Downloaded from jada.ada.

org on June 17, 2014

An update on fixed prosthodontics

RJ Cronin and DR Cagna
JADA 1997;128(4):425-436
10.14219/jada.archive.1997.0226

The following resources related to this article are available online at

jada.ada.org (this information is current as of June 17, 2014):

Updated information and services including high-resolution figures, can be found

in the online version of this article at:
http://jada.ada.org/content/128/4/425

This article appears in the following subject collections:

Implants http://jada.ada.org/cgi/collection/implants

Information about obtaining reprints of this article or about permission to reproduce

this article in whole or in part can be found at: http://www.ada.org/990.aspx

Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly
prohibited without prior written permission of the American Dental Association. The sponsor and its products
are not endorsed by the ADA.
 Downloaded from jada.ada.org on June 17, 2014

An Upd gate on

Fixed Prosthoonis
ROBERT J. CRONIN, D.D.S., M.S.; DAVID R. CAGNA, D.M.D.

abricating and maintaining fixed

prosthodontics occupies a major portion of The practice of fixed
V every restorative-treatment-based dental
prosthodontics has continual-
practice. As a subspecialty in the discipline
of prosthodontics, the provision of fixed ly evolved as a result of

prosthodontics increased considerably in the past decade, progress in laboratory and bio-
with surveys indicating increasing demand in the future1"2
materials science, clinical
(Figure 1). Fixed prosthodontic topics are consistently
technologies and adjunctive
among the top three most-requested course topics on contin-
uing dental education interest surveys (Academy of General multidisciplinary treatment ad-
Dentistry Course Preference Survey, 1995). vancements. This brief review
Recent material, technical and clinical innovations in
describes those enhance-
fixed prosthodontics have increased the complexity of treat-
ments and how they affect
ment planning and decision making. Many of these ad-
vances have not replaced but have augmented a wide vari- the state-of-the art practice of
ety of existing materials or treatment protocols, as well as fixed prosthodontics.
clinical techniques and skills. Several advances in dental
technology reflect the public's increased awareness of the
aesthetic potential of fixed-restoration procedures. The en-
thusiasm of some clinical proponents of these aesthetic pro-
cedures has resulted in a shift from restorative efforts di-
rected toward a pleasing, natural appearance to procedures
designed to achieve a better-than-natural ideal.

JADA, Vol. 128, April 1997 425


-COCVER STORY
Figure IA. The demand for fixed prosthodontic care is reflected in
data gathered as part of the Third National Health and Nutrition
Examination Survey.2 This figure shows percentage of dentate
adults in specific age groups.
1-gure i D. . ne mean number oT permanent teen in specific age
groups as found in NHANES 111.2
This brief update on fixed
prosthodontics will review fun-
damental concepts and explore
technical advances in clinical,
laboratory and material sciences
that enable dental clinicians to
better serve their patients.
FIXED PROSTHO-
DONTICS: THE BASICS
The art and science of fixed
prosthodontics is predicated on
426 JADA, Vol. 128, April 1997
Downloaded from jada.ada.org on June 17, 2014
accomplishing precise and clini-
cally accurate operative tech-
niques based on sound biologi-
cal and mechanical principles.
Critical clinical decisions must
be made to achieve sound aes-
thetic and functional goals
within the limitations of avail-
able restorative materials.
Diagnostic casts.
Successful dental restorative
therapy begins with a thorough
patient examination. The cor-
nerstones of diagnostic exami-
nation are radiography, peri-
odontal examination and
occlusal analysis. Precisely
mounted, accurately construct-
ed diagnostic casts are an inte-
gral part of this examination.
When indicated, these articulat-
ed casts will facilitate occlusal
analysis for restorative therapy
involving several occlusal
restorations. The diagnostic
wax-up of proposed restorative
procedures is essential in com-
plex treatment plans and will
greatly facilitate the provisional
restorative phase of therapy
(Figure 2). The diagnostic wax-
up serves as a three-dimension-
al treatment plan that facili-
tates communication with the
patient. In treatment requiring
alteration of the vertical dimen-
sion of occlusion, diagnostic
casts can be duplicated and
used in the construction of a
pretreatment occlusal orthosis
or of other diagnostic occlusal
devices.
The occlusal ideal.
Previously distinct philosophies
and theoretical concepts of oc-
clusion have slowly coalesced
toward a universally accepted
occlusal goal. In recent years,
removable prosthodontic oc-
clusal concepts have increasing-
ly emphasized lingualized occlu-
sion, enabling the clinician to
use aesthetically acceptable
tooth molds in a functionally
balanced occlusal scheme. For
the patient requiring fixed
prosthodontic therapy, the gen-
erally accepted occlusal ideal in-
volves maximum intercuspation
coincident with centric relation.
Ideal occlusion is characterized
as mutually protective-that is,
the anterior teeth provide
smooth, continuous contact and
disengage the posterior teeth
 Downloaded from jada.ada.org on June 17, 2014

COVER SIORY

during all eccentric mandibular

movements, while the posterior
teeth contact to prevent exces-
sive occlusal loading of the an-
terior teeth in the maximum, in-
tercuspal position.3
Retention and resistance.
Recent advances in dental ad-
hesive technology and all-ce-
ramic restorative options have
led to innovative conservative
preparation designs. However,
applying sound engineering
principles of tooth preparation
for fixed prosthodontics, incor-
porating optimal retention and
resistance form during tooth
preparation, remains essential Plig.,I23.AW*h an 1*Ig DOUwiO Ug _en wAup ;u1 help
for metal and metal-ceramic IdentHfy treatment plIgol reloted to vertical dimension of oc-
clusion and orientation of the ooolusel plane.
restorations.4"Pp79159)'6
Conservation of tooth
structure. Conservation of
tooth structure remains another
valid treatment objective. When
not contraindicated by overrid-
ing aesthetic concerns, a partial
veneer crown preparation pro-
vides a high-quality, functional
restoration. A thorough knowl-
edge of restorative materials and
a sound biological respect for
pulpal and gingival tissues
should dictate tooth preparation.
Laboratory support. The
final basic concept of fixed
prosthodontics to be considered
is that of laboratory commuim
cation, technique and instru- F A
W`i id btt @f AxAlal
mentation. The clinician must occlusal orfho si and p e l toratln ma,nd It will gulde
the clinician and tchnn durlng fabrication of the final restoration.
approach laboratory-based diag-
nostic techniques and instru-
mentation realistically. When procedure, the greater the ne- many fixed prosthodontic clini-
creating complex fixed prostho- cessity for optimum practition- cal techniques and adjunctive
dontic restorations, the clinician er-laboratory communication. interdisciplinary procedures.
will achieve a higher quality of The accurate initial mounting of Treatment goals are best ac-
patient service by paying care- precisely created diagnostic casts complished when the clinician
ful attention to accurate regis- using appropriate instrumenta- not only has a thorough techni-
tration of the appropriate max- tion provides the basis for all fu- cal knowledge of fixed
illomandibular relationship and ture laboratory communication. prosthodontic materials and
selecting appropriate two- or techniques, but also uses all
three-dimensional occlusal in- CLINICAL TECHNIQUES available interdisciplinary ad-
strumentation.6 The more com- Technical innovations have re- junctive therapy in preparing
plex the fixed prosthodontic cently taken the spotlight from the patient for the proposed

JADA, Vol. 128, April 1997 427

 Downloaded from jada.ada.org on June 17, 2014
-CO VEIR STOHY
Figure 3. The aesthetic and Tunctional replacement ot bilaterally im-
pacted maxillary canines by single-tooth implant-supported restora-
tions, in lieu of conventional metal-ceramic fixed partial dentures, is
indicative of dentists' increased treatment options.
fixed prosthodontic procedure.
Dental implants. The explo-
sion of interest in endosseous im-
plants since 1983 has been cen-
tered on valid biological research
and surgical techniques. As the
placement of dental implants be-
came more predictable, emphasis
has changed to their aesthetic
restoration as well as the biome-
chanical aspects of implant load-
ing. Several evidence-based mul-
ticenter clinical trials have
increased the credibility of im-
plant-supported restorations,
and use of these restorations con-
tinues to expand exponentially.
The potential for restorative
support from dental implants
has drastically changed the phi-
losophy of our fixed prosthodon-
tic diagnostic procedures and
the timing of treatment. Since
the introduction of improved
antirotational abutments with
increased aesthetic utility, the
single-tooth fixed prosthodontic
restoration has become a valid
alternative to the three-unit
fixed partial denture when po-
tential abutment teeth do not
428 JADA, Vol. 128, April 1997
require restoration (Figure 3).
Multiple-unit fixed prosthodon-
tic restorations supported by
dental implants are often used
in lieu of removable partial den-
tures. Multidisciplinary restora-
tive procedures involving en-
dodontic therapy, crown
lengthening procedures and
root amputation or hemisection
surgeries are often eschewed in
favor of an implant-supported
restoration. The availability of
this additional means of sup-
port has greatly expanded the
scope of fixed prosthodontic
treatment.
Guided tissue regenera-
tion/guided bone regenera-
tion. A review of recent litera-
ture in the area of periodontal
therapy reflects an explosive in-
terest in the use of barrier
membrane, guided tissue and
guided bone regenerative tech-
niques. The impact of such tech-
nical innovations has revolu-
tionized conventional
restorative diagnostic decision
making, from the periodontal
treatment of teeth with in-
frabony defects to site prepara-
tion for dental implant therapy.
Excellent controlled clinical
trials have demonstrated the
benefit of both resorbable and
nonresorbable barrier mem-
branes used to facilitate regen-
erative therapy. These reports
provide a general therapeutic
basis for consideration during
treatment planning.' 1-2 The ap-
plication of regenerative tech-
nology before the restoration of
a single tooth or around abut-
ments for fixed partial dentures
may lead to an improved long-
term prognosis for the planned
restoration. However, this
treatment is not without com-
plications. The most commonly
reported complication is prema-
ture membrane exposure."
The adjunctive use of regen-
erative techniques in preven-
tion of post-extraction, localized
alveolar ridge deformities has
also proven quite beneficial.1
When preparing edentulous
alveolar ridges for implant
placement, a staged approach
using titanium-reinforced barri-
er membranes and demineral-
ized freeze-dried bone has been
recommended.1lAppropriate
alveolar site development, be-
fore the placement of dental im-
plants, has greatly improved
our ability to provide our recon-
structive patients with implant-
assisted fixed restorations that
are optimally functional and
aesthetically pleasing.
Periodontal plastic
surgery. The use of mucogingi-
val plastic techniques to create
an aesthetically harmonious
restorative-gingival junction
has recently received atten-
tion.1" Modifications in conven-
tional coronally positioned flap
procedures have been reported
to be successful, not only for
aesthetic improvement, but also

in the decrease of problematic
root sensitivity. The ability to
effect mean root surface cover-
age of 98 percent17 and 84 per-
cent18 has been reported.
In addition to mucogingival
surgery, guided tissue regenera-
tive therapy has been success-
fully applied in the aesthetic
management of gingival reces-
sion. The use of nonresorbable
barrier membranes in the treat-
ment of gingival recession has
been reported to achieve a mean
root coverage of 72 percent.19
The success of these mucogingi-
val techniques, along with
subepithelial connective tissue
grafting procedures, enhances
the uniformity of gingival tex-
ture and color as compared with
results commonly seen when
thick soft-tissue autografts har-
vested from the palate are used.
Research has clearly demon-
strated the protective role of
keratinized gingival tissues that
surround the transmucosal
emergence of dental implants
used to support fixed prosthe-
ses.20
Preprosthodontic or-
thodontic therapy. The use of
adjunctive, prerestorative or-
thodontic therapy can yield a
variety of benefits:
- uprighting of tilted molars
facilitates abutment tooth
preparation and improves
biomechanical aspects of pros-
thetic occlusal load application;
- extrusion of noncarious root
segments secondary to severe
horizontal fracture facilitates
treatment of otherwise non-
restorable teeth;
- orthodontic reorientation of
malpositioned teeth may im-
prove their restorative incorpo-
ration into an acceptable oc-
clusal plane or their potential
for use as abutments for a fixed
partial prosthesis;
Downloaded from jada.ada.org on June 17, 2014
- more appropriate orthodontic
tooth alignment may improve
the aesthetic display of the ex-
isting natural dentition,
planned restorations or perio-
dontal supporting tissues.
When orthodontic interven-
tion is required before orthog-
nathic surgery, meticulous and
thoughtful diagnosis is neces-
sary for fixed prostheses to suc-
ceed. The adjunctive use of or-
thodontic treatment, while
sometimes not considered due
to its inherent delays, can maxi-
mize the aesthetics, function,
comfort and biomechanics of the
final fixed dental prostheses.
An exciting new restorative
option is the use of dental im-
plants as orthodontic anchorage
in the elimination of interdental
space resulting from the loss of
posterior teeth. Roberts and col-
leagues21 reported on the use of
dental implants strategically
placed to serve as orthodontic
anchorage in the prosthodontic
management of complex
restorative situations. Because
of their outstanding and proven
stability in bone, dental im-
plants may be considered ideal
orthodontic anchorage units.
A well-conceived restorative
diagnosis and treatment plan,
carried out before dental im-
plant placement and orthodon-
COVER STORY
tic intervention, can produce su-
perior prerestorative tooth
alignment and positioning.
Furthermore, once the or-
thodontic movement is com-
plete, the implant will be appro-
priately positioned to assist the
fixed prosthodontic reconstruc-
tion. Pretreatment diagnosis
must be directed at reliable pre-
diction of posttreatment tooth
positions and, therefore, must
involve an accurate diagnostic
tooth wax-up and the fabrica-
tion of a precise surgical im-
plant placement template.22
INNOVATIONS IN
MATERIALS SCIENCE
The immense effort put forth in
recent years to advance our
knowledge and understanding
of dental materials science un-
doubtedly has benefited the pa-
tient, the practitioner and the
profession. Thoughtfully con-
ceived, well-documented, evi-
dence-based research has pro-
vided a wealth of valuable
information on new materials
and procedures affecting the de-
livery of fixed prosthodontic
dental therapy. It is not the au-
thors' intention to report on all
recent materials innovations af-
fecting fixed prosthodontics.
This article will focus on the
most relevant and clinically ap-
plicable scientific developments
that have directly influenced
the practitioner's daily thera-
peutic approach.
Materials innovations influ-
encing fixed prosthodontic den-
tal therapy have been both dy-
namic and voluminous. Annual
and semiannual cumulative re-
ports appearing in The Journal
of Prosthetic Dentistry,23-26
Dental Materials27-31 and
Journal of Dentistry,32234 as well
as a recent review article,35 sur-
veyed a variety of dental and
JADA, Vol. 128, April 1997 429
 Downloaded from jada.ada.org on June 17, 2014
~COVER STORY
Figure 4. A master die aemonstrating the ciassic facial snoulaer-lin-
gual chamfer preparation for a metal-ceramic fixed restoration.
materials-science-related peri-
odicals, accumulating several
hundred relevant citations.
These efforts can be extremely
valuable to the interested pro-
fessional who has neither the
time nor the resources to pur-
sue such an arduous endeavor,
but is interested in a thorough
and accurate cumulative report.
Dental casting alloys.
Dental literature is replete with
reports concerning the develop-
ment and refinement of dental
alloys for application in metal-
ceramic restorations. The state
of the science in metal-ceramic
technology has advanced dra-
matically in this regard. Issues
of potential biological hazards
associated with metals current-
ly used in dentistry-although
poorly founded in evidence-
based scientific scrutiny-have
provoked concern among profes-
sionals and the lay public about
the biocompatibility of dental
materials. The use of titanium
and titanium alloys in dental
implants and as a coronal
restorative material has
sparked a flurry of scientific in-
vestigation. Initial application
430 JADA, Vol. 128, April 1997
of titanium in fixed prosthodon-
tic restorations has proven diffi-
cult because of its unique physi-
cal properties and required
handling characteristics.
Titanium's favorable biocom-
patibility, excellent corrosion
ellent cor
istance and
ible cost
resistance and reasonable cost
make it a desirable metal for
intraoral use. However, as a re-
sult of its high chemical reactiv-
ity in the molten state, process-
ing it by the conventional lost-
wax casting technique has been
challenging.36 Fortunately, ma-
chining of unalloyed titanium
has met with greater success.
Developed in the late 1980s,3
one method for fabrication of
conventional fixed prosthodon-
tic restorations, Procera (Nobel-
pharma AB), involves reproduc-
tion of the original gypsum die
following dimensional modifica-
tion, using machine duplication.
Electrical discharge machining
creates the internal coping sur-
face, while computer-directed
machining produces accurate
external contours for titanium-
ceramic restorations.38 The com-
pleted framework, whether tita-
nium or ceramic, is now ready
for ceramic veneer application
and final clinical placement.
Because of the relatively low co-
efficient of thermal expansion of
titanium, as well as its tenden-
cy toward excessive oxidation at
conventional firing tempera-
tures,39 low fusing/low expan-
sion porcelains are required for
veneer application.
A review of the longitudinal
clinical data on Procera crowns
requires cautious scrutiny. Most
reports suggest the marginal in-
tegrity of these crowns to be in
the satisfactory to excellent
range.38'4043 Early in the clinical
experience, fracture and discol-
oration of the titanium veneer-
ing resin were a concern,43 but
improved aesthetic durability
has resulted from porcelain ve-
neering systems.4044 Good over-
all clinical longevity has been
reported for clinical observation
of up to 30 months3,40,1,43,45
Dental ceramics materials.
Owing to their natural appear-
ance and marked durability in
the caustic oral environment,
dental ceramic materials are ex-
tensively used in fixed
prosthodontic restorations.
Since its inception in the
1880s,46'47 the metal-ceramic ap-
proach to dental crown fabrica-
tion has been most popular. To
optimize color and translucency

in the critical gingival aspect of
metal-ceramic restorations,
tooth preparation involving a
shoulder finish line allows for
the fabrication of a ceramic
margin (Figure 4). Development
of alumina-reinforced dental
porcelain in 196548 opened the
door to predictable and relative-
ly durable all-ceramic crowns
with superior aesthetic and op-
tical characteristics. Advanced
ceramic technology and process-
ing methodology surfaced with
the introduction of shrink-free
all-ceramic49 and castable glass-
ceramic50 crown systems in the
1980s. Today, with the applica-
tion of advanced ceramic sci-
ence and the development of
new all-ceramic crown systems,
researchers are meeting the
challenges of clinical durability,
long-term survival, wear of op-
posing natural tooth structure
and fit. Excellent, detailed re-
views of dental ceramics are
available elsewhere.3551 Here, a
brief review will suffice as an
informative source for the scien-
tific basis and clinical applica-
bility of the ceramic systems
discussed.
Glass-infused Al203 and
MgAI204 core ceramic. An alu-
mina-reinforced ceramic materi-
al (In-Ceram, Vita Zahnfabrik)
appeared in the dental litera-
ture in the late 1980s,52 and has
been recommended for single
anterior and posterior crowns,
as well as for anterior three-
unit fixed partial dentures.51
The two-phase core material is
produced during a slip casting
process and subsequently
strengthened during a glass-
infiltration firing process.52 The
core is trimmed and built to
anatomical contour using con-
ventional techniques with dentin
and enamel porcelains, such as
Vitadur Alpha (Vita Zahnfa-
Downloaded from jada.ada.org on June 17, 2014
I|
Figur S.Rslso
tems.5 lxrlsrnt_et
brik). The superior fit of In-
Ceram crowns is attributed to
low-temperature sintering of the
core material, which results in
minimal volumetric shrinkage
and excellent marginal adapta-
tion (as judged clinically).53
Although the In-Ceram core
has great strength, its optical
properties are characteristically
opaque. If the clinical objective
is to match adjacent teeth that
demonstrate a high degree of
cervical translucency, use of In-
Ceram as the restoration sub-
strate may prove aesthetically
COVER STORY
o oencrmcss
challenging. Modification of the
slip, incorporating magnesium
aluminate spinel rather than
aluminum oxide (In-Ceram
Spinell, Vita Zahnfabrik), re-
sults in improved optical prop-
erties characterized by in-
creased translucency with a
small reduction in flexural
strength.54'55
The flexural strength of the
In-Ceram material has been
studied using three-point-55 and
four-point-56 bend methodology
to compare available ceramic
restorative materials. The supe-
rior performance of In-Ceram is
remarkable, demonstrating
flexural strengths exceeding
those of other ceramic materials
tested.57"6
Injection-molded leucite-rein-
forced glass-ceramic. The densi-
ty change that occurs during fir-
ing of conventional feldspathic
porcelains or during the ceram-
ming procedure for castable
glass-ceramics typically leads to
unwanted dimensional changes
that result in inaccurate fit. The
IPS Empress system
(Williams/Ivoclar) attempts to
overcome this effect by starting
JADA, Vol. 128, April 1997 431
 Downloaded from jada.ada.org on June 17, 2014
-COVER STOfY
Figure 6. The in vitro wear of enamel when opposed by various
restorative materials.69
with a precerammed, precol-
ored, leucite-reinforced glass-ce-
ramic ingot. Pneumatic pres-
sure injection of the molten
glass-ceramic into the heated
mold requires a special furnace
capable of high temperatures.62
The dimensional change that
occurs during solidification of
the molten glass-ceramic is
compensated by accurately
matched expansion of the in-
vestment material. The IPS
Empress system may be used
for laminate veneers and com-
plete crowns on anterior teeth
and inlays, onlays, partial-cov-
erage crowns and complete
crowns on posterior teeth.63
The flexural strength of the
IPS Empress glass-ceramic has
been reported to increase subse-
quent to the high-temperature
injection molding process, as
well as following the glaze
and/or enamel porcelain appli-
cation firing.6264 Numerous au-
thors have reported on the
strength of this glass-ceramic
material, and positive in vivo
research attests to its utility as
an inlay, onlay and single-
crown restorative material.6"6
432 JADA, Vol. 128, April 1997
Figure 5 compares newer all-ce-
ramic materials with those pre-
viously used (Vita VMK, Vident;
Hi Ceram, Vident; Optec HSP,
Jeneric/Pentron; Dicor, Dents-
ply, L.D. Caulk Division).
Low-fusing dental porcelain.
The recent introduction of sev-
eral low-fusing ceramic materi-
als with unique physical proper-
ties has created much interest.
These low-fusing ceramics are
compatible with a variety of
popular metals, including tita-
nium, allowing a greater range
of alloy choice. One of the most
important advantages of low-
fusing ceramics is their low
abrasive wear against natural
enamel66 0 (Figure 6). This is a
prime indication for their use in
fixed restorations opposing nat-
ural dentition. Low-fusing ce-
ramic is also highly polishable
in the mouth, decreasing the
need for glazing procedures
after intraoral adjustments.
Currently, these materials are
marketed under the names The
Golden Gate System (Glidewell
Laboratories), Ducera Gold
(Ducera Dental), Finesse
(Ceramco Inc.) and Procera All-
Ceram (Nobelpharma AB).
In the production of all-ce-
ramic crowns using the Procera
system,7' ,2 high-purity alumina
powder is dry-pressed against
an enlarged, machine-duplicat-
ed die, removed from the die
and sintered at 1550 C for one
hour. More recently,73 a major
modification of the Procera sys-
tem used contact digital scan-
ning of the gypsum die rather
than machine duplication. Once
these data are loaded into a
computer, a Procera software
package can manipulate the
scanned image to define the
preparation finish line, estab-
lish coping thickness and cervi-
cal collar design, and allow for
adequate space for the luting
agent. Data can then be trans-
ferred by modem to a remote
manufacturer for production of
a titanium or ceramic fixed
prosthesis framework. For tita-
nium-ceramic fixed partial den-
tures, the framework compo-
nents are adjusted using the
electrical discharge machining
process and assembled by stereo
laser welding. The completed
framework, whether titanium
or ceramic, is then ready for ap-
plication of the low-fusing ce-
ramic veneer and final clinical
placement.
Provisional restorative
resin materials. The applica-
 Downloaded from jada.ada.org on June 17, 2014

COVER SIORY-

tion ofbiologically accurate, me-

chanically precise and aestheti-
cally sound provisional restora-
tions during the course of fixed
prosthodontic treatment is essen-
tial to successful therapy. After
tooth preparation, well-con-
structed provisional restorations
may be used to accomplish sever-
al important goals"PP'll-Il,"":
- the accurate sealing and in-
sulation of prepared tooth struc-
ture;
- the preservation of pulpal vi-
tality;
- the maintenance of tooth po-
sitions;
- occlusal function and com- Figure 7. Max,ary ful-awtn hixea provisuonat restorations usea to
fort; verify maxillomancibular relations and vertical dimension of occlu-
slon as well as to Identify the most approprlate aesthetic and pho-
- accessibility for adequate netic form of the final fixed restorations.
oral hygiene;
- the maintenance or acquisi-
tion of periodontal tissue
health;
- acceptable transitional den-
tal and gingival aesthetics.
Varying direct and indirect
fabrication techniques have
been described.77'78 A provisional
restorative phase should be
used to acquire critical diagnos-
tic information for patients with
advanced destruction of tooth
structure (such as dental attri-
tion, rampant caries, traumatic
fracture), gross occlusal plane
discrepancy or severe maxillo-
mandibular malrelations
(Figure 7). Particularly in areas
of aesthetic concern, the sys-
tematic use of provisional
restorations to establish harmo-
nious phonetics, aesthetics and serve as an excellent guide for convenience, material biocom-
function will facilitate an opti- the dental laboratory technician patibility, predicted functional
mal restorative outcome.79 in the construction of the defini- and parafunctional occlusal
Provisional restorations should tive fixed prosthetics. 79-81 loading, biomechanical and
be modified and maintained The dental literature is re- strength requirements, durabil-
until they are deemed to have plete with reports on the wide ity and aesthetic ramifications.
successfully fulfilled phonetic, variety of resin materials avail- In a thorough review of avail-
aesthetic and functional able for fabrication of fixed pro- able provisional materials,
restorative goals. At this point, visional restorations. The ration- Burgess74 describes three conve-
an irreversible hydrocolloid im- ale for material selection may nient classifications: polymethyl
pression cast in gypsum can be based on issues of clinical methacrylate-based resin, or

JADA, Vol. 128, April 1997 433

 Downloaded from jada.ada.org on June 17, 2014
-CO OVER STORY
PMMA; composite resin; and
other acrylic resins, including
polyethyl methacrylate, polyiso-
butyl methacrylate and
polyvinyl methacrylate.
Of particular interest are the
more recently developed com-
posite resin provisional materi-
als. In general, this group of ma-
terials demonstrates relatively
low exothermal reaction on poly-
merization,82'83 minimal polymer-
ization shrinkage, good flexural
strength, improved occlusal
wear resistance, good resistance
to toothbrush abrasion, 4 im-
proved intrinsic color stability84
and excellent periodontal tissue
biocompatibility. Unfortunately,
these materials are susceptible
to brittle fracture, tend to have
rougher surfaces after polishing
procedures,84 are relatively sus-
ceptible to extrinsic stain accu-
mulation or absorption84 and are
relatively expensive.85
Dental luting materials. A
number of materials are cur-
rently available for cementing
fixed prostheses, including zinc
phosphate, polycarboxylate,
glass ionomer, zinc oxide-
eugenol and resin-based ce-
ments.86 Zinc phosphate has
served the dental profession
well for many years. Its clinical-
ly proven longevity,87 however,
must now be weighed against
newer materials that are less
caustic to vital pulp tissues,
more stabile in a fluid environ-
ment, provide adhesion to tooth
structure and possess anticario-
genic potential. Comprehensive
reviews of these materials ap-
pear periodically in the dental
literature.86'8890 A recent survey
of general practitioners and
prosthodontists9' revealed high
usage of resin-based cements
and first-generation glass
ionomer materials for cement-
ing single crowns and fixed par-
434 JADA, Vol. 128, April 1997
tial dentures. Resin-based ma-
terials and dual-cured, resin-
modified glass-ionomers were
most frequently used for placing
porcelain laminate veneers.
In recent years, the increased
emphasis on adhesive luting
agents has resulted in intense
investigation of glass-ionomer
and resin-based media. The
glass-ionomer cements, devel-
oped in the late 1970s for use as
a luting material,92 have the fol-
lowing advantages relative to
zinc phosphate:
- improved strength character-
istics93;
- greater resistance to dissolu-
tion in the oral milieu once fully
mature94 98;
- adhesion to dental hard tis-
sues86,90,99i
- greater retentive capacity'00;
- fluoride release upon place-
ment. 101,102
Although post-cementation
hypersensitivity has been sug-
gested, in vivo experimental
data'03-10' and survey results'06"07
fail to demonstrate a difference
between glass ionomer and zinc
phosphate in this regard. An
apparent improvement over the
glass ionomer luting materials
has recently appeared in the
dental marketplace in the form
of resin-modified glass-ionomer
Dr. Cronin is associ- Dr. Cagna is assistant
ate professor and di-
professor and assis-
rector, Postdoctoral tant director,
Prosthodontics,
University of Texas
Postdoctoral
Prosthodontics,
Health Science Detrent of
Center at San Prosthodontics, The
Antonio, Dental University of Texas
School, Department Health Science Center
of Prosthodontics, at San Antonio,
7703 Floyd Curl
Drive, San Antonio,
Dental School, San
Antonio, Texas.
Texas 78284-7912.
Address reprint re-
quests to Dr. Cronin. cements'08
(Figure 8).
Thoroughly described by Sidhu
and Watson,109 these materials
are less technique-sensitive
than composite resin cements,88
release fluoride, have improved
physical properties"0 and offer
greater bond strengths to
dentin."' Because these materi-
als have only recently been in-
troduced, long-term prospective
clinical reports have not yet ap-
peared in the scientific litera-
ture.
CONCLUSION
The practice of fixed prostho-
dontics is a demanding disci-
pline requiring clinicians to con-
sistently upgrade their clinical
skills, their knowledge of bioma-
terials and familiarity with lab-
oratory technological advances.
Persistent study is necessary to
maintain current understanding
of new multidisciplinary treat-
ment adjuncts that can greatly
increase the efficiency of fixed
prosthodontic treatment. .
1. Clinical Research Associates. Future of
dental practice-survey results. Clinical
Research Associates Newsletter 1985;9(10):1-2.
2. Brown LJ, Winn DM, White BA. Dental
caries, restoration and tooth conditions in
U.S. adults, 1988-1991. Selected findings
from the Third National Health and Nutrition
Examination Survey. JADA
1996; 127(9): 1315-25.

3. Academy of Prosthodontics. Glossary of
prosthodontic terms. 6th ed. J Prosthet Dent
1994;71(1):50-112.
4. Shillingburg HT, Hobo S, Whitsett LD.
Fundamentals of fixed prosthodontics. 2nd ed.
Chicago: Quintessence; 1981:79-159, 161-93.
5. Shillingburg HT, Jacobi R, Brackett SE.
Fundamentals of tooth preparations for cast
metal and porcelain restorations. Chicago:
Quintessence; 1987.
6. Hobo S, Shillingburg HT, Whitsett LD.
Articulator selection for restorative dentistry.
J Prosthet Dent 1976;36(1):35-43.
7. Pontoriero R, Lindhe J. Guided tissue re-
generation in the treatment of degree II fur-
cations in maxillary molars. J Clin
Periodontol 1995;22(10):756-63.
8. Mellonig JT, Seamons BC, Gray JL,
Towle HJ. Clinical evaluation of guided tissue
regeneration in the treatment of grade II
molar furcation invasions. Int J Periodontics
Restorative Dent 1994;14(3):254-71.
9. Andersson B, Bratthall G, Kullendorff B,
Grondahl K, Rohlin M, Attstrom R.
Treatment of furcation defects: guided tissue
regeneration versus coronally positioned flap
in mandibular molars; a pilot study. J Clin
Periodontol 1994;21(3):211-6.
10. Garrett S, Gantes B, Zimmerman G,
Egelberg J. Treatment of mandibular class III
periodontal furcation defects: coronally posi-
tioned flaps with and without expanded poly-
tetrafluoroethylene membranes. J Periodontol
1994;65(6):592-7.
11. Cortellini P, Pini Prato G, Tonetti MS.
Periodontal regeneration of human intrabony
defects with titanium reinforced membranes:
a controlled clinical trial. J Periodontol
1995;66(9):797-803.
12. Mellado JR, Salkin LM, Freedman AL,
Stein MD. A comparative study of ePTFE pe-
riodontal membranes with and without decal-
cified freeze-dried bone allografts for the re-
generation of interproximal intraosseous
defects. J Periodontol 1995;66(9):751-5.
13. Murphy KG. Postoperative healing com-
plications associated with Gore-Tex periodon-
tal material. Part I. Incidence and characteri-
zation. Int J Periodontics Restorative Dent
1995;15(4):363-75.
14. Nevins M, Mellonig JT. The advantages
of localized ridge augmentation prior to im-
plant placement: a staged event. Int J Perio-
dontics Restorative Dent 1994;14(2):96-111.
15. Jovanovic SA, Nevins M. Bone forma-
tion utilizing titanium-reinforced barrier
membranes. Int J Periodontics Restorative
Dent 1995;15(1):56-69.
16. Caudill R, Chiche G. Establishing an
aesthetic gingival appearance. In: Chiche G,
Pinault A, eds. Esthetics of anterior fixed
prosthodontics. Chicago: Quintessence;
1994:177-98.
17. Harris RJ, Harris AW. The coronally po-
sitioned pedicle graft with inlaid margins: a
predictable method of obtaining root coverage
of shallow defects. Int J Periodontics
Restorative Dent 1994;14(3):228-41.
18. Allen AL. Use of the supraperiosteal en-
velope in soft tissue grafting for root coverage.
I. Rationale and technique. Int J Periodontics
Restorative Dent 1994;14(3):216-27.
19. Trombelli L, Schincaglia GP, Scapoli C,
Calura G. Healing response of human buccal
gingival recessions treated with expanded
polytetrafluoroethylene membranes: a retro-
spective report. J Periodontol 1995;66(1):14-
22.
20. Warrer K, Buser D, Lang NP, Karring
Downloaded from jada.ada.org on June 17, 2014
T. Plaque-induced peri-implantitis in the
presence or absence of keratinized mucosa: an
experimental study in monkeys. Clin Oral
Implants Res 1995;6(3):131-8.
21. Roberts WE, Nelson CL, Goodacre CJ.
Rigid implant anchorage to close a mandibu-
lar first molar extraction site. J Clin
Orthodont 1994;28(12):693-704.
22. Smalley WM. Implants for tooth move-
ment: determining implant location and ori-
entation. J Esthet Dent 1995;7(2):62-72.
23. Allen EP, Bayne SC, Donovan TE,
Hanson TL, Klooster J, Kois JC. Annual re-
view of selected dental literature. J Prosthet
Dent 1996;76(1):56-93.
24. Jendresen MD, Allen EP, Bayne SC, et
al. Annual review of selected dental litera-
ture: report of the committee on scientific in-
vestigation of the American Academy of
Restorative Dentistry. J Prosthet Dent
1993;70(1):44-85.
25. Jendresen MD, Allen EP, Bayne SC, et
al. Annual review of selected dental litera-
ture: report of the committee on scientific in-
vestigation of the American Academy of
Restorative Dentistry. J Prosthet Dent
1995;74(1):60-99.
26. Jendresen MD, Allen EP, Bayne SC, et
al. Report of the committee on scientific in-
vestigation of the American Academy of
Restorative Dentistry. J Prosthet Dent
1994;72(1):39-77.
27. Swift EJ, Thompson JY, Bayne SC.
Review of dental materials citations: Part B,
July to December 1995. Dent Mater
1996;12(2):127-41.
28. Swift EJ, Bayne SC, Marker VA, Ford
KY. Review of the 1994 dental materials liter-
ature. Dent Mater 1995;11(1):52-77.
29. Thompson JY, Bayne SC, Swift EJ.
Dental materials citations: part A, January to
June 1996. Dent Mater 1996;12(4):272-86.
30. Bayne SC, Swift EJ, Thompson JY.
Review of dental materials citations: part A,
January to June 1995. Dent Mater
1995;11(4):281-93.
31. Bayne SC, Swift EJ. Review of the 1993
dental materials literature. Dent Mater
1994;10(1):59-76.
32. Lloyd CH, Scrimgeour SN, Brown D, et
al. Dental materials: 1993 literature review. J
Dent 1995;23(2):67-93.
33. van Noort R, Brown D, Clarke R, et al.
Dental materials: 1991 literature review. J
Dent 1993;21(1):5-30.
34. van Noort R, Brown D, Clarke R, et al.
Dental materials: 1992 literature review. J
Dent 1994;22(1):5-28.
35. Kelly JR, Nishimura I, Campbell SD.
Ceramics in dentistry: historical roots and
current perspectives. J Prosthet Dent
1996;75(1): 18-32.
36. Boening KW, Walter MH, Reppel PD.
Non-cast titanium restorations in fixed
prosthodontics. J Oral Rehabil
1992;19(3):281-7.
37. Andersson M, Andersson M. Swedish
patent no. 8400396-1 (Sweden), 1987.
38. Andersson M, Bergman B, Bessing C,
Ericson G, Lundquist P, Nilson H. Clinical re-
sults with titanium crowns fabricated with
machine duplication and spark erosion. Acta
Odontol Scand 1989;47(5):279-86.
39. Togaya T, Suzuki M, Tsutsumi S, Ida K.
An application of pure titanium to the metal
porcelain system. Dent Mater J
1983;2(5):210-9.
40. Nilson H, Bergman B, Bessing C,
Lundqvist P, Andersson M. Titanium copings
COVER STODY
veneered with Procera ceramics: a longitudi-
nal clinical study. Int J Prosthodont
1994;7(2):115-9.
41. Walter M, Boning K, Reppel PD.
Clinical performance of machined titanium
restorations. J Dent 1994;22(6):346-8.
42. Leong D, Chai J, Lautenschlager E,
Gilbert J. Marginal fit of machine-milled tita-
nium and cast titanium single crowns. Int J
Prosthodont 1994;7(5):440-7.
43. Bergman B, Bessing C, Ericson G,
Lundquist P, Nilson H, Andersson M. A 2-
year follow-up study of titanium crowns. Acta
Odontol Scand 1990;48(2):113-7.
44. Razzoog M, Russel M. A comparison of
the color stability of conventional and titani-
um dental porcelain. J Prosthet Dent
1994;72(5):453-6.
45. Chai J, McGivney G, Munoz C,
Rubenstein J. A multicenter longitudinal clin-
ical trial of a new system for restoration. J
Prosthet Dent 1997;77(1):1-11.
46. Jones DW. Development of dental ce-
ramics: an historical perspective. Dent Clin
North Am 1985;29(4):621-44.
47. Sproull RC. A history of porcelain in
dentistry. Bull Hist Dent 1978;26(1):3-10.
48. McLean JW, Hughes TH. The reinforce-
ment of dental porcelain with ceramic oxides.
Br Dent J 1965;119(6):251-4.
49. Sozio RB, Riley EJ. The shrink-free ce-
ramic crown. J Prosthet Dent 1983;49(2):182-7.
50. Grossman DG. Cast glass ceramics.
Dent Clin North Am 1985;29(4):725-39.
51. Anusavice KJ. Dental ceramics. In:
Anusavice KJ, ed. Phillip's science of dental
materials. 10th ed. Philadelphia: Saunders;
1996:583-618.
52. Probster L, Diehl J. Slip-casting alumi-
na ceramics for crown and bridge restora-
tions. Quintessence Int 1992;23(1):25-31.
53. Pelletier LB, Giordano RA, Campbell
SD, Pober RL. Dimensional and composition-
al analysis of In-Ceram alumina and die ma-
terial (Abstract no. 1180). J Dent Res (Special
Issue) 1992;71:253.
54. Sieber C, Thiel N. Spinell/luminary
porcelain: natural light optics for anterior
crowns. Quintessence Dent Technol
1996;19:43-9.
55. Seghi RR, Sorensen JA. Relative flexu-
ral strength of six new ceramic materials. Int
J Prosthodont 1995;8(3):239-46.
56. Giordano RA II, Pelletier L, Campbell S,
Pober R. Flexural strength of an infused ce-
ramic, glass ceramic, and feldspathic porce-
lain. J Prosthet Dent 1995;73(5):411-8.
57. Sorensen JA, Kang S-K, Torres TJ,
Knode H. Status of prospective clinical trials
on In-Ceram bridges through 1991 (Abstract
no. 142). J Dent Res (Special Issue)
1992;71:533.
58. Probster L. Survival rate of In-Ceram res-
torations. Int J Prosthodont 1993;6(3):259-63.
59. Kelly JR, Tesk JA, Sorensen JA. Failure
of all-ceramic fixed partial dentures in vitro
and in vivo: analysis and modeling. J Dent
Res 1995;74(6):1253-8.
60. Scotti R, Catapano S, D'Elia A. A clini-
cal evaluation of In-Ceram crowns. Int J
Prosthodont 1995;8(4):320-3.
61. Probster L. Four year clinical study of
glass-infiltrated, sintered alumina crowns. J
Oral Rehabil 1996;23(3):147-51.
62. Dong JK, Luthy H, Wohlwend A, Scharer
P. Heat-pressed ceramics: technology and
strength. Int J Prosthodont 1992;5(1):9-16.
63. Haller B, Klaiber B, Hofmann N.
Bonded all-ceramic restorations with IPS
JADA, Vol. 128, April 1997 435

-CO VER STORY
Empress system. Pract Periodont Aesthet
Dent 1995;5(7):39-48.
64. Richards MW, Kelly JR. Indentation-
strength of unpressed and pressed Empress
disks (Abstract no. 717). J Dent Res (Special
Issue)1994;73: 191.
65. Mackert JR, Russell CM. Leucite crys-
tallization during processing of a heat-
pressed dental ceramic. Int J Prosthodont
1996;9(3):261-5.
66. Krejci I, Krejci D, Lutz F. Clinical evalu-
ation of a new pressed glass ceramic inlay
material over 1.5 years. Quintessence Int
1992;23(3): 181-6.
67. Tidehag P, Gunne J. A 2-year clinical
follow-up study of IPS Empress ceramic in-
lays. Int J Prosthodont 1995;8(5):456-60.
68. Sorensen JA, Fanuscu MI, Choi C, Mito
W. Status of clinical trial on Empress crowns
(Abstract no. 1182). J Dent Res (Special
Issue)1995;74: 159.
69. Hacker CH, Wagner WC, Razzoog ME.
An in vitro investigation of the wear of enam-
el on porcelain and gold in saliva. J Prosthet
Dent 1996;75(1):14-7.
70. Shotwell J, Beard C, Lang B, Lang B.
Scientific verification of the wear properties
of hydrothermal ceramics. Lab Digest
1997;Winter: 15-7.
71. Hegenbarth E. Procera aluminum oxide
ceramics: a new way to achieve stability, preci-
sion, and aesthetics in all-ceramic restorations.
Quintessence Dent Technol 1996;19:21-34.
72. Andersson M, Oden A. A new all-ceram-
ic crown: a dense-sintered, high-purity alumi-
na coping with porcelain. Acta Odontol Scand
1993;51(1):59-64.
73. Russell MM, Andersson M, Dahlmo K,
Razzoog ME, Lang BR. A new computer-as-
sisted method for fabrication of crowns and
fixed partial dentures. Quintessence Int
1995;26(11):757-63.
74. Burgess J. Provisional materials: crown
and bridge removers; temporary resin ce-
ments. Dent Advisor 1995;12(3):1-8.
75. Gough M. A review of temporary crowns
and bridges. Dent Update 1994;21(5):203-7.
76. Trushkowsky R. Fabrication of a fixed
provisional restoration utilizing a light-curing
acrylic resin. Quintessence Int
1992;23(6):415-9.
77. Hesby RA, Morgano SM, Malone WF,
Flocken JE, Kaiser DA, Cavazos JE. Treat-
ment restorations (temporization). In: Malone
WF, Koth DL, eds. Tylman's theory and prac-
tice of fixed prosthodontics. 8th ed. St. Louis:
Ishiyaku EuroAmerica; 1989:255-72.
78. Gegauff A. Provisional restorations. In:
Rosenstiel S, Land M, Fujimoto J, eds.
436 JADA, Vol. 128, April 1997
Downloaded from jada.ada.org on June 17, 2014
Contemporary fixed prosthodontics. 2nd ed.
St. Louis: Mosby-Year Book; 1995:325-57.
79. Preston J. A systematic approach to the
control of aesthetic form. J Prosthet Dent
1976;35(4):393-402.
80. Chiche G, Pinault A. Communication
with the dental laboratory: try-in procedures
and shade selection. In: Chiche G, Pinault A,
eds. Esthetics of anterior fixed prosthodon-
tics. Chicago: Quintessence; 1994:115-42.
81. Alpert R. A method to record optimum
anterior guidance for restorative dental treat-
ment. J Prosthet Dent 1996;76(5):546-9.
82. Driscoll CF, Woolsey G, Ferguson WM.
Comparison of exothermic release during
polymerization of four materials used to fabri-
cate interim restorations. J Prosthet Dent
1991;65(4):504-6.
83. Tjan A, Grant B, Godfrey M.
Temperature rise in the pulp chamber during
fabrication of provisional crowns. J Prosthet
Dent 1989;62(6):622-6.
84. Wang RL, Moore BK, Goodacre CJ,
Swartz ML, Andres CJ. A comparison of
resins for fabricating provisional fixed restora-
tions. Int J Prosthodont 1989;2(2):173-84.
85. Christensen GJ. Provisional restora-
tions for fixed prosthodontics. JADA
1996;127(2):249-52.
86. Shen C. Dental cements for bonding ap-
plications. In: Anusavice K, ed. Phillips' sci-
ence of dental materials. 10th ed.
Philadelphia: Saunders; 1996:555-81.
87. Kydd W, Nicholls J, Harrington G,
Freeman M. Marginal leakage of cast gold
crowns luted with -zinc phosphate cement: an
in vivo study. J Prosthet Dent 1996;75(1):9-13.
88. McComb D. Adhesive luting cements-
classes, criteria, and usage. Compend Contin
Educ Dent 1996;17(8):759-73.
89. Oilo G. Luting cements: a review and
comparison. Int Dent J 1991;41(2):81-8.
90. Albers H. Conventional cementation.
ADEPT Report 1991;2(3):41-52.
91. Weisman G. General practitioners and
prosthodontists: restorative preferences seem
firmly "cemented." Dent Products Report
1996;30(12):8-15.
92. Wilson A, Crisp S, Lewis B, McLean J.
Experimental luting agents based on the
glass ionomer cements. Br Dent J
1977;142(4):117-22.
93. Finger W. Evaluation of glass ionomer
luting cements. Scand J Dent Res
1983;91(2): 143-9.
94. Hersek N, Canay S. In vivo solubility of
three types of luting cement. Quintessence
Int 1996;27(3):211-6.
95. Williams J, Billington R, Pearson G.
The effect of maturation on in-vitro erosion of
glass-ionomer and other dental cements. Br
Dent J 1992;173(10):340-2.
96. Um C, Oilo G. The effect of early water
contact on glass-ionomer cements.
Quintessence Int 1992;23(3):209-14.
97. Phillips RW, Swartz ML, Lund MS,
Moore BK, Vickery J. In vivo disintegration of
luting cements. JADA 1987;114(4):489-92.
98. Pluim L, Arends J, Havinga P,
Jongebloed W, Stokroos I. Quantitative ce-
ment solubility experiments in vivo. J Oral
Rehabil 1984;11(2):171-9.
99. Powis D, Folleras T, Merson S, Wilson
A. Improved adhesion of a glass ionomer ce-
ment to dentin and enamel. J Dent Res
1982;61(12):1416-22.
100. Dahl BL, Oilo G. Retentive properties
of luting cements: an in vitro investigation.
Dent Mater 1986;2(1):17-20.
101. McCourt J, Cooley R, Huddleston A.
Fluoride release from fluoride-containing lin-
ers/bases. Quintessence Int 1990;21(1):41-5.
102. Swartz M, Phillips R, Clark H. Long-
term F release from glass ionomer cements. J
Dent Res 1984;63(2):158-60.
103. Kern M, Kleimeier B, Schaller HG,
Strub JR. Clinical comparison of postopera-
tive sensitivity for a glass ionomer and a zinc
phosphate luting cement. J Prosthet Dent
1996;75(2):159-62.
104. Bebermeyer R, Berg J. Comparison of
patient-perceived postcementation sensitivity
with glass-ionomer and zinc phosphate ce-
ments. Quintessence Int 1994;25(3):209-14.
105. Brackett W, Metz J. Performance of a
glass ionomer luting cement over 5 years in a
general practice. J Prosthet Dent
1992;67(1):59-61.
106. Reinhardt J, Swift E, Bolden A. A na-
tional survey on the use of glass-ionomer ce-
ments. Oper Dent 1993;18(2):56-60.
107. Klausner L, Brandau H, Charbeneau G.
Glass-ionomer cements in dental practice: a
national survey. Oper Dent 1989;14(4):170-5.
108. Clinical Research Associates. Glass
ionomer-resin cements (GI-R). Clinical
Research Associates Newsletter 1995;19(3): 1-2.
109. Sidhu SK, Watson TF. Resin-modified
glass ionomer materials: a status report for
the American Journal of Dentistry. Am J
Dent 1995;8(1):59-67.
110. Burgess J, Norling B, Summitt J.
Resin ionomer restorative materials: the new
generation. J Esthet Dent 1994;6(5):207-15.
111. Hinoura K, Miyazaki M, Onose H.
Dentin bond strength of light-cured glass-
ionomer cements. J Dent Res 1991;70(12):
1542-4.