and the beginning of closing.
• With reduction.
• No reduction or locking.
Predisponing factors
1. Joint anatomy (articular eminence is inclined requires a higher degree of
rotation )
2. Condyles are flattened and small
3. Angled fossa
4. Laxityoftheligaments.
5. Lateral pterygoid insertion

4.Diagnosis
• Clinical history
Pain. Start, location and triggers
 Dysfunction or functional limitation
EMOTIONAL STRESS.
Tinnitus (a constant or periodic ringing or roaring in the ears).
Cervical pain.
Headaches.
• Examination
1. Dental inspection.
2. Analysis of mobility and amplitude. (END-FEEL)
Opening: degree of opening (45 mm) and deviations. Assessment of the
ELASTIC forced opening without pain.
o Laterality: 15mm elastic end.
o Protrusive. 15 mm without deviations.
o Soft: indicates muscle problem
o Hard: indicates TMJ disorder
3. Palpation.
Static tests. Impeding movement against strong pressure. Painful – it comes
from muscle.
Dynamic tests. Mobility against light pressure. Painful – it comes from joint
or the muscle.
• Complementary tests: X-ray, CAT or CT, NMR.
Radiological signs:
1. In the periodontium.
Widening of the periodontal space.
Vertical bone resorption in wedge.
Pulp stones.
2. In the teeth
Hypercementosis
3. In the TMJ
Flattening of the articular surface
Subchondral sclerosis.
Disappearance of the joint space.

5.Treatment
• Orthodontic treatment of malocclusions.
• Dental equilibration by selective grinding or occlusal adjustment
• Mouthguard (nightguard) or Bite splint.
• Prosthetic rehabilitation treatment.
• Surgical treatment of TMJ.

Anterior disc replacement with reduction
• Anterior Disc Displacement with Reduction (Clicking): A clicking or popping
sound occurs as the disc returns to its normal position in relation to the
condyle. During closure, the disc again becomes anteriorly displaced,
sometimes accompanied by a second sound (reciprocal click).
• Anterior Disc Displacement without Reduction (ADDWR/Locking): A
progression of Anterior Disc Displacement with reduction. The displaced
disc acts as a barrier and prevents full translation of the condyle. Only
rotation occurs.
Etiology: The three main causes of internal derangement of the intra-articular disc
are:
1. Trauma
2. abnormal functional loading of the joint and
3. degenerative joint disease.
Acute macrotrauma is the most common cause of internal derangement (blow to
the jaw, intubation, stretching of the joint during dental procedures).

Articulators and face-bows

Concept
• Mechanical instrument that stimulates mandibular movement
• Relate the lower model to the upper model in its exact position, which will
have been transferred thanks to the facial bow.
• The face bow allows to orient the upper model in a similar way as it is
related to the base of the skull
• Reproduces the lower teeth trajectory displacement with respect to the
upper ones

Articulator

Types of articulators
Not adjustable
• Hinge type: very inaccurate
• Fixed guidance articulators:
Opening closing and literalities
Inaccurate à the condylar guidance can not be adjusted
Not accepted
Semiadjustable
• Most used
• Admit face-bowl
• Allow adjustment and individualization
• They only reproduce condylar movements in a straight line
Fully adjustable
• Kinematic face bow à locate the actual hinge axis
• They are adjusted with pantograph

Classification à condylar mechanism
Arcon type
• Condylar spheres attatched to the lower frame à as in the patient
• Mechanical glenoid fossa attached to upper frame
• Most of the semi-adjustable and fully adjustable
No Arcon type
• Condyles spheres at the upper frame
• Mechanical Glenoid fossa at the lower
• Lower accuracy reproducing the CPI

Requirements of an articulator
1. Accept a facebow
2. In opening and closing the articulator must be rigid and stable and have a
defined and safe position
3. Adaptable condylar mechanism
4. Adjustable incisal stem (rod) that allows changes in the vertical dimension
5. Adjustable incisal table à individualize the anterior guidance
6. It should have an adjustable intercondylar distance à dentatus

Objective of the articulator
Diagnosis
• Evaluate the occlusal status
• Mounting in CR
Planning
• Necessity of selective occlusal grinding
• Diagnostic waxing up
• Design
Carrying out
• Manufacture of different prosthesis

Not adjustable articulator
• They cannot be adjusted à inexact
• They do not reproduce the mandibular biodynamic properly
• They only reproduce the MI
• They are not even correct in opening and closing
• Advantages
Cheap
Less mounting process time
• Disadvantages
Poor occlusal result
They are not acceptable

Semi adjustable articulator
• They reproduce more accurately the mandibular biodynamic
• MI
• Eccentric movements
• CR à Face bow + correct wax bite registration
• It can be adjusted:
CPI à Height of cusps and depths of fossas
BA à Width of fossa and direction of grooves (furrows)
Intercondylar distance
• Methods needed for use:
Transfer the relation of the maxilla to the cranial base à face bow
CR à waxes
Pin (rod) +5mm (you put it to +3)
• Inconveniencies
Expensive
It takes more time in mounting process
 They only reproduce condylar movements in a straight line
• Advantages
Exact restorations
Better results
Less occlusal corrections
• Indications
Almost all cases: except severe TMD/complete rehabilitations/occlusal
pathology

Fully adjustable articulator
• More sophisticated and more accurate
• Adjust
Condylar inclination
Movement of curved lateral translation of NWS
Movement of lateral rotation and translation of WS
Intercondylar distance
• Requirements
Kinematic face-bow à real hinge axis
Pantograph à exact trajectory of border movements
CR
• Disadvantages
Very expensive
Time consuming
• Advantages
Adjustment is very precise
• TMD

Face-bow
• It reflects the spatial orientation of the upper jaw with respect to the base of
the skull à maxilla to cranial base relationship
• Transfer and mounting in CR or MI
• Match the patients intercondylar axis (hinge axis) to the articulator axis
• This condylar axis can be fixed or localized
1. Fixed:
Condylar
Nosebar/nasion
Bite fork
Earplugs/tragus
Lower model MI, CR
2. Kinematic
A face bow with adjustable caliper ends to locate the transverse horizontal
axis of the mandible.
In addition to registering positions, they record mandibular biodynamics
The lateral arms can be oriented in the 3 planes of the space
Parts:
• Horizontal anterior bar
• Two side bars
• Bite fork
• Infraorbital pointer
 Craniometric references
• Posterior points à hinge axis with locator
• Anterior point à infraorbital
Procedure for face-bow transfer using kinematic face-bow
• Face-bow is attached to the lower jaw by means of clutch.
• Graph of Grid paper is placed near the temporomandibular joint
region detects the stylus movement
• Patient is asked to open and close the mandible at centric. Initial
movement of the stylus may be arc shaped.
• The stylus is adjusted until the tip rotates instead of arcing.
• This point identified as the hinge axis is tattooed on the skin

Fixed axis or arbitrary
• Semiadjustable articulator
• As it does not have a real axis, it is always better to mount in MI
• If we mount in CR when closing there will be a slight shift
• With increased wax thickness, increase the CR error
• With thin wax CR registration thickness (1-2mm). It will provide a very
slight difference.
• With increased discrepancy between the actual patient hinge axis and the
articulator hinge axis. It will increase the MI error
• We will mount in CR when we are going to carry out an occlusal baseplate
in full dentures changing the incisal pin (plus 3) or a total rehabilitation
with fixed prosthesis, without modifying the VDO

Hinge axis location
• When we mount in CR
• When using a fully adjustable articulator
Edentulous patient

Concept
• Toothless (edentate) patient by losing the teeth or never had them.
• Synonym: edentulous or genetic anodontia
• related to syndrome.
• According to WHO from 6 to 10% of the world population is edentulous.
• 10% population in USA.
• 8% in Spain.
• Age: It is more frequent from 65 years.

Etiology
• Genetic absence (ectodermal dysplasia)
• Caries
• Periodontal disease
• Trauma

Clincial
• General changes
Personality change
Lack of self-esteem
Social withdrawal
Knowing the expectations of the replacement therapy
Set positions. Be realistic.
• Local changes
Morphological: facial, mucosa, tongue, salivary glands, TMJ and bones
Functional: chewing, swallowing and phonation

Facial changes
1. Loss of vertical dimension.
2. Loss of lip support (sinking) due to the bone loss.
3. Loss of facial muscles support with contraction(tone).
Accentuation of the nasogenian furrows.
Commissural cheilitis due to the decreased VDO.
4. Pseudo-prognathism.
Positional mandibular: protrusion.
Bone resorption centripetal- centrifugal.

Oral mucosa changes
• Mucosa atrophy due to the age, systemic deterioration, smoke, ill-fitting
prosthesis and poor hygiene causing:
• Thinning: Decreased epithelial thickness.
• Retraction: Degeneration of collagen fibers
• causing more bone resorption due to pressure.
• Loss of elasticity due to increase of collagen fibers.
• Increase in friability due to cellular dehydration and lower capacity of
cellular repair

Tongue changes
• Tongue size increase due to expansion caused by a lack of muscle tone.
Relative macroglossia.
• Filiform papillae atrophy (smooth and bright tongue).
• Decreased taste sensitivity due to atrophy of taste buds (hypogeusia).

Changes salivary glands
• Glandular atrophy with xerostomia.
• It is characteristic of the age by fat degeneration mainly on sublingual and
submandibular.

TMJ changes
• Alteration of the disc.
• Flattening of the articular eminence.
• Flattening of the condyle.
• Possible degeneration causing arthrosis.

Bone changes
Bone resorption which magnitude depends on:
1. Genetic basis of the Maxilla size.
2. Hormonal balance. (PTH, TSH, Calcitonin, vitamins).
3. Cause of tooth loss.
4. Previous surgical treatments.
5. Functional factors for prosthetic use.

Prosthetic functional factors
Bone resorption is increased with poorly adapted prosthesis or malocclusion.
According to two laws:
1. Bose pressure intensity law.
2. Jones Frequency force law.

Prosthetic functional factors
1. Bose pressure intensity law.
Very intense pressure causes irreversible resorption
Medium pressure intensity promotes osteogenesis promotion
The lack of pressure (no function) favors the resorption
2. Jones Frequency force law.
Continuous pressure leads to a resorption
Discontinuous pressure with very short rest intervals behaves like a
continuous pressure
Discontinuous pressure with prolonged rest intervals promotes bone
formation

Morphology maxillary residual ridge
Centripetal atrophy: from the outside in, with loss of height and width.
It does not usually have a greater height of1-1.5 cm.
Final form:
 • In U: More retentive.
• In V: Long term edentulism. More traumatic area.
• In C or “Drop”: Convex flanks. Worse prognosis due to trauma when insert
and remove the prosthesis
Centrifugal atrophy: from the inside out. More intense than the maxilla. (4 times)
height of 0.5-0,3 cm.
Final form:
• V: in incisors. Knife edge.
• U: in molars.

Alterations in mastication
• Chewing against the gums generates fibromucosa thickening.
• Proprioception is lost due to the lack of teeth.
• Inaccurate mandible movements.
• Loss of muscle strength.
• Incomplete grinding.
• Poor bolus formation.
• Overload on the rest of the digestive tract.

Alterations in deglutition
• No prosthesis.
Child swallowing pattern using tongue and perioral muscles. Lack of
mandibular stability produces frequent choking.
• With prosthesis.
Adult swallowing pattern.

Alteration in phonation
• Prosthetic dysglossia.
Alteration in the pronunciation of the lingual-dental and lip-dental
phonemes (sounds) by modification of lingual support in these teeth as It
changes their position.

Correction of all these factors through our prosthesis
• Psychological.
• Aesthetic.
• Functional.
Adaptive capacity of the patient.

Clinical history. General principles of full dentures retention.

Concept
The concept of medical history includes many sections, groups and subgroups but
right now we will only consider the minimum and indispensable for every
professional may require effective patient history

Anamnesis
• Psychological considerations: Information on how the patient presents the
condition of edentulism and explain that the outcomes may vary according
to the circumstances
• Age: Young patients have better adaptation and soft tissue status leading to
a most favourable prognosis
• General condition: The role of the general condition of the patient in
treatment success is very important

Examination
1. Loss of lip support.
2. Relationship between lips and alveolar ridge.
3. Size of the lips. Thick ones are more favourable
4. Tongue expansion. Macroglossia
5. Floor of the mouth
6. Mobile tissues insertion: Delimits the extension of the prosthesis baseplates

7. Mucosa status
8. Shape of the palatal vault
9. Posterior palatal area: PostDam posterior palatal seal
10. Size and shape of the alveolar ridges.
11. Interalveolar distance: (VD): It is diminished due to edentulism status.
Previously the patient maintain the distance through reflex arc but in time
no periodontal propiception information leads to have contact between
mandible and maxilla.
12. Interalveolar line: Imaginary line between the most prominent alveolar
ridge from lateral view
13. Presence of exostosis
14. Saliva: Xerostomia, viscous saliva and sialorrhea leads to uncertain
prognosis
15. TMJ
16. Phonetic disorders

Complementary tests
• Radiologic study: t is advisable to make a panoramic radiograph to evaluate
properly and study the structures of the prosthetic support (symmetry,
bone quality, retaining roots, tooth impactions, TMJ and other pathologies.
Also with periapicals
• Other tests for thorough examination :
1. Radiography study of joints with Tomography. Scanner, magnetic
resonance or pantography analytics
 2. Blood test.
3. Biopsy.
4. Sialography.

Concept of full denture
General concepts
• When the prosthesis installed in the edentulous are at rest position create a
prosthetic space that is occupied by its own volume and is bounded by the
structures that surround them (maxilla, mandible, fibromucosa, tongue,
cheeks and lips) causing a series of forces which will act on the prosthesis.
• Passive tension: Developed when install them
• Functional: Postural changes (when the patient chew, swallow, drink, suck,
speak and laugh)
• According to the displacement caused by these forces:
Intrusive: They tend to impact the prosthesis on the structure in which they
rest (fibromucosa and bone)
Extrusive or antagonists: Displaces the prosthesis from its settlement
• In order to avoid and nullify these destabilizing forces we have to consider
1. Support: To the Intrusion forces oppose the supporting force
Extrusion forces are counteracted in two ways:
2. Retention: Prevent movement in the opposite direction to the support,
vertically
3. Stability: Prevents extrusion caused by forces acting laterally

Support
• Support is the ability of the prostheses to resist intrusion forces acting on
them
• The fibromucosa and bone are the support structures
• It depends on the function of the prostheses bases shape and its relation to
the tissues
• In case of deficient tissues or ill-fitting prosthesis we will have an
inadequate support in both cases

Retention
• Is the Capacity to avoid prosthesis extrusion Fundamental concepts:
• Adhesion
 Adhesion is the attractive force that holds molecules together of different
chemical species
The adhesive action in the edentulous prosthesis is given by the attraction
of the molecules of saliva and acrylic bases, and the relationship between
saliva and fibromucosa
The adhesion is in direct proportion to the surface covering prosthesis,
fitting and saliva fluidity
• Cohesion
Cohesion is an intimate bond between the molecules of a body and the
attractive force that holds them together
This mechanism constitutes a retaining force being present with saliva on
the inner surface of the prosthesis plates and the fibromucosa
Direct relation to the extension of the prosthesis
• Periapical seal
It is produced by contact between the soft parts of the mobile peripheral
tissues surrounding the prosthesis and the polished outer edges thereof so
that nothing comes into the inside of the prosthesis
The peripheral seal results in a negative air pressure on the inside of the
prosthesis
The action of the negative atmospheric pressure is relatively high due to the
result of the difference between external and internal pressure
• Other factors: atmospheric pressure)
The atmospheric pressure only acts and provides retention when
dislocating forces are applied to the prosthesis (suction)
When the prosthesis are at rest, the internal pressure (negative) is equal to
the external nullifying its action temporally (protect the soft tissue)
We must consider completely abolished cameras and suction cups.
(Hyperplasia)

Stability
• Stability is the property that is opposed to horizontal and lateral forces
• The stability of the prosthesis is the property of preserving its rest position
or return to it after having made functional movements
• The appropriate way to achieve stability in the complete prosthesis is called
balanced occlusion

Clinical classification of Crespi
Based on the morphology of the residual alveolar ridges:
• Class I: Recent edentulous with bulky ridges
• Class II: High residual ridges but thinner and sharp
• Class III: Alveolar ridge that has lost thickness and height remain low and
give prosthesis low retention
• Class IV: There is no alveolar ridge, with resorption that has even been able
to invert

Impressions in full dentures

Concept
Reproduction in negative of the oral cavity tissues, especially of the edentulous
alveolar ridge.
Objective: Get a model as accurate as possible which is a positive copy of the oral
tissues shape and size in order to make the prosthesis.

Requirements according to Saizar
• Previous thorough examination of the patient.
• Knowledge about the tissues that we will take impressions through a
proper examination and a correct diagnosis.
• Be self-critical.
• Careful pouring as soon as possible (alginate).

When taking impressions?
In recent edentulous patients. Options:
1. Wait 9 (nine months) for bone healing.
2. Using the old patient prosthesis adding teeth as necessary.
3. Make a temporary prosthesis. More expensive
4. Make an immediate temporary prosthesis.
5. Make a permanent prosthesis and reline it after nine months.
In edentulous with long term evolution or patient with previous prosthesis.
Immediately, if they do not present:
1. Candidiasis (Mycosis): Need specific treatment with Micostatin prior to
start the prosthetic treatment
2. Irritative lesions by previous prosthesis.
3. Hyperplasias: Surgical treatment

Types (impression technique)
Anatomic o muco-static.
• With an impression material that does not press the mucosa.
• Objective: Fibromucosa reproduction at rest with minimum deformation
without function or pressure.
• To get maximum support and retention (adhesion and cohesion) of our
prosthesis with mouth opening by appropriate design of the bases
extension and proper adaptation thereof. MGL (mucogingival line: up to
functional zero line or line limit between the inserted gingiva and the
mobile mucosa
• Material: standard edentulous tray and alginate (minimum pressure).
• Procedure: The alginate has to copy the structures without function or
pressure as it is a flowable material (creamy). Overextended.
• Indication: Class I and II of Crespi (favorable).
Functional or muco-dynamic.
• Objective: To record the movements of the vestibule, bridles, floor of the
mouth, during the the orofacial muscle contraction in order to have the
exact limits of the prosthesis fixed and get a peripheral seal through molded
edges
 • We try to extend the impression to the maximum within the limits of
function (surpass 1-2 mm without interfering the correct function)
• Types: No pressure : It is most commonly used technique With pressure:
Not convenient With selective pressure: Questionable technique
• Material: with custom tray, sealed with Godiva and zinquenolic paste or
medium consistency silicone.
• Indication: Class III and IV of Crespi.

Material
Pastes:
• Alginate.
• Zinquenolic paste
• Addition silicone of medium or fluid consistency.
• Low fusion Godiva.
Trays:
• Standard.
Stainless steel with retention tab Rib-Lock type
Types:
1. Regular
2. Edentulous
• Individual (Custom).
Material: self-curing acrylic
Elaboration: previous model obtained with standard tray
Types:
1. With no inner space for zinquenolic paste. (rigid)
2. Inner space of 2 mm for fluid silicone. (elastic and flexible)
Requirements
o Biocompatible.
o Well-adjusted to the model
o 2 mm thickness to be rigid.
o Rounded and polished edges.
o Well attached handle.
o Easily trim.
o Perforations to retain material (alginate and zinquenolic paste).
o Cheap and easy to make.

Impressions general procedure
Preparatory phase
1. Preparation of materials and instruments. Proper selection of bowl and
spatula.
2. Preparation of the patient. Seated in an up right position.
3. Selection size of standard tray or custom tray try in.
4. Material handling with dosers.
5. Creamy consistency.
Oral phase
1. Mouth suction (removing saliva).
2. Topical anesthesia or cotton swab with alcohol.
 3. Placing the tray with the help of a mirror.
4. Centering the tray from behind in the maxilla.
5. Impaction from front to back,
6. Hold the tray.
7. Wait setting.
8. Vertical Detachment.
Post-oral phase
1. Careful washing of the impression.
2. Critical evaluation.
3. Trimmed if necessary.
4. Plaster whitewash treatment if it is alginate.
5. Pouring the plaster within 10 minutes.
6. Humidity chamber 45-60 min and obtaining the master model.

Systematic of the functional impression
1. Confection of the custom tray.
2. Try-in and trim until MGL (mucogingival line or junction).
3. Paint the in patient's mouth the out-lines and the Postdam to check the
limits.
4. Godiva placement on the edges of the tray.
5. Tray edges modelling with functional movements by sector.
6. Taking final impression.

Conclusion
• Support and retention of the prosthesis is directly proportional to the
extent of the denture base. It is achieved by adhesion and cohesion and if it
is necessary, the peripheral seal.
• Extension of the bases:
o Class I and II: MGL (mucogingival line or junction)
o Class III and IV:
Convex 1 to 2 mm beyond the line of the maximum contour.
No Convex 2mm above to the functional vestibule bottom line.
(normally it coincides with the MGL but we have to check it in the
mouth)

Baseplate and occlusal rims of registration and transfer

Registration baseplates
Baseplates:
• Acrylic elements that try to simulate as It will be the base of the prosthesis.
• It is made on the master model
• Together with the occlusal wax rims, it registers and transfers the
craniomaxillary and maxillomandibular relationship to correctly assemble
the models on the articulator.
They are used to:
• Transfer the cast models to the articulator
• Arrangement of artificial teeth
• Wax bite try in
• Muffle (Flask) process

Baseplate functions
1. Quality control of the model
Adjust on the model but not in the mouth à Repeat
It does not fit in the mouth or on the model à Repeat
It has to adjust on the model and in the mouth
2. Retention of the future prosthesis Mouth try in
3. Extension control
Determine functional limits
4. Registration transfer
Aesthetic registration
• With wax rims à (VD, CR, Lip support..)
• With artificial teeth à (Smile line, Canine line, Midline, Upper lip, Lower
lip)
Teeth size, inclination, shape, shade..)
Coming to the practice with a relative to check the steps
Functional registration
• Phonetic action
Wax teeth try in
Phonetics will improve over time
• Instruments
Taking records with the face-bow
• Wax rims (blocks)
Upper à Occlusal plane
Lower àCR and VD
• Artificial Teeth
Evaluate the correct arrangement à CO

Properties of baseplates
1. Fit and well adapted
From them the trials are carried out and the final prosthesis is made, so
they must be well adapted and avoid displacement or misfit
(maladjustment).
 2. Uniform thickness
Resin made prosthesis thickness with 2mm (approx.) and to correct ridges
defects it will be made in wax
The greater thickness in palatal area will lead to worse phonetic
3. Do not deform with heat
We manipulate the wax rims with heat
4. Rigid
They should not be deformed under pressure
5. Retouchable
Strictly necessary to make functional adaptations
6. Capable of carrying teeth
To try them in the patient`s mouth at the practice and for later muffle
process
7. Biocompatible (Non-toxic)
8. Economic (cheap)
9. Easy handling and making
10. Good dimensional stability

Baseplate materials
Acrylic
1. Self polymerized (most recommended)
2. Heat polymerized (discarded)
3. Photo polymerized (expensive, difficult to retouch, trim or ease)

Baseplate making
• Self curing acrylic
• Limits on the study model with pencil
• Unfavourable case:
Class III and IV of Crespi
Custom tray and zinquenolic paste
Limits at the vestibule bottom (godiva)
• Favourable case
Classes I and II of Crespi
Conventional impressions with alginate
Up to mucogingival line (MGL) 2-3mm from vestibule bottom

Design
Maxillary baseplate
• Vertical Insertion
• Convex shape à Determine lines of maximum contour and extend 1 to 2mm
beyond
• Non-retentive areas à 2-3 mm from vestibule bottom
• Posterior border à tuberosities and in front of vibratory line and fovea
palatinae
Mandibular baseplate
• Retentive areas à Maximum contour lines à 1-2mm beyond
• Non-retentive à 2-3 mm from vestibule bottom
• Design as straight as possible


Baseplate making
• Do not use Vaseline or separator on model à submerge in water and dry
• Acrylic mixing (powder / liquid)
• The plate is making with a uniform thickness of 2mm approx.
• Adapting the plate to the model with care
• Trimming the excess
• Continuous pressure on the acrylic in order to not expand during its setting

• File and trimming of the edges to finish the plate
• Functionalize the limits of the plate

Baseplate assessment
• Good support à no tilt or swing
• Good passive and static retention
• Adequate stability and dynamic retention

Functions of the wax rims
AESTHETIC RECORDS
• Upper lip
Anterior part of the wax rimàInclined 20o
It will be advanced or retracted to fill the upper lip properly
• Upper Incisisor
Parallel to the interpupillary line
Wax rimà1-2mm longer than lip edge
• Occlusal plane
Inclined relative to the horizontal plane in order to coincide with the
condylar trajectories
Parallel to Camper's PlaneàFox plane
• Midline
It does not always match the labial frenulum
• Smile line
Patient's broad smile
Aesthetic
• Canines
Determine the width of the anterior teeth
 Perpendicular to the horizontal plane passing through the pupils
• Teeth size
Depends on the canines and the smile line
Fox plane
• The Fox plane is used to adjust the upper wax rims in full dentures for
determination of the Occlusal plane that is parallel to Camper plane and
horizontal (interpupillary line) planes

Functional registration
• Vertical Dimension Record
Modifications will be made on the lower wax rim
• Centric relation record
Unimanual technique / Dawson
• Instrument carriers
Face-bow
• Transfer and mounting of the models on the articulator
Edentulous bite fork
• The edentulous bite fork is an accessory of the Face-bow that has two
adjustable poles for adaptation in the alveolar rim of total edentulous (wax
plans), as well as for dentate patients with different widths of dental arch.
• The bite fork is attached to the maxillary occlusal rim
• Occlusal rim are inserted into patient mouth
• The midline of bite fork should coincide with the midline of the maxillary
occlusal rim.

Wax rim properties
• Handling
• Modification
• Stability
• Biocompatibility
• Economic

Wax rims (blocks)
• Made from hard waxes
• Upper wax rim
Rectangular with horseshoe shape
12mm height in incisors area
8mm height in posterior area
5-8mm width
• Lower wax rim
Wax rim divided in 2 pieces
8mm in height and thickness
 • Making process
Rubber wax base former spread with vaseline
Wax is heated until it melts and is poured into the base former
It is placed on the baseplate and is adjusted with the data previously
provided

Upper wax rim record. Cranio-maxillary transfer

Records in upper wax rim.
• Aesthetics
Upper lip support
Midline
Location of anterior incisors
Orientation of the incisal edges
Smile lines
Location of canines
• Functional: occlusal plane

AESTHETICS:
Lip support
• Depends: thickness and antero-posterior position of the wax rim
• Method: frontal and lateral view of the patient
• Objective: slight anterior lip inclination in lateral view
Horizontal orientation of anterior teeth
Insufficient support of lips
• Drooping of corner of mouth
• Deepening of nasolabial groove
• Depending of sulci
• Reduction in prominence in philtrum
• Reduction in visible part of vermillion border
Excessive support of lips
• Stretched appearance of lips
• Elimination of contour of lips
• Distortion of lip and sulci
• Tendency of lip to dislodge the denture

Midline
• It depends: choose the facial landmarks according to nose and chin. Not the
upper frenulum
• Method: in front of the patient with spatula marking the wax throughout
the length of the wax rim
• Objective: center of the teeth

Situation incisal edges
• Depends: length of the wax rim and presence of short-long, thick-thin, fixed
mobile lip.
• Method: with millimetre ruler, mark and cut (reduce) the wax.
• Objective: showing the incisor 2mm under the lip at rest with slightly ajar
(half open) mouth

Incisal edges orientation (position)
• Depends: parallelize interpupillary line and incisal edges line
• Method: millimetre rule in interpupillary line and Fox plane from a frontal
view
 • Objective: frontal symmetry, non-inclined plane.
Relation with the upper lip
Incisal two-thirds of labial surface of teeth supports the lips
• If set too far posteriorly
Lip look unsupported
Vermillion border would not be visible
• If set too far anteriorly
Lip would taut & stretch
Nasolabial fold may fill out

Smile line
• Forced or maximum
• Method: mark with the wax knife the intersection of the midline with the
position of the upper lip in forced smile as well as the commissures
• Objective: to define the length of the central incisors
• Anterior teeth will generally follow the contour of the lower lip
• Anterior teeth positioned incorrectly (This set-up does not following the
contour of the lower lip)

Location of canine
• Method: perpendicular line by the wing of the nose should match the cusp
of the canine
• Objective: define the width of the anterior group to choose teeth from the
table
Teeth size (width mesiodistal)
• A vertical line extending along the lateral surface of the ala often will pass
through the middle of the natural upper canine
• Measure the distance between the previously marked canine lines on the
maxillary wax occlusion rim.
Medio-lateral position
• Midline of face passes between 2 upper & lower central incisors
• Ala of nose – line dropped from the Ala passes through tip of canine

FUNCTIONAL
Location of the occlusal plane
• Work on wax rim in posterior sector. Spatula work is a must.
• Method: lateral view Fox plane and millimetre ruler of the tragus to the ala
of the nose (Camper plane). Both sides.
• Objective: Parallel to the Camper plane.







Cranio-maxillary transfer

VD and CR registration. Lower model mounting.

Introduction
• Registrations which depends on the lower wax rim
• IFS (interocclusal freeway space) à from MI to VDR (2-4mm)
• VD à height of the lower third of the face
VDO à in MI
• VDR à Mandible in postural resting position (myotatic reflex)
• CR can occur at different heights (grades) of oral opening with different VD.
When a patient has lost the VDO we can increase that VDO we can increase
that VDO with our prosthetic rehabilitation
We can increase it slightly as long as we do not invade iFS

VD in edentulous patient
• There is no VDO
• There is VDR but it is minimally altered à slightly diminished
• Re-establish VDO
The VDR, although it varies, but not much. It is the way to restore the VDO
We will also match MI with CRàCO
• In the lower model
VD à vertical position
CR à horizontal and anteroposterior position

VD registration
Technique
1. Interalveolar distance (not used)
2. Facial proportions (orientative)
3. Muscular action (electromyography)
4. Radiographic evaluation (lateral teleradiography)
5. Phonetic evaluation
S, CH à 2mm of upper and lower wax rims separation
M à4mm of upper and lower wax rims separation
6. Aesthetic evaluation
7. PRP- Postural Resting Position (the most used)
8. Deglutition evaluation
After swallowing having the VDO
Most used

Establish (determine) VD
1. Mark 2 pointsàSUBNASAL point and POGONION (CHIN)
2. Maximum opening during 2minàmuscle fatigue
Ask the patient to close and rest
At least 4 measurements
Using a calliper
3. Obtain VDO through deglutition
Swallowing repeatedly
Measure
 Contrast VDR – VDO = IFS
4. Insert baseplates and wax rims
We never adjust the upper wax rim
The adjustments will be made on the lower wax rim

Techniques to VD
• Del Rio: VDR - 2-4MM=VDO
• Casado: VDO through DEGLUTITION
VDR after fatigue of 2min mouth opening having 4 measurements
VDO without baseplates through deglutition
Baseplates and wax rims measure VD =VDO
• Patient in CR
• Uniform contact on all wax rim surface
Favourable aesthetics

Consequences of incorrect VD
VDO high
• Mouth half open, long face
• Functional limitation
• Rattle (noise) in speech
• Muscle or joint pain
• Alveola resorption
• Fibromucosa lesion (injureis)
VDO low
• Projected chin
• Anterior resportion of the MB
• Short face
• Lack of lip support
• Patient bites the lips and the cheeks
• Flaccidity and wrinkles

Registration and CR transfer
• Goal (objective) à CO
Record the CR in the patient ́s mouth
Mount the lower model on the articulator in CR
It is the only recordable, reproducible, repeatable and in constant position
The opening and closing movement in the THIOP edentulous patient is the
only one that can be 100% reproduced by the semi-adjustable articulator
Single position that does not generate TMD
More stable position with less resorption
• Failure to achieve: functional failure of the prosthesis
• It has to be registered through the interposition of waxes (Alluwax)

Principles of the CR registration
1. Simultaneous contact of the articular surfaces of both condyles on the wax
rims
2. Between both wax rims should be placed soft wax
 3. Lingual or mandibular protrusion should be avoided
a) The tongue tends to move forward until it reaches the top of the lower
incisors
b) The complete edentulous patients tends to protrude the jaw to seek
contact and chew with the anterior alveolar ridges

Clinical systematics
1. Registration of the upper wax rim
2. Upper model mounting with face bow
Upper rim: Occlusal plane and aesthetics
Lower rim: VDO and CR
3. CR registration
a. Patient with hyperextension neck
Unimanual technique
Repeat several times
d. CR registration: very thin Alluwax layer in CR
e. Wait until it cools in the mouth
f. Remove the baseplates

CR transfer to the articualtor
• Centric lock up (articulator)
• Pin at 0
• CPI at 45º
• BA 15º
• Denture try-in
Artificial teeth. Selection and arrangement.

Types
Material:
• Acrylic (chemical bonding to base plates)
• Porcelain (mechanical bonding)
• Composite
Position
• Anterior
• Posterior

Anterior teeth
Shape
• Triangular
• Square
• Oval

Size:
• Small
• Medium
• Large

Interalvoelar crest line

Properties of artificial teeth
1. Biocompatible.
2. Aesthetics.
3. Masticatory efficiency (cutting, grinding and chewing).
4. Resistant and non-deformable (to maintain VD and CR).
5. Gradual wear (to transmit forces of chewing and stimulating action on the
tissues).
6. Shade stability.
7. Non-porous (they have to avoid deposits of plaque and its retention,
external agents or odors).
8. Easy handling.
9. Adequate cost.
10. Comfort or well-being feeling.
Acrylic teeth in anteriors and porcelain teeth in posteriors

Selection
Clinical.
Anteriors:
• Size: according to the upper rim information.
• Shape.
• Shade: Hue, saturation, brightness, translucency
Posteriors:
• Shape: anatomical or functional.
Size and height: according to prosthetic space between the wax rim occlusal plane
and the baseplate beneath.

Arranging teeth and waxing
• Technician (Under the supervision of the clinician). Objective: to respect the
aesthetic lines of the upper rim
• and achieve a bilateral balanced occlusion.
• How:
Absence (lack) of the anterior guidance without overbite and with
increased overjet in order to avoid posterior disocclusion
Posterior teeth with anatomical cusps of 33o in normal occlusion or in cross
bite.
 Accentuating the curves of Spee and Wilson.
Arranging teeth systematic
1. Upper anterior group respecting all upper rim information. (Length, width,
incisal edge position).
2. Posterior upper groups respecting the upper rim occlusal plane and
accentuating the Spee and Wilson curves.
3. Lower anterior group according to the tables controlling overbite and
overjet.
4. Lower posterior groups.

Differences between natural and artificial occlusion
Natural teeth Artificial teeth
Natural teeth function independently Artificial teeth functions as a group and
and each individual tooth disperses the the occlusal loads are not individually
occlusal load managed.
Malocclusion can be non problematic Mal occlusion poses immediate drastic
for long time problems
Non-vertical forces are well tolerated Non-vertical forces damages the
supporting tissues
Incising does not affect the posterior Incising will lift the posterior part of
teeth the denture
The second molar is the favoured area Heavy mastication over the second
for heavy mastication and better molar area can tilt or lift the denture
base
Bilateral balance is not necessary and Bilateral balance is mandatory to
usually considered as hindrance produce stability of denture.
Proprioceptive impulses give feedback There is not feedback and denture
to avoid occlusal prematurities. This rests in centric relation. Any
helps patient to have habitual occlusal prematurities in the position can shift
away from centric relation the base.

Balanced occlusion
Advantages of balanced occlusion:
• Bilateral simultaneous contact help to seat the dentures in a stable during
position during mastication, swallowing and maintain retention and
stability of the denture and the health of the oral tissues
• Cross-arch balance
• Denture bases are stable even during bruxing activity

Contact during lateral movement

Objectives of the waxing
1. Restore face support. Giving volume to the prosthesis mainly on buccal
surface in order to recover the lost tissues. (Alveolar bone)
2. Increase the retention of teeth.
3. Give a natural and pleasing appearance to the prosthesis. Texture.
4. Modify the shape of the teeth in the alveolar ridge area.
5. Contributes to the adaptation of the plates

Waxing

Denture try-in. Clinical evaluation of the baseplates with teeth arrangement.

Starting point
• Articulator:
CPI 45º
Bennet 15º
Incisal pin 0
Both condyles blocked
• Baseplates:
OC mounted teeth (Monitoring overjet and overbite)
Waxed outer surface

Denture try in evaluation
Baseplate
• Retention
• Support
• Stability
• Limits and sealing
Facial aesthetics
• Face height
• Upper lip
• Nasogenian furrows
• Cheek support

Denture try in evaluation - Dental Aesthetics
• Extend 1-2mm the edge of the lip
• Symmetrical distribution
• Parallelism of the anterior group
• Appropriate shape
• Appropriate width
• Appropiate height
If it goes wrong
1. Repositioning them ourselves (only if the teeth are malpositioned)
2. Remove the anterior group and fit a new wax rim in case the shape and
shape are inadequate
When it seems all right we will show the mock-up to the patient. NEVER BEFORE

Denture try in evaluation – Phonetic Evaluation
Requirements:
1. Adequate thickness: palate à (L, Ch, S)
2. Appropiate extension (K, G, A,)
3. Appropiate lip position (B, M, P, F, V, C, D, N, T, Z)
4. Adequate VDO à(S)
Functional evaluation
• Comparing VDO with VDR
• If they are not correct à we remove the posterior sectors and determine the
CR again
 • We will not check the balanced occlusion to prevent the wax teeth from
moving

Laboratory technology in complete denture prosthesis

Functions of prosthesis bases
1. Teeth support.
2. Allow mastication function.
3. Transmit occlusal loads.
4. Participate in aesthetics.
5. Stimulation of supporting tissues.
6. They participate in phonation. Palatolingual (L) Dento palatolingual (S, Ch)
7. Tissue replacement

Properties of prosthesis bases
1. Biocompatible. Thermo-polymerizable acrylic.
2. Aesthetics. (Simulate gingiva, pinkish color)
3. Color stability.
4. Well adapted to the tissues support and retention. *
5. Resistant and nondeformable. (To support teeth, perform mastication,
transmit loads and stimulating action on tissues). *
6. Lightweight. *
7. Non-porous (avoid retaining plaque, external agents, odors).
8. Easy handling allowing rebase (reline). *
9. Adequate cost (affordable).
10. Comfort or wellness sensation (thermal conductivity).

Laboratory phases
1. Arrangement of teeth in wax (lesson 16).
2. Final waxing (item 16).
3. Flask processing.
4. Packaging and polymerization of acrylic.
5. Flask removal.
6. Review, finish and polish.

Arrangement of teeth in wax
Technician under the supervision of the clinician. Objective: Bilateral balanced
occlusion and respect all information of the wax rims.
How:
Lack of anterior guidance without overbite and with increased overjet.
Posterior artificial teeth with anatomical cusps of 33o in normal occlusion or in
crossbite.
Accentuating the curves of Spee and Wilson

Method of arranging artificial teeth
1. Upper anterior group set respecting all upper wax rim information. (Length,
width, incisal edge position).
2. Posterior upper group set respecting the occlusal plane of the upper wax
rim and accentuating Spee and Wilson curves.
 3. Lower anterior group according to the combination tables controlling
overbite and overjet.
4. Lower posterior groups. Placing first 1st molar then the pre-molars 1st and
2nd and then 2nd molar

Definite waxing
1. Restore facial support. Giving volume to the prosthesis mainly in buccal
surface and to recover the lost tissues. (Alveolar bone)
2. Increase the retention of the artificial teeth.
3. Give a natural and pleasing appearance to the prosthesis. Texture.
4. Modify the shape of the teeth in the alveolar ridge area.
5. Contribute to the adaptation of the baseplates.

Flask for processing (flasking)
• Objective: To replace the base plates of the prosthesis, the wax support of
the teeth and definitive waxing by thermo-polymerizable acrylic without
moving the teeth from its position.
• How: putting in a flask (muffle) the master model with base plates, wax
rim with teeth and definitive waxing with plaster and bring the muffle to a
hot water bath (90º) for 10 minutes so the wax softens

Flask (muffle)
• Muffle, countermuffle and cap.
• The process of investing the cast and a waxed denture in a flask to make a
sectional mould used to form the acrylic resin denture base.
o Lower half (which contains the cast)
o Upper half
o Cover/Lid

Flask opening
• After 10 minutes the Flask is opened
• Were move softened wax.
• The baseplates are removed.
• The teeth remain fixed in the counter-muffle by the plaster.

Packaging and processing (polymerization) of acrylic
• Traditional. Pressing and polymerization for 30 minutes at 100º (14%
shrinkage polymerization)
• Injected:
o Sr- Ivocap: injection and constant pressure (6% contraction)
o Inkovac: injection and vaccum suction (undesirable teeth
movement)
o Microbase: injected and cured with microwaves (3% contraction).
The smallest of all
o Ivobase

Packing
• The closed muffle is placed with a clamp in a press (constant pressure) and
It is introduced in hot water for the acrylic to polymerize
• Processing, acrylic polymerization: by exogenous moist heat
The muffle is introduced into an acrylic processing machine
8 hours at 71 degrees and 30 minutes at 100 degrees
Let the muffles cool down

Deflasking
• We removed the clamp
• The muffle is opened with a mallet
• The cast is removed
• The prosthesis is separated from the model that is lost










Review, finish and polish
• Review of the bases edges leaving a uniform thickness of 2mm and blunt
(rounded)
• Polished with felt wheels and pumice powder
• Finishing polish with Spanish white paste

Laboratory remound
Occlusal correction
Laboratory remount
• To eliminate the processing error
• Depends on
Jaw relation technique
Instrumentation

Microwave system
Processing technique
• Use the split mold technique to form molds
• Acron MC microwave cured acrylic
• Need special flask
o One minute microwaved to soften wax
o Eliminate wax from mold
o Three minutes curing in microwave
o Leave 15-20 minutes from opening flask
o Less VDO increase
o Easy to use
o Low water absorption
• Microbase: injected and cured with microwaves (3% contraction)
• It does not contain free monomer
• Three minute curing in microwave
o Fast, easy to use
o Allows more efficient use of time
o Produces denture in short processing time
o Denture repair
o Interim partial

Processing ivoclar technique
Injection
1. Ivocap injection system
In mid 1970s
VDO is more stable compare with conventional
Flask is closed during the procedure
2. Success system
PMMA Lucitone 199
90 PSI, use heat-polymerized resin



Remounting and occlusal adjustment in complete dentures

Waxing

Remounting
• Remounting the processed complete dentures BACK AGAIN on the
articulator
• Act on the prostheses surfaces to achieve:
CO
BBO
• Essential treatment
• Never carry it out in the mouth à the bases might be destabilized
• New Face-bow transfer
• We have to remount it
Why is remounting necessary?
• Dimensional changes of the bases
1. Linear and volumetric changes of the processed base
2. Displacement of the teeth
Increased DV
Prematurity’s/ interferences
Inappropriate transmission of the forces
Decubitus ulcers
Bone resorption
Alterations of the neuromuscular system

Creating and obtaining the remounting model
• Block the retentive areas inside the denture and pour the plaster filling it
• Turn it upside down and Immerse the edges of the denture 2 mm in the
plaster Make cutouts in the plaster around the edges of the denture before
getting set in order to be easily removed from the new model
• Make a model base form
• Trim

In the practice
• Articulator preparation
CPI 45
BA 15
PIN 0mm
• Registration of the cranio-maxillary transfer
Upper complete denture placed in the mouth
Face-bow positioned in order to transfer the upper denture
 Upper denture placed back in the mouth and use Aluwax wax in order to
have the lower complete denture in CR with the pin +2mm to compensate
the thickness
• Adjust CPI and BA according to articulator manufacture
• BBO (Bilateral Balanced Occlusion)

Objective of Selective Grinding
Balanced occlusion
• Laterality
WS à Contacts between homonymous cusps
NWS à Internal slopes of active cusps
• Protrusive
Anterior group + UDS (upper distal slope) and LMS (lower mesial slope)
Centric occlusion
• Simultaneous contacts of equal intensity
• Not in anterior teeth due to overje

Contact during lateral movement

Concepts on selective grinding
Morphology and function of the cusps
• Active à Spheroids
Mainatian CR position
Food trituration
Guide the mandible
• No active à Sharpened
Cut the food
Increase the stability of the prosthesis in laterality
Protects bites in soft tissues (cheeks and tongue)
Position of the cusps
• All active cusps à corresponding to fossa or marginal ridge
• Not too much deep mesh in order to avoid intercuspal blockage during
eccentric movements

Rules or basic principles
Direction of wear in movement
• Transversal in WS
• Diagonal in the NWS
Localization of wear
• Respecting the occlusal morphology
• The wear will be made on the cusp slopes
Contacts
• As many as possible in the eccentric movements
Occlusal adjustment
• Preferable on non active cusps
• With the exception of NWS
Adjust the central occlusion
• Deepening fossae or trimming marginal ridges
UCMS (Upper cusp mesial slope)
LCDS (Lower cusp distal slope)
Remove all undesirable contacts to get BBO (Bilateral
balanced occlusion)
The adjustment will be made in lower prosthesis

Occlusal adjustment systematics
• Lauritzen: Grinding on non active cusps à Upper buccal à BE CAREFUL
WITH AESTHETICS (buccal upper cusps)
• Articulating paper as thin as possible
• Using turbine, low speed handpiece or straight handpiece
• Prematurities in centric occlusion: analyse its existence
• Laterality movement:
1st right, 2nd left
WS à Homonymous cusps ESAC (External slope of active cusps)
NWS à ISAC (Internal slope of active cusps)
• Protrusive movement
1st à Contacts on both sides UDAC (Upper distal active cusp)/LMAC (Lower
medial active cusp)
2nd à Contacts in anterior teeth (edge to edge) due to 2mm protrusion
(previous overjet) and posterior at the same time
• Centric occlusion
Eliminate causes of shift
Deepening fossae or trimming ridges (avoiding active cusps)

Installation of the prosthesis in the patient (fitting). Use and maintenance advice
(tips). Reviews.

Installation
1. Inspection prior to install the prosthesis.
Palpate internal areas and edges searching poorly polished areas.
2. Insertion (instructions).
Moisten the prosthesis.
First lower, then upper.
Mouth closed 5-10 minutes
3. Initial checks.
Correct extension of prosthesis bases.
Support and retention of each prosthesis separately.
Aesthetic.
Phonation (pronunciation S).
Occlusion (VD, MI and CO).
4. Initial use advice (tips).
Foreign body sensation and occupied mouth
Soft food first week
Slow and bilateral chewing
Read aloud for adaptation of the language and pronounciation
If ulcers appear, remove prosthesis and rinse with salt water and
chlorhexidine gel.
5. Maintenance advice (tips).
Brush after each meal
Weekly chemical cleaning with tablet
Nightitme rest
Do not keep in water overnight
Brushing tongue, palate and mucosa gently
Chlorhexidine rinses

Reviews
• 1st appointment: Two days later.
• 2nd appointment: In two weeks.
• After a year: Calling the patient for check-up.

Complications
Immediate.
• Traumatic ulcer. Retouching (denture ease).
Very common
Two days of placement
Causes:
a. Edges over extended that cause decubitus
b. Poor retention
c. Poor stability of prosthesis due to poorly balanced occlusion
Treatment: remove the prosthesis 48 hours and rinse
• Lack of retention. Rebase (reline).
 Objective: to add acrylic resin inside the prosthesis in order to improve the
retention.
How: taking impressions with the mouth closed using fluid silicone placed
inside the dentures after applying adhesive in order to retain the material.
When: always after 2-3 years of the prosthesis placement (fit). Before, in
case if it is necessary.
Where: Practice or laboratory.
• Poor mastication. Occlusion control.
Check the balanced occlusion.
Check (review) vertical dimension.
• Poor phonation.
Difficulties to pronounce letter S due to high vertical dimension.
Must reduce vertical dimension
• Persistent nausea.
Over extension of the posterior edge of the upper denture
Lack of retention or stability and peripheral seal
Late treatment.
• Breakage of the prosthesis.
Longitudinal palatal fracture.
Send to the lab to fix it and then ease for later rebase (reline)
• Breakage or teeth debond.
Teeth can be glued in practice with auto polymerized acrylic making
retentions in the heel of the artificial tooth.
Tooth part breaks require sending the prosthesis to the laboratory to
replace them.
• Oral mucosal lesions.
a. Prosthetic candidiasis.
Very common 50% prosthesis wearers.
Clinical: diffuse erythema palate with papilla hyperplasia.
Treatment: rinses three times daily with Nystatin (Micostatin) for
two weeks.
Wash prosthetics with nystatin.
Prevention: do not sleep with prosthetics, keep them dry during
nightime and mechanical brushing.
b. Burning mouth syndrome.
c. Burning sensation on the palate , tongue and mucosa. Monitor
systemic cause, lack of salivation, contact allergy due to free
monomers.
d. Irritative hyperplasia.
e. Alveolar fibrosis.
f. Angular cheilitis.

Immediate prosthesis

Concept
• They are made before the extraction of the teeth
• Placed immediately after the extractions
• In 9 months maximum a definite prosthesis must be made
Physiological alveolar remodelling
• Patients with very advanced periodontal disease
• Avoid psychological trauma
• Know the limitations of the type of prosthesis

Advantages
• Bleeding control
• Protects against postsurgical taumas
• Protects against wound infections
• Better phonation
• Prevents macroglossia
• Prevents lip and cheek collapse
• Does not impair masticatory function
• Psychological Influence
• Facilitates healing
• A CO can be achieved
• We avoid TMD

Disadvantages
• No adequate VDO
• Poor tissue adaptation

Indications
Pathologies
• Systemic (Coagulation disorders in order to control bleeding)
• Periodontal (Reduce bone loss and help healing process)
Functional causes
• TMD (irreversible disorder)
Psychological reasons (edentulous)

Contraindications
Relate to the age and general health status

Systematics
• Clinical History, Examination, Assessment, X--ray and Treatment plan
• When and how extractions will be made
Only anterior teeth àAll at once
All teethà1st posterior teeth and in 15 days time take impressions
àanteriors will be extracted
Fit the immediate prosthesis
• Aesthetic data (prior to carry out the extractions)
 Teeth shade
Photograph
VD

Impressions and models

• Impressions with standard tray and alginate
• Cranio-Maxillary transfer
Sufficient number of teeth àFork
The rest of the cases à Wax rim bite registration
• Articulator mounting
Maxillary teeth anterior and posterior à no baseplate
If there are no posterior sectors à Baseplate + wax rims
• CR Registration
If we do not use plates à Interpose wax and CR registration
Same systematic as in the edentulous
• Tooth selection
• Tryal of teeth in wax (try-in)
• Polishing, polymerization and finishing
Teeth are removed from the plaster
• Denture try-in
We can never do it, unless there are no posterior teeth
• Laboratory Phases
Flaking, polymerization and finishing
• Immediate Prosthesis Fit
24hours without removing the prosthesis
• Review in 24hours
Light occlusal adjustment in MI
• Remounting and Occlusal Adjustment
In 15days time after the extractions


The partially edentulous patent

Concept
A patient is considered partially edentulous when at least he is missing a single
tooth of his permanent dentition
Prosthodontics: It is not considered P. edentulous:
1. Defect in odontogenesis
2. Anomalies in the eruption
3. Absence of the third molar
Causes
1. Congenital: Those that come from birth
2. Acquired: Caries, trauma, periodontal disease ...
The loss of teeth causes in the patient insecurities, Low self-esteem or even
depression

Physiopathological alterations
It depends on:
• Number of missing teeth
• Location
• Canines and first molars have more important role due to its strategic value
So we can have:
A) Loss of anterior teeth
• Aesthetic alterations –
• Phonatory alterations
B) Loss of posterior teeth -Mastication alteration -Deglutition alteration

Etiology
Missing teeth caused by extractions is fundamentally due to:
• Caries, under 40 years old
• Periodontal disease in patients over 40 years old

Epidemiology
• The prevalence of partial edentulism is very wide
• The specific figures depend on the country of study and the age group
• More than half of the population over the age of 40 are partial edentulous

Loss of tooth: local consequences
1. Destabilization of the arch
• Migration of teeth in to the edentulous areas following the loss of the
natural dentition causing destabilization
• Either adjacent or opposing teeth
• Mesialisation of the distal tooth
• Distalisation and rotation from the mesial tooth
• Extrusion of the antagonist
• Relative balance through a process of adaptation
2. Occlusal changes
• Facet of Wear
 • Prematurity
• Interferences
3. Periodontal problems
• Cervical erosions
• Dental mobility
• Periodontal pockets
• Gingival recessions
4. Alterations at the TMJ level
• Opening problems
• Clicks
• Crepitations
5. TMD
6. Loss of adjacent teeth
7. Phonetic alterations
8. Alterations in chewing and deglutition
9. Loss of support of the neighbouring teeth: Septum syndrome (contact point
plung

Classification of partially edentulous arches
Classification according to the most posterior
edentulous span or spans (Kennedy Class):
• Class I: Bilateral edentulous areas located
posterior to the remaining natural teeth
• Class II: Unilateral edentulous area located
posterior to the remaining natural teeth
• Class III: Unilateral edentulous area with
natural teeth, both anterior and posterior
to it
• Class IV: Single, bilateral edentulous area
located anterior to the remaining natural
teeth







Kennedy Class I
Kennedy Class I describes a patient who has BILATERAL free-end saddles, i.e.
they have edentulous posterior areas bilaterally. This is the most common
classification. There are no further posterior teeth to the edentulous area. A free-
end saddle is where the saddle is not resting on teeth on both sides (i.e. is lacking
an abutment tooth). (Dental-muco- supported)

Kennedy Class II
This describes a patient who has a UNILATERAL free-end saddle, i.e. they have a
one-sided, posterior edentulous area. They have no further teeth behind the
edentulous area. It is like a Class I but just covering one side of the arch. (Dental-
muco-supported)

Kennedy Class III
This describes a patient who has a UNILATERAL BOUNDED POSTERIOR saddle.
This means that the edentulous area has teeth located both anteriorly and
posteriorly to it. As they do not possess free-end saddles, they tend to be far more
secure cases when designing. (Teeth supported)

Kennedy Class IV
This describes a patient with a SINGLE, ANTERIOR BOUNDED saddle. This is the
rarest of the classifications. (Teeth supported)

Modifications
This refers to multiple edentulous areas present in a case. Modifications can only
apply to Kennedy Classes I, II and III. This is because a Kennedy Class IV case with
modifications would fall in to one of the other classifications, as these
take priorities.
Examples:
This is a Kennedy class i mod ii case as along with having bilateral free-end
saddles, there are two further edentulous areas that need replacing.

This is a class III mod I as there is a unilateral bounded saddle with one further
edentulous area. Note: the extra edentulous area is anterior but class iv cases don’t
have modifications!

This is a class ii mod i case as there is a posterior free-end saddle with one further
edentulous area.

Summary
• Class I: posterior, bilateral free-end saddlers
• Class II: posterior, unilateral free-end saddle
• Class III: posterior, unilateral bounded saddle
• Class IV: anterior bounded saddle
• Class I, II, and III can have modifications

Kennedy rules
• The classification is done after the necessary extractions have been carried
out
• The third molar is not considered into the classification if it is not to be
replaced
• If the third molar is to be used as the abutment of the prosthesis, it must be
considered into the classification
• The second molar is not considered into the classification if it is not to be
replaced
• The most posterior edentulous area is the one that gives the classification
name
• Edentulous areas other than the one that gives the name to the
classification shall be designated by their number
• Only the number of edentulous areas is considered, not their extension
• In class IV there are no modifications, inasmuch as to be anterior, if there is
any other gap will be the one that gives the name

Prosthesis III Lecture Notes 1

PROSTHODONTICS; BASIC CONCEPTS. INDICATIONS

CONCEPT
“Dental speciality pertaining to the diagnosis, treatment planning, rehabilitation and maintenance of the oral function, comfort,
comf
appearance and health of patients with clinical conditions associated with missing or deficient teeth and/or oral and
maxillofacial tissues using biocompatible substitutes”.

HISTORY
• Egypt (3000bc): Human teeth joined by shells and gold.gold
• Etruscans (500bc): Artificial teeth from oxen connected with gold.
gold
• Romans (45bc): Fixed and Removable prosthesis made with ivory and wood. wood
• XVI (16th) Century: Ambrosio Pare;; Bridges with bone and ivory inserted and joined with gold. gold
• XVII (17 ) Century: Abutments prepared to replace lost incisors with spikes at the lingual part of
th

the adjacent teeth.

• XVIII (18 ) Century: Pierre Fauchard;; “The Surgeon Dentist”, this book described basic oral anatomy and function, signs and
th

symptoms of oral pathology, operative methods for removing decay and restoring
teeth, periodontal disease, replacement of missing teeth and tooth transplantation.
Mouton; Creates a golden crown with a spike inserted in the root canal.
Border; Human teeth cut in half by the neck and joined by ivory and gold.
• 1789, Alexis Duchâteau and Nicolas Dubois:
Dubois: made the first prosthesis made from porcelain.
• Giuseppangelo Fonzi: Individual porcelain
orcelain teeth with a lingual or palatal spike to join the crown to
the root of the tooth.
• XIX (19th) Century: M Land; Built the first porcelain dental crown with a platinum base in 1901.
1901
• Since the 1900’s; 1925: Hydrocolloids (substance
substance that forms a gel in the presence of water);
water Alginate used as common
impression material.
1955: Silicone begins to be used as an impression material.
1960-70: Branemark introduces the dental implant concept and the titanium implant. implant
• XXI (21st) Century: CAD-CAM
CAM and Digital Impression Techniques; Everything is possible

TYPES OF FIXED PROSTHETICS

Protection
Depending on… Amount of remaining crown
Aesthetics
Plaque control
CROWN
Replace
(replace) Lost teeth to… Restore function
Occlusion
Aesthetics
BRIDGE

TYPES OF FIXED PROSTHETICS; CROWNS

1. Partial Cover Restoration
1.1 Onlays (covers
covers some but not all cusps of the tooth), Overlays (cover all the cusps of the tooth)
tooth
1.2 Inlays (don’t cover any cusps of the tooth)
tooth
2. Full Cover Restoration
2.1 Veneer (covers
covers the entire buccal surface)
surface
2.2 Total-crown
3. Depending on the Material
3.1 Simple
• Metal
• Porcelain
• Acrylic
3.2 Mixed
• Bonded porcelain to metallic substructure crown
• Zirconia
Prosthesis III Lecture Notes 2

CONCEPT OF BRIDGES
“A bridge is a partial fixed prosthesis that replaces several teeth”
Parts of a Bridge
• Abutment; Primary Anchor
Secondary Anchor
Intermediate
• Retainer; part of the bridge which is cemented to the abutment tooth
• Pontic; the tooth that is missing/ that we are replacing.
It is joined to the main abutment by connector and retainer.
• Connector; joins the individual retainers and pontics together.

DECISION MAKING
1. Abutment State
-Anchors hold the forces of the lost teeth
-It is better to have healthy teeth, although it can have endodontic treatment
-Cannot use tooth with direct pulp therapy
-Requires a healthy soft tissue
-Anchors with no mobility
Crown-Root Proportion
• Best 1:2 (Crown : Root)
• Minimum 1:1
• Most Frequent  2:3 (Crown : Root)
Root Configuration
• More width B/P/L than M/D
• Divergent roots
• Curved roots
The more space that a root occupies the better.
• Periodontal surface
2. Length of the Edentulous Ridge
-Tylman’s Law: 2 anchors can hold 2 pieces to replace
-Ante’s Law: The total root surface area (length + width) of all supporting teeth
must equal or exceed the total root surface area of the teeth being
replaced.

Root Surface area of Mandible

pieces If the…Anchors are periodontally healthy
Retainers well executed
Edentulous ridge is short and straight
…The bridge will have a long survival rate & functionality

Root Surface area of Maxilla

pieces
Prosthesis III Lecture Notes 1

DECISION MAKING; TREATMENT PLANNING

DECISION MAKING
• Fixed prosthesis groups from the restoration that an individual crown to the whole dental arch.
• Health
• Functionality
• Aesthetic/Psychology
• TM Dysfunction

DIAGNOSE
• Soft and Hard Tissue
• General Health

Treatment Design
• Dental necessities
• Psychological/Medical/Individual

• Medical History
• Study Models
• Oral Examination
• Radiographic Exploration

CLINICAL HISTORY
• Ideal treatment
• Individualised treatment; physical or mental disabilities  Postpone/Change/Stop treatment

Main Symptom
• Patients Reason  Disease/Problem
• Comfortability
• Function
• Social Aspects
• Look
• Complete Treatment
• Patients Satisfaction

Personal Data

Medical History
• Before touching the patient we must know of any diseases they may have or any medication they may be taking.
• Allergies
• HBP/Heart Disease
• Rheumatic Fever; causes inflammation and pain in the joints
• Epilepsy
• Diabetes
• Hyperthyroidism
• TMJ

DENTAL EXPLORATION
Dental History
1. Tooth decay
2. Periodontal
3. Endodontic treatment
4. Orthodontics
5. Prosthesis
6. Surgery
7. Radiographs
8. TMJ

Oral Exploration
1. Edentulous ridge
2. Tooth decay
3. Restorations
Prosthesis III Lecture Notes 2

4. Bruxism
5. Fractures
6. Food impaction
7. Hygiene
8. Fracture lines
9. Vitality tests
10. Occlusion; Teeth alignment
Contacts
Malocclusion

RADIOLOGICAL EXAMINATION
1 2
1. Periapical
2. Panoramic
3. TMJ

It allows you to assess; Apex structure

Bone support
Apex morphology
Tooth decay
Periodontal disease
Temporomandibular
emporomandibular Joint

STUDY MODELS
• The models must always be articulated (placed) in the dental articulator
• We can study the following with the models; Edentulous zone, length and curvature
Height-Vertical dimension
Anchor migration
Anchor rotation
Design and preparation
Insertion axis
Occlusion; premature contacts, extrusion

DIAGNOSIS
• The Prosthodontics American School (PAC/American
(PAC College of Prosthodontics)) developed the Prosthodontics Diagnosis
Index (PDI)
Benefits
• Equal Diagnosis; improved diagnostic consistency
• Periapical Practice Guide
• Trade Dentist-Patient
• Objective Criteria; an objective method for patient screening in dental education
Diagnostic Criteria (For Partially Edentulous Classification System)
1. Location and Extent of Edentulous Ridges
Location and extent of the edentulous area(s) includes 4 levels, described as…
• Ideal or minimally compromised edentulous area (single arch)
• Moderately compromised edentulous area (both arches)
arches
• Substantially compromised edentulous area
• Severely compromised edentulous area
2. Abutment Periodontal Condition
Abutment conditions are described as…
• Ideal or minimally compromised abutment condition
• Moderately compromised abutment condition
• Substantially compromised abutment condition
• Severely compromised abutment condition
3. Occlusal Scheme
Occlusion includes…
• Ideal or minimally compromised occlusal characteristics
• Moderately compromised occlusal characteristics (some adjunctive adjustments and Angle’s class I jaw/molar
relation)
[Adjunctive adjustmentss may include Enameloplasty
Ename on premature occlusal contacts]
Prosthesis III Lecture Notes 3

[Class I: MB cups of upper 1st molar occludes in MB groove of lower 1st molar]
• Substantially compromised occlusal characteristics (re-establishment
( of occlusion and
Angle’s class II jaw/molar relation))
[Class II: MB cusp of the upper 1st molar occludes MESIAL to the MB groove of the lower 1st
molar]
• Severely compromised occlusal characteristics (re-establishment
( of occlusion and
vertical dimension occlusion/VDO,
/VDO, and Angle’s class II division 2 and class III
jaw/molar relation)
[Class II Division I: PROCLINATION of the upper 4 incisors  Increased Overjet]
[Class II Division II: RETROCLINATION of upper central incisors + PROCLINATION of
upper lateral incisors  Increased Overbite]
[Class III: MB cusp of the upper 1st molar occludes DISTAL to the MB
groove of the lower 1st molar]
4. Residual Ridge
Residual ridge classification follows that used to categorise any of the
edentulous area that will be restored in the partially edentulous patient.
Categories
Based on the diagnostic criteria, the patient is categorised into one of the
following classes…
Class I
• Criteria I: Location and Extent of Edentulous Ridges
-Edentulous areas are confined to a single arch
-Doesn’t
Doesn’t compromise the physiologic support of the abutment
-Anterior Maxillary  Max 2 incisors missing
-Anterior Mandibular  Max 4 incisors missing
-Posterior Maxillary/Mandibular  Max 2 premolars or 1 premolar and 1 molar
missing
• Criteria II: Abutment Periodontal Condition
-No need for pre-prosthetic therapy
• Criteria III: Occlusal Scheme
-No need for pre-prosthetic therapy
-Class I molar/jaw relationship
• Criteria IV: Residual Ridge
-Residual
Residual ridge morphology resists horizontal and vertical movement of the denture base

Class II
• Criteria I: Location and Extent of Edentulous Ridges
-Edentulous
Edentulous areas are confined to a single arch
-Doesn’t
Doesn’t compromise the physiologic support of the abutment
-Anterior Maxillary  Max 2 incisors missing
-Anterior Mandibular  Max 4 incisors missing
-Posterior Maxillary/Mandibular  Max 2 premolars or 1 premolar and 1 molar
missing or a missing canine (maxillary/mandibular)
• Criteria II: Abutment Periodontal Condition
-Abutments in one or two sextants have insufficient tooth structure to retain or
support intra/extracoronal restorations
-Abutments
Abutments in one or two sextants require localised adjunctive therapy
• Criteria III: Occlusal Scheme
-Occlusal scheme requires localised adjunctive therapy
-Class I molar/jaw relationship
• Criteria IV: Residual Ridge
-Residual
Residual ridge morphology resists horizontal and vertical movement of the denture base

Class III
• Criteria I: Location and Extent of Edentulous Ridges
-Edentulous areas may be in one or both arches
-Compromises the physiologic support of the abutment teeth
-Posterior Maxillary/Mandibular  Edentulous area greater than 3 teeth or 2
molars
Any edentulous area including anterior/posterior areas of 3 or more missing
-Any
teeth
• Criteria II: Abutment Periodontal Condition
-Abutments in 3 sextants have insufficient tooth structure to retain or support
intra/extracoronal restorations.
-Abutments in 3 sextants require re more sub
substantial localised adjunctive therapy
(i.e. periodontal, endodontic
tic or orthodontic pr
procedures)
Prosthesis III Lecture Notes 4

-Abutments have a fair prognosis

• Criteria III: Occlusal Scheme
-Requires re-establishment of the entire occlusal scheme without any change to the
VDO
-Class II molar/jaw relationship
• Criteria IV: Residual Ridge
-Residual ridge morphology resists horizontal and vertical movement of the denture base

Class IV
• Criteria I: Location and Extent of Edentulous Ridges
-It can be extensive and in multiple areas in opposing arches
-It compromises the physiologic support of the abutment teeth to create a
guarded prognosis
-It includes acquired or congenital maxillofacial defects
-At least one edentulous area has a guarded (doubtful) prognosis
• Criteria II: Abutment Periodontal Condition
-Abutments in 4 or more sextants have insufficient tooth structure to
retain or support intra/extracoronal restorations
-Abutments in 4 or more sextants require extensive localised adjunctive
therapy
-Abutments have a guarded prognosis
• Criteria III: Occlusal Scheme
-Requires re-establishment of the entire
occlusal scheme, including changes in the
VDO
-Class II Division II and Class III
molar/jaw relationship
• Criteria IV: Residual Ridge
-Residual ridge morphology resists
horizontal and vertical movement of the
denture base

Worksheet Used to Determine the Classification

Individual diagnostic criteria are evaluated and the appropriate box is

checked.

The most advanced finding determines the final classification.

TREATMENT PLANNING AGAIN

1. Abutment Condition
-Anchors hold the forces of the lost teeth
-Better health teeth, although we can have endodontically treated teeth
-Not teeth with direct pulp therapy
-Healthy soft tissue
-Anchors with no mobility
2. Crown to Root Ratio
-Ideal  1:2
-Minimum  1:1
-Most Common  2:3
3. Root Configuration
-More width B-P/L than M-D; roots that are broader B-L than M-D are preferable to
roots that are round in cross section
-Divergent roots; multi-rooted posterior teeth with widely separated roots will offer better
periodontal support than roots that converge, fuse or generally present a conical
configuration.
Prosthesis III Lecture Notes 5

-Curved roots; a single rooted tooth with some curvature in the apical third of the root is preferable to a tooth with near
perfect taper.
-Periodontal surface
4. Periodontal Ligament Area
Johnston et al, in 1971 in their statement designated as “Ante’s Law”, said that the root surface area
of the abutment teeth had to equal or surpass that of the teeth being replaced with pontics (an
artificial tooth on a fixed dental prosthesis that replaces a missing natural tooth).

MAXILLARY MANDIBULAR
TOOTH AREA (mm2) RANKING AREA (mm2) RANKING
Central 139 7 103 8
Lateral 112 8 124 7
Canine 204 3 159 4
1st Premolar 149 5 135 6
2nd Premolar 140 6 135 5
1st Molar 335 1 352 1
2nd Molar 272 2 282 2
3rd Molar 197 4 190 3

BIOMECHANICAL CONSIDERATIONS
• Span length-Direction of force-Secondary
abutment-Arch curvature
• Bridges bend and flex under masticatory force
-It varies direction with the cube of the length
and inversely with the cube of the thickness of
the pontic
-1-1
-2-8
• Span Length; relative deflection is directly proportional to
span length and inversely proportional to occlusogingival
thickness
• Direction of Force; dislodging forces on a FPD retainer tend to
act in a MD direction. Preparations should be modified
accordingly to produce greater resistance and structural
durability

• Secondary Abutment; overcomes problems concerning unfavourable root-crown ratios and long
spans.
Should be comparable to primary in terms of; root surface area, favourable
crown-root ratio and retainers.
Flexure of the pontic applies tensile forces on the retainers on the secondary
abutment, thus a sufficient crown length and space between adjacent
abutments is requires, to prevent impingement on the gingiva under the
connector.
• Arch Curvature; When the pontics lie outside the interabutment axis
line, it produces torqing movement. This is a common problem in the
replacement of all 4 maxillary incisors, and most pronounced in the
pointed taper arch anteriorly (the more circular the arch curvature,
the less of a problem it will be). The more taper the arch, the longer
the lever arm will be and the more torque generated. To offset the
torque, additional retention is obtained in the opposite direction of
the lever arm and at a distance from the interabutment axis, equal to
the length of the lever arm.

Double Abutment
• It refers to the use of 2 adjacent teeth at one or both ends of a
fixed prosthesis joined by a solid connector.
• Its reasons for use include…
-Retainer Retention; Increased retention of the restoration
-Stabilisation of periodontally compromised teeth
-Increased area of the supporting PDL and bone
-Root surface
-% Crown-Root
• The canines act as a secondary abutment to the primary
(premolar), to avoid flexibility.
Prosthesis III Lecture Notes 6

Arch Curvature
• Pontics out of abutment axis parallelism
• A common problem in replacing all 4 maxillary incisors with a fixed partial denture is that
the pontics lie outside the interabutment axis line, thus acting as a lever, which can produce
torque. This movement can be offset by placing additional retention in i the opposite
direction of the lever arm and at a distance from the interabutment axis equal to the length
of the lever arm.
• The first premolars are sometimes used as secondary abutments for maxillary 4-pontic
canine-to-canine
canine FPD. Because of the tensile forces that will be applied to the premolar
retainers, they must have excellent retention.

Pier Abutment (Intermediate Abutment)

• An abutment with edentulous spaces on either side of it.
• It is in the middle of both primary abutments.
[Secondary abutment is always beside the primary abutment]
• It suffers from mobility, acting as a fulcrum, balancing the forces on the
bridge.
• If a long span fixed prosthesis is placed on this abutment, it will
wi create a huge
stress on the terminal abutment and the pier abutment will act as a fulcrum,
causing failure of the prosthesis.
• Stress can be prevented by placing a non-rigid
non connector;
mechanical union between retainer (dovetail keyway) and
pontic (T-shaped key)
• The use of a non-rigid
rigid connector transfers shear stress to the
supporting bone rather than concentrating it in the connectors.
It also minimises MD torque of the abutment, while permitting
independent movement.
• The key and keyway should be placed in the middle abutment, as
placement on the terminal abutments can lead to the pontic
acting as a lever arm. The key way is placed in the distal
contours of the pier abutment and the key is placed on the
mesial side of the distal pontic.
• A non-rigid
rigid connector is placed in the fulcrum (next to the
intermediate abutment, NEVER the primary), to allow flexibility,
mobility. It joins the intermediate to the rest of the bridge.

Tilted Molar Abutments

• Dental axis v. Insertion axis
• Early loss of mandibular 1st molar can cause mesial tilting of the mandibular 2nd molar into
the space formerly occupied by the first molar. Further complication occurs if the 3rd molar is
present and also tilts with the second molar.
• The tipped 3rd molar encroaches upon the path of insertion of the FPD and the tilted 2nd
molar no longer allows for a parallel path of insertion without interference with adjacent
teeth.
• 3rd molar tipped and retention in 2nd.
• Solution… 1) Orthodontic Correction
-Extract the 3rd molar and upright the tilted 2nd molar by orthodontic
treatment
-This
This will also help in the distribution of forces under occlusal loading and
eliminate bony defects along the mesial surface of the root.
2) Proximal Half Crown on Distal Retainer
-Proximal
Proximal half crowns can be used as a retainer on distal abutment.
-This
This is a ¾ crown that has been rotated 90° so that the distal surface is
uncovered.
-Possible
Possible if; distal surface is caries free and not decalcified, there’s low incidence
of proximal caries and the patient is able to keep the area exceptionally clean.
• To allow proper force distribution between pontic and abutment, we must create a parallel
insertion axis preparation.

Canines
• The curvature of the arch will always be a problem; canines tend to be outside the curvature.
• FPD replacing canines can be difficult because the canine often lies outside the interabutment
axis.
• The prospective abutments are the lateral incisors (usually the weakest tooth in the entire arch;
arch
thus it will never be used as a primary
ry abutment,
abutmen always as secondary) and the 1st premolars (the
weakest posterior tooth)
Prosthesis III Lecture Notes 7

• Upper worse than lower; a FPD replacing a maxillary canine is subjected to

more stress than that replacing a mandibular canine, since the force is
transmitted outward (labially) on the maxillary arch, against the inside of the
curve (its weakest point) and the pontic lies further outside the interabutment
axis. While on the mandibular canine the forces are directed inward (lingually),
against the outside of the curve (its strongest point) and the pontic is closer to
the interabutment axis.
• A fixed partial denture replacing a canine should not replace more than one
additional tooth; support from secondary abutments will have to be
considered.
• An edentulous space created by the loss of a canine and any 2 neighbouring teeth is best restored with implants or RPD.
• The root of the canine is the longest of the entire oral cavity, so its root ratio will always be difficult to replace (ante’s law).
• Loss of canine also causes loss of canine guidance, so its recovery must be considered.
• We should not replace a canine with a 1st PM and lateral incisor because we lose canine guidance.

Cantielver-1 Abutment at 1 End Only

• A cantilever is a FDP in which only one side of the pontic is attached to a
retainer; there is only 1 primary abutment and 1 pontic.
• There is only 1 anchor to hold and support all the forces.
• This design is destructive.
• It is used when we have a strong abutment (i.e. canine) and no occlusion in
the pontic (in case of occlusion, the force the pontic receives should be parallel
to the axis of the tooth).
• Its long-term prognosis is poor.
• It can be used in provisional’s or implant surgery or when you have a young patient and can later place an implant.
(1) Lateral Incisors
-Canine as the abutment
-Small support placed on central incisors; metallic rest on the distal of the central incisor to prevent rotation of the pontic
and abutment
-Never use central incisor as the abutment; its root configuration makes it an unfavourable cantilever abutment
-No occlusal contact on the pontic in centric or lateral excursions
(2) 1st Premolars
-Abutment in 2nd premolar and (a small preparation in the) 1st molar
-Solution if canine is intact and you want to place a crown on the 1st molar
Prosthesis III Lecture Notes 1

OCCLUSAL CONCEPTS

CONCEPT
• Occlusion is the contact relationship between the teeth of both arches
• Disocclusion is the disappearance of occlusion,
occlusion carried out by the same occlusion
• Occlusion and Disocclusion lead to an organic occlusion; occlusion of the teeth when the mandible closes in centric relation
• Centric relation is the most superior, anterior position of the condyle in the glenoid fossa.
• Stability  Occlusion  Posterior Teeth
• Stability is provided by occlusion. The posterior teeth will produce disocclusion
d
• No interference  Disocclusion  Anterior Teeth
• If there is no interference, we will have disocclusion and anterior guidance (by incisors and canines)
• Posterior teeth protect when closing to…
-Anterior
Anterior Teeth: Mutually protected occlusion (cuspid protected)
-TMJ:
TMJ: Mutually protected occlusion (prevents excess loading)
Mutually Protected Occlusion: Molars protect the incisors and canines by withstanding vertical loads (occlusal forces); the
incisors cannot support these loads because they areare inclined, so if they were to receive these loads they would collapse.
collapse
Anterior teeth protect the molars through anterior guidance; During protrusion the incisors provide anterior guidance, which
results in posterior disocclusion.. During laterality the canines
canines provide canine guidance which also protects the molars.
Organic Occlusion = Mutually Protected Occlusion

VERTICAL DETERMINANTS OF OCCLUSAL MORPHOLOGY

“Factors that influence the height of cusps and the depths of fossa”
1. Condylar Guidance
• Condylar guidance is thehe angle formed by an imaginary horizontal line
at the head of the condyle and the path where the condyle will pass
through during function (protrusive movement)
• The greater the inclination (sloping/steepness
/steepness) of the angle, the
more space created between the molars during protrusive
movement. Higher posterior cusps and deeper grooves.
2. Incisal Guidance (Horizontal Overlap)
• Incisal guide is an angle formed in maximum intercuspation,
by the intersection of the occlusal plane and a line
determined by the incisal surface.
• An angle formed by the intersection of the occlusal plane
and a line (in the sagittal plane) determined by the incisal
edges of the maxillary and mandibular central incisors,
when the teeth are in maximum intercuspation.
• The greater the horizontal overlap,, the lesser the space
between the superior and inferior molars and the shorter the
height of cusps and lesser deepness of fossa.
• Anterior guidance affects the occlusal morphology of posterior
teeth
• The greater the vertical overlap of anterior teeth, the
longer/taller the posterior cusp height.
• The greater the horizontal overlap of anterior teeth, the
shorter the posterior cusp height.
3. Bennett’s Movement
• Bennett movement is the bodily lateral movement of the mandible,, which results from the
movement of both condyles along the mandibular fossa.fossa
• The degree of medial movement of the orbiting condyle depends on the morphology of the
medial wall of the fossa and the inner horizontal portion of the temporomandibular
temporomandibular ligament.
ligament
• The greater the amount of lateral translation movement, the shorter the posterior cusp.
• The greater the immediate side shift (when
when the lateral movement occurs early),
early , the shorter the
posterior cusp.
• The more superior the movement of the rotating condyle, the shorter the
posterior cusp.
4. Occlusal Plane
• The occlusal plane is a line joining the midpoint of the overlap of the
mesiobuccal cusps of the upper and lower molars with a point bisecting the
overbite of incisors.
• The height of the cusps
ps acts as interferences at the lateral movements.
Prosthesis III Lecture Notes 2

• The relationship between the occlusal plane and the condylar guidance influences
the steepness of the cusps. As the occlusal plane becomes more parallel to the
condylar guidance,, the posterior cusps must be made shorter.
• The more parallel the plane to the condylar guidance,
guidance the shorter the posterior
cusps.
5. Compensatory Curves (Spee and Wilson)
5.1 Spee Curve
• The curve of spee joins the incisal edges of anterior
teeth and the active cusps of posterior teeth.
• It follows the condylar eminence, curving upwards
from anterior to posterior.
• The effect of the spee curve is determined by
comparing the planes of each tooth in the curve with
the path of the orbiting condyle, with the same rule
as in the occlusal plane.
• The more they diverge from each other, the lesser the allowable cusp
height.
• 3 components affecting the cusp height; Length and Radius of the curve
Degree of curvature of the curve
Orientation of the curve
• The more acute/greater the spee curve, the shorter the posterior
cusps.
5.2 Wilson Curve
• Wilson’s curve is a mediolateral curve that contacts the buccal
and lingual cusp tips on each side of the arch.
• It results from the inwards inclination of the posterior teeth
(mandibular molars), making the lingual cusps lower than the
buccal cusps.
• The higher the curve of wilson in the upper maxilla, the lower
the cusp height
6. Cusp Angulation

FACTORS INFLUENCING BALANCED OCCLUSION

The 5 basic factors that determine the balance of an occlusion are…
a
1. Inclination of the condylar path or condylar guidance
2. Incisal guidance
3. Orientation of the occlusal plane
4. Cuspal angulation
5. Compensation curve

HORIZONTAL DETERMINANTS OF OCCLUSAL MORPHOLOGY

“Factors that influence the direction of ridges and grooves on the occlusal surfaces”
1. Escape Grooves
Grooves in the Horizontal Plane
• Lateral movement of rotating (working side;
side active side to which the jaw moves) condyle
ondyle
effects the ridge and groove direction of the occlusal surfaces.
surface
• Distal positioning of the grooves and ridge is done in mandibular teeth.
2. Bennett Movement
• Bennett movement is the lateral bodily movement of the rotating (working side) condyle,
condyle,
with medial movement of the orbiting (non-working
(non side/translating) condyle.
• The greater the Bennett movement, the more distal the grooves in the posterior teeth of the
maxilla.
• The greater the lateral translation movement, the wider the angle between the laterotrusive
and mediotrusive pathways.
3. Inter-Condylar Distance
• It is the distance between the rotation centres of both condyles.
• The greater the intercondylar distance, the more distal the grooves are in the lower molars, and
the more mesial the grooves are in the upper molars.
• The greater the intercondylar
ylar distance, the smaller the angle between the laterotrusive
terotrusive and
mediotrusive pathways.
Prosthesis III Lecture Notes 3

4. Distance from the Hinge Axis

Distance from the Rotating Condyle
• The hinge axis is an imaginary line around which the condyles rotate, without translation.
• The smaller the angle between the laterotrusive and mediotrusive pathways.
• The greater the distance, the smaller/wider?
/wider? the angle between the
laterotrusive (working side;; moves away from the midline)
midline and
mediotrusive (non-working side;; moves towards the mid-palatal
mid suture of
the maxilla) pathways.
5. Distance from the Midsaggital Plane
• The greater the distance, the wider the angle between the laterotrusive and
mediotrusive pathways.

OCCLUSAL PATTERNS
• The most stable occlusion is Centric Occlusion
• Centric occlusion is when CR and MI coincide.
• Dawson: 1. Anterior guide
2. Posterior disocclusion
3. (tooth) Contacts in the working side and no contact in the translating
(non-working side)
4. Cusp-fossa pattern occlusion
5. Posterior teeth are separated and are not in contact in all eccentric
movements
• Full Edentulous: The most stable occlusion is Bilateral Balanced Occlusion
-Balanced
Balanced occlusion is when there is contact between all teeth in maximum intercuspation and during all eccentric
movements.
-It
It is implemented in full denture treatment to avoid dislodgement of the denture
-Complete
Complete dentures are made with this type of occlusion for the purpose of stability.
-Victor
Victor Sear, 1925; “In every movement there will always be 3 contacts, 2anterior and 1 posterior. A tripod is the most stable
system in mechanics”.
Prosthesis III Lecture Notes 1

PRINCIPLES OF TOOTH PREPARATION I

In the absence of dental regenerating capacity.
Prosthodontic success is based on fundamental principles.
ACCORDING TO ROSENSTIEL
1. Biologic
-Conservation of tooth structure
-Avoidance of over contouring
-Supragingival margins
-Harmonious occlusion
-Protection against tooth fracture
2. Mechanical
-Retention form
-Resistance form
3. Esthetic
-Minimum display of metal
-Maximum thickness of porcelain
-Porcelain occlusal surfaces
-Subgingival margins
An optimal restoration incorporates all 3 of these principles.

ACCORDING TO SHILLINGBERG
7 key principles of preparation…
1. Conservation of Tooth Tissue
-To avoid unnecessarily weakening the tooth
-To avoid compromising the pulp
2. Resistance Form
-To prevent dislodgement of a cemented restoration by apical or
obliquely-directed forces
3. Retention Form
-To prevent displacement of a cemented restoration along any of its
paths of insertion, including the long axis of the preparation.
4. Structural Durability
-To provide enough space for a crown which is sufficiently thick to
prevent fracture, distortion or perforation
5. Marginal Integrity
-To prepare a finish line to accommodate a robust margin with close
adaptation to minimise microleakage
6. Preservation of the Periodontium
-To shape the preparation such that the crown is not over contoured
and its margin is accessible for optimal oral hygiene
7. Aesthetic Considerations
-To create sufficient space for aesthetic veneers where indicated

BIOLOGICAL CONSIDERATIONS
The most important thing is the preservation of tooth structure. We must be conservative and try to maintain as much tissue as
possible.
1. Prevention of Damage during Abutment Preparation
1.1 Adjacent Teeth
They are protected by…Placing a metal strip around the adjacent tooth
Sound tooth preparation techniques
1.2 Soft Tissues; Tongue, Mucosa…
Use a dental mirror to retract soft tissue structures
1.3 Pulp
Extreme temperatures, chemical irritation or microorganisms can cause an irreversible pulpitis, particularly when they
occur on freshly sectioned dentinal tubules.
Sensitivity causes irreversible pulpitis: Temperature; Chemical Action
Bacterial Action
Implement methods and techniques to reduce risk.
Consider the form of the pulp cavity.
Temperature
• Considerable heat is generated by friction between the turbine and the dental surface, which can lead to irreversible
pulpitis.
• Heat is also produced by; Excessive pressure
(higher) Speed of rotation
Prosthesis III Lecture Notes 2

Type, form (shape) and status (condition) of the (cutting) instruments

Irrigation; used to reduce heat and wash away debris, which prevent clogging of the rotatory
thus maintaining efficiency.
It also prevents desiccation of the dentin, which can cause pulpal irritation
Accumulation of waste
Chemical Action
• The chemical action of certain dental materials (restorative resins, solvents and luting agents) can cause pulpal damage,
particularly when applied to freshly cut dentin.
• The use of some chemical solvents or surfactants has shown to produce pulpal irritation, thus they are generally
contraindicated, especially because they do not improve the retention of cemented restorations.
• Irritant agents; Resins
Solvents
Adhesives
• Don’t improve retention of cemented restorations
Bacterial Action
• Pulpal damage under restorations occurs due to bacteria that was either left behind or has gained access to the dentin
via microleakage.
• Many dental materials i.e. zinc phosphate cement, have an antibacterial effect.
• Healthy dentin resists infection.
• Many dentists use antimicrobial agents such as CHX gluconate disinfecting solution, post tooth preparation and prior to
cementation.
• All carious dentin must be removed before placing a restoration.
• Teeth with indirect pulp caps are contraindicated as abutments, because subsequent failure of the pulp cap can
jeopardize the prosthesis.
• Enter by microleakage; Zinc phosphate cement
Health dentine
Chlorhexidine
Tooth decay
Direct pulp capping; thus we avoid them as primary abutments
2. Preservation of Dental Structure
• We must preserve the maximum amount possible of dental structure, respecting the mechanical and biological
considerations
• Dentin thickness/pulp status
• Tissue preservation reduces the harmful pulpal effects of various procedures and materials used.
• Dentin thickness is inversely proportional to pulpal response, and tooth preparation in close proximity to the pulp should
be avoided.
• Tooth structure is conserved through adherence to the following guidelines…
-Partial or total restoration; use of partial-coverage rather than complete-coverage
restorations
-Narrowing between parallel walls; tooth preparation with minimal taper
(narrowing) between axial walls
-Anatomic occlusal restoration; reduction should follow the anatomical planes of
the occlusal surface, producing a uniform
thickness in the restoration
-Peri-pulp thickness; the maximum thickness of residual tooth structure
surrounding pulpal tissue should be retained.
-Conservative margin
-Apical length; avoid unnecessary apical extension of the preparation, which would
result in the loss of additional tooth structure.
3. Considerations for the Health of the Future Abutments
Improper tooth preparation may have adverse effects on the
long-term health of the tooth. Insufficient axial reduction
results in overcontoured restorations that hinder plaque
control, which can in turn lead to periodontal disease or
dental caries. Inadequate occlusal reduction may result in
poor form and subsequent occlusal dysfunction. A poor
choice of margin location i.e. in areas of occlusal contact can
cause chipping of enamel or cusp fracture.
3.1 Axial Preparation
• It should be enough to prevent excessive curve profile,
as over-contouring will cause periodontal disease.
• Gingival inflammation is commonly associated with
excessive axial contours, because it is more difficult to
maintain plaque control around the gingival margin.
Prosthesis III Lecture Notes 3

• The junction between the restoration and tooth should be smooth and free of any ledges or abrupt changes in
direction.
• A slightly undercontoured flat restoration is better because it is easier to keep free of plaque.
3.2 Margin Location
• Whenever possible, the preparation margin should be supragingival. Subgingival margins
have been identified as a major etiological factor in periodontal disease, particularly where
they encroach on the epithelial attachment.
• Supragingival margins are easier to prepare without soft tissue trauma and facilitate
impression making.
• Supragingival (enamel)
-Simple and no trauma to soft tissues
-Easy hygiene
-Easy impression
-Easier evaluation; at the time of placement and at recall appointments
• Subgingival (dentin, cementum)
Indicated in the presence of the following conditions…
-Tooth decay; caries, cervical erosion
-Infragingival restorations; restorations extended subgingival and a crown-length procedure is contraindicated
-Length interproximal contact; proximal contact area extends apically to the level of the gingival crest
-Needs higher retention; additional resistance or retention is needed
-Root sensitivity; root sensitivity cannot be controlled by more conservative procedures, such as applying dentin
bonding agents
-Aesthetic; the margin of an aesthetic restoration is hidden behind the labiogingival crest
-Axial contour modification to removable connector; i.e. placing an undercut to provide retention for a partial
removable dental prosthesis clasp
3.3 Marginal Surface
• Flat and smooth
• Different form of the margin according to the bur
• Depending on that we will have different terminations
3.4 Occlusal Considerations
• Occlusal plane
• Root treatment
• A satisfactory tooth preparation allows sufficient space to develop a functional occlusal scheme in the finished
restoration. Sometimes endodontic treatment may be necessary to make enough room.
3.5 Avoid Dental Fractures
• Inlays vs. Onlays
• The likelihood that a restored tooth will fracture can be lessened if the tooth preparation is designed to minimise
potentially destructive stresses.
• Inlays (intracoronal cast restoration) have a greater potential for fracture, because when occlusal forces are applied
to the restoration, it tends to serve as a wedge between opposing walls of the preparation. The wedging must be
resisted by the remaining tooth structure; if this structure is thin, the tooth may fracture during function.
• Onlays (cuspal coverage restoration) lessen the chances of such fracture.
• A complete crown offers the greatest protection against tooth fracture, tending to hold the cusps of the tooth together.

DIFFERENT MARGIN DESIGNS

MARGIN DESIGN INDICATIONS ADVANTAGES DISADVANTAGES
Feather Edge Not recommended Conservative of tooth structure Does not provide sufficient bulk
Location of margin is difficult to
Chisel Edge Occasionally on tilted teeth Conservative of tooth structure
control
Facial margin of maxillary
Removes unsupported enamel, Extends preparation into sulcus if
Beveled partial-coverage restorations
allows finishing of metal used on apical margin
and inlay/onlay margins
Cast metal restorations,
Distinct margin, adequate bulk, Care needed to avoid
Chamfer lingual margin of metal-
easier to control unsupported lip of enamel
ceramic crowns
Facial margin of metal-
Less conservative of tooth
Shoulder ceramic crowns, complete Bulk of restorative material
structure
ceramic crowns
Facial margins of metal- Bulk of material, advantages of Less conservative of tooth
Sloped Shoulder
ceramic crowns bevel structure
Facial margin of posterior
Bulk of material, advantages of Less conservative, extends
Shoulder with Bevel metal-ceramic crowns with
bevel preparation apically
supragingival margins
Prosthesis III Lecture Notes 4

A. Feather edge (shoulderless)

B. Chisel edge
C. Chamfer
D. Beveled
E. Shoulder
F. Sloped shoulder
G. Beveled shoulder

MECHANICAL CONSIDERATIONS
1. Retention; Avoids crown coming off
• The quality of a preparation that prevents the restoration from becoming dislodged by forces parallel to the path of
insertion is known as its retention form.
• The following factors must be considered when deciding if retention is adequate for a given fixed restoration…
1) Magnitude of the dislodging forces; Sticky food
-The greatest removal forces generally arise when exceptionally sticky food is eaten.
-The magnitude of the dislodging forces exerted by the elevator muscles depends on the stickiness of the food and on
the surface area and surface texture of the restoration.
2) Form of the tooth preparation
-Following one axis only; it should be parallel
-Cements increase friction; depending on the ‘kind of cement’
-Superficial surface should be smooth and rounded
-Round off the angles (occlusal-axial, interproximal)
3) Roughness of the fitting surface of the restoration
The internal surface of the crown must be rough to achieve retention.
-Acid etching
-Sand blasting
4) Materials being cemented
-Metals are believed to be the ideal material for cementation
5) Types and thickness of the adhesive material
-The type of luting agent affects the retention of a cemented restoration.
-Generally, adhesive resin cements are shown as the most retentive.
2. Resistance; Avoids fractures
• To support lateral forces on the abutment, which tend to displace the restoration by causing rotation around the gingival
margin, effectively tipping the crown off its preparation.
• Resistance form is the features of a tooth preparation that enhances the stability of a restoration and resists dislodgement
along any axis other than the path of placement.
• It is a mechanism that increases the strength of the restoration and avoids it coming off by forces that are not parallel to
the axis.
• Avoids displacement (coming off) by forced caused by eccentric movements (lateral or protrusion) in the posterior teeth.
• Lateral forces rotate around the margin of the preparation
• Adequate resistance depends on…
1) Magnitude and direction of the dislodging forces
-A successful tooth preparation and restoration must be able to withstand considerable oblique forces, as well as the
normal axial ones.
2) Form of the tooth preparation
-Convergence of the axial wall (5-22 degrees); a preparation taper of 5-22° is of a clinically acceptable range
-Diameter of the preparation
-Height of the preparation; additional height is necessary as tooth diameter increases.
-Resistance decreases as taper or diameter increases or as preparation height is reduced; short tooth preparations with
large diameters have very little resistance form.
3) Physical properties of the adhesive
-Resistance to deformation is affected by the physical properties of the luting agent’s i.e. compressive strength
(resistance to compression) and modulus of elasticity.
-Zinc phosphate
-Glass ionomer
-Resins
-Zinc eugenol
-Glass ionomer cements and most resins have a higher compressive strength, whereas polycarboxylates have values
similar to those of zinc phosphate.
-Zinc phosphate cements have a higher modulus of elasticity than polycarboxylate cements, which exhibit relatively
large plastic deformation.
Prosthesis III Lecture Notes 5

3. Avoid distortion of the restoration

• The restoration must have sufficient strength to prevent permanent deformation during function.
• This may be the result of; Inappropriate alloy selection; choose the proper composition metal
Inadequate tooth preparation
Poor metal-ceramic framework design
Alloy Selection
• Type I and II gold alloys are satisfactory for intracoronal cast restorations, but are too soft for crowns and fixed dental
prosthesis.
• Type III and IV gold alloys are chosen for dental prosthesis, since they are harder. Their strength and hardness can be
further increased by heat treatment.
• Metal ceramic alloys with high noble metal content have a hardness that is equivalent to that of type IV gold alloys
• Nickel chromium alloys are considerably harder. These may be indicated when large forces are anticipated, as with
long-span fixed dental prosthesis.
Adequate Tooth Reduction
Dental Preparation; Things to Consider…
• The alloy needs sufficient bulk in order to withstand occlusal forces. There should be a minimum alloy thickness of
1.5mm over the functional cusp and a 1mm thickness over the non-functional cusp (since it has less stress, it requires
less metal over it for protection)
• 1.5mm minimum thickness in active cusps
• 1mm minimum thickness in non-active cusps
• Anatomic preparation; occlusal reduction should be uniform, following the cuspal planes of the teeth. This ensures that
sufficient occlusal clearance is combined with preservation of as much tooth structure as possible. Additionally,
anatomically prepared occlusal surfaces provide rigidity to the crown.
Margin Design
• Keep the preparation margin 1 to 1.5mm away from occlusal contact locations; to prevent distortion of the restoration
margin occlusally.
• Enough preparation to get volume for the metal in the margin; cervically, tooth reduction must provide sufficient room
for bulk of restorative material at the margin to prevent distortion.

AESTHETIC CONSIDERATIONS
• Most patients prefer their dental restorations to look as natural as possible; however aesthetic considerations should not be
pursued at the expense of the prognosis of the patient’s long-term oral health or function.
• The patient’s aesthetic expectations must be discussed in relation to oral hygiene needs and to the potential for development
of future disease.
• The final decision regarding an appropriate restoration can then be made with the full cooperation and informed consent of
the patient.
• Options for aesthetic restorations include; Partial veneer crowns
Metal-ceramic restorations
All-ceramic restorations; Porcelain

PRINCIPLES OF TOOTH PREPARATION II

PRESERVATION OF TOOTH STRUCTURE

• We must preserve the maximum amount possible of dental structure, respecting the mechanical nd biological considerations.
• The restoration replaces the structure loss and protects the remaining preparation.
• Preserve healthy structures
• Efficiency or convenience
• Full crown vs. Partial restoration
• Guidelines: Partial or Total restoration
Narrowing between parallel walls
Anatomic occlusal restoration
Peri-pulp thickness
Conservative margin
Apical length
• Minimum Space Needed: Remove 1.5mm  Active Cusps
Prosthesis III Lecture Notes 6

Remove 1mm  Non-active cusps

Remove 1mm  Margin (shoulder)
Generally, for
or the occlusal surface we remove the ‘thickness of the bur’.
bur’
Everything must be well polished, removing all sharp angles.

RETENTION & STABILITY

• Retention: Resistance to forces parallel to the abutment (vertical forces; they cause the tooth to slide up)
up
• Stability: Resistance to any other forces in any direction
• In fixed prosthesis they are always related.

Obligatory to Consider
• There is no biocompatible cement with enough adhesive power to keep our restoration totally fixed.
• It is mandatory to study the geometry of our preparation.
-Basic
Basic retention is given by 2 opposing walls, internally or externally.
-The walls must be parallel or slightly conical (6°). This makes a convergence angle around 3-6 3 degrees (parallel diamond
approx. 3°)
[Slightly conical angle
gle of the walls is provided by the bur]
-Only 1 way of insertion which follows the axis of the tooth.
tooth
-The
The insertion axis must be parallel to the adjacent surface.
surface
-The
The sulcus walls must be perpendicular to the rotation forces.
-The height of the abutment nt is important for retention and stability; it should be enough to avoid
rotation. The shorter the wall is, the more important the inclination angle.
-The
The higher the abutment, the higher the retention and stability.
-Correct visual technique: only one eye

STRUCTURAL DURABILITY
The preparation must let enough thickness of the restoration to be capable of managing the occlusal forces.
• Interocclusal space
• Replicate the occlusal planes
• Axial preparation: Overcontoured restorations
Periodontium
Adjacent interferences
• Round up active cusps

MARGIN AND FINISHING LINES

• The margin of the restorations must adapt in the finishing line of the abutment.
• Localisation: The crown must ALWAYS be placed on ENAMEL not cement.
-Juxtagingival
-Subgingival
-Supragingival
Subgingival or Infragingival margin is only in the anterior teeth on the buccal side in metal-ceramic
metal ceramic crowns.

Types of Finishing Lines 1mm thickness of shoulder to

1. Feather edge support the crown
-Periodontal teeth
-Destroyed teeth
-Lingual walls of molars
2. Chisel edge
3. Chamfer
-METALLIC restorations
-Lingual and palatal walls of
PORCELAIN or CERAMIC
restorations
-It is placed in the lingual
and palatal because you
won’t see it
-Chamfer allows easier
bevelling
4. Shoulder
-PORCELAIN crowns
-Buccal walls of METAL
CERAMIC crowns
Prosthesis III Lecture Notes 7

-Bevel: Onlays
Partial restorations
-The
The shoulder is the most aesthetic design. It is always placed in the buccal walls.
-It
It is also used in partial restorations, onlays, inlays…
-Bevelling
Bevelling is making everything well rounded and smooth
5. Sloped shoulder
6. Bevelled shoulder

Types of Burs

S68
S6801: Round diamond; Depth grooves before reduction
Establish rest seats
Reduce lingual surfaces of anterior teeth
811: Barrel-shaped;
shaped; For occlusal reduction of posteriors
6909: Round diamond wheel/Donut; For lingual walls i.e. in the incisors to go through
the cingulum but not remove it.
S6379 Oval-shaped; Occlusal reduction
S6379:
Reduction of palatal fossa of anterior teeth
6848: Flat end tapered diamond cylinder; Occlusal reduction
Shoulder finish
S6882: Round-ended tapered diamond nd cylinder; Axial and occlusal reduction
Chamfer margins
6886: Straight cylinder diamond with a tapered point/Torpedo
/Torpedo; Chamfer placement
848: Thin tapered diamond cones (needle); Proximal cutting to isolate teeth from
adjacent teeth
10839: End-cutting;
cutting; Extending preparations apically without axial reduction
Prosthesis III Lecture Notes 1

METAL CERAMIC RESTORATIONS

CONCEPT
“It is a cast-coated metallic crown with a coat of molten porcelain that imitates the appearance of a natural tooth”.

CHARACTERISTICS
• They combine the strength and fit of a metal crown with the aesthetics of a porcelain crown.
• The porcelain will have a greater longevity and resistance thanks to the support on the metallic cap.

MATERIALS
Metals
1. High Noble Alloys
• Gold-Palladium
• Gold-Platinum-Silver
• Gold-Platinum-Palladium
2. Noble Alloys
• Palladium
• Palladium-Silver
3. Non-noble Alloys
• Chrome-Nickel
• Chromium-Cobalt
• Chrome-Nickel-Beryllium
4. Zirconium

Porcelain
3 layers…
1. Opaque Porcelain
-Starts the colour; masks the colour of the metal alloy
-Responsible for the metal-ceramic bond
2. Body Porcelain (dental)
-Colour; provides some translucency and contains metallic oxides that aid in shade matching
3. Incisal Porcelain (enamel)
-Usually translucent, thus the perceived colour of the restoration is significantly influenced by the colour of the underlying
body and opaque porcelain
-Special effects

The first ceramic layer, which is opaque masks the dark metal oxide and is the primary source of colour for the completed
restoration. The opaque layer is covered with slightly translucent body porcelain, which is then veneered with an even more
translucent enamel overlay that contains relatively little pigmentation.

CLINICAL SEQUENCE
1. Previous Impression
(provisional, guide)
-Previous impression is needed to make the provisional (so that the patient isn’t left without teeth while you are making the
prosthesis)
2. Abutment Preparation
-In endodontic teeth, we do not need to administer local anaesthetics. But in non-endodontically treated teeth, we do need to
administer local anaesthetics.
3. Preparation Impression
-Impression is taken using double silicone (heavy and light)
4. Provisionalisation
-In the 1st visit, we make the provisional and the patient leaves
5. Metal Try-in
-In the 2nd visit, we check the… Fitting; if it does not fit correctly, we may need to reshape the abutment
Colour; we pick the specific colour of the patient
Occlusion
6. Biscuit Try-in
-3rd visit, in which we have the metal covered by the opaque porcelain layer and can also have the body porcelain (2nd
layer).
-But it is not finished yet, we still need to polish.
-Check the occlusion.
Prosthesis III Lecture Notes 2

7. Finished Crown
-4th visit in which the crown is bleached and cemented on the abutment.
-Check the occlusion.
-This is the last visit.

The patient will generally visit the clinic 4 times, though depending on the circumstance and the patient, this number may
decrease. If the patient is in a rush, we can omit the ‘biscuit try-in’ when we know the metal try-in is perfect. We never omit the
metal try-in, as it is the first try-in, in which we know the colour, fit, occlusion.

INDICATIONS & CONTRAINDICATIONS

Indications
1. Teeth that need complete coating and with aesthetic challenges
1.1 Duration
1.2 Marginal adjustment
1.3 Retainers
1.4 Occlusal rest
2. Extensive destruction due to cavities
3. Injury or previous restorations (but conservative)
4. Retention and resistance requirements
5. Endodontic teeth (pin/post)
6. Axial/occlusal reconstruction, inclinations (tilted teeth)

Contraindications
1. Active caries or untreated periodontal disease
2. Young people with very large pulp chambers
3. When a more conservative reconstruction is possible
4. Vestibular wall intact

ADVANTAGES & DISADVANTAGES

Advantages
1. The combine resistance and aesthetics
2. Characterisation
3. Excellent retention
4. Axial correction
5. Preparation less demanding than partial coverage

Disadvantages
1. Significant dental reduction
2. Vestibular wall the preparation is
slightly subgingival
3. Colour selection problems
4. Many laboratory steps; Cast
Porcelain
Expensive

PREPARATION
Materials
• Turbine
• Periodontal probe
• Burs; Barrel
Round
Wheel
End Cut
Oval
Flat End
Torpedo
Round End
Needle
• Impression material; Heavy & Fluid silicone
• According to the thickness of the bur, the colour coding varies; (most) Black  Green  Blue  Red  Yellow  White (least)
• The thicker the bur, the greater tooth removal.
Prosthesis III Lecture Notes 3

Characteristics
1. Vestibular Surface
-Shoulder with bevel (0.3mm)
-Subgingival
-1.2mm reduction
2. Proximal Surface
-Flap of vestibular and lingual reduction
3. Lingual Surface
-Reduction of atleast 0.7mm
-Union cingulum/lingual wall
-Line: Curved chamfer
4. Incisal Half
-Reduction of 2mm (1.5mm in functional cusp and 1mm in non-functional cusp)
-Respecting the occlusal morphology

Preparation Steps 1
1. Depth Orientation Grooves Placed in the Vestibular Face and the Incisal Half
-Vestibular in 2 planes; Parallel to the gingival half (1.2mm)
Parallel to the incisal half (1.2mm)
-Incisal; Gingival orientation (2mm)
2. Incisal/Vestibular Reduction
Incisal Reduction
-Parallel to the incisal half
Vestibular Reduction
-Incisal half 2
-Gingival half exceeding 1mm the contact point
3. Lingual Face Reduction
-Reduction is made with a diamond wheel bur, reducing
at the level of the palatine fossa, respecting the shape of
the cingulum (NOT FLAT)
4. Axial Reduction of the Interproximal Walls and the
Lingual Wall
-Using a tapered diamond bur, reduce the lingual vertical 3
wall and start the interproximal contact point (DON’T touch
the adjacent tooth)
-Using a needle bur, eliminate the contact point and give
continuity to the vestibular-lingual gingival margin line. 4
5. Finish
Place gingival bevel on the shoulder and
round incisal angles.
-0.3mm bevel with flame cutter
5
-Incisal angles are rounded to have a
curved surface that allows casting
Prosthesis III Lecture Notes 4

POSTERIOR TEETH
• The lingual or palatal faces are reduced in a straight line with adequate
angulation for retention (6°)
• Bevel the active cusps; Maxillary  Palatal Cusp
Mandibular  Vestibular Cusp

PRACTICES
Chamfer is performed at the gingival level throughout the structure, with chamfer bur and is placed subgingival on the buccal
face.
Prosthesis III Lecture Notes 1

ALL CERAMIC RESTORATIONS

CONCEPT
• Total coating crowns made of porcelain
• Aesthetic treatment for anterior teeth; they are the most aesthetically pleasing restorations currently available as they can be
made to match natural tooth structure in terms of colour, surface texture and translucency

CHARACTERISTICS
• They do not have a metal core; the entire structure is porcelain
• Land introduced them in 1903; it needed a platinum plate that was eliminated before cementing.
-Traditionally ceramic crowns were made on a platinum matrix and were referred to as ‘porcelain jacket crowns’
-Land made the first ceramic crown and inlay with a platinum foil and was granted a patent in 1887. Though this method did not
become popular until many years later.
• As they have no metal, they do not block the transmission of light and imitate the colour and translucency of the dental
structure better than other options.
• The porcelain will have a greater aesthetic but also a greater susceptibility to fracture (ceramics are brittle and thus
susceptible to fracture during placement and function. Tooth support is more critical to fracture resistance of the restoration)

MATERIALS
Porcelain
• Dicor
• IPS Empress
• In Ceram
• Procera

TREATMENT SEQUENCE
1. Previous Impression
2. Preparation
3. Preparation Impression
4. Provisionalisation
Check the colour of the patient when placing the provisional (since there is no metal try-in)
5. Biscuit Try-in; This can be done or skipped and we can check the occlusion and colour in the finished crown step.
6. Finished Crown; Cementation

INDICATIONS
• High aesthetic commitment areas
• More conservative restoration is inadequate
• Facial or proximal caries which cannot be treated with composite resin
• Tooth with sufficient coronal structure; mainly incisal <2mm
• Possibility of favourable distribution of occlusal load
• Allergic to metals
• Endo-treated teeth with post and cores

CONTRAINDICATIONS
• When more conservative treatment is possible
• In the posterior sectors (molars)
• Unfavourable occlusal load
• Missing adequate support
• If its impossible to obtain a uniform shoulder (1mm); thin teeth facial-lingual
• Incomplete eruption
• Pulp affection
• Parafunctional habits: Bruxism
Pipe smoking
Contact sport

ADVANTAGES
• Better Aesthetics; ideal optical characteristics
• No Thermal Conductivity; pulp protection
• Biocompatible; best soft tissue response, even subgingival
Prosthesis III Lecture Notes 2

• Resistant to Chemical Agents; fluorhydric (hydrofluoric acid)

• More Conservative Facial Preparation; than metal ceramic
• Can be used in a Single Restoration

DISADVANTAGES
• Less Resistance (Fragility); compared to conventional cements
• Very Demanding Preparation; 90° cavosurface angle
• Less Conservative Proximal and Lingual Preparation; more tooth removal
• Complex Laboratory Techniques; more complex than metal-ceramic techniques
• Higher Cost
• Antagonist Wear
• Can be used as a Single Restoration only

FLUORHYDRIC (HYDROFLUORIC) ACID

• Surface preparation for mechanical/chemical bonding; it roughens the surface of dental ceramic restorations for stronger
bonding.
• When preparing a new crown/veneer for seating or repairing one that is already seated.

PREPARATION
Materials
• Turbine
• Periodontal probes
• Burs; Round-ended tapered, diamond bur
Flat-ended tapered, diamond bur
Bud-shaped bur
• Impression materials; Heavy + Fluid silicone

Preparation Characteristics
• Facial Reduction
Always do a shoulder preparation for porcelain crowns.
-Shoulder: Smooth, continuous and without irregularities
Juxtagingival or slightly subgingival
-1mm reduction
• Interproximal Reduction
-There is no binding flap  Vestibular lingual reduction
• Lingual Reduction
-Shoulder: Smooth, continuous and without irregularities
Juxtagingival
-1mm reduction
• Incisal Half
-1.5-2mm reduction
-Respecting the occlusal morphology
Prosthesis III Lecture Notes 3

Preparation Sequence
1. Facial/Incisal Reduction
Incisal Reduction
• 1.5-2mm reduction
• In the molars (NOT USED) a minimum of 1.5-2mm
1.5 of clearance is necessary
• 3 incisal depth orientating grooves are made at 1.3mm deep
• The grooves will be perpendicular to the
he axial axis of the antagonist (suitable support)
• Complete the reduction and verify the space, otherwise increase preparation.
Facial Reduction
• Vestibular in 2 planes
-Parallel to the gingival half (0.8mm)
-Parallel to the incisal half (0.8mm)
• Incisal: Gingival orientation (1.3mm)
2. Lingual Reduction
• Depth groove 0.8mm
• Use a diamond wheel bur; reduce to the level of the palatal pit, until
obtaining a space of 1mm for the porcelain in all the excursive
movements.
• Respect the shape of the cingulum (NOT FLAT)
3. Axial Reduction of the Interproximal and Lingual
• Use a tapered diamond bur to reduce the vertical lingual wall
• Create grooves on the lingual wall (half of the cingulum)
• Extend until reaching the vestibular preparation
• Follow the top of the free gingival margin to avoid leaving too subgingival preparation (BIOLOGICAL
WIDTH)
4. Finish
• Finish the surfaces, making them smooth
• Round acute angles
• Refine the margin

PORCELAINS
Feldspathic Crowns
• Lack of adjustment
• Difficult to change colour
• Difficult to work with platinum
Low tensile strength
-Additives
-Kaolin
-Quartz
Alumina Crowns
• Mc Lean and Hughes (1965)
• Add 40% alumina crystals
• Reduces brittleness
Prosthesis III Lecture Notes 4

Dicor (Cast)
• Wain (1923) discovered cast ceramics, although it was not used until the 1980’s
• Improved the fit and chromatic fidelity
• Includes Si, K, Mg, Al, Zn, FlMg oxides and fluorescers; Aesthetics
• Achromatic, external staining
• Fragility
IPS Empress (Compressed)
• Enriched with leucite (mineral composed of potassium and aluminium)
• It is compressed, not casted
• Stratification
• Inlays and onlay
• Adequate resistance in anterior
In Ceram (injected)
• Necessary models for very resistance special dyes (Al2O3 powder)
• Opaque porcelains
• Dentin porcelains
• Incisal porcelains
-Coloured
-Opalescence
-Translucence
• Manufacture of porcelain core of 0.5mm + conventional layers
• 1.5mm shoulder
Variants
• In Ceram Spinelli
-Magnesium oxide (MgO2) higher translucency
-Less resistance
-Don’t use acid etching (sand blasting and composite cement)
• Mirage II
• Fiber
• They incorporate the optimal percentages of O, Zn, MgO and AlO
Procera All Ceram (Nobel Biocare, inc)
• Computer-assisted design and manufacture
• Coated aluminium oxide, densely sintered and covered with porcelain
• Chaflam, chamfer for the greater resistance of the substructure
Provisionals in fixed prosthesis
Objectives : types and techniques

Concept
● Restoration placed after abutment preparation until final restoration
○ Temporary : months, to correct tissues
○ Provisional: days, to let the technician finish the job

Why?
● Because we protect our abutment until getting the final restoration and comfortability
for the patient

Objectives
1. Biological factors
a. Pulp protection
b. Periodontal protection
c. Occlusal maintenance
d. Prevention of fractures
2. Mechanical factors
a. Keep functional forces
b. Resistance to peel away and displacement
c. Possibility of placing it back
3. Esthetic factors

Material and methodology

Characteristics of the ideal provisional material
1. Easy manipulation (time efficient and curing)
2. Dimensional stability, to avoid margin discrepancies
3. Resistant to fracture, attrition …
4. Esthetic and colour control
5. Biocompatibility

Materials
1. Metal
2. Non metal
● Acrylic methyl methacrylate
○ Advantages: strong, high wear resistance, easy to add, last
long periods of time with good esthetics
○ Disadvantages: exothermic polymerization which can damage
pulp, polymerization shrinkage that can affect fit
■ Smell is V.strong
■ Remember : not comfortable for the patient
● Acrylic ethyl methacrylate
○ Advantages : better time efficiency, less exothermic
polymerization, wide colour variety
○ Disadvantages : low resistance to attrition (tend to break),
colour not stable, last less time
● Composite bis acril , flow composites (for provisionals)
 ○ Advantages : good resistance to attrition, no residual
monomer, easy to work with and better mechanical properties
○ Disadvantages : troublesome marginal fit, (marginal
adaptation), colour variety limited, relatively expensive
● ETC

Types
Preformed custom crown shells
Customized resin restoration
Direct technique
Indirect technique → done by the lab

The objectives to get a better provisional restoration are get using an indirect technique
(better quality+ more expensive)

Direct technique : time efficient, fast and cheap but difficult in SOME CASES (ask for
indirect) exothermic reaction and difficult margin fit.

1. Aluminium shell
● Not used nowadays → difficult to adapt + not aesthetic
● Need to be adapted and cut in the gingival margin
● Resin can be added over them
● Cemented in occlusion
● Indicated in posterior teeth

2. Preformed custom crown

● Similar to the previous one, but with anatomic form
● Different shapes
● Don’t damage marginal soft tissue
● Indicated in posterior teeth
Not used (hyper) nowadays

3. Metal restoration
4. Acetate shell crowns
● Anatomic shell crowns
● Handling
○ Choose correct shape
○ Cut at gingival margin
○ Resin
○ Separate with vaseline to reduce exotherminc reaction
○ Remove the shell
● Indicated in anterior teeth
 5. Resin crown shells - More aesthetical
● Preformed crowns with different kind of colour and shape
● Handling
○ Choose proper shape and form
○ Cut at gingival margin
○ Resin
○ Separate with vaseline to reduce exothermic reaction
○ Polish the resin
○ Cement
● Indicated in anterior teeth (incisors, canines)
● More expensive

6. Provisional composite crowns

● Composite not polymerized
● Indicated in any tooth (molares, canines, Pm)

Ambulatory provisionals
Handling : impression before preparing the abutment (can be partial)
1. Direct technique:
Abutment preparation
Resin inside the silicone
We place it and let it cure
Cut the excess of resin
Cemented

2. Indirect technique:
Second impression after abutment preparation
We place the silicone with resin in the final model
We cut the excess of resin
Try in mouth and cementation

We send an impression to the technician before 1st appointment

More difficult, esthetical cases
More expensive

Laboratory provisions
Work on the study models before the abutment preparation
Later needs to be fixed so it can fit the restoration

Cementation
● Calcium hydroxide cement
● In case of sensitivity
● Remove excess in gingival margin and circus
● Check occlusion and polish
● Zinc oxide eugenol ​more useful in metallic restoration
Restoration of the endo treatment tooth

In root restoration or teeth with huge loss of crown structure, we look for a
method to replace the lost structure without extracting the tooth. In
endodontic treated teeth we use POST

Effect of endo treatment on teeth

● Tooth loss structure
○ Less resistance because of the removal of tooth structure
● Loss of elasticity of the dentin
○ Collagen fibers are lost so there is less resistance to forces
● Less sensitivity to pressure
○ Mechanoreceptors in the pulp and periodontal ligament
● Esthetic alteration
○ Loss of translucency
○ Color changes

Diagnose
● Evaluation of the endo tooth
1. Can be used as an abutment
2. Can’t
3. Could be after treatment
● Analysis of several aspect

➢ Postendo evaluation
➢ Amount of crown remainder
○ 2-3 mm of crown structure remainder : ferrule
○ Positive : restoration (post core, abutment prep, crown)
○ Negative :
■ Orthodontics
■ Crown enlargement (if we have 2:1 ratio , periodontal surgery :
remove bone and make a recession around the bone)
■ Extraction
○ Most important part of restored tooth is tooth itself
○ Axial walls of crown engage the axial walls of prepared tooth forming
the ferrule
○ Fracture resistance higher significantly with higher amount of sound
tooth structure and ferrule
○ Ferrule is a band that encircles the external dimension of
residual tooth, similar to metal bands around and barrel
○ Formed by walls and margins of the crown, at least 2-3 mm
of sound tooth structure

Crown enlargement technique→

 ➢ Periodontal evaluation
○ Crown-root configuration
○ Periodontal surface
○ Root shape
Post must be under the bone surface if not extracted

➢ Esthetic evaluation
○ Esthetic pbs
○ Choose materials
○ Keep a natural and translucency aspect

➢ Root shape configuration

○ Root canal thick and straight (and longest)
○ Curved roots (endo pbs , the post can break or break the root)
■ Length pbs
■ Steel post

Kurrer class
(exam)

Class 3: lost most of anatomic crown

→ endo / post core
Class 4: → lead to extraction of the tooth
Posterior teeth​ :
> occlusal forces
Crown root ratio 1:1
● Crown destruction
● Correct the direction and canal morphology
● Thin and short roots in comparison to long crowns

Minimum crown loss

- Loss < 40%
- Minimum occlusal forces
- Low fracture risk
→ composite, inlay,onlay

Moderate crown loss

- Loss 40 to 70%
- Moderate occlusal forces
- Higher fracture risk
→ post core crown

Advanced crown loss

- Loss > 70%
- Strong occlusal fractures
- High fracture risk

→ post + crown

Use as abutment in fixed prosthesis

● Anterior
○ Crown destruction
○ Edentulous ridge length
■ Lateral upper incisors
● If moderate or advanced- impossible
■ Inferior incisors
● Lack of resistance to fracture with
some posts
● Posterior
○ There is not a big difference between endo ttd
abutments and vital teeth
○ Bridges in extension (Cantilever) 40 % failure of endo ttd abutments against a
2% of vital teeth
○ Post crown: failure 12.8% and stainless steel 47%
Post types
● Cast post
○ + 1 root
○ Adapt to the conduct
○ 1 piece post and abutment
● Prefabricated post
○ 1 root
○ The conduct adapts to the post
○ Post abutment

Preparation
1. Remove root canal treatment :
Endo materials
Contra angle
- Peeso
- Gates
2. Widening the conduct
- Dependant on the system
3. Crown restoration
- preserve= success
- Ferrule
Crown enlargement
Orthodontic extrusion

● Length of the preparation minimum ⅔ ¾ of the root

● Length and 5mm of gutta percha at the apex (3mm minimum)
● Gap between post-gutta percha > 1 mm
● 2 or more roots:
● Parallel roots
● Upper M : palatal root
Inferior M : distal root
● Upper PM : Palatal root

Length of the post (EXAM)

The larger the post → more retention
Length must be :
- Equal or more than the amount of crown
- ⅔ ¾ of the root
- Half of the post must be inside the root

Diameter of the post :

- The thickness of the can’t be larger than ⅓ of the minimum diameter of the root
Retention factors
● Less convergence= higher retention
● Length of the post
○ Higher length = higher retention
○ L= ⅔ of the root
○ Gutt = 3mm minimum -5 ideal
● Post thickness
○ ⅓ of the minimum diameter of the root
○ 1mm of dentin thickness
● Surface of the post
○ Better rugous
● Adhesive
○ Adhesive
○ Hybrid resin
○ VIC

● Prefabricated technique
● Cast fabrication
○ Direct method : in mouth, acrylic resin
○ Casted by technician
● Indirect method
○ Impression of a calcinable post
(NOT USED ANYMORE)
Prosthesis III Lecture Notes 1

DESIGN OF BRIDGES
BIOMECHANICS. SPLINTING & RUPTIONS. SELECTION OF RETAINERS. CONNECTORS.

CONCEPT
“A prosthesis that replaces 1 or more absent teeth in a fixed way (without being able to be removed by the patient), through
permanent support in the remaining teeth or in implants.”

TYPES
1. Abutment Tooth
• Natural tooth
• Implant
2. Number of Teeth Replaced
• Simple
• Complex; 2 or more, a canine
3. Material
• Casted metal
• Metal-porcelain
• Pure porcelain
• Metal-acrylic
4. Connectors
• Fixed-fixed bridge
• Fixed-movable bridge
• Cantilever
• Compound bridge
• Adhesive prosthesis

OBJECTIVES
Of the bridge…
1. Prevention and Re-establishment of…
• Dental function
• Aesthetics
Of dental prep…
1. Biological Objectives
• Integrity of the periodontium and surrounding tissues
2. Mechanical Objectives
• Retention and stability
• Structural solidity
• Precision of margins

BIOMECHANICAL OBJECTIVES
Strength and Durability
1. Characteristics and Abutment Disposal
An abutment is a tooth that serves to support and retain a prosthesis.
• Crown/Root Proportion
-Ideal  1:2
-Optimum  2:3
-Minimum  1:1
• Root Shape
-Divergent multi-root posterior teeth have better retention
-Higher B-L (P) dimension than anterior
• Inserted Radicular Surface Area
-Periodontal ligament
-Larger teeth have a greater surface and thus are able to withstand greater forces
-In teeth periodontal disease there is less bone, thus making it a worse abutment
-Ante’s Law; Root Surface Area: The combined pericemental area of all abutment teeth supporting a fixed dental
prosthesis should be equal to/greater in pericemental area that the tooth/teeth being
replaced.
Factors modifying ante’s law…
Bone loss  Increases no. of abutments needed
M/D tip/ changes in axial inclination  Increases no. of abutments needed
Migration of abutment tooth, decreasing arch length Decreases no. of abutments needed
Prosthesis III Lecture Notes 2

Increased occlusal load  Increases no. of abutments needed

Endodontically restored teeth with root resection  Increases no. of abutments needed
Greater leverage factors  Increases no. of abutments needed
Tooth mobility after osseous surgery  Increases (splinting)

1.1 Splinting in Secondary Abutment Tooth

• Splint a Retainer to the Adjacent Primary Tooth (Rigid Connectors)
-Periodontal conditions
-Length
-Curvature
-Complex bridges according to Ante’s
nte’s
• Secondary Abutment Conditions
-Same
Same radicular surface as the primary and favourable crown-root proportion
-Same retentive capacity

Replacement of 22-21-11-12
22 12 may cause problems, depending on the arch curvature; the
pontic may act as a lever arm. To fix this we use the 1st/2nd premolar as a secondary
abutment for additional retention
retention to balance the length of the lever arm.

1.2 Ruption in Intermediate Teeth/Fixed/Fixed Movable Bridge

• Avoid Lever Fulcrum
-Intermediate
Intermediate abutments are used to avoid fulcrum. They are located between abutments.
-Increase
Increase retention in the weak end.
-Ruptions: Non-rigid connectors
Male component placed in the pontic (artificial
(artificial tooth, replacing the missing natural tooth)
tooth
Female component placed on the distal surface of the intermediate tooth.
-It
It has a rigid connector at the distal end of the point
poi and a movable connector
that allows some vertical movement of the mesial abutment tooth.
-Advantages: Allows flexure
Allows units to be cemented as individual sectors
-Disadvantages:
Disadvantages: More space is required
Metal may show occlusally
Wear of the joints
ts

Displacement
Interlocking
1.3 Inclined Abutment Tooth
• Affects inferior molars.
• Solutions: Orthodontics
Telescopic crowns; fabricated to fit over a coping (primary crown fixed in
the mouth to anchor teeth)
Half-crown
Parallel preparation
Biomechanical Considerations of Inclined Molars
• Dental axis v. Insertion axis; the abutment preparation
must always be parallel
• 3rd molar prep (recontouring
recontouring its mesial wall)
wall + retention in
the 2nd premolar (B-L grooves)
• 2nd molar orthodontics
• Mesial half-crown; 3/4 crown, rotated 90°, preserving the distal surface of the tooth.
This design is primarily indicated for the distal retainer of a mandibular FDP with a
tilted molar abutment.
1.4 Canines
• Canines are the LONGEST tooth in the arch.
• The bridge will be thee most difficult to pr
prepare, since they are situated outside of the arch cu
curvature and we must also
take into consideration
ion canine guidance.
Prosthesis III Lecture Notes 3

• Disocclusion; Superior: Vestibular

Inferior: Lingual
• Examples: Fixed-Fixed
-4 units: CI-LI-C-1PM
-3 units: LI-C-1 PM
Cantilever
-3 units: C-1 PM-2 PM
-2 units: C-1 PM
Biomechanical Considerations
• Cantilever
-Very destructive
-Only indicated if…The abutment(s) are very strong
Occlusion pontic is zero or minimal
• Lateral Incisors
-Retainer in the canine (long root and bone support)
-Pontic: no occlusal contact in excursions
-Occlusal rest central (avoid rotations)
-NEVER use central incision as a retainer
• 1st Premolar
-Retainer in 2nd premolar and 1st molar
Solution if the canine is intact and should crown the 1st molar.
• It provides support for the pontic at only one end. The pontic may be attached to a single retainer or 2/more
retainers that are splinted together
• Disadvantage: Length of the span is limited to 1 pontic only
Forces off the axis
1.5 Extensions
2. Longitude, Thickness and Form of the Pontic/Length, Width and Shape of the Pontic
• It relates to rigidity and deflection; Short + Heavy  Rigid
Long + Thin  Deflective
• Deflection is proportional to the length and is inversely proportional to the thickness in a
cubic relationship.
• The alternation deflexion/recovery of the pontic is transmitted to the roots of the
abutment: Extraction.
• The thinner the bridge, the easier it is for flexion to occur, thus we need thickness and
rigidity to allow deflection.
• Prosthesis with shorter pontics have a better prognosis than larger ones.
• Larger pontics may produce greater torque forces in the fixed prosthesis (with weak retainers)
• Large anterior (lower arch) pontics band end, better to use harder allows and wider designs.
• If the pontic lies outside the axis line, they will act as a lever arm, which can produce a torque movement.
3. Bridge Materials
4. Balanced Occlusion
5. Patient Hygiene

SELECTION OF RETAINERS
Total Cover
Will cause…
• High cariogenic index
• Fractures
• Coronal malformations
• Rotation
• Artificial antagonists (if there’s a natural tooth or a FP/implant)
Partial Cover
Will cause…
• Dental crowding
• Extrusion or inclinations affecting the insertion route
Prosthetic Space
• Extrusion or antagonist; level of eruption
• Bruxism (wear factors); raise the vertical dimension
Interdental Relationship
Maximum Intercuspation
Prosthesis III Lecture Notes 4

CONNECTORS DESIGN
Background
• Connectors are used to join the individual retainers and pontics together in an FDP
• Non-rigid connectors are usually indicated when it is impossible to prepare a common path of placement for the abutment
preparation for a partial FDP
• Rigid connectors can be made by casting, milling, laser sintering, soldering or welding. Cast connectors are shaped in wax.
They are convenient and minimise the number of steps involved in the laboratory fabrication. But, the fit of the individual
retainers may be adversely affected because there is easier distortion.
• Non-rigid connectors are indicated when it is not possible to prepare 2 abutments for a partial FDP with a common path of
placement. Thus, segmentation of the large design into shorter components that are easily repaired and replaced as
individuals is recommended. Non-rigid connectors are often made with pre-fabricated plastic patterns and are then cast
separately and fitted to each other in metal.
Factors
1. Shape (Form; disc)
T-shape
Like a disc at the B-L and M-D; a properly shaped connector has a similar configuration as that of a
meniscus formed between 2 parts of the prosthesis.
It is curved buccolingually to facilitate cleansing and mesiodistally it is shaped to create a smooth
transition form one partial FDP component to the next.
-V-L
-M-D
2. Size
It must be sufficiently large to prevent distortion or fracture during function, but not too large to
interfere with effective plaque control and contribute to periodontal breakdown over time.
-Distortion
-Radiographic (plaque) control
3. Position
-Anatomical interproximal; the position will be anatomical, placed interproximally -usually at the distal of the abutment
-Included in the casting; the retainer of the main structure is included in the metal cast
-Vertical height will be 3-4mm
4. Type
4.1 Rigid
-They are incorporated in the wax pattern with retainers and pontics.
-Cast in full coverage
-Weld; Wax and cut to then weld them (0.25mm gap)
-In loop; to keep diastemas (x-ray)
-Plaque retention
4.2 Non-Rigid
-Female spike on retainer and male (tenon) spike on the pontic
-Female (mortise) on the distal side of the anterior retainer and parallel to the insertion pathway of the distal retainer
The one we want to use is the NON-RIGID one. We need thickness, but we also need deflection.
Pontics in Fixed Prosthesis

Pontic
Replaces teeth absent recovering health, function and aesthetics
It is joint by connectors and retainers

● The design depends on:

○ Esthetic
○ Function
○ Hygiene
○ Soft tissue
○ Comfortability to the patient

Considerations for a successful pontic

Before treatment
Pontic space :​ (space from mesial and distal and space in the
coronal portion)
Displacement of adjacent teeth:
- Orthodontics
- Rise the contour (of soft tissue) no only for hygiene
also to improve aesthetics
- Keep space without prosthetic treatment
Contour of the ridge​ ​(to improve hygiene)
- Height and width
- Avoid frenum and keep papillas
- Loss of contour black triangles

Classification of ridge defects:

● Seibert 1983 classified the various types of ridge loss into 3 classes :
○ Class I : buccolingual loss of tissue with normal ridge height in
api coronal dimension (no loss of height of ridge)
○ Class II : Apioronal loss of tissue width in a buccolingual
dimension
○ Class III: combination bucco-lingual and apico
Keep the soft tissue dimension:
- Atraumatic extraction
- Provisionals ​(temporals (weeks/months) / or tempo (days/week)
- Ovate pontics 2.5 mm subgingival
- Orthodontic extrusion. Maintenance

(to improve : health, function and esthetics)

Sanitary/Hygienic
● Easy hygiene
● Plaque control
● No contact with edentulous ridge
● Occluso-gingival thickness superior than 3mm (if its
less it break)
● Bad esthetic-indicated in mandible molars ​(never in
anteriors)
● Modificated:
○ Curve between retainers
○ Avoid tissue formation
Saddle ridge lap
 ● Covers buccal and lingual side of the ridge
● Bad hygiene IMPOSSIBLE (no gap between pontic and gingiva)
● Esthetic good
● Pb in the pic : swollen gingiva

Modified ridge lap

(tries to improve the saddle ridge and sanitary one)
● Combine:
○ Esthetic (ridge lap)
○ Better hygiene (sanitary)
○ Convex lingual side, tissue tolerant
○ Tissue contact as a “T”
○ Lingual and palatal gap--SMALL
○ Modified the contour of soft tissue
○ May lead to a recession

Conical
● Convex
● 1 only point in contact to the soft tissue
(only the middle of the pontic)
● + hygiene
● Low esthetic -- better in the posterior mandible
● Combination of modified and sanitary for hygiene
● Can’t use in the anterior bcz of esthetic
● Small gap between tissue and the bridge

Ovate (​THE BEST ONE)

● +++ esthetic
● Convex surface
● Treatment planning
○ Soft tissue surgery
○ Surgical lesion
○ Provisions
● Improve hygiene by the patient
○ Interproximal hygiene
○ Better access
● Pseudopapillitis : new papilla
 ● NOT ONLY WITH TEETH BUT ALSO WITH IMPLANTS
CHANGE THE SOFT TISSUE
● COVER: BUCCAL AND LINGUAL
● PONTIC IS SUPPORTED IN THE MIDDLE ALLOW THE PAPILLAS TO GROW
● TRY TO INCREASE THE TISSUE

Advantages:
● Not susceptible to food impaction
● Broad convex geometry is stronger
● Accessible to dental floss
Disadvantages
● Surgical tissue management
● Cost

Biological considerations
Cleansable surface
● Ridge
● Pilar
● Antagonist
● Soft tissue

Factors
1. Contact point - pontic and ridge
a. No pressure in contact
2. Hygiene (super important)
a. Hygiene techniques: interproximal hygiene
3. Materials
a. porcelaine , gold
4. Occlusal forces
More than 30% pontic width, if the ridge is narrow

Mechanical considerations
● Wrong materials
● Bad designs of the
structures
● Bad abutment
preparation
● Malocclusion

Esthetic considerations
 ● Gingival dimension
○ Traumatic changes after extraction
○ Modificated ridge lap
● Length incisor - gingiva
○ Excessive contour
○ Equal periodontal tooth
○ Pink porcelain
● Mesiodistal width
○ Lateral discrepancy
○ Orthodontics
○ Interproximal alterations
■ Anteriors
■ Posteriors

(if we want to change tissue always ovate)

Always!!!

Root submerged technique

Pet - partial extraction therapies
Maurice salama (1995) Markus Hu erzeler (2010)
Restorations with ceramic veneers

Concept
It’s a lamina of porcelain​ (or composite​) that are partially covers the tooth as a veneer, which
is joined by mechanical means
Small part of composite or porcelain on the buccal surface

Adhesion is achieved by four different elements (4 diff bonding)

● Veneer etched in it’s internal surface
● Conditioning the tooth
● Silane as coupling agent (cement-veneer)
● Composite cement

Indications
Veneers : most conservative approach
● Aesthetics (for anteriors)
1. Changes in tooth color
- Dyschromias and intrinsic stains (tetracyclines, fluorosis, devitalized
teeth, amalgam staining, natural aging)
- The deeper the stain, the deeper the preparation
2. Changes in dental position
- Unorthodox preparation
3. Changes in the superficial texture of the tooth
- Dental erosion
- Plaque retention
4. Diastema closure
- Not recommended in diastemas bigger than 1mm
 ● Anatomical
- Congenital anomalies : enamel hypoplasia, microdontia, conical teeth…
- Acquired anomalies: fractures, attritions, abrasions…
- Eating disorders: bulimia…

● Functional
- restoration of canine and anterior guidance

● Other indications
- Metal-ceramic crown preparation (limitations space)
- When we can’t do crown bcz not enough space ofor abutment teeth

Contraindications
● Changes in colour
○ Difficult to camouflage very intense colorations
■ Porcelaine transparency
■ Excessive dental preparation
■ Excessive veneers thickness
● Better to place a crown in these cases
● Functional
○ Excessive charge or inadequate fracture
○ Parafunctional
○ Implan antagonis → ​dental erosion for veneer in this case + tend to break bcz
they are fragile, alwo with bruxist patient → NO VENEER
● Others
○ Inappropriate habits : onychophagy, nibbling of pens, screw nails​ (should
prevent ur patients before)
○ Insufficient hygiene
○ High caries risk

Advantages:
● Conservative preparation​ ​(only buccal surface and sometimes incisal border too
- when need anterior guidance- )
● Optimal aesthetics
● Colour modifications ​(it depends of the case)
● High resistance to force
● Biocompatible
● Wear resistance
● Stain resistance
 ● Resistant to chemical attack ​(related with the type of food)
● Radiopacity ​(x-ray can see both : veneer and the tooth)
● Acceptable cost nowadays

Disadvantages :
● Most difficult technique​ (be careful with the incisal margin and gingival margin)
● Fragility​ ​(bcz they are thin)
● Difficult reparation --​ one broken should be removed and perform a new one
● Complex adhesive technique ​(4different bonding)
● Irreversible technique
● Once cemented impossible​ to change the color

Ceramic VS composite
Composite
Adv:
1. Adhesion
2. Tissue preservation (​sometimes no need preparation)
3. Hardness similar to dentine

Disadv:
1. Contraction to polymerization ​(changes in the structures)
2. Coefficient of ceramic expansion ​(a lot of wear, not very resistant)

Ceramic (porcelaine)
Adv:
1. Aesthetic (​better than composite)
2. Durability ​(more than compo)
3. Hardness similar to enamel

Disadv:
1. Fragility
2. Characteristic of wear

Dentists should review all the adv and disadv and depending on the cases should know
which one to use.

TIP :
● Establish patients expectations
○ Take a pic of before and after to show the result
● Document the treatment as complete as possible, incluiding photographs, dental
waxing, provisional models … the patient requesting venners is usually a very
demanding
● Its better to have objective data from the ealy stages, to then be able to show its
improvement
○ Texture
○ Shape
 ○ Color
○ Position
○ Smile

Veneers procedures : a step by step guide

➔ Dental reduction
➔ Impressions
➔ Provisionals
➔ Different lab phases
➔ Cementations
➔ Final instructions

Dental preparation
(only on buccal or also incisal edge)
We reduce incisal edge only when the anterior guidance should be fixed
Dental reduction
1. No dental reduction
● Indications when we need morphological change
● In microdontia and rotated cases
2. With dental reduction
● The most conservative as it can be :
○ Final aspect of the tooth
○ Width and strength of the veneer
○ Adhesion (50% enamel)
○ Standard reduction
○ Non standard reduction (damaged teeth)

Standard reduction
- Buccal preparation
● Chamfer bur or shoulder bevel
● Depth of 0.5 to 0.8 mm , minimum 0.3mm
● In central and lateral incisors: two planes, ⅔ incisal y ⅓ gingival
○ Horizontal grooves
○ Vertical grooves
- Proximal preparation
● Proximal preparation
○ Extend preparation onto proximal surfaces just labial or slightly
into contact areas. With chamfer bur
○ In cases of diastemas we create new contact areas. Between
ceramic tooth or ceramic ceramic
- Prepare incisal edge
1. Finish at the incisal edge
Finish haway in vestibular
Non reduced incisal edge

2. Finish at palatal / lingual side

3. Reconstruction of the incisal edge
 Veneer that covers the incisal edge of the palatal side of the tooth.
Soft edges : final aspect with chamfer of shoulder bevel
Anterior guidances→ need to be recover : remove incisal edge

- Gingival reduction
Always in enamel and not in cement. Chember or shoulder bevel
- Exception : gingival recession
- Low resistance interphase

Juxta Gingival : ​it's the ideal , it allows aesthetics, good vision, we do not
invade biological space, easy prep and impression
Supragingival:​ when the smile line does not let the margin be seen and
there is no difference between tooth and veneer. The patient will be very
critical
Subgingival ​: when we want to resolve pbs with colors. Do not invade the
gingival sulcus more than 0.5 mm and maintain at least 2mm of biological
width.

- Finishing touches
Round any sharp angles
Polish facial surfaces of preparations as desired. WIth a thin diamond bur

Color election (Shade guide) -- depends on the patients

Impression : ​same as for any abutment teeth
● Conventional impression technique
● Material
○ Polyether
○ Additional silicone
● Type IV mounted cast
● Gingival retraction
○ When we want a subgingival margin, use a retraction
cord

Temporization technique
1. Indirect technique
● cast and silicone impression
● Self curing acrylic
2. Direct technique
● Silicone mouth key
 ● Use of acrylic separator and dental adhesive
3. Finishing and polishing
● Eliminate excesses and polish especially in the margins to avoid gingivitis
4. Provisional cementation
● Calcium hydroxide and zinc oxide without eugenol

Veneer try IN
Aesthetic -- adjustment-- cementation order

Cementation
● Conditioning the enamel -- on the tooth
○ Orthophosphoric acid + bonding
● Conditioning of the vener
○ Hydrofluoric acid + silane (-- act as bonding for a porcelaine)
● Dual polymerization cement → between surface of tooth

Very important to have a good isolation to do it otherwise the veneer can fall off
Prosthesis III Lecture Notes 1

IMPRESSIONS IN FIXED PROSTHODONTICS; TYPES AND MATERIALS

CONCEPT
An impression is…
“A detailed, intraoral reproduction, used to transmit to the lab the information required for the manufacturing of a dental
prosthesis”.
• Obtaining an impression is the first step necessary for the indirect fabrication of prosthesis.
• The fitting of the restoration can only be made from high quality impressions
• It can be obtained when we know the properties and techniques of the materials
• Impression: negative likenesss of the surface of an object
• Impression tray: device used to carry and confine the impression material (free of bubbles)
• Individual try-in;
in; acrylic tray. It fits perfectly in the patient as a
prior impression of the edentulous arch is taken

IMPRESSION MATERIALS
1. Rigid
2. Elastic
2.1 Hydrocolloid Impression Material
2.1.1 Reversible Hydrocolloid
2.1.2 Irreversible Hydrocolloid
• Alginate (antagonist)
2.2 Elastomeric Impression Material
2.2.1 Silicone
• Condensation
• Addition
2.2.2 Polyether
2.2.3 Polysulfides

Polyether and Addition silicone exhibit long-

term dimensional stability (the impression
can be stored for some time before making
the cast.

Reversible hydrocolloids must be poured immediately after the impression is made. They also cannot be used if the impression has
to be poured in epoxy/electroplated, because it is only compatible with die stone.

Ideal Properties of Impression Materials

1. Dimensional Accuracy
• Ability to accurately record the morphology of the anatomical structures
• “Reproduce details of 25 microns”
• Indirect adjustments; 50-100 microns
• Viscosity; heavy silicone (75 microns)
• Silicone has a better dimensional accuracy than alginate
2. Elastic Recovery
• Ability to recover its original shape after deformation by deinsertion
• Alginate doesn’t have elastic recovery
• Tilting
• Retention zones
• Viscoelastic materials
3. Dimensional Stability
• The ability of a material to maintain its shape and dimensions over time
• This is important as it indicates the amount of time we have to make the cast of the impression
• Volumetric variations: Polymerisation; contraction towards the tray
Expansion into the tray
Larger model
• Condensation Silicone: Releases ethyl alcohol (its dimensional stability will last 30 minu utes)
• Addition Silicone: They do not release alcohol. Thus they last longer than condensation silicones
Release hydrogen (plaster)
• Polyether: Very hydrophilic, absorbs water (its( dimensional stability will last 1 hour)
• Alginate: Gain/Lose water (its its dimensional stability will last 10 minutes)
Place in a humidity
idity chamber or
o disinfectant; it always needs to be wet or it will contract and be destroyed
Prosthesis III Lecture Notes 2

4. Sufficient Fluidity to Record Fine Details

• Fluidity is a property studies only in polymers and measured in terms of the melt flow index, calculated on the basis of
viscosity (flow resistance), pressure (required to force the material to flow) and size of the orifice (through which the
material is pushed.
• Tixotrophy is the ability of some viscous fluids (i.e. polyethers) to change fluidity in a fixed time.
• Types (elastomeres
elastomeres available in several consistencies);
consistencies Putty
Heavy body
Medium density silicone (single phase)
Light body impression material flows easily into the finest details
Extra-light body
• Fluid V: Great for capturing details
Increased contraction
5. Complete Elasticity After Cure
Elasticity-Stiffness
• It avoids the deformation derived from the expansion of the plaster
• If it is very stiff…
-Fracture the sulcus material
-Fracture
Fracture the models; thin and long trunks
periodontal teeth
narrow neck
These areas should be filled with wax to aid in removal of the impression
(not necessary in the case of alginate)
6. Ability to Wet The Oral Tissues
Hydrophilia
• It is desirable in the void appear (incompatible pores and with wet plaster)
• Impressions in humidity
• Polyethers (hydrophilic)
7. Biocompatibility

CONDENSATION SILICONES; POLYDIMETHYL SILOXANES

• Polymerised by condensation reaction, releasing ethyl alcohol.
• Poor dimensional stability; 0.3% deformation in 1 hour (so they are not used in fixed prosthesis)
• Double impression is taken; 25 microns details
Recovery of 99.5%
• Hydrophobic; no humidity in the mouth (the
(the prepared teeth and gingival sulcus must be completely dried so that the
impression can be free of defects )
• Control: catalyst and paste base

ADDITION SILICONE; POLYVINYL SILOXANES (PVS)

• They undergo addition polymerisation reactions without the formation of collateral products.
• Great detail of reproduction
• Dimensional stability; 0.05-0.2mm/24
0.2mm/24 hours
• Elastic recovery: 99.8%
• Hydrophobic with surfactants; surfactant gives them hydrophilic properties, imparting wettability similar to that of the
polyethers.
• Release hydrogen; do not empty in 30-60 60 minutes
• Latex inhibits polymerisation (latex and hemostatic sulphides)
• They allow 2 voids; the second to adjust to the soft tissue
• Automated systems
• When taking impressions in periodontal patients we must fill in the black triangles to eliminate retention of material
(except teeth prep)

POLYETHERS
• Very used, improved
• High degree of detail reproduction
• Elastic recovery: 98.5%
• High stiffness; so it’s the best for periodontal patients (just fill the gaps)
Thin and single teeth are liable to break unless great care is taken
• High dimensional stability; addition silicones have slightly better dimensional stability than polyethers
• Hydrophilic
• Elevated thixotrophy (high gingival sulcus pene
penetration; better for thin periodontium and periodontal
periodon patients )
Prosthesis III Lecture Notes 3

SUMMARY
EXAM: LEARN ALL VALUES
Contraction at 24 hours Elastic Recovery % Flexibility %
Addition Silicone 0.05-0.2
0.2 99.8 4
Polyether 0.1-0.3
0.3 98.5 3
Condensation Silicone 0.6-0.7
0.7 99.5 5
Hydrocolloids 98.8 11
Polysulfide 0.3-0.5
0.5 97.9 7

GINGIVAL DISPLACEMENT TECHNIQUES (Short Q. /Practical Exam Q.)

• Objective: To include in the impression the subgingival finishing line.
• These techniques need to be reversible, if not we will cause a recession.
• Take care in thin biotypes, as mistakes can provoke an irreversible recession.
• Preparation: Deepen 0.5mm and respect the biological width;width thin biotypes have a shorter biological width than thicker ones
• The patient should have a healthy gingiva (provisioning and inflammation), if not it can bleed and become inflamed
• Insert the impression
ssion material into the sulcus (minimum 0.15-0.20mm)
• Open the sulcus slightly and place polyethers; ideal for periodontal disease patients
Gingival Displacement
1. Mechanical Retraction
• Single cord tech
• Braided cord
• Metal cord
• Knitted cord
• Displacements paste
2. Chemic-Mechanical Retraction (“different types of chemical retractors”)
• Epinephrine
• Peroxide
• Alum solution (potassium aluminium sulphate)
• Aluminium chloride
• Ferric sulfate 15% or 20%
3. Electrosurgery (laser)
4. Mix: Chemical + Cord

Double Cord Technique

• Performed with local anaesthesia
• The SAFEST
• Requires adequate sulcus thickness (upper anterior in facial)
Method…
1. A smaller diameter cord is placed in the sulcus; this cord is DRY
2. Preparation
3. A second cord is placed above the first one with hemostatic; leave it inside for 4-10
10 minutes
-The second cord is MOIST; moisten with water, dry with cotton, NOT AIR
-It is used to achieve a SUBGINGIVAL finishing line
-It controls crevicular fluid
-Hemostasis; no blood = better impression
-0.2mm sulcus opening
4. Remove the cord and place a fluid impression material
5. Impression is taken with only the first cord inside the sulcus; it will cause the sulcus to be
opened perfectly and all the details can be
b recorded

Single Cord Technique

• Indicated in cases of JUXTAGINGIVAL/SUPRAGINGIVAL termination
• The cord and hemostatic are placed after the preparation and removed before taking the
impression
• Bleeding; if the patient bleeds, remove the cord and place local anaesthetic

Impression material reaching

the finishing line
Prosthesis III Lecture Notes 4

Expansion Paste

IMPRESSION TECHNIQUES
Double Mix Technique
• Impression taken with dense material in standard tray
• Peel of the spaces impression: Sharp knife
Before prep impression
Diagnosis model impression
• High viscosity material + cord
• Drying
• High viscosity silicone in tray

Single Mix Technique

• At the same time high and low viscosity silicone; Mixes both types of silicone (heavy + light)
• Heavy silicone displaces the fluid one, take care in the margins
• The greater density difference, the worse; heavy silicone with more initial fluidity
• Single technique is faster since it only has one step.

CLEANING AND DISINFECTION

• Avoid volumetric variation
• Avoid reactions with the impression material
Solutions
• Silicone + Alginate: Povidone Yodate (Iodide) 1:200/ 10 minutes
• Polyethers: Sodium hypochlorite 1:10/ 10 minutes
• Silicones + Polysulfides: Glutaraldehyde 2%/ 10 minutes
Dental cements in fixed prosthodontics

Introduction
● Cement procedures in indirect restoration in FP is one of the most important steps
when aiming for a good retention, resistance and sealing in the interface between the
restoring material and the tooth

Most important aim : sealing interphase tooth - restoration

Physical properties
● Translucity
○ Transparent
○ Opaque (made of oxides y hydroxide of zinc or calcium)
○ Translucency (glass ionomer and resins) (with veneer we should choose resin
type of cement)
○ These cements may include some metallic particles to change the color
● Dimensional changes (bcz the cement is a mixture -- always change in type)
● Conduction

Mechanic properties (not very important)

● Mechanic resistant (always high when it get harder)
○ Resistant to compressive forces
○ Fracture with torsional forces
● Elasticity modulus
○ Similar to dentin -- resin
● Plastic deformation
○ A non desirable effect
○ Cements of resins with low percentage of inorganic filling

Chemical properties (important for exam)

● Solubility : depending on the cement (it must be low)
○ Ca salts -- higher solubility
○ Al salts → lower solubility
● Union to dental structure
○ Chemical or mechanical union to the tooth
○ Glass ionomer cements → mechanical and chemical union
○ Setting time
○ Width of the layer (25 micromes)
(we need thin layers of cements, gets subgingival in the patients -- it’s not
good)
● Radiopaque : allows the detection of decay on RX
● PH and sensibility. Glass ionomer and zinc phosphates are very
● Release fluoride
○ Bacteriostatic and remineralizing

Indications of the cements

 ● Restoration base
● Cementing
○ Temporal or provisional cement
○ Definitive or permanent cement
● Restoration
○ Temporal or provisional restorations
○ Permanent restorations
● Surgical dressings (not so often done nowadays, in small
surgeries)
○ For example PERIPAC (dentsply, konstanz, Germany
■ It contains:
● Calcium sulphate
● Zinc oxide
● Zinc sulphate
● Acrylic type of resin
● Glycol solvent
● Ascorbic acid
● Flavor and iron oxide pigment

Classification of cements (important exam)

● According to composition
○ Minerals (Zn phosphate)
○ Organic minerals (GIC , polycarboxylates)
○ Organs (resins)
● Type of union
○ Mechanic (ZN phosphate or resin)
○ Chemical (GIC , hybrids, adhesive resins)
● According to permanence (most important one!!!!)
○ Temporal
○ Permanent
● According to chemical reaction
○ Acid base (ZN phosphate o GIC)
○ Polymerization ‘resinsà , contraction
○ Hybrids
● According to activation
○ Self Curing
○ Photocuring
○ Dual
Provisional cement (short exam qst)
2 types :
- ZN eugenol with , or
- Zn without eugenol
- Ca hyxide

1. Calcium hydroxide
● Low mechanic resistant cements
● Antimicrobial and calcifiant effect
● Disadvantages : high solubility and bad mechanic properties. GOOD FOR
CHILDREN
● Always going to use when we have sensitivity
● Work in short period of time
● Very good in peadiatic dentistry
● When patients having pain when waiting for the metal try in to come back, we
remove it and seal it with this
● It comes in different preparations :
1. Pure or non setting calcium hydroxide
- The calcium hydroxide is pure, mixed with distilled water or
methyl cellulose
- Mixed with distilled water makes a product really diffictu to
work with
 -It may also include other substances: local anesthesia,
antibiotics or radio opacifiers
2. Combined or setting calcium hydroxide
- Used a luting agent
- It is combined with other substances to solidify the final
product
- Two combination systems
- Paste paste system
- Photopolymerizable system (not used in fixed
prosthesis)

Provisional type of restoration with endo : if the

patient suffers from sensitivity or we suspect it we are
going to use DYCAL as a provisional type of cement
If XE HAVE SENSITIVITY

2. Zinc oxide (most common)

● The presentation of these cements is in powder liquid or in two pastes
● Powder: Zn oxide
● Liquide : eugenol
● The chemical reaction ends with a material called ZN eugenolate/ eugenate
● This is an acid base setting reaction, accelerated by water an non exothermic

ZN eugenol cements are classified in

1. Type 1 : temporal cements (most common) - Use IRM to do small temporary filling
2. Type 2 : permanent cement
3. Type 3: used for temporal obturation
4. Type 4: cavity base (for amalgam type of restoration only , never with resin only with
metal)

Provisional restoration :
- These restorations are made with Type 3 -- TEMP BOND brade
- Due to the germicide, sedative and thermal isolation characteristics, it is the
ideal material
- Eugenol can irritate the tissue be careful
- It depends on some cases if we use or not eugenol, but in the most cases we
use with eugenol

Properties
 ● Sedative effect
● Pulp irritant if it contacts the pulp
● Thermal insulation
● Germicide -- kill bacteria

Definitive cements in fixed prosthesis

Types of permanent cements
● For retaining restorations, posts and crowns
● Retention mechanisms used :
○ Chemical retention
○ Mechanic (friction)
○ Micro mechanic (tissue hybridation)

➔ Zn phosphate (we barely use it anymore bcz of acid , that allow bacteria to appear)
◆ Good mechanical properties
◆ Inicial acidity !!!! (lead to bacteria)
◆ Layer width : 25 micras
◆ High solubility
◆ Setting time 4 to 10 min
◆ Composition
● Powder : zn oxide
● Liquid : orthophosphoric
◆ The retention depends on the geometric form of the dental preparation.
MECHANICAL
◆ It was the gold standard, it work very well, but we should avoid it
Advantages
- Easy manipulation
- Clinical durability
- High resistance to compression
- Thin layers
DIsadv:
- High solubility
- Pulp irritant (will always need endo)
- Non adhesive
- Non anticariogenic

➔ Polycarboxylate cement (improvement of Zn phosphate)- not used neither

◆ Less acid
◆ But higher solubility comparable to Zn phosphate (we wznt to avoid
solubility)
◆ It is said it has a chemical retention to dental structure but there is not enough
evidence
 ➔ Glass ionomer (most important cement in fixed) (when u don’tknwo which one
to use - glass ionomer )
◆ Most used
◆ Similar behavior to dentin
◆ Release fluoride!!!! -- anticariogenic properties
◆ Thin layer
◆ Good mechanical properties
◆ But high solubility (only pb)

➔ Hybrid cement / GIC reinforced with resin

◆ When u want to improve GIC
◆ It’s GIC modified with resins
◆ Are the ones that we are gonna use in post and core !!!
◆ Short setting time , it cures very fast
◆ Dual type of polymerization
◆ Bonding the tooth and also to metal (adhesion to tooth and metal)
◆ Works very well
◆ Indication : metallic restoration, not recommended without metal

Advantages:
● Dual polymerization
● Releases fluoride
● Higher resistance to flexion than conventional cements
● Capacity of adhesion to composite

Disadvantages
● Not enough adhesion to enamel and dentine (not totally true it depends on the layer
● Weakens if its in control with water before setting
● Water loss -- contraction and breaking of cement

➔ Resins
◆ Resins with inorganic fillings
◆ Insoluble
◆ Volumetric changes : absorbs water
◆ Delicate cementing system: photo polymerizable , photopolymerizable , dual
polymerization
 Cement of resin
- Adhesive procedures are basic in actual dentistry
- The success depends on union mechanisms to the tooth and restoration

➔ Adhesive resins
◆ veneer

Technique and systematic of cementing

● Aesthetic, retention, marginal adjustment, contact point and occlusion
● Prepare the instrument and material
○ Disinfection of the prosthesion
○ Cleaning and disinfecting of the tooth
○ We should know which type of cement
○ Vital tooth--W desensitizing agent(calcicum hydroxide
○ Isolation

We should remove the excess, check the occlusion

Abutment preparation has been clean with alcohol

Then dry
Should work on the abutment but also in porcelaine of veneer
We place cement
Polymerize
Then we remove excess of cement
And we finish

Indications for patients

● They can’t eat any sticky food in 24 hours (chocolate for ex)
● Oral hygiene
○ Take more care of the crown
 ○ Tell them to use toothbrush , dental floss/ interproximal brush
● Teach patients
● Informed consent
● Post operative controls depend on the diagnosis
○ Periodontal disease always predominates (they ahve to come every 6
months)
○ Systemic diseases may affect oral health
■ Depending on the patient are going to give different instructions and
the postoperative controls
INDIVIDUALIZED

Patients classification :
➔ Periodontal patient (with splinting)
➔ Patient with high cariogenic risk
➔ Patient with moderate cariogenic risk
➔ Patient with low cariogenic risk (with trauma or iatrogenic injuries on treated tooth)
➔ Patients with systemic alterations (antidepressants)
◆ Show risk

Ideal basic protocol (exam)

● 15 days
● 3 months
● Every 6 months
○ No decay -- once a year
○ With decay -- every 6 months
Exam : if a patient needs to come back after placing a fixed prosthesis first come 15
days, 3m, every 6 m …

Recommended cements
● Metal porcelain crown
○ Zn phosphate (not nowadays ) we prefer Glass Ionomer type of
cement
● Crown without metal
○ Vita in ceram
■ Zinc oxide cements
■ Glass ionomer cements
■ Hybrid ionomer cements
■ Compomer cements
○ Procera
■ It is possible to use any cement

Cement on a conventional way when possible, cement on an adhesive way

when necessary

Discussion
● To choose the correct cement on each case we must pay attention to
 ○ Vitality of the tooth (some cements may cause an aggression to the pulp )
○ Whether the termination is on enamel or cement (always in enamel, if the
margin line is on the cement we can place acid , zn phosphate- to be more
careful)
○ Type of restoration
○ translucency/ opacity of the restoration

Conclusion
- Cementing indirect restoration in FP is one of the most important steps when you are
trying to reach retention, resistance and sealing of the interphase between tootha nd
the restored material. On this depends a restoration that lasts for a long time
- There is no ideal cement so we must study the case and choose the correct material
for cementing

Glass ionomer cements are characterized by :

● Water solubility
● Being provisional
● Bacterial contamination
● Pulp irritant
● Not releasing fluor

What of the following cements had a dual core polymerization

● Glass ionomer cement
● Zinc phosphate eugenol
● Calcium hydroxide
● Polycarboxylate cement
● Glass ionomer cement modified with resin

Single / taken
Healthy or toxic (relationship)
Going out or staying in
Sloppy drunk or funny drunk
Alcohol or weed
Nice or mean
COLOR GUIDE

Informed consent (always always before starting the treatment)

(make sure that the patient going to sign)
How are we going to choose the color?
Most common one is to tooth the guide selection that help to choose the color

The challenge of achieving accurate colour matching in restorative dentistry is central to

success in aesthetics

● Shade selection or tooth color selection as the determination of the color and other
attributes of appearance of an artificial tooth or set of teeth for a given individual
● Spectrophotometer (too expensive, try to choose the shape of the color by placing
them on top of the tooth) --->
Sometime ask for a different shapes for gingival portion than cervical portion depends
on

Value of the color (exam)

● The relative darkness or lightness of a color, or brightennes of an object

- Range : 0-10 (0 : black, 10= white
● Amount of light of energy an object reflects or transmits
● Objects of different hues / chroma can be identical value
● Restorations too high …
 ●

Vita classic shade guide (important for the exam)

● Very popular shade guide
● Tabs of similar hue are clustered into letter groups
○ A (red yellow)
○ B (yellow
○ C (grey)
○ D red yellow gray
● Chroma is designated with numerical values
● A3: hue of red yellow, chroma of 3

Shade distribution chart

● The tooth is divided into 3 regions: cervical, middle and incisal

Shape mapping
● Recommended even when good custom shade match exists
● Tooth is divided into
○ Three regions
○ Nine segments
● Each region is matched independently
● Further characterizations are sketched on diagram, may include
 ○ Craze lines
○ Hypocalcifications
○ Proximal discolorations
○ Translucency

Principles of shade selection (before taking impression) (exam important)

1. Teeth to be matched must be clean
2. Remove bright colors from field of view
- Make up / tinted eye glasses
- Bright gloves
- Neutral operatory walls
3. View patient at eye level
4. Evaluate shade under multiple light sources
5. Make shade comparisons at beginning of appointment
6. Shade comparisons should be made quickly to avoid eye fatigue

(make choose more than 1 shade to decide which one would be ideal)
Should be doing it fast

If we do it after local anesthesia, if it contains epinephrine -- it gonna modify the color of the
tooth --- and then we can choose a wrong color

QST EXAM LAST YEAR

The value or the brightness of the colour
● Decreasing the value means reducing the amount of gray, reducing the excessive
whitness or purity of the light colours
● In older patients the value is increased because of the amount of shape of the pulp
● Depends on the thickness of the dentin and in influenced by the color and thickness
of the enamel
● Is not something that matters
● Everything is false
Taking the shade of a bridge in 11 12 13 , we will take into consideration
● The shade is taken with teeth wet
● The shade is taken with the teeth dry
● We will switch off the lights
● Look 5 seconds nd then rest looking a red surface
● We will take the shades afer local anesthesia is applied
PROSTHESIS IV
Candela de Fortuny

1. Epidemiology of the temporomandibular disorders

Terminology

• Costen syndrome 1934, he was the first one to study TMD disorders

• TM articulation disorders (1940-50)

• TM articulation syndrome (Shore, 1959)

• TMJ functional alterations (Ramfjord and Ash)

• According to etiological factors

• Occlusomandibular disorder

• TMJ myorathropathy

• According to pain

• Functional pain syndrome

• Functional myofascial syndrome

• Functional TMJ pain syndrome

Temporomandibular disorders (Bell, 1982)

• Defined temporomandibular disorders: articulating and disorders in relationship with the

masticatory function

• Accepted by the ADA

Evolution

• Dr James Costen (OLR)

• Taking evidence in 11 cases, took dental disorders in relationship with hearing problems

• Everything was wrong but he was the first one

• Devices to elevate the bite (1939-1940)

• 1940-50: Costen’s devices are discussed and studies of the bite are done

• 1950-60: Scientific studies show the relationship between the occlusal moments and the face
muscles

• 1960-70: Occlusion and emotions principal caused of articulation disorder

• Studies in TMJ

• 1980: TMD complexity is appreciated

• Planning treatment

TMD

• Several kind of disorders related with temporomandibular joints and or muscles of mastication
that modify the correct function of the masticatory system. Masticatory dysfunction of
Mandibular Disorders (AAOP, 1933)

• Pain or sensitivity in the masticatory muscles and the temporomandibular joints with and
different kinds of noises (IASP, 1994)

Epidemiology

• Frequency of the temporomandibular disorder

• Etiology of the temporomandibular disorder

• Dental treatment

• If the TMD has an occlusal etiology the patent will go to the dentist which will perform an
occlusal modification. If it has a non occlusal etiology it will go to another specialist for other
treatment and may still need occlusal modification done by the dentist.

• Among 5-7% of the population need treatment for these kinds of disorders, this is due to high
stress

• 22% of the general population have experienced the following signs and symptoms in the last 6
months:

• 12% dental pain

• 6% pain caused by TMD

• 4% another type of facial pain

• TMD are the most frequent cause of frequent chronic pain in the masticatory system

• Dental origin in TMD is frequent with different kind of signs and symptoms

2, 3. TMJ anatomy

TMJ

• Craniomaxillary connection area

• Two at both sides of the head acting at the same time

• The TMJ is a diarthrosis, better defined as a ginglymoarthroidal joint.

• The TMJ is a gingymoarthrodial joint, ginglymhus meaning a hinge joint allowing motion only
backward and forward in one plane, and athrodia meaning a joint which permits a gliding
motion of the surfaces

• It is bicondylar

• All these aspects result in the following:

• 2 convex surfaces

• Allows sliding and rotating movements

• Allows hinge movement in 1 axis

• Mobile articulation

Articulation of the masticatory system

• TMJ is one of the most complex articulations

• Consists of

• Both TMJs, passive axis which allows movement

• Masticatory muscles are the engine of the system

• Dental occlusion is the balance

• It behaves a s third gender lever which allows it to protect the masticatory system.

• Resistance: occlusion

• Power: muscle

• Support: TMJ

The TMJ is formed by

• Articular surfaces

• Temporal

• Superior synovial cavity (posterior)

• Articular eminence (anterior)

• Mandible

• Condyle

• Articular disc

• Synovial surface

• Upper (disco-temporal)

• Lower (disco-condyle)

• Ligaments

• Inner

• Outer

• Vascularity and innervated parts: retrodiscal

• Muscles

Bones of the TMJ

• Mandibular fossa

• Condyle

• Articular eminence

• Posterior part of the fossa is too thin, not ready to hold

intense force. Articular eminence is formed by dense and
compact bones that allow it to hold these forces

Condyle

• In contact with the skull, around it movement is produced

• Length: 18-23mm

• Width 8-10mm

• Articular surface

Articular disc

• Biconcave disc which allows contact between both articulated surfaced

• Formed by thick and fibrous connective tissue (reshuffle capacity), without blood vessels or
nerves (only in anterior part)

• Divides in superior synovial cavity and inferior synovial cavity

• Has an elliptic 8 form

• Function: follows passively the condyle in every movement

Retrodiscal tissue

• Has vascularity and nerves

• Superior retrodiscal portion

• Inserted in the posterior part of the mandibular fossa

• Limits the disc

• Towards the anterior part

• Inferior retrodiscal portion

• Inserted in the posterior part of the condyle

• Allows the synchronised movement

Synovial membrane

• Reshuffle capacity, regeneration

• Surrounds the disc

• Vascularity

• Synovial liquid is produced, lubricates the surface and contributes with the metabolites to the
tissue

Ligaments

• Connect the different parts of the articulation and limits the movement

• Inner ligaments

• Joint capsule

• Disc ligament

• TM ligament

• Outer ligaments

• Sphenomandibular ligament

• Stylomandibular ligament

• Pterygomandibular ligament

Joint capsule

• Surrounds the entire TMJ

• Inserted in the superior part in the mandibular fossa and the articular eminence

• In the inferior part inserted in the neck of the condole

• Innervated

• Functions

• Avoids forces to separate the articulation

• Surrounds the articulation and keep inside the synovial liquid

Disc or collateral ligaments

• 2: lateral and medial

• Lateral extensions of the disc are over the condyles

• Functions

• Allow certain rotation of the disc over the condyle

• Keep the disc joined to the condyle, going along with it in every
movement

Temperomandiblar ligament

• Passive stability

• Runs from zygoma to the condyle

• 2 parts

• Outer oblique portion: limits mouth opening

• Inner horizontal portion: limits the movement of the condyle and the disc
towards the back

Outer ligaments

• Sphenomandibular ligament

• Spine of the sphenoid

• Bone to the lingual of mandible

• Passive stability

• Pterygomandibular ligament

• Pterygoid to oblique lingual part of the mandible

• Limit the movement

• Stylomandibular ligament

• Styloid process to the angle of the mandible

• Limits movements of excessive protrusion

Neurovascular bundle

• Irrigation: anterior deep temporal artery, middle meningeal artery from the front. Posterior deep
temporal artery from behind and maxillary arteries and veins from beyond.

• Innervation: deep temporal nerve (trigeminal nerve)

Muscles and their action

• Protrusion: lateral pterygoid assisted by medial pterygoid

• Retraction: posterior fibres of temporalis, deep part of masseter, and geniohyoid and digastric

• Elevation: temporalis, masseter, medial pterygoid

• Depression: digastric, geniohyoid and mylohyoid muscles, and gravity

Muscles of mastication

• Elevation muscles (Chewers)

• Depression muscles (Suprahyoids)

• Fixer muscles (Infrahyoids)

Temporalis muscle

• Origin: floor of the temporal fossa

• Insertion: margins and deep surface of coronoid process

• Function

• Elevation (1)

• Elevation and retraction (2)

• Retraction (3)

Masseter muscle

• Origin: zygomatic arch

• Insertion: ramps of the mandible, from second molar to the angle of the mandible

• Function: elevation and protrusion of the jaw

Medial pterygoid

• Origin: pterygoid fossa

• Insertion: internal surface of the angle of the mandible

• Function: elevation and protrusion

• Contraction in 1 side leads to mediprotrusion movement

Lateral pterygoid

• Inferior

• Origin: lateral surface of the lateral pterygoid plate

• Insertion: anterior surface of the new of the condyle

• Superior

• Origin: infralateral surface and crest of greater wing of sphenoid

• Insertion: anterior margin of articular disc and capsule of TMJ

• Function

• Inferior: protrusion and depression (with suprahyoid muscles). One side, grinding movement.
Left lateral pterygoid and right medial pterygoid turn the chin.

• Superior: elevation

Suprahyoid muscles

• Muscles

• Geniohyoid

• Stylohyoid

• Mylohyoid

• Digastric

• Function

• Depression

• Digastric and mylohyoid also produce retraction

Infrahyoid muscles

• Muscles

• Sternohyoid

• Homohyoid

• Thryhyoid

• Function

• Allow the movement and work of the supra hyoid muscles

Mastication movements

• Opening

• Inferior head of lateral pterygoid, anterior digastric, mylohyoid

• Opening is also controlled by eccentric contraction of the closing muscles against gravity

• The articular disc moved forward with the condyle as it glides forward, effectively extending
the superior articular surface of the mandibular fossa.

• Closing

• Masseter, anterior and middle temporalis, medial pterygoid, superior head lateral pterygoid

• Protrusion

• Bilateral contraction of the lateral pterygoid

• Retrusion

• Middle and posterior temporalis, possibly helped by deep posterior portion of the masseter

• Laterotrusion (side to side)

• Ipsilateral middle and posterior temporalis, contralateral inferior head lateral pterygoid

Opening movement

Two phases

1. Condyle rotation

• Pure condyle rotation around the hinge axis inside the glenoid cavity

• Opening close to 19mm, inferior disc portion, supra hyoid muscles

2. Condyle translation

• Translation of the condyle and the disc

• Superior disc portion, opening close to 50-60mm

• Simultaneous action of both lateral pterygoids

Closing movement

Two phases. Opposite movement

1. Condyle translation

• Superior portion of the disc. Condyle and the disc translate towards glenoid cavity

• Temporalis, masseter and medial pterygoid

2. Condyle rotation

• Inferior portion of the disc, condyle rotated inside the glenoid cavity

• Temporalis, masseter and medial pterygoid

Protrusion

1. First phase

• Smooth depression of the mandible to avoid incisal contact

• Condyle rotation

• Geniohyoid

2. Second phase

• Simultaneous condyle translation

• Lateral pterygoids

• Mandible elevated by temporalis

Retrusion

• Opposite of protrusion

• Temporalis and posterior digastric

Lateral movement - chewing

1. Rotating condyle

• Working condyle

• Movement towards this side

2. Orbiting condyle

• Non working condyle

• Lateral pterygoid

Right lateral border movements

• Mandible comes back to the centric relation the right lateral border movements

• Left condyle, the orbiting condyle as it is orbiting around the frontal axis of the right condyle

• Right condyle, the rotating condyle because the mandible is rotating around it

Left lateral border movements

• With the condyles in the centric relation position

• Left condole still in centric relation the result will be left lateral border movement

• Left condyle, the rotating condyle/working condyle

• Right condyle, the orbiting condyle/nonworking condyle

4. Etiological factors of TMJ disorders

Oral and facial pain classification by Okeson 1995

1. Neurovascular

• Tension headache

• Migraine

• Cluster headache

• Giant cell arteritis

• SUNCT

• SUNA

2. Neuropathic

• Primary

• Trigeminal nerve

• Glossopharyngeal nerve

• Secondary

• PHN, DM, MS, HIV

• Post surgical

• Lingual inferior alveolar nerve injuries

3. Idiopathic

• Burning mouth syndrome

• Persistent idiopathic (ATFP/ATO)

• TMJ pain

International headache society headache classification

Journal of the American Ostheopathic Association

• The Journal of the Americas Osteopathic Association includes every TMD inside category 11 in
the headache classification

• Furthermore 11.1, 11.7 and 11.8 are entirely related to TMJ

• 11.1: Skull bones including the jaw

• 11.7: TMJ

• 11.8: Masticatory muscles

TMJ disorders causes

• Alterations of the skull bones and the mandible

• TMJ internal alterations

• Disorders of the masticatory muscles

TMJ disorder symptoms

• Inflammation

• Articular/muscular pain

• Splinting

• Tooth sensitivity

• Tooth mobility

• Arthrosis

• Dental migration

• Increase of bone

• Dental erosion

• Muscular hypertrophy

Development of TMJ disorders

• Event takes place and depending on the tolerance margin it can go two ways

• TMJ disorder symptoms

• Muscle activity regulations. Depending on the sensory stimuli received. Nociceptive reflex.
Active protection mechanisms.

Physiological toleration

What is an event?

1. Local alterations

• Cause acute change in sensitive stimuli and proprioceptive in masticatory structures.

Examples:

• Crown: wrong occlusal schema

• Trauma: excessive opening or for a long time, local anaesthesia, third molar eruption,
chewing gum,..

• Constant deep pain: origin can be dental, particular or muscular

• Patient needs to change muscular activity

2. Systemic alterations

• Psychological conditions which increase muscle activity

• Acute diseases

• Virus infections

• Anxiety and other factors: immune response and ANS

Not all patients have the same reaction to a given stimulus. They exhibit a differing grade of
individual physiological tolerance (Okeson)

Tolerance margin

Variable, depends on each person

1. Local: stability of TMJ

• Organic occlusion

• Occlusal scheme: stability

2. Systemic

• Level of pain

• Fitness of the person itself

Physiologic tolerance

• Every structure from the masticatory system has its own tolerance

• Structural tolerance

• Depending on

• Anatomic form

• Previous traumas

• Local conditions

• The weakest structure is the one that fails first: failure sign

• Influenced by local and systemic factors

• Local: orthopaedic stability (relation between mandible and maxilla), good stability; mandible
closes with the condyles in their most superior and anterior position against posterior slopes of
articular eminence, contact with all possible teeth

• Here masticatory system is best at tolerating local and systemic events

• Individual response

1. Local factors

• Orthopaedic stability: articular alteration, occlusal alteration, or both

• Anatomic alteration, disc displacement, articulate disorder

• Genetic, developmental, iatrogenic

• Lack of harmony, occlusion scheme, muscle stability

2. Systemic factors

• Genetic

• Gender

• Age

• Diet

• Examples

• Acute and chronic diseases

• Physical conditions of the patient

• Efficacy of pain regulation

• Stress

TMJ disorder symptoms

• If alteration is bigger than tolerance margin

• Big structural tolerance

• Depends on every person

• Anatomy

• Previous trauma

• Local condition

• Symptoms include

• Pulpitis

• Tooth erosion

• Tooth mobility

• Molar to molar pain

• TM pain

• Earache

• Headache

5,6: Classification of pathologies

Signs and symptoms

• Signs: clinical observation detected during the exploration of the patient

• Symptoms: description from the patient of its suffering

• Pain: sign and symptom

• Dysfunction: sign and symptom

Joint pain versus muscular pain

Joint Muscular

Located at fingertip Pointed palm of the hand

Pungent, oppressive Deaf, diffuse, deep pain

Intensity: moderate-severe Intensity: mild-moderate

Frequently referred to the ear Morning or evening dominance

Related to function Little related to movement (if with prolonged

mastication, overload and stress)

It radiates to zygomatic region and mandibular Cyclical evolution

ramus

Rate if there are any clicks or rubs No functional limitation

Assessment of mechanical limitation Improvement with NSAIDs

Little response to NSAIDs Worse with cold climates

Positive end feel Negative end feel

Muscular functional disorder

• Most frequent along with toothache

• Symptoms

• Pain (myalgia)

• Most frequent symptom

• Associated to headaches

• Origin: discussed (tiredness, tension, CNS)

• With mandibular movements

• Treatments

• Increase activity of the muscle

• Effects over CNS

• Dysfunction

• Decrease of movements (because of pain)

• Acute malocclusion (as a consequence of muscle disorder)

• Do no do selective tooth preparation. Treat origin of muscle pathology

• Types of disorders

• Protective co-contraction

• First muscular response vs went

• Response induced by CNS

• Protection against further injury

• No functional limitations

• Muscle stiffness, feeling of a certain muscular weakness

• No pain at rest, pain during function

• If prolonged there will be myalgia symptoms and pain

• Local muscle pain

• First response vs protective co-contraction

• Deep pain on palpation and during function

• Real muscle weakness causing limitation of function

• Non inflammatory origin

 • This pain can cause more protective co-contraction which leads to cyclic muscle pain

• Local alterations inside the muscular tissue

• It can modify or be the real reason of the pain therefore a good medical history and amnesis
is important

• It can activate the ANS, leading to emotional tension leading to death

• Protective co-contraction and local muscular disorders

• Origin in local muscular tissue and possible CNS effects

• The rest of muscular disorders receive much more influence of the CNS.

• They are classified in

• Acute: myospasm

• Chronic

• Regional

• Myofascial pain

• Chronic myalgia central action

• Systemic

• Fibromalgia

• Myofascial pain (trigger myalgia)

• Regional myalgia of complex ethology

• Localised hard and hypersensitivity muscular tissue

• Constant and deep pain on palpation

• Referred pain (+ trigger point pain)

• Difficult diagnosis

• Most frequent referred pain is from headaches

• 1 side

• It may be in a state where it is

• Active: palpation of trigger point, headache

• Latent: trigger point is not sensible on palpation. Give the patient an appointment when
the headaches are back

• There are trigger points on the shoulders and on the cervical muscles, which can cause
protective co-contraction of the masticatory muscles

• Myospasm

• Myalgia of tonic contraction (muscle affected is contracted)

• On palpation muscles are hard

• Not shown on electromyography

• CNS included

• Not very frequent

• Affected muscle is contracted: acute malocclusion

• Chronic central meditation myalgia

• It is due to a nociceptive impulse that originates in the CNS (neurogenic inflammation) and
that acts on muscle tissue

• Irritating and constant myogenic pain

• The fundamental causes are

• Prolonged local muscle pain

• Myofascial pain (trigger point)

• Fibromyalgia

• Global muscoskeletal pain

• Sensitivity in 11 or more of the 18 specific pain points throughout the body

• Sometimes it can be confused with an acute masticatory muscle disorder

• 42% of patents with fibromyalgia suffer from TMD

Functional joint disorders

Types

• Condyle disc complex alterations

• Structural incompatibility of articular surfaces

• Inflammatory joint disorder

Condyle disc complex alterations

• Failure in the rotation condyle-disc

• By macro or micro trauma (bruxism)

• This causes

• Elongation of discal ligaments

• Elongation of the inferior retrodiscal lamina

• Thinning of the posterior edge of the disc

• Symptoms

• Pain; arthralgia

• Joint surface does not hurt (denervated)

• Pain in surrounding soft tissue structures

• Discal ligaments distension

• Capsular ligament distension

• Retrodiscal tissue compression

• Acute, sudden, unexpected

• Ceases at rest

• Pain in function: limits mandibular movement

• Dysfunction

• Limitation of mandibular movements due to pain

• Joint sounds (they do not always mean pathology and when there is a TMJ pathology they
do not always appear)

• Clicks: isolated, short

• In opening: unique

• In closure: unique

• In both (opening-closing): mutual

• Crepitation: multiple, rough, “step on snow or gravel”

• Types

• Anterior disc displacement

• Macro and microtraumas result in thinning the posterior edge of the disc (biconcave). This
increases movement between mandibular disc-condyle which results in displacement of
anterior-medial disc.

• Disc at rest is no longer at 12 o clock position

• No blockage

• There is usually no pain (only if great distension of ligaments)

• There are usually no noises but clicks are possible

• Unique at opening

• Mutual if very severe

• Disc dislocation with reduction

• Disc progressively thinned and greater strength from eternal pterygoid muscle (less strength
from the superior retrodiscal lamina) results in the disc being in a retained position more
anterior and it doesn’t go back to its position for 12 hours

• Dislocation (joint surfaces separated) where the patient with certain lateral movements does
achieve to reposition the disc and thus make maximum openings

• Advanced disc

• History of clicks

• There is pain

• Sensation of recent blockage

• It does “relocate”

• Strong click: reduction

• Diverts at the opening but it focus back after the opening click

• No limitation of movements

• Disc dislocation without reduction

• Displacement of the articular disc on closing, and failure to reduce or recapture the normal
relationship with the condyle upon opening

 • There is a greater loss of elasticity of the superior retrodiscal lamina, which makes the
relocation of the disc more difficult

• You can never make maximum openings (the advancing condyle stumbles against the disc)

• Closed blockage

• No sounds

• Limitation on opening (<35mm)

• Deviation of the mandible to the affected side

• Limited lateral movements towards the healthy side (TMJ affected is the non-working)

Structural incompatibility of articular surfaces

• Morphological alterations

• Real change on the articular surfaces

• Usually form chronic dysfunctions that have never shown pain

• They cause friction and adhesion that inhibit joint function

• Types

• Flattening of condyle or fossa

• Existence of disc perforations

• Condylar protuberances

• Etiology

• Static and prolonged charge

• Hemarthrosis

• Macrotrauma

• Surgical intervention

• Features

• With or without pain

• Alterations on the mandibular movements

• Long history of dysfunction

• Dysfunction in a concrete point which matches the movement of opening and closing

• Adhesions

• Two surfaces that are glued in a temporary way

• There are no physical changes in the joint tissues

• Etiology

• Because of a prolonged static charge on the TMJ (decreased synovial fluid leads to reduced
lubrication)

• Due to hemathrosis from trauma/surgery

• Types

• Disc condyle

• Rotation movement is inhibited

• There is translation: nearly complete opening with irregular movement

• There is a jump or block in the condyle when we achieve maximum opening

• Disc fossa (disc is anchored)

• Inhibition of translation movement

• Anchors the disc and prevents the sliding of the disc on the articular eminence, which
results in the disc only being able to rotate

• Etiology also by suction effect that faces the disc with the fossa

• It can be

• Occasional: normal maximum opening and a click when opening

• Permanent: normal movements, difficult when closing

• Subluxation (hypermobility)

• Sudden movement of the condyle forward during the final phase of mouth opening

• Facilitated by characteristic anatomical features (short and inclined posterior articular

eminence and the anterior part is long and flat)

• No pain

• Not a pathological disorder

• A considerable preauricular depression appears

• Spontaneous dislocations

• Synonym of: open blockage or TMJ hyperextension

• Jaw blocked in open mouth position

• Pain

• Always bilateral

 • There may be fiscal displacement

• To reduce it we perform Nelaton manoeuvre

Inflammatory joint disorder

• Capsulitis

• Inflammation of the capsular ligament

• Pain on palpation of the outer pole of the condyle

• Increased pain during movement

• Causes

• Macrotraumas open mouth

• From swelling of neighbouring tissues

• Synovitis

• Synovial tissue inflammation

• It is from an irritant inside the TMJ due to

• An unusual function of the TMJ

• A trauma

• Constant pain that increases in movement

• Arthritis.

• It not inflammatory

• Set of phenomena in which bone destruction is observed

• Subtypes

• Osteoarthritis

• Destruction bony process of condyle and fossa in response to an overload of the joint

• Pain that increases with movement and crepitus

• An erosion and flattening of the surfaces can be observed radiographically

• Osteoarthrosis

• Phase during osteoarthritis in which the joint surface deteriorate and the bone is
remodelled at the same time

• It hinders sliding and opposition of the two joint surfaces within the TMJ

• The signs in an MRI compatible with osteoatrosis are

• Subchondral sclerosis irregularities in the surface

• Condylar erosion

• Condylar deformations

• Polyarthritis

• They are a less frequent group of arthritis

• Types

• Traumatic (macrotraumas)

• Rheumatoid (affects more joints)

• Infectious hyperuricemia (gout)

• Psoriatic

• Ankylosing spondylitis

• Retrodiscitis

• Inflammation of retrodiscal tissues

• By macro/micro trauma

• Constant pain when closing teeth but if we interpose a teether on the affected side closing no
longer hurts

• Can cause acute homolateral posterior malocclusion

7. Diagnosis of the alterations in the TMJ

Diagnosis

1. Anamnesis (compilation of information)

2. Exploration

3. Complementary tests

Anamnesis

• Personal information

• Medical history

• Trauma

• Reason for consult

• Pain: articular or muscular?

• Orofacial pain

• Clicks

• Functional limitations

• Dental abrasions

• Intermittent locks

• Headaches

• Tinnitus

• Other

• Muscular dystrophy (internal disease)

• DDwr

• Intermittent blockage

• Acute blockade

• Chronic blockade

• Osteoarthritis

• Osteoarthrosis

• Subluxation

• Luxation

• Time and type of evolution

• Previous treatments

• Actual medications

• Usual activities and habits

• Eat sunflower seeds, chewing gum, biting nails, use of phone, teeth grinding, chewing only on
one side, profession, stress,..

• Quality of sleep

• Number of hours, all night, on the side/downwards,..

• Emotional evaluation

• Personal attitude

• Psychological evaluation

• Informed consent

Diagnosis

• TMJ

• Joint palpation: bilaterally with mouth closed, maximum opening, during opening and closing
movements

• Capacity of opening and laterality

• Comfortable opening

• Maximum opening

• Stop feel, end feel

• Normal opening: 53-58mm (<40mm limitation)

• Lateral movement: 8mm

• Protrusion: 10mm

• Symmetry of movements

• Movement must be rectillinear, symmetrical and without interruptions

• Any deviation greater than 2mm is considered pathological

• Noises

• Clicks: single noise of short duration (pop)

• Crepitation: multiple noise as of gravel, chirp

 • Pain and joint mobility

• Masticatory muscles

• There should be no pain when a healthy muscle is palpated

• When palpating the muscles we use the entire palmar surface of the middle finger, the index
and annular will explore the adjacent surfaces, gentle but maintained pressure is applied, any
pain or discomfort will be recorded

• Temporal: above the ear, also indie at tendon of the temporal

• Masseter: cheeks

• Sternocleidomastoid muscle: neck

• Posterior cervical: nape

• Splenius: behind ear

• Trapezius: clavicle

• Pterygoid muscles (lateral and medial) are almost impossible to palpate, functional
manipulation (contraction and distension) will be performed for these

• Lateral pterygoid

• Inferior lateral pterygoid

• Contraction opens and protrudes the mouth. Protrusion against resistance

• Muscle strain in maximum intercuspidation. Lingual depressor in posterior teeth

• Super lateral pterygoid

• Contraction when biting hard, depressor

• Muscle strain open your mouth a lot, all elevators except this one will be relaxed

• Medial pterygoid

• Contraction it is an elevator muscle, lingual depressor between posterior teeth

• Muscle strain when opening mouth widely

• Hypertrophies

• Hypertonic

• Pain on palpation

• Trigger points

• Occlusion

• Structural

• Functional

• Posture

Functional analysis of muscles

• Principle: a muscle which is fatigued and symptomatic elicits pain on further function and is
painful both on contraction and stretching

• Lateral pterygoid

• Inferior belly

• Contraction: mandibular protrusion, mouth opening or both

• Stretching: maximum intercuspidation of teeth

• Differentiation test: place tongue blade in between posterior teeth. This prevents the teeth
from reaching maximum intercuspal positon. Hence lateral pterygoid does not stretch

• Superior belly

• Differential test: tongue blade is placed bilaterally and patient is asked to bite. This increases
the pain if it is symptomatic while the stretching pain of inferior belly of lateral pterygoid is
relived

• Stretching also produces clenching

• Differential test: patient is asked to open mouth widely. If pain is elected it is from the
elevator muscles

• Medial pterygoid

• Contraction: clenching

• Differential tests: tongue blade is placed bilaterally and patient is asked to bite. This increases
the pain if it is symptomatic because elevators are still contracting.

Functional manipulation

Muscle Contracting Stretching

Inferior lateral pterygoid muscle Protruding against resistance, Clenching on teeth, increase pain

increase pain Clenching on separator, no pain

Superior lateral pterygoid muscle Clenching on teeth, increase pain Clenching on teeth, increase pain

Clenching on separator, increase

pain

Opening mouth, no pain

Medial pterygoid muscle Clenching on teeth, increasing Opening mouth, increasing pain
pain

Clenching on separator,
increasing pain
8. Complementary exams

Panoramic xray

MRI

Normal TMJ closed mouth

Normal TMJ open mouth

Coronal view

Open mouth Closed mouth

CAT

9. Splints

Etiology summary

1. Predisposing factors

• Pathological: neurological, vascular, rheumatic, metabolic, hormonal, degenerative, neoplastic,

infectious diseases, etc.)

• Psychological: emotional factors, personality, attitude, depression, anxiety)

• Structural: from biodynamic relationships of the oral cavity

2. Trigger factors

• Injuries, inadequate loads, habits, parafunctions, stress, anxiety, alterations of sleep, etc

3. Perpetuating factors

• They are risk factors that have not been eliminated and that continue causing symptoms

Treatment

• Multidisciplinary

• Dentist

• Physiotherapist

• Psychologist

• Maxillofacial

• ORL

• GP

• 2 types

• Conservative treatment (usually sufficient 90% of the times)

• Healthy - posture measure measures: sleeping on the back, soft diet, no gums/caffeine,
posture of the trunk, head and neck, heat

• Physiotherapy: relax movement, increase movement, breaking fibrosis

• Pharmacology: NSAIDs, myorelaxants, diazepam

• Oral splits

• Surgical treatment

Oral splits

• Removable appliances usually made with hard acrylic resin, which fit on the teeth of one of the
jaws, establishing a specific occlusal scheme, specific to the design and objectives pursued by
said splint

• Retention and stability

• Easy insertion and removal without discomfort

• Not dislodging with unilateral finger pressure or with excursion positions of the jaw

• Splint comfort (ensure acceptance and patient compliance)

• A splint without stability subjects the teeth to uncontrolled forces that produce dental
movement and contributes to a parafunctional activity

• Occlusal contacts

 • It will provide a stable occlusion by a flat surface following the curve of occlusion

• Free contact in centric of at least 0.5mm from the centric relation position to the positions of
“free closing” and also lateral (for antagonists)

• Excursive contacts

• Canine guidance that provides a separation of about 2mm in excursive movements

• In protrusive the contact and disocclusion will be carried out with the two canine guidance
simultaneously

• Exceptional case

• Shape

• It will follow the normal anatomical contours of the teeth above the dental equator in the
buccal and lingual read

• Sufficient thickness to resist occlusal forces, without much increase in vertical dimension

• In maxilla it extends from 4-6mm on the palate

Objectives

• Stabilise and improve TMJ function

• Normalise the activity of the masticatory muscles improving the functioning

• Protect the parts from the effects of traumatic parafunctional loading

• Coadjutant elements in the diagnosis of a stable and reproducible musculoskeletal relationship

prior to complex treatments in restorative dentistry

Mechanism of action

• Neuromuscular pacification: restore symmetry, improve postural activity and reduce masseter
muscle activity

• Increasing of vertical dimension: decreased neuromuscular activity (transient effect)

• Improves maxillomandibular relations: “occlusal disengagement”

Classification of splints

• Stabilization SP = Michigan

• Anterior repositioning SP

• Anterior bite plane

• Posterior bite plane

• Pivot splint

• Soft splint

Michigan splint

• It adapts to the maxilla and provides an optimal occlusal relationship for the patient

• Condyles in their more stable muscle position

• Teeth contact uniformly and symmetrically

• Canine dislocation of the posterior teeth during eccentric movements (lateral and protrusive)

• Eliminates orthopaedic instability between occlusal and joint position

• Indications

• Acute muscular disorders

• Severe malocclusions with important parafunctional activity

• Excessive and uncontrollable tooth wear

• Controls the progression of periodontal disease by eliminating occlusal trauma (primary, by

excessive forces)

• Differential diagnosis between pathology with predominantly muscular or joint symptoms

• Treatment before the realisation of a definitive occlusal therapy (selective carving, prosthesis)

• Obtain more reliable inter maxillary records (improvement of symptoms and ease of getting
them)

• Long term treatments with a slightly modifiable, dominating or chronic etiology

• Chronic

• General: anatomical, physiological or psychological reasons

• Specific: if this splint is not the most appropriate therapeutic option

• Success or failure of a split will depend: from its correct selection, manufacture, adjustment
and cooperation of the patient

• Setting in clinic (essential)

1. Analysis of the patients occlusion without splint

2. Insertion in the mouth (anterior teeth first)

3. Elimination of retentive zones

4. Inspection and verification of the correct settlement

• Eliminate interferences or add self curing acrylic in areas that need readjustment

• Vaseline in teeth and soft tissues

• Self curing resin in Dappen glass and monomer inside the splint. Placement of 1-2mm of
resin in the splint

• Placement in the mouth and elimination of excesses. When the resin is heated, it is removed
and hardened outside of the mouth

5. Adjustment of the contacts in centric relation (maximum number of occlusal contacts)

6. Adjustment of the previous guide (protrusive)

• Usually made with canines bilaterally

• No interference from posterior during the protrusive

7. Setting the canine guide (laterality)

• Canine disocclusion preferably

• Left laterality

• Right laterality

• Absence of contacts in non working sides

• Considerations

• The michigan splint is preferably maxillary

• Exceptions of michigan maxillary splint:

• Dental abscess in maxilla (no retention)

• Class II or III severe (lack of stability)

• Patient preference (nausea, overwhelming,..)

• Severe crossbones

• Semi-adjustable articulator in centric relation and individualise ITC and Bennet

Anterior repositioning splints

• Also called FARRAR Splint (they are direct splints)

• Preferential placement in maxilla (can also be jaw)

• Function: guide the mandible towards a more ventral and caudal position, to improve the
condyle-disc relationship in the pits

• Its foundation is fiscal recaptation, but it has been shown that is rarely achieved, thus being
ineffective for anterior discal dislocation problems and reserving its use to:

• Acute phase synovitis: for 3 weeks, 24 hours a day (+ use)

• In cases of anterior discal dislocation without reduction in phase of acute block: the
dislocation is reduced manually and then RAS + 3 weeks, 24 hours a day

• In cases of discal dislocation with reduction (that in the morning they present pain and
reversible joint blockage due to nocturnal tightening)

• The fabrication of the splint is done by placing the models mounted on the articulator in a
protrusive 1-2mm with respect to maximum intercuspidation

• Evolution

• When the symptoms cease, the splint is replaced by a michigan splint

 • If the click is maintained, ask the patient to perform opening-closing movements from a more
protrusive position to maximum intercuspidation in which there are no disc alterations and this
position will be recorded at the dental level with joint paper

• Requirements

• In this position, joint symptoms must decrease

• The palatal ramp should prevent the retrusion of Mb

• Must be polished to be compatible with soft tissues

• Negative effects

• Avascular necrosis

• Muscle pterygoid fibrosis ext.

• Lengthening/breaking ligaments

Anterior bite plane (SVED)

• Only incisal surfaces of anterior teeth of Mb contact

• It is intended to disclose posts sectors eliminating mastication forces

• They are used for short times because they can cause over eruption o lateral sectors

• Uses

• Treatment of muscle disorders related to orthopaedic instability or with an acute change of the
occlusal state

• Severe bruxism (although the michigan splint is better because this extrusion does not occur
in lateral sectors)

Posterior bite plane (GELB)

• Made in mandibular

• It is a hard acrylic plane that is located bilaterally in the posterior sectors and are joined by a
lingual bar

• Use

• Cases of significant loss of vertical dimension

• Important changes in the positioning of the Mb and certain disc disorders (for disc disorders a
michigan splint)

• Also in orthodontics they use it to make an extrusion of the previous sector

Pivot splint

• Also called disimpaction splint (disimpacts fossa condyle)

• It covers all the dental arch, it is made of hard acrylic and it has one unfolded contact (in distal
of 7 of each quadrant), which acts as fulcrum

• Reduce the joint pressure by making the jaw vascular on these occlusal support points during
the masticatory forces (idea that is difficult to reach since the forces are posterior to the fulcrum
and that lever is not achieved)

• Only with the help of a ventral force, e.g. elastic bandage on chin, this effect is achieved

• Uses: remove symptoms osteoarthritis

• Never more than 1 week for risk of intrusion of the 7 (pivots)

Soft splint

• Elastic material

• Does not require adjustment in the mouth

• Objective: uniform and simultaneous contact of opposing teeth (difficult with soft materials)

• Uses

• For dental whitening

• Urgent treatment in joint pain after michigan splint, no more than 4-6 months because it
causes undesirable tooth movements and is destabilised

• Mouthguards

• In patients with sinusitis, we reduce symptoms with these splits because they reduce
occlusion force on antra teeth, but we must treat sinusitis

Summary

Splint Indications

Michigan splint Muscle, art disorders, bruxism,..

Anterior reposition splint Acute synovitis, anterior disc dislocation

Anterior bite plane Muscle disorder, bruxism

Posterior bite plane Mb reposition, recover vertical dimension

Pivot splint Codnylar disimpaction, osteoarthritis symptoms

Soft splint Mouthguards, whitening

10. Obstructive sleep apnea syndrome

Obstructive sleep apnea

• Is the most common type of sleep apnea and is caused by complete or partial obstructions of
the upper airway. It is associated with a reduction in blood oxygen saturation.

• It is a chronic condition of the upper airway characterised by a repetitive (cycle) episodes of

shallow or paused breathing during sleep which is associated with symptoms even during the
daytime.

Epidemiology

• OSA is estimated to affect 27% of men and 9% of women, and the disease is common in both
developed and developing countries

• Middle aged men

• Apnea: refers to a pause in respiration for more than 10 seconds and is seen in central sleep
apnea and obstructive one

• Hypopnea: refers to a pause in respiration for more than 10 seconds

• An apnea/hypopnea index greater than 10 per hour is considered abnormal

Classification

• Two types

• Obstructive sleep apnea: the muscle tone of the body ordinarily relaxes during sleep, and at
the level of the throat the human airway is composed of collapsible walls of soft tissue which
can obstruct breathing. It can obstruct breathing which decreases oxygen saturation
disturbing sleep

• Central sleep apnea: the brains respiratory control centres are imbalanced during sleep

• Based on the apnea/hypopnea index per hour of sleep or index of respiratory events

• It is considered pathological when this index has a value greater than 5:

• 5-15: mild

• 15-30: moderate

• >30: severe

Etiology

• Multifactorial and complex

• Under normal conditions during inspiration, a sub atmospheric pressure occurs in the pharynx
that tends to collapse the walls of the duct, counteracted by the normal tone and respiratory
contraction of the muscles: genioglossus, geniohyoid, sternohyoid tensor and palatal elevator

• During normal sleep, there is a moderate decrease in muscle tone, this is because the pharynx
narrows without becoming an obstacle to airflow, unless the collapsibility (compliance) of the
pharynx is greatly increased (oropharynx, hypopharynx and velopharynx) or intraluminal
pressure (diaphragm) is very negative, leading to collapse and as a result apneas and
hypopneas

• There are several factors involved in the greater collapsibility of the upper airway

Risk factors

• Age/gender

• Obesity

• Family history (genetic component)

• Lifestyle factors (smoking/irritants)

• Predisposing anatomical or functional alterations:

• Craniofacial syndromes (micrognatia, retrognatia)

• General medical disorders (kyphoscoliosis, hypothyroidism, acromegaly,..)

• Obstruction of the upper airway (nasopharynx, oropharynx, hypopharynx, larynx)

• Mallampati III, IV

Diagnosis

• OSA is a medical condition where the patient life is at risk

• We are not qualified or legally protects to make the diagnosis of a sleep disorder

• The diagnosis is always done by the sleep specialist

• 95% of cases stay undiagnosed

• Questionnaire: the patient and spouse: is he obese, daytime sleepiness (Epworth scale),
snoring?

• Examine the structure of the lower jaw, upper airways

• Complete polysomnographic study with recording of multiple respiratory signals while sleeping

Epworth sleepiness scale

How likely are you to doze off or fall asleep in the following situations

Answer

• 0: Would never dose

• 1: Slight chance of dozing

• 2: Moderate chance of dozing

• 3: High chance of dozing

Situations

• Sitting and reading

• Watching TV

• Sitting inactive in a public place (e.g. theatre or meeting)

• As a passenger in a car for an hour without a break

• Lying down to rest in the afternoon when able

• Sitting and talking to someone

• Sitting quietly after a lunch without alcohol

• In a car while stopped for a few minutes in traffic

Differential diagnosis

• Inadequate sleep time

• Encourage increased sleep if behavioural factors are the cause of inadequate sleep

• Treat insomnia if cause of inadequate sleep

• Confounding causes of sleepiness (depression, sedating substances, chronic diseases)

• Address primary care

• Adequate sleep time

• High suspicion of OSA (snoring, witnessed apneas, choking/gasping episodes, increased BMI

• Polysomnography or home sleep testing

• Low suspicion of OSA

• Refer to sleep centre to rule out non-respiratory sleep disorders

Signs and symptoms

• Neuropsychiatric manifestations: excessive daytime sleepiness, decreased cognitive ability,

poor sleep, sexual dysfunction

• Cardiorespiratory manifestations: snoring, objectified apnea per family member, hypertension,

arrythmias

• Night-time symptoms

• Loud persistent snoring

• Witness pauses in breathing

• Choking or gasping for air

• Restless sleep

• Frequent visits to the bathroom

• Daytime symptoms

• Early morning headache

• Daytime sleepiness

• Poor concentration

• Irritability

• Falling asleep during routine activities

Complications

• Cardiovascular: hypertension, heart failure, arrythmias, stroke, coronary artery disease

• Metabolic: dyslipidemia, MD

• Increased susceptibility to respiratory insufficiency in the following situations: aesthetic drugs,

atelectasis, obesity, pulmonary edema

• Due to daytime sleepiness, work accidents, traffic accidents

Treatment

• Lose weight

• Avoid alcohol

• Quit smoking

• Reposition splints. Mandibular Advancement Splint which repositions the mandible and tongue

11. Obstructive sleep apnea syndrome treatment

When to treat?

• HA index > 20 treat every case

• HA index 5-20 treat if daylight symptoms

• HA index from 5-20 treat if daylight symptoms with risk factors (smoke, high blood pressure,
hypocholesterolemia, diabetes,..)

• HA index from 5-20 no daylight symptoms but ischemic heart disease diagnosed

Daylight sleepiness

• Wrong sleeping habits

• Irregular sleep schedule

• Irregular sleep routing

• Not sleeping increases upper always resistance syndrome

• Adequate environment, no noises, ventilated room, 23-25ºC and soft colours

Objectives

• Upper airway resistance syndrome

• Reduce snore intensity

• OSA

• Sort out signs and symptoms

• Improve AH index

• Improve the oxygen saturation levels

Predisponing factors

• Snoring and OSA have multifactorial risk factors

• Risk factors

• Snoring (main one)

• Men

• Age 40-60

• Position at sleep

• Myorelaxants and benzodiazepines

• Metabolic alterations: hypothyroidism and acromegaly

• Menopause

• Alcohol before sleeping

• Anatomic alterations

• Neurologic alterations: motoneuron disease

• Miastenia gravis

• Down syndrome

Treatment

1. General measures

2. Medical treatment of nose obstruction and oral breathing

3. Pharmacological treatment

4. Continuous positive airway pressure device

5. Mandibular advancement splint

6. Surgery

General measures

• Less weight

• Obesity increases 10 times the risk of OSA

• 60-70% of patients with the disease are obese

• Reduce weight can even heal the disorder

• In men fat is distributed in neck and in the abs

• In women it is related with hormonal changes and increments of weight during this period

• Healthy daily food

• No diabetes

• Less alcohol

• Alcohol helps deep sleep at the beginning of the night, but alter produces alterations in the
dreams, nightmares, etc.

• Less tobacco

• 2 types of mechanism can lead to develop OSA

• Stretching of the upper airway path

• Nicotine concentration in blood gets lower during the sleep

• No sedative medication nor muscle relaxant drugs

• Benzodiazepines

• Sleep disturbance

• REM sleep alteration

• Avoid in the mornings

• Confusion its the symptoms

• Prescribe sleep drugs with no benzodiazepines like Zolpiden. For insomnia 2-5mg, for
headaches 10mg

• Muscle relaxants

• Antidepressants (tryciclic and IMAO) cause sleep disturbance

• Antihistamines cause REM sleep alterations

• Hypothyroidism control

• Frequent in OSA patients

• Thyroid hormones control must be carried out frequently

• Control of the sleep position

• Avoid decubitus supine position

• Lateral decubitus position

• Snore bracelet stopper

• Elevate the head

Medical treatment of nose obstruction and buccal breathing

• Pharmacological treatment

• Nasal inhalers to improve air flow (Fluticasone)

• No decongestants before sleeping (oxymetazoline)

• Nasal dilator in low snoring

• Buccal breathing reeducation to improve function

• Avoid etiological factors

• Nasal stimulators at night

• When ventilated properly use a buccal flange obturator

Pharmacological treatment

• To increase upper airway tone

• ISR (Prozac)

• Protripilitina

• Acetazolamida

• Modafinil

Continuous air positive pressure devise (CPAP)

• First option in severe OSA patients

• Its use for more than 6 hours decreases day sleepiness, can help with memory and daily
functions

• 46-83% of patients show little adherence to this device

Mandibular advancement devices

• Acrylic splint which produces mandible advancement

• Many types

• According to function

• Mandibular advancement splints

• Tongue retention splints

• Mixture of mandible splint and CPAP

• To determine tongue position and occlusal register

• Kel gauge

• George gauge

• 2/3 of maximum protrusion

Surgery

• Widen the upper always

• Success

• Apnea indexes (IA) less than 20 per hour of sleep

• Minimum level of saturation of oxygen more or less than 90%

• Decrease of the daylight sleepiness

• Regulate sleep time

• Similar response to the CPAP at night