The emphasis in this chapter will be on the general principles guiding the operator in

designing restorations for teeth whose mutilation or disease exceeds the restorative
capacity of any previously described designs and modalities. In order to restore a
tooth permanently when confronted with such extensive tooth destruction, the
systemized, disciplined approach described herein is essential to the success of the
procedure.
Posterior Teeth
An operator may have a mental image of a restorative design, material, and
technique when examining a badly broken down tooth; however, four basic steps
should be taken before finalizing that design and executing it (Fig. I). They are:
I. Evaluate the P-D organ and the periodontium of the tooth to be restored,
preferably before the patient is anesthetized.
II. Remove all undermined enamel. There is no place for such enamel in all
permanently restored posterior teeth.
III. Clean all surrounding walls from dentin that is diseased or is otherwise a 'liability
to the mechanical stability of the contemplated restorations.
IV. Treat the pulpal and axial walls with intermediary bases, as previously described
in chapters 13 and 14.
Evaluation of Remaining Tooth Structures (Fig. 2)
At this point, the operator must make a mental note of the dimension and
nature of the remaining tooth structures mechanically, biologically, and
cariogenically (Fig. 3). This is vitally important if the final restoration is to be built
up in the most acceptable fashion; i.e., sacrificing the least amount of dental tissues,
time and expense, using the most indicated material and technique, and creating the
least irritation to dental tissues. To obtain this information, the operator should
engage in the following procedure.
I. Recollection of the Stress Pattern in Posterior Teeth and Correlating It to the
Remaining Tooth Structure and Conditions
 This correlation should emphasize four things. First, is the locations of the
tooth in the arch and the opposing items should be noted. Remembering that stresses
are maximum at second
premolar and first molar teeth, design features to counteract such stresses
should be maximized in restorations for these particular teeth. Remember, too, that
stresses are more induced and better resisted in upper than in lower teeth. On the other
hand, functional stresses are least in teeth opposing a bridge pontic, a denture, an
inclined tooth (if the occluding cusp is not a plunger one) or a space.
Secondly, if the remaining tooth structures contain stress concentration areas
(Fig. 4), (e.g., marginal ridges, crossing ridges, cusps, a junction between clinical
crown and clinical root, and/or axial angle of the tooth, etc.), the restoration should be
designed in a way that will not induce additional stresses at these areas. Every effort
should be made to keep these critical areas of the tooth undisturbed by the restorative
process. Any weakening or loss of these parts will necessitate drastic design changes.
Third, the functional, non-functional (orbiting), or over-functional cuspal
elements should be noted by examining the involved teeth during static and functional
mandibular movements. The operator can then recognize the nature of the stresses that
can be expected in the remaining tooth structures, especially the occluding ones. From
this information (Figs. 2 and 3) a decision can be made about the ability of these parts
of the tooth to withstand stresses without failure. If they cannot, these intolerant
portions of the tooth should be replaced or protected by appropriate restoration design
changes.
The fourth emphasis is that if the remaining tooth structures contain naturally
weak areas; e.g., thin dentin bridge, exposed subpulpal floor, nearby bifurcation,
cementum, etc., they should be recognized and every effort should be made not to
involve them in the mechanical problems of the future restoration, or in the stress
pattern of the restored tooth.
 II. Diagnosis and Recognition of the Vital Capability of the Tooth or the
Part of the Tooth Being Restored
Since non-vitality usually implies hypermineralization and/ or dehydration of
the tooth dentin, such a decrease in dentin fluids is recognized mechanically by a drop
in ultimate strength. an increase in brittleness, and a decrease in modulus of resilience
of dentin. This should be differentially diagnosed according to the following criteria.
A. If the tooth is totally non-vital; i.e., endodontically treated, the operator
should first confirm all signs and symptoms of successful endodontic therapy as
revealed by:
1. An apical seal with complete obliteration of the root canals without under- or
overfilling.
2. A lack of radiographically recognizable apical radiolucency, or evidence of a
present one being reduced in dimension.
3. A lack of pain during percussion on the tooth.
4. A lack of pain from pressure at the periapex from either the facial or the lingual
sulcus.
5. A lack of fistula.
The operator must then recognize the technique used in the root canal treatment
including the materials used to obliterate the root canal system. The post-endodontic
use of the pulp chamber or root canal system in the retention form of a restoration
necessitates different procedures for each technique or material used.
The most important criterion to note is the dimension of the pulp chamber
relative to the dimension of the future restoration. Also to be evaluated are the number
of the opposing walls in the pulp chamber and their occlusal inclinations and surface
dimensions. The closer that the ratio of these dimensions is (i.e., pulp chamber size
relative to restoration size) and the more opposing walls with generous surface
dimensions there arc, the greater will be the possibility of using the pulp charmas a
principal retention form for the future restoration.
 Furthermore. the more root canals there are, the greate7ird. be the possibility of
using some of them to accommodate ausMary. anti-rotation, and reciprocal means of
retention. Sack canals are easier to incorporate into the restorative desien their shapes
are more regular and they are more readils a rcessible from their pulpal orifices. Of
course, the larger tot the diameter of the root canal is, the better will be its chasms of
accommodating a restorative material as a retentive emir sion from the restorations.
a. The second most important criterion to diagnose and evaluate with regard to a
non-vital tooth is the bulk of the remaining tooth structure surrounding the
opening of the root canal. As mentioned before, this is an aica of maximum
stresses. If, ideed, the root canals are to be used as retention modes, the nore bulk
that they have at this location, the safer will be the Ise of these root canals as
retention modes.
b. If only parts of the tooth are non-vital (e.g., dead-tract treas), they, too, should be
recognized so the operator can avoid locating retention modes there. This will
eliminate the )ossibility of cracking or fracture failure. If anatomically possible,
non-vital areas should he prepared such that they arc surrounded by flat floors and
ledges.
c. If parts of the tooth are only partially vital (e.g., calcific barrier, sclerosed dentin,
and tertiary dentin), they, too, should be recognized as areas unacceptable for
housing retention modes. If it is absolutely unavoidable to locate retention modes
there, the least stressing modes should be prepared and used. However, they must
be augmented with more retaining reciprocal and adjacent retention modes. Such
augmenting modes should involve fully vital tooth dentin in addition to the
partially vital areas.
In reality, non-vital and partially vital dentin in an otherwise vital tooth is usually located
far inside the cavity (tooth) preparation close to the pulp and root canal system where
retention modes are contraindicated anyway.
III. Cariogenic Evaluation of Remaining Tooth Structures
 This should proceed according to the principles mentioned in the descriptions
of outline form. This will help decide which areas of the remaining tooth structure are
to be involved in the tooth preparation.
IV. Correlative Three-Dimensional Evaluation
The operator should carefully study the radiographs as well as make a physical
examination of the tooth to have a good idea about the dimension and nature of
remaining enamel and dentin and their relation to invested pulp chamber and root
canal system. This evaluation will also assist the operator in correlating the pulp
system to the surface configuration of the crown and root surfaces, the investing
periodontal tissues, and the surrounding musculature.
V. Possibilities, Locations, and Dimensions of Resisting Flat Planes
It is necessary to always be on the lookout for the possibility of creating flat
planes in the remaining tooth structure at right angles to the direction of the occlusal
loading, without compromising the tooth biologically (Fig. 5). This is the most
effective resistance form in a tooth preparation for any restorative material. To be
maximally resistant, fiat planes should have bulky tooth structure apical to them., as
this will dilute and properly resist induced stresses. This is why the ideal location
for these planes is in the tooth structure peripheral to the pulp chamber and root
canal system, where the tooth structure apical to these flat planes can extend as far
as the root tip or at least the closest furcation. Also, the closer these planes are to the
occlusal surfaces, the greater will be their bulk. The more surface area of these flat
planes that there is, and the closer they are to the applied forces, the more efficient
will be their resisting capability. However, any dimension or location for these planes
is acceptable. They should be part of the tooth preparation as their effect is
cumulative. These flat planes can be in one or more of the following forms:
Pulpal floor (Fig. 5, A and B)
Although it is always at the regular depth (0.5 mm from the DEJ), forming part
of the peripheries of the tooth preparation, it can and should be prepared at different
levels. This design feature will be advantageous from the standpoints of both retention
and tooth structure conservation.
Gingival floors (Fig. 5, C and D)
These always form one or more of the lateral peripheries of a tooth preparation,
taking full advantage of the tooth structure bulk apical to their location. They, too, can
and should be formed of different levels in three dimensions (proximo-axially, bucco-
lingually, and gingivo-occlusally).
Both pulpal and gingival floors should ideally be entirely flat. However, this is
a situation that is anatomically not feasible in most cases of badly broken down teeth.
The next logical choice, then, is a peripherally flat circumference, or at least flat in
two opposite areas, leaving the rest of the floor in whatever shape it was left in by the
destruction (Fig. 5, A and B).
Tables (Fig. 5C)
These flat planes are to be located in areas of reduced (or completely lost)
cusps, axial angles, marginal ridges, or crossing ridges. Again, they may be formed in
different levels.
Ledges and shelves (Fig. 5E)
These are flat planes prepared in bulky lateral surrounding walls, usually
reciprocating with one or more flat planes to
tensions can be done for teeth with a doubtful prognosis and/ r for teeth that
have drifted minimally. On the other extreme, lid a procedure can be used on
extensively drifted teeth that re beyond repositioning.
ecHowever, trying to•restore a tooth in such a situation can e a futile
experience. The proper axial contour and adequate ontact areas, as well as the
indicated occluding surface components, will seldom be achieved without moving the
tooth teeth) back to their normally indicated positions, thereby repining the mesio-
distal dimension of the dental arch. This is te second and most sound alternative, i.e.
regain the lost mace. If this is contemplated, the operator should evaluate:
a. The distance the tooth must travel to arrive at its original °cation.
b. The number of teeth and their roots to be moved (esecially the overall root surface
area).
c. The amount of interceptal bone between the teeth (roots).
There are innumerable ways to achieve such tooth movement. if the tooth in
question is the only one to be moved and/ cc the drifting distance is slight (up to 2
mm), and it has the proper amount of interceptal bone, then wood wedges, over-
contoured temporary restorations, or separating wires can be 4sed (as mentioned in the
chapter on contact and contour) to effect the necessary relocation. However, if space
loss involves more than the tooth and/or it is a sizable distance, but •with sifficient
interceptal bone intervening (more than 2 mm), orthodontic tooth movement could be
undertaken, using a variety A appliance designs, to move the tooth (teeth) according
to the diagnostic criteria you have just collected. E.g., decide on the most acceptable
direction of movement, solidify the segment of the arch opposite to that direction by
brackets and arch .ire (labial and/or lingual arches). Then cut a coil spring 2-3 mm
longer than the dimension you need to regain. Place the irch wire through it and force
it to stay between the brackets pf the teeth to be moved and the closest tooth of the
anchor k.-gment. Periodic activation of the coil spring is needed (Fig. 5C). Removable
appliances can be used with retractors, an:hored to the base of the appliance.
If the drifting results in root-to-root contact or if it is beyond orthodontic
therapy, the tooth in question should be removed :f it is single-rooted. If it is
multirooted, it may be hemiseconed, leaving intact the bony supported segment to be
restored :o a reduced dimension.
IX. Gingival Margin Location Relative to the Periodontium Components (Fig. 7)
The gingival peripheries of the destruction should be recorded, and the gingival
margins of the contemplated restoration should be decided upon (see chapter on single
tooth restoration and the periodontium). If the gingival limit of the destruction is
located supra-gingivally, even with the free gingiva, or within the gingival crevice,
and the adjacent periodontium has adequate width of attached gingiva and fomex
depth, no change in the periodontium is needed to maintain the periodontium. Regular
procedures (as mentioned in the chapter on single tooth restoration and periodontium)
should be followed. If the gingiva covering the apical end of the tooth destruction is
hyperplastic, a gingivectomy (usually using electrosurge) May be performed, in order
to expose the apical limits of the defect.
If the gingival limitation of the destruction is apical to the bottom of the
gingival crevice, but still suprabony, the width of the attached gingiva (for facial and
lingual defects) and the occluso-apical thickness of the interdental papillae (for prox-
imal defects) should be evaluated relative to the attaching (dento-gingival) epithelium
and the apical limit of the defect. If sufficient width of the attached gingiva or
thickness of the interdental papillae is verified, the apical limit of the defect can be
exposed by gingivectomy procedures without changing the artchitectural contour of
the surrounding periodontium. However, if gingivectomy procedures Would
unfavorably affect the peridontium, a full thickness muco-gingival flap should be
reflected, so that the entire periodontal apparatus may be repositioned and reattached
apical to the gingival limit of the defect.
When the apical limitation of the destruction is infrabony, yet there can be
sufficient bone support for the tooth after the hone occlusal to the apical limit of the
defect is removed,
together with enough bone to create a 2-3 mm attaching epithelial zone with
sound tooth surface apical to the apical limit of the destruction, a full thickness muco-
gingival flap is again utilized, exposing the indicated site and amount of bone to be
removed by osteoectomy. Again the reflected flap is re-attached apical to the gingival
limit of the defect.
If the apical end of the defect is infrabony, but osteoectomy and apical
repositioning of the investing periodontal apparatus component cannot be performed
due to insufficient supporting bone or fear or exposing important anatomy, etc.,
intentional extrusion of the tooth may be attempted in order to expose the apical end
of the destruction supragingivally, facilitating restoration of the tooth. There are
several methods for accomplishing this:
If the tooth is endodontically treated, wire hooks can be temporarily cemented
within the root canals, so that each hook protrudes from the tooth occlusally. The
tooth is moved occlusally using a rubber elastic attached on one side to the hook(s)
and on the other side to any anchoring device, maintaining the pulling forces parallel
to the long axis of the tooth being extruded. The anchoring device can be either a
heavy
wire crossing over the tooth and attached to occlusal (inc surfaces of adjacent
teeth (Fig. 8A), or a hawley appliE or brackets attached to the adjacent teeth, or
brackets atm: to opposing teeth (Fig. 8B).
If the involved tooth is vital, facial or lingual brackets (I or without bands)
should be attached close to the gingival of the tooth. The adjacent teeth (at least one
on each s should each have a bracket, but located more incisally (oc sally) on the
facial or lingual surfaces. Elastic bands are hoc to the brackets in a way to be located
apical to the bracke the tooth to be extruded (Fig. 8C).
If the tooth is vital, but does not have enough facial or lib surfaces to
accommodate a bracket, cemented or threaded with hooks may be inserted in the
deepest portions
The anchorage can be any of those previodsly mentioned. F.. tic bands are
hooked to both the anchorage device an.i hooked pins in the tooth to be extruded (Fig.
8D).
 In all situations the occlusal (incisal) surfaces shoui periodically adjusted to
make room for sufficient extra until the apical termination of the destruction appears si
gingivally. Also, the anchorage should be planned, so this movement will occur to the
affected tooth, not to the ancbc ones. The extruded teeth should be evaluated as an
odontally affected and treated teeth. As the surface topc of the new clinical crown and
the stress pattern in the tooth and the involved periodontium will be similar.
In any of the previously mentioned situations, if the depth of the facial or
lingual vestibule is not physiologically deep enough, i.e., partially or totally depriving
the peridontium of its attached gingiva, restoring defects at these areas will be doomed
to failure from periodontal and/or cariogenic breakdown. Sulcular deepening may be
performed to obtain the indicated fornex depth and attached gingiva dimension.
X. Badly Broken Down Teeth Whose Periodontium Has Been Affected and Treated
When restoring badly broken down teeth that have undergone periodontal
therapy, the operator can expect to confront one of several problems in the remaining
tooth structures.
First, he may encounter the exposure of unusual anatomy, due either to the
healing recession of the gingiva or as a result of the disease process. These unusual
anatomies for a crown surface can be in the form of concavities (Fig. 9), flat surfaces,
deep grooves, and/or flutes. Each will necessitate modifications in the usual features
of the preparation if they approximate the area of destruction.
Second, a furcation exposure (Fig. 10), ranging from a simple exposure of the
occlusal flutes to the furca proper to through-through connection between two
opposite furcations, will necessitate special design features, if involved in the area of
destruction.
Third, because of bone loss, there may be a biologically negative crown to root
ratio (Fig. 11), challenging the resistance of the tooth and the contemplated
restoration.
Fourth, because of the taper of the root, if a proximal lesion is present, the tooth
preparation will have a very thin dentin bridge axially, endangering the status of the P-
D organ (Fig. 12).
Fifth, for the same reasons just mentioned, the gingival floor for a proximal
preparation in the root portion will be very narrow, minimizing its resistance-retention
capabilities (Fig: 12).
Sixth, because of the root taper and presence of surface concavities there,
preparing the tooth for a cast restoration can be nearly impossible, or, at the very least,
involve a consid
erable amount of tooth structures occlusal to the root portion in an attempt to
remove undercuts in the preparation.
Seventh, periodontally treated teeth may have been affected by primary or
secondary traumatism which may still be present at this stage of therapy. Any
traumatism or its symptoms should be corrected by the restorative procedure or
intercepted prior to the restoration, with the indicated occlusal equilibration.
Eighth, periodontally affected and treated teeth will have multiple facets at the
contact area and/or occlusal surfaces, which may accompany mesio-distal and
occluso-apical loss of tooth structure. These facets should be involved in a tooth
preparation if any margin comes close to them. They may complicate reproduction of
contact and contour in the final restoration.
Ninth, because of uneven bone loss accompanied by gingival recession, two
opposing axial portions of a destruction and preparation may not have symmetrical
lengths in their axial walls. Consequently, the locations of the gingival floors (mar-
gins) at the opposite axial surfaces will be uneven (Fig. 12). This situation may create
imbalance in the resistance and retention form, necessitating modifications to increase
the length of the short side of the restoration; e.g., gingival pin.
Tenth, a missing adjacent tooth (teeth) is a usual occurrence with dentitions
affected by periodontal diseases. This situation leads to numerous modifications in the
restorative design, e.g., use of the involved teeth as an abutment for a prosthesis. Also,
loss of teeth can lead to tilting, rotation, extrusion, or drifting of teeth with the
predictable sequelae necessitating modifications in the restorative design.
Eleventh, the supereruption of teeth (Fig. 13), although not always a result of
periodontal problems, usually occurs as a
 result of the loss of opposing tooth (teeth). Supercruption can complicate presented
problems by:
A. Necessitating the reduction of the involved tooth occlusally.
B. Requiring replacement of opposing missing teeth to prevent further extrusion.
C. Exposing an extruded tooth furcation and root surfaces.
D. Causing changes in the location and .the nature of the contact areas.
E. Creating a biologically negative crown root ratio.
F. Causing the usual resistance, retention, and P-D organ problems associated with
elongated clinical crowns.
Twelfth, the periodontium will require more than the usual care, as plaque control
is made more difficult by exposure of the root surface anatomy.
Thirteenth, tipping of cusps or an entire tooth as a result of the loss of the mesio-
distal dimension (Fig. 14), missing or loose-movement of adjacent teeth, can change
occluding and contacting characteristics of the tooth, putting it at a disadvantage
from the resistance point of view. Therefore, teeth should be moved back to their
physiologic position and/or interfering cuspal elements should be selectively ground
before restoring them.
Fourteenth, loose teeth can not only complicate instrumentation, but may also
necessitate future splinting, possibly in the contemplated restoration.
Fifteenth is the possibility of hemisectioning or root amputation of a
periodontally affected multirooted tooth. llemisectioning is a procedure by which a
segment of a multi-rooted tooth, which is confirmed unrestorable or periodontally
affected beyond repair, is removed, leaving a sound restorable part of the tooth. It
may
1
be indicated for multi-rooted teeth, in situations of severe .bone loss (less than
/4 normal bone support is left) that is confined to less than all the roots; when
severe root decay is confined to less than all the roots of the tooth: and when
proximal drifting of the multi-rooted tooth with complete loss of the interceptal bone
results in root-to-root contact between adjacent teeth. It is also indicated for teeth with
very subgingivally (infrabony) located decay restricted to 1/2 or less of the tooth,
wherein surgical or extrusion exposure of the apical limit of the decay is not
feasible.
Hemisectioning can be done in the following sequential 'steps:
I. Root canal therapy must be perfc
With a long-shanked cylindrical round-ended stone or carbide but separate the
indicated at intact part of the tooth through the correspond:7.: (Fig. 15). As much
as possible, trim the tooth
formed by removal of the furcation there.
Extract the unwanted separated root(s).
One may need to make a flap opening to theu some osseous contouring, root
planning for the and curettage. Close the .operation area, using as periodontal pack.
The remaining tooth portion may need a mars. leo
toration and provisional splinting until periodocIa.: completed.
When it comes to restoring the remaining pars tic INS sectioned tooth (around
3-4 months after, for *lb lialization of the periodontium), certain evaluaticct the
restorative design.
 If the remaining tooth portion is in the form ;:f z am. (lower molars missing one
root or upper molars IN roots) or a narrow elongated molat (upper root), or a
triangular table (upper molars :::Lisng awl buccal or disto-buccal roots), the final
restora that same shape. Moreover, the occlusal sarillttr
be related to the underlying bone support and 7:•c as areas of the newly created
clinical crown to be the restorative design should be well supporte lying resisting
root bone complex.
The location and type of the sectioning lip as the gingival margin of the restoration
should ally, after the hemisection, the remaining tooct need a foundation prior to a
final restoration. As
tooth is usually to be used as an abutment. the missed portion of the tooth, it should
be abutment tooth. Sixteenth, dimensions of newly created maximum. A situation that
may he necessan fcr control but may be predisposing to further rer-.7c-ormer. restored
or maintained properly.
Seventeenth, the possibility of evaluated as a viable procedure by which, for
example, a double-rooted molar tooth is sectioned in the middle to create two
bicuspids. The procedure is indicated for:
a. Teeth with deep uncleansable exposed furcation(s).
b. Unresolved horizontal pockets in the mesio-distal direction or facio-lingual
direction, accompanying a furca involvement.
c. Apical furcation decay.
d. Divergent roots with sufficient intraradicular bone the future interceptal bone of
the created bicuspids.
If the space between the two sections of the tooth is not enough to allow for
adequate axial contour, contacts, and embrasures for future restorations, look for the
possibility of orthodontic separation of the bicuspidized molar segments. This will
necessitate:
i. A space between the separated teeth parts and adjacent teeth with sufficient
interceptal bone there.
ii. Favorable root(s) inclination and anatomy as related to its (their) movability
by orthodontic means.
i. The availability of anchorage sites.
From this, the type of orthodontic appliance, the amount of forces and their direction,
and time to accomplish the desired separation for proper contact and contour of the
formed bicuspids are decided.
The bicuspidization procedure can be done in the following steps:
A.Root canal therapy for the indicated tooth is performed.
B. With a long-shanked, round-ended (nose-ended) cylindrical diamond stone or
carbide but cross the tooth at its in.dicated furcation, involving the lesion if present
there and removing the sectioning tooth structure lip(s) (Fig. 16).
C. A provisional temporary restoration splinting the two separated
segments of the tooth is constructed and cemented in place.
D. Flap operation for the involved area may be needed to eradicate the
remaining part of the pockets. In addition, there may be some osseous
contouring, root planning, and curettage, followed by suture and
periodontal packs.
E. After removal of sutures and packs, the periodontium is left to heal
and epithelialize with the temporary provisional splinting restoration in
place.
If orthodontic separation is indicated, the two
bicuspids are banded and separated by springy devices or dragged toward
banded adjacent teeth with elastic bands.
After healing and creation of sufficient space the two created bicuspids are
evaluated as any periodontally affected and treated tooth with emphasis on:
The type of embrasures to be created between them and between each one and
the adjacent tooth, as they should be conforming to the newly created periodontium
and attachments.
The type of occlusion (statically and functionally) on the created bicuspids
and accordingly the possible stress pattern, so the restoration design will be
conforming and resisting.
Restorations for periodontally treated teeth can be done only if:
a. The periodontium did heal as symptomatized by:
i. The free gingivae stopped receding. They are firm and properly cuffing the tooth.
ii. Attached gingivae are intact and pronounced.
iii. No measurable pocket and no gingival bleeding.
iv. No indication of further bone loss.
v.No indication of occlusal traumatism.
vi. Oral hygiene and plaque accumulation is well under control.
b. The periodontium is in the process of proper healing.
c. The restoration(s) is (are) needed to facilitate and/or promote the healing of the
periodontium.
Mechanical Evaluation of Lost Tooth Structure Preparatory to Designing the
Retention-Resistance Features of the Tooth Preparations
During this portion of the pre-operative evaluation, the operator must envision the
restoration replacing lost tooth structures being subjected to functional loading, and
then try to plan the best tooth preparation to both retain this restoration and make it
resistant to these loads. Certain criteria must be considered here.
I. The Dimension and Nature of the Destruction Relative to that of the Tooth
Occluso-apical destruction presents more retention than resistance problems,
as the restoration build-up in a longitudinal direction definitely encounters
displacing forces. Bucco-lingual and mesio-distal destructions pose both resistance
and retention problems. This is because, in addition to the loss of tooth • structure,
decreasing the substance for housing retention modes, a large surface area of the
restoration will be subjected to displacing loads, while remaining thinned tooth
substance will be less resistant to the direct loading.
The loss of the stress concentration area of a tooth poses a major resistance
problem necessitating certain restorative design features. Naturally, the area should
house "self-resistance" features for the replacing part of the restoration. These
include bulk, slanting wall angulations toward the fulcrum, flat floors, and proper
fulcrum features for the center of the restoration.
In addition, the restoration should be designed in the stress concentration area
so as not to encounter additional stresses from retaining other parts of the
restoration, or stemming from additional forces directly applied there. Finally,
special retention features should be added to the stress concentration area in the
form of nearby "immobilizing modes". These serve to decrease micromovement of
the restoration thereby sparing this part of the restoration any additional stresses
resulting from such movements.
I. Partial or Complete Loss of a Cusp
After removing all undermined enamel, a cusp should be evaluated in the following
sequence:
A.Is it functional or non-functional? (This is an arbitrary nomenclature, as each type
is stressed in a different way and pattern.) Generally, replacing a non-functional cusp
poses more resistance-retention problems than replacing a functional cusp. As
mentioned before, the stresses in the non-functional cusps are more displacing and
destructive than on the functional cusp.
B. What are the types (working or balancing) of cuspal inclined planes involved in
the destruction? Generally, the na' ture of loading on the working incline is much
more than on the balancing incline.
C. What is the width of the destruction (loss) relative to the intercuspal distance? This
is the most important measurement. (It should be measured in the bucco-lingual
directions in all posterior teeth and in the bucco-lingual and mesio-distal directions in
posterior teeth having more than one cusp facially and/or lingually [Fig. 17).) As
mentioned before, at conventional depths (1.5-2 mm), the loss of width can be
detrimental to the resistance form of the remaining portion of the cusps if it exceeds
1/2 to 1/2 the intercuspal distance. This situation is aggravated in a deeper preparation.
It is in these cases that protective resisting measures should be introduced into the
restorative design.• Usually, horizontal structural loss is deviated toward one cusp
more than the other (Fig. 18). This situation should be noted, as only the cusp toward
which the destruction is deviated may need additional design changes.
D.The bucco-lingual partial loss of a cusp from the occlusal direction can create both
resistance and retention problems that need to be solved in the restorative design. This is
due to the increased exposure of the restoration to loading and to less cusp bulk
remaining for self-resistance.
E. The mesio-distal partial loss of a cusp, if not accor., panied by bucco-lingual
loss, can only pose resistance pc7c.. - lems. These stem from exposing part or all of
the restoraric mesial and/or distal inclined cuspal planes to direct loar.1:-
The occiuso-apical partial loss of a. cusp usually cre:a
retention problem with slight resistance problem. This type 3f
loss actually decreases the resistance problems in the rerna'
cuspal tooth structures due to the indirect loading of the remaining cuspal
elements.
G. The length of the remaining part of the cusp relative to its width, is the
second most important measurement ( Fig.
19A). The ideal ratio for this measurement is one or less. Usually, if the
ratio exceeds two, cuspal protections and reinforcing measures should be
incorporated in the restorative design, especially when using restorative
materials stronger than the tooth structure.
H. In restorations involving two or more surfaces, the occluso-gingival
length of the axial wall relative to that of the surrounding walls, should be in a
ratio of I :2 or more (Fig.
 19B). Anything less will seriously compromise retention and resistance.
1. The complete loss of a cusp (Fig. 20) imposes major retention and
resistance problems for the restoration. The resulting restorative design should
include all features required in replacing a stress concentration area
J. Cusp loss (partial or complete), complicated by loss(es) of other stress
concentration areas or parts of areas (Fig. 20) should be recognized and
recorded. In this situation, the operator's clinical judgement, experience, and
imagination should lead to the following objectives:
1. Retention-resistance modes at different areas of the preparation not
counteracting or neutralizing each other
2. If possible, immobilizing retention modes next to a lost stress concentration
arca, reciprocating with a retention mode for the same means of immobilization
in another lost stress concentration area, e.g., two opposing proximal grooves
next to two opposing lost cusps
3. If anatomically possible, two or more lost stress concentration areas having
the same principal. auxiliary, and/or reciprocal means of retention, e.g , an
external box between two lost facial cusps in a molar
4 Preparing retention-resistance modes for one area so as
not to impinge on the self-resistant bulk of another involved or uninvolved
area (see chapter on Class Ili
5. If the final restoration involves two or more stress con centration areas,
retention modes for one stress concentration area should not immobilize the
restoration there more than the retention modes for another stress concentration
area and the vice versa should also be observed, as the part with less im -
mobilization will have its micromovement extremely exagger ated, even if its
modes are quite sufficient for its own potential movement. Overimmobilization
for one area can direct stresses to the closest stress concentration area in the
restoration.
 III. Partial or Complete Loss of a Marginal or Crossing Ridge ( Fig. 21)
As these ridges arc the belting elements between the buccal and lingual
cusps, they should be observed from several aspects:
The width of the partial loss, relative to the intcrcuspal distance, is the most
important measurement for these anatomical landmarks. It is closely associated
with the same measurement in cusp loss, and should be compared prior to
planning a restorative design. The closer that the ratios are, the greater will be
the chances of having the same treatment. However, the farther apart that the
ratios are, the more will be the necessity for different design features for the
cusps than for the ridges. Generally speaking: the more that the horizontal
loss of the ridge is, especially at a depth more than 2 mm. the more the
resistance and retention problems for the previous!) ridge held cuspal elements
will he. In any event, whatever the crossing destruction width for these ridges.
the reinforcingand-protecting measures should be part of the same measures
applied to adjacent connected cuspal elements.
Rucco-lingual deviation of the partial ridge loss, toward functional or non-
functional cuspal elements (i.e., leaving more bulk of the ridge toward the
opposite side), is an important observation to make in order to correlate with
the adjacent cusp's width to length ratio. The cuspal width dimension, in the
form of a ridge, is more of a positive sign for self-resistance than the same
dimension in a non-ridge area. This is because of the tooth structure
thickening in such an area.
Thinned ridges in the mesial and/or distal direction (crossing
and proximal marginal ridges) and in the facial and/or lingual direction (facial and
lingual marginal ridge) is a situation most often observed in occlusally attacked
ridges. Generally speaking, intact and even thickness of ridges are important to
maintain in any dimensions, as there is a drastic drop in the self-resistance of
adjacent cuspal elements when they are lost, Also, the amount of thinning in three
directions is very influential in shaping the self-resistance of the ridge as well as the
combined cuspal elements. Because of all of these factors, the following criteria
should help decide how to handle thinned ridges:
A.If the thinned parts of the marginal ridges are not involved in occluding contact
during centric and functional relations, any thickness as low as 0.5 mm is adequate,
provided the cavity depth at that point does not exceed 2 mm, and the adjacent axial
surface is intact.
B. If the thinned part of a marginal ridge comes in contact with opposing cuspal
elements during centric or excursive relations, it should have at least 1.5-2 thickness
at its thinnest cross-section which is always at its occlusal or pulpal ends. If it is
thinner than that, it should be crossed.
C. In cases of oblique and transverse ridges, even if they are in static or dynamic
occlusal contact, do not cross them unless they are as thin as 0.2 mm, provided the
cavity depth at that point does not exceed 2 mm.
D.If the conditions mentioned above are not satisfied, and if it is necessary to
cross the ridge, the crossing should be confined to the thinnest portion only, if this
places the created cavity margins in self-cleansable areas. Otherwise, it is necessary
to include more of the ridge to satisfy these basic principles.
E. The crossing depth should be confined to the minimum thickness of the
restorative material that can be self-resistant (e.g., 1.5 mm in amalgam and 0.5 mm
for cast alloy). Furthermore, the ridge thickness or length: width ratio of 1 should be
achieved without consideration to the depth of the rest of the preparation. This latter
feature may be used provided it will locate the gingival margin of the preparation (in
case of proximal marginal ridges) at a self-cleansable area and will not interfere with
the retention features of the final restoration.
F. If anatomically feasible, in place of a partially or totally crossed ridge, leave an
elevation of tooth structure (struss) connecting separated cusps and remaining
segments of the ridge to help resist transverse stresses (see Class 1, Design 4). This is
vital if the ridge joined a weak, highly stressed cuspal element with a stronger, bulkier
one.
G. Complete loss of the ridge is usually accompanied by critical intercuspal
dimensions of the destruction as well as a high cusp length-to-width ratio. It
necessitates reinforcing-protective features previously described.
H. Ridge loss (partial or complete), complicated by loss of other stress
concentration areas, requires the operator to follow the same criteria as for the partial
or complete loss of a cusp.
IV. Partial or Complete Loss of Axial Angle(s)
This creates major resistance problems for the contemplated restoration and remaining
tooth structures. This is not only because the axial angles are the place for the most
concentrated and deleterious stresses, but also it is fairly difficult to immobilize the
restoration there without involving adjacent tooth
pans externally. This situation may complicate the stress situation more. It (they)
should be examined and evaluated in the following order (Figs. 20, 22, and 23).
A.Is the involved axial angle at the functional or nonfunctional side? Since more
mechanical problems can be expected on the non-functional side axial angles than
the functional side ones, more stress concentration features should be introduced in the
preparation design on the non-functional side.
B. What is the location of loss relative to the rest of the axial angle? (This
includes terminal partial loss or midway partial loss.) Terminal loss(es) (Fig. 23),
especially at the oc-
C.material stronger than those forming the clinical crown and root.

D.VII. Occlusal Abnormalities That Change the Relative Position,

Functionality, and Stress Pattern of Cuspal Elements
E. Such an evaluation should attempt to elucidate any localized abnormalities
(Fig. 26), e.g., crossbite, tooth rotation, tilting, extrusion, intrusion, or version. It
should be determined at this point if the tooth is going to be correctly repositioned by
orthodontic treatment, in which case a provisional restoration must be placed and the
final restorative design delayed until after successful orthodontic therapy.
F. However, if orthodontic treatment will not be undertaken, occluding restoration
parts in both static and dynamic relationships should enter into the restorative
design. The direction of tooth inclination or version should also be diagnosed and
recorded, because the tooth preparation design and instrumentation will need to be
modified according to these inclinations
IX. Determining Whether or Not the Tooth Will Be Splinted to Another-Tooth
as a Part of Overall Treatment, and, if so, if the Tooth is a "Splinter" or a "Splintee"
The "Splinter" restoration and remaining tooth structures can accommodate more
stresses than the "splintee", which must partially depend on the "splinter" tooth for
resistance and retention forms. If the splinted teeth are part of a prosthesis attachment or
retainer, the "splinter" will invite even more stresses in addition to these already
mentioned. Of course, it is not only the amount of lost tooth structure that decides
whether the tooth be a "splinter" or a "splintee", but it is also the amount of.bone
support around the tooth.
The amount, direction and concentration of stresses in the remaining tooth structure
and replacing restoration of the splinter can be calculated with safety margins by
combining the possible stresses in the splintee and the prosthesis (if it is to be used)
and add them to that of the splinter under normal loading situations. But initially one
should recognize which tooth is the splinter and which one is a splintee and plan our
restorative design accordingly.
IX. Relative Length of the Restored Clinical Crown to the Clinical Root
Normally, this ratio should be 1:3. The less that the ratio is, the stronger will be
the resistance form of the entire tooth to the loading stresses. The resilience of the
periodontal membrane and supporting bone is responsible for absorbing and dissipating
most of the mechanical energy applied on the tooth. When these investing tissues are
decreased in dimension, resulting in an increased crown:root ratio, much of the applied
forces must be resisted by the tooth structures themselves. The stress is further
exaggerated by increased surface area of tooth exposed to loading in an offset
crown:root ratio. Therefore, when the contemplated restoration and/or the remaining
crown structure will create a crown:root ratio more than 1:3, the restorative design
should be modified to reduce the increased stresses. This may be accomplished, for
example, by reducing dimensions of occluding surfaces, decreasing the steepness of
inclined planes, rounding the occlusal terminations of cuspal elements, and minimally
involving cuspal elements in excur-• sive and disclusive mechanisms.
IX. Unusual Strength and Power in the Bite of the Patient and any Habits that
Might
Introduce Different and/or Additional Types of Magnitude and Directions of Stresses
These include bruxism, pipe smoking, tobacco chewing, ice chewing, etc. Once
recognized and observed, they should be analyzed, recording the affected occluding
cuspal elements, approximate magnitude, type and direction of expected stresses on
the contemplated restoration. All of this will fa cilitate any design modifications
which the situation might necessitate.
X. Tilting of the Destructed Tooth
Such tilting may be due to original eruption pattern; or non-bodily drifting caused
by, missing adjacent teeth, proximal tooth structure loss, or periodontal .disease.
When confronted with a broken down and tilted tooth, one should consider the ideal
treatment, i.e., orthodontic uprighting. Several factors influence the decision to upright
a tooth, including the amount and direction of tilt, the amount and condition of
investing bone to be involved in the orthodontic movement, the root surface area of
the tilted tooth and the changes in occluding cuspal elements and contacting tooth
components which would result from uprighting; or any vertical or closing tendencies
as indicated by the Y-axis, gonial angle, and mandibular angle. If the decision is made
to upright the tooth, there are several techniques available to effect such movement,
ranging from the same-arch anchor devices to opposing arch ones. The resulting
conditions substantially simplify the restorations for such a tooth. An example of this
technique is:
A.A removable applicance '(modified Hawley) is constructed so that it will be
retained by the rest of the teeth and contains an incisal inclined plane to release
occlusion not to interfere with uprighting. Retracting springs, anchored to the
appliance are attached to the tooth surface toward which the tilting occurred and
activated in the reverse direction. The spring should be activated periodically.
B. A fixed appliance in the form of solidifying-tying together a good segment of
teeth anterior or posterior to the tilted tooth, e.g., teeth ## 27, 28, 29, and 30, to act as
an achorage to upright a tilted tooth, tooth # 31, (Fig. 29). All teeth are connected
with an arch wire (sequential from 0.016 to 0.018 x 0.025"). In addition, there is an
uprighting device, e.g., a Helix looped wire with a loop at the tilted tooth and free
arm to be attached to the anchoring teeth' arch wire. The Helix loop is activated to
place intrusion forces on the anchoring teeth and rotating extruding forces on the
tilted tooth (Fig. 29). In both procedures periodic occlusal adjustments and frequent
disclusion of teeth are needed to allow the up-righting movement.
On the other hand, if the decision is made to restore the tilted tooth as is, the
operator must evaluate a different set of problems. For example, how the restorative
design will deal with other than normal occluding surfaces, especially with some
cuspal elements overloaded while others are not loaded at all. The restorative design
might have to deal with exposed root anatomy and possibly a furcation on the side of
the tooth opposite the tilt. Furthermore, when instrumenting tilted teeth, the operator
must make a conscientious effort to avoid over-
 cutting on one side and undercutting on the other (tilted) side.
Similarly, when preparing internal retention modes, there is a
very real danger of perforating either to the surface or the pulp.
At any rate, in evaluating these teeth for a restoration, one should look for the degree
of tilting relative to the long axis of the tooth, using a radiograph. One should also
explore if the loading in the tilted part is tolerated by investing periodontium, will
further tilting occur, if the same type of loading is reproduced in the restoration, or
will no further tilting happen due.to opposing tooth contact preventing it. Finally
consider the possibility of adequately preparing these teeth for restoration without
the above mentioned hazards.
Planning the Restorative Design
Most of the restorative modalities have been described in detail elsewhere in this
text. For restoration of badly broken down teeth, these modalities should be used
intelligently where they arc most indicated. These applications should be done
with whatever modifications are necessary in order to achieve their goals
successfully. During this part of the chapter an attempt will be made to describe in
detail the treatment modifications and specific procedures required for certain
exemplary cases. As of today, amalgams, casts or combinations of both are the
only permanent restorative materials for posterior teeth. So, with this in mind,
following are principles to be followed in the restorative design.
I. Management of Total or Partial Cuspal Loss
As mentioned beforc, the ideal length:width ratio of a totally self-resistant cusp
is one or less. Therefore, when using amalgam, a material which depends on its
resistance and retention form on remaining tooth structures.
A.If the average cusp length:width ratio is 2 or more on the functional side, the
non-orbiting cusp should be capped or replaced completely with amalgam.
B. If the average ratio is 3 or more on the non-functional side, the orbiting cusps
should be capped or replaced completely with amalgam.
 In case of cast restorations, which arc dependent on tooth structure only in their
retention form.
C. if the cusp length:width ratio is more than I on the functional side, the cusp
should be capped or replaced in cast material.
D.If the ratio is more than 2 on the non-functional side. the cusp should be
capped or replaced in cast material.
E. Ideally, the width of a preparation should not exceed one-fourth to one-third
the intercuspal distancc, when restoring a tooth with amalgam. if the horizontal
width of the preparation exceeds one-half the intercuspal distance, the cusp should
be capped with the' restorative material. On the other hand, when restoring a tooth
with a casting, if the cavity width : intercuspal distance ratio is more than one
:three, the cusps should be capped as well as be reinforced or protected in some
way.
G. The ideal length of the axial wall is half (or more) of the length of the
surrounding cavity walls. In restorations using amalgam. if the axial wall length
is less than one-third the length of surrounding walls, capping of cusps is
indicated. In cases involving cast restorations, if the axial wall length is less
F. than one-half the length of surrounding walls, reinforcing or protecting those
surrounding walls by capping cusps is indicated.
The specific design features for capping or replacing cusps with amalgam were
described in detail under Class 11, Desip 6 cavity preparations. However, in
addition to the features mentioned therein, a stress concentration area design feanae
should be added, as described earlier in this chapter.
The design features for capping, shoeing, or replacing cusps by castings were
described in the chapter on design of tooth preparations for cast restorations.
Further design features whit should be addcd include:
1. Stress concentration area design features as described earlier in this chapter.
2. Facial or lingual "skirting" of shortened or badly thinned cusps, instead of
counterbevels.
3. Expanded use of reverse secondary flares to tie pre:*- ration components
together.
4. Extended, exaggerated bevels to reinforce minimally A.-- volved cusps.
H. Management of Total or Partial Loss of Axial Angles
When axial angles arc to be involved, the maximum details of stress
concentration area design features, as pre iousty *- scribed, should he incorporated.
In addition, there should soc be any acute-angled marginal tooth structure at this
area. Rattier, margins should be right-angled, if using amalgam. and obtuse-
angled. if using a casting. Also, the restorative matcrai.. if completely replacing
the axial angle. should have its ramimum bulk at that location, as compared to
the other pars id the restoration. If a casting is the restorative mode, the a' angle
could be protected or reinforced using skirts. res secondary flares, or collar
extensions. Under no circumstaras should retention features be placed at the site
of a lost sad angle. Immobilization can be accomplished with retention fa* tures
placed at other nearby locations.
III. Management of Partial or Complete Loss of Marginal and Crossing Ridges
Both amalgams and cast materials can either partially a ' totally replace
marginal and crossing ridges. However. alai! casting can protect or reinforce these
areas. Preparations is replacement can be as any of the previously described
desapa of a tooth preparation. Preparations for protection or minks= ment might
take the form of extended bevels. overang.:Ise bevels. counterbevels and
sometimes skins.
IV. Management of Partial or Complete Loss of the Crown-Root Junction
Using either amalgam alloys or cast materials. crown-7.1 junctional areas can he
replaced. Naturally. amalgam requim greater bulk than a cast material in this area.
When using calm material. do not put retention modes at the crown-root jum -Paai
Cast restorations can reinforce or protect thinned cross-scam of the area through
the Ferrule effect, described in the ct^.go
dealing with the restoration of root canal trcatcd teeth. Cross linking retention
modes are valuable in this area.
V. Management of Enamel Crazing (Microcracking)
If it is confirmed that a tooth demonstrates the signs and symptoms of cracked
tooth syndrome, and/or if cracks are numerous and have an unlimited extent,
carc should be taken not to involve them in the tooth preparation. The tooth in
these cases will need an amalgam foundation, then restoration with a reinforcing
or protecting type of cast restoration, such as an onlay or full veneer casting. to
splint together the separated portions of the tooth.
If cracks penetrate deep into dentin or to the pulp-root canal system and/or the
periodontium. they should not be involved in the tooth preparation, as the tooth
will need a restorative design as mentioned above. This may be donc after
cndodontic therapy if the P-D organ has been affected beyond its reparative
capabilities. If cracks are limited in number and penetrate enamel only, with no
traces in dentin. eriamelcctomy may be performed and the reduced areas to be
involved in the final cavity preparation.
If cracks are limited in number. and only pan of the enamel is involved.
enamcloplasty can be tried until the cracks arc • eradicated. Then the thickness
and nature of the remaining enamel should be evaluated relative to the future
restoration. If this enamel is of sufficient dimension and maintains the capacity
to support marginal tooth structure. it should be left untouched. Otherwise the area
should be included in the final cavity preparation.
A.Stress receiving and stress inducing components of
the tooth structure-restoration complex should be kept
away from recognized involved weak areas of the tooth
Examples of this are: avoid putting tables and flat gingival floors over or near
the furcation. don't use a subpulpal floor as a load receiving area, avoid putting
retention modes in thinned dentin bridges or dentin around the furcation. and avoid
directly loading thinned dentin bridges. etc.
 B. Preparation margins should be located so that they do not contact
opposing teeth during masticatory cycles
In such large restorations, there is great possibility of bending thinned cavity
walls away from the restoration as in Fig. 30A and of moving the restoration
away from the cavity walls as in Fig. 30B.
A. Junctions between
different parts of the preparation must be rounded
This is especially true in junctions acting as fulcra. for reasons mentioned
before.
l). Isthmus areas in the future restoration should he recognized. and an effort
should he made to prevent failure there
This is carried out by increasing restorative material hulk and by bringing the
fulcrum close to the area of anticipated maximum stresses, as described before
H. E. Surface decalcifications or defects
I. If these are adjacent to the destruction ( Figs. 26 and 28) to be involved in
the preparation. they can be handled by either a boxed extension (for amalgam
or casting), a grooved extension (for amalgam and casting). or secondary flares,
reverse secondary flares. skirts, and elongated oveningulated bevels (for cast
restorations).
 J. VI. Tilted Teeth
K. As previously discussed. the ideal treatment for tilted teeth is orthodontic
uprighting. followed immediately by restoration. However, if orthodontic therapy
is not feasible and/or if tilting is slight, the tooth is stable. and the surrounding
periodontium can withstand loading, the tooth can be restored right away.
However, certain modifications in the restorative designs will he warranted.
L. First. it will be necessary to allow maximum loading stresses to be applied
away from the direction of inclination. This is possible by changing the tooth's
occluding anatomy in the restoration in a way which creates maximum functional
contact away from the inclination. However. this may necessitate additional
reciprocal retention at the side toward which the tooth is tilted.
M. Second. the occluding surfaces should be built in such a way that the applied
functional forces on the restoration s+tll not predispose to further tilting. Both of
these modifications should be executed without creating any centric or excursive
interferences for physiological mandibular movements, or predisposing the investing
periodontium to any breakdown.
Finally. it is important to visualize the tooth structure in three dimensions in its
tilted position so as to avoid undercutting. overcu VII. Crosslinkage Using Cemented
Pins or Posts (Fig. 31)
Such additional retentive and resisting modes are indicated for four specific
restorative situations:
A.Cases in which the occlusal one-third to one-half of a cusp have sufficient bulk to
withstand stresses, but it is locally discontinued at its apical base by lateral spreading of
the decay (Fig. 3l A)
B. Cases in which there is an extensive cervical lesion (Class V) continuous with a
Class II lesion (Fig. 31B)
C. Cases in which it is necessary to reinforce the junction between the anatomical
crown with the anatomical root (Fig. 31C)
 D.Teeth with incomplete fractures which make it necessary to join the partially
separated segments together (Fig. 31D) The technique for the first two indications is
as follows:
I. The distance between the contemplated locations for the two opposing pin
channels is measured, and a piece of wire 3-4 mm longer than the measured
distance is cut and adjusted.
2. Pin channels are prepared. One should be deeper than the other
(usually the root pin channel is the deeper one).
3. A pin should be tried and adjusted so that when it is seated to
the full depth of the deeper channel, it does not penetrate the
shallower one.
4. Cement is mixed and flowed into the pin channels. Also, the pin
ends are soaked with cement. The pin is inserted into the deep channel,
and aligned with the orifice of the shallower one. Then it is inserted into
the shallow pin channel only to a depth that will not disengage it from
the deeper channel. The procedure for indication (C) may be any
cemented post technique as described in the chapter on pin- and post-
retained restorations. The procedure for (D) is similar to that for (A)
and (B), but it is in the horizontal direction. For indications A, B and
D, cemented pins obliquely located and crossing each other could be
used (Fig. 31A and D).
VIII. Retention Features
Different retentive modes have been mentioned and described in detail
throughout this text, usually in conjunction with specified tooth preparation
designs. In restoring badly broken down teeth any of these means may be used
without the necessity of including the entire preparation design features that were
described within. In addition, these basic retention features should follow certain
rules of usage:
 A. Always recognize and analyze the displacing forces on the anticipated
restoration, observing and recording the origin, termination, and fulcrum of its
movements. As practically as possible, locate the retention modes at one and
preferably at both ends of the moving part away from the fulcrum.
B. The retention modes should fit the restorative technique and materials, e.g.,
counterbevels should not be used with amalgam alloys restorations.
C. Retention modes should not introduce intolerable stresses in the remaining sound
tooth structures, e.g., threaded pins in root canal treated teeth.
D. Locking retentive modes should have sufficient tooth structure bulk in the area
of the tooth that will receive stress as a result of this locking activity.
E. Retention modes should have Sufficient tooth structure bulk, peripheral to them
to be self-resistant.
N. tting. or perforations during tooth preparation
A. No single retention mode should work alone; rather, it should be
augmented by auxiliary and reciprocal means. This is to minimize
failure and to decrease stress concentrations in both tooth structure and
the restorative material.
B. A replacement of stress concentration areas should have a nearby
retentive mode.
C. Retentive modes should be comparable in their locking capability to
the magnitude of the displacing forces, and these locking components
should be in the opposite direction to ilia: of the displacing forces.
D. There should be complete compatibility, reciprocity, and
synchronization between the retention and resistance forms of the tooth
structure-restoration complex. If not contradicting and interfering with the
resistance form, every segment of the preparation should have its own
retention modes, if possible. This is to minimize interdependency of
one part of the restoration on the other for retention, so that minimal
 stresses will be induced at junctional areas of the restoration.
E. Retention means should not compromise the biologic integrity of
the involved tooth structures and surrounding oral tissues.
IX. Resistance Features
The only limitation to resistance form features is the clinician's imagination. Many
of these design features have been mentioned throughout this text. As with retention
form, although certain resistance modes have been described in coejunction with
other designs, it is not necessary to use the ocher features of these designs when using
its "resistance modes.
In using the resistance features previously described, de following rules of usage
should be observed:
A. As practically as possible, the resistance features in dr remaining tooth structures
should not be at the expense of resistance features of the restorative material, and
vice versa
B. "Bulk" is the most efficient, practical, and most eas:. : accommodated resistance
feature.
C. Creating planes at right angles to anticipated loads is second most effective
resistance form. Of course, the great=- that the dimensions of these planes are, the
more will be 1:-.t resistance. Also, the resistance effect of several planes is
mulative.
D. Junctional areas should be studied carefully and
interdependency of the joined segments there should be evaluated. If such an
interdependency is obvious, all possible resistance features should be placed there.
E. Resistance forms of the restoration and remaining tooth structures should be
synchronized with occlusion in both its static and its dynamic form.
F. Details of the resistance features should be designed for both the restoration and
remaining tooth structures, always minimizing shear stresses as much as possible.
G. Non-vital tooth structures (partially or totally) are the least resistant to stresses,
especially in thin cross-sections. This is the reason why design features should
include reinforcing and protecting aspects by a more resistant restorative material
than the tooth structures, e.g., capping, skirt, collars, etc. For ideal resistance. form,
weakened tooth structures should be replaced or reinforced (Fig. 32) with a stronger
restorative material. This is a condition that necessitates certain design features in
the remaining tooth structure to fully utilize the reinforcing capabilities of these
restorative materials (e.g., surface extensions, caps, shoes).
H. One resistance feature in a tooth preparation should not aggravate stress Patterns
in other areas of the preparation or the restoration.
J. As mentioned in the discussion of retention features. resistance features should be
in complete cooperation with retention features without each nullifying the other's
capabilities.
J: Resistance features should not interfere with the biologic integrity of the involved
and surrounding tissues.
K. Resistant items in a preparation should direct forces along the most
advantageous angulation for the tooth roots, investing bone, and periodontal
ligament; i.e., along the long axis of the tooth.
L. Flat planes, at right angles to applied forces, will receive all the applied forces
and react accordingly. If it is thought that the resisting status. of the Nat plane cannot
withstand applied forces without failure, the effect of these forces can be reduced by
inclining the plane. Stress reduction is proportional to the amount of the inclination.
The inclination should preferably be directed to a more resisting item in the
preparation.
X. Restorative Design Features for Endodontically Treated Teeth
After verifying the success of root canal therapy and collecting the necessary data
the restorative design may be planned with the following considerations:
A.If marginal and crossing ridges are intact, amalgam restoration in a Class I,
Design 8 can be the final restoration.
B. If one or more of the marginal ridges or crossing ridges are involved in the
cavity preparation of an endodontica4 treated tooth, amalgam must act as a
foundation for a reinforcing type of cast restoration.
C. If the pulp chamber has 2 mm and more dimensions in three directions, has
dimensions amounting to one-fifth the amount of lost tooth structure, has at least two
intact opposing walls, and one or more of its rodts is sizable enough to ac-
commodate amalgam to a depth of 4 mm. use Class I or Design 8 cavity
preparation for an amalgam restoration or foundation.
D.Use posts and pins, as described in detail in the chapter vn in "C" are not
fulfilled.
E. Any badly broken-down, endodontically-treated tooth (with one or more
marginal ridges or crossing ridges lost) should have a foundation (substructure),
usually in amalgam, under its restoration (superstructure) which is usually made of a
cast material. This design is necessary to avoid further intraradicular instrumentation
if this type of restoration should fail. Removing previous intraradicular retention
modes usually invites root fracture (Fig. 38).
The amalgam foundation under a casting is also necessary to eliminate undercuts
for the cast restoration tooth preparation without the necessity of sacrificing massive
amounts of sound tooth structures. Furthermore, less micromovements of the res-
torations inside the root canals and pulp chamber occur if the restorative procedure is
done in two parts, rather than one. This is because the inner portion (foundation) will
be indirectly loaded, especially if the peripheral segments of the cast restoration are in
contact with tooth structures. This arrangement also predisposes to less stresses in the
pulp chamber and root canal walls, with a lowered possibility of fracture there.
More simplication and standardization of the restorative technique is accomplished
if done in two segments, rather than one. Less intraradicular instrumentation with
less residual stresses and always less tooth structure involvement is assured when
using a two-piece restoration rather than a one-piece.
Amalgam is the ideal plastically inserted material for a. foundation because of the
following advantages:
1. Amalgam has minimum porosity if it is properly condensed.
2. Due to the inherent properties of the material and the incremental insertion
procedure. accompanied by the condensation energy. amalgam will have the
maximum adaptability to retention modes, tooth preparation surfaces, and
details. As a result, the foundation will exhibit adequate strength and minimum
leakage, a characteristic that improves with age (especially in the presence of a
casting alloy covering a restoration).
3. Of all plastically inserted materials, the strength of amalgam is the most
comparable to that of the wrought metal retentive modes and the restorative cast
material.
4. Modern amalgam can be prepared for the superstructure reduction as soon as
fifteen minutes after insertion.
5. Amalgam can be seen radiographically, facilitating future diagnostic procedures.
6. Amalgam can be completely dried from moisture, thereby allowing adequate
retention and setting of the luting cement for the covering casting.
7. Amalgam has a contrasting color from tooth structures. This characteristic can
facilitate finishing and subsequent marginal removal of amalgam at barely
accessible and visible areas gingivally.
The use of presently available composite resins as a foundation for a cast restoration
superstructure should be restricted for several reasons. First of all, there is the difficulty
of finishing and completely removing composite from margins subgingivally. This is a
necessary step to allow the cast restoration superstructure to be the most peripheral
material. This same drawback becomes worse, if the composite is not radiopaque. The
high porosity of composite is an inherent characteristic (Fig. 33). Unfortunately, the
bulk pack way of inserting it enhances this problem leading to extensive leakage
problems, in addition to lowering its strength. The characteristic water sorption of
composite resins, combined with this porosity, will lead to retainment of moisture
despite attempts to dry it. This moisture content will prevent adhesion of any luting
cement to the composite, or inhibit proper setting of the cement resulting in a possible
cementation failure.
In addition to bodily and interfacial leakage between their components, composite
resins show poor adaptability to retention modes and cavity details. This may lead to
future leakage, with possible marginal break-down.
F. The Ferrule Feature
As mentioned in a chapter on pin- and post-retained restorations, the ferrule effect is
the most important resistance feature in a restoration for an endodontically treated
tooth. Utilizing this feature, the cast restoration should encompass the tooth
circumferentially, bringing its components together to efficiently resist splitting and to
assure maximum reinforcement for the remaining tooth structure (Fig. 34). To do this
the cast restoration should involve sound tooth. structure at least 2 mm apical to the
gingival periphery of the foundation. This may take the form of a skirt, collar,
counterbevel, veneer or exaggerated bevels.
XI. Restorative Design Features for Badly Broken Down, Periodontally Treated
Teeth
Restoration of badly broken down periodontally treated teeth, especially those
previously suffering from advanced periodontitis, or intentionally extruded, pose quite
a challenge to the clinician.
The following are the areas in the restorative design that should be emphasized for
previously periodontally affected but treated teeth:
 A. Tooth preparation
Tooth preparation should emphasize the following features:
1. Try to put gingival margins supragingivally (Fig. 35).
2. When preparing for cast restorations, the bevels, especially the gingival bevels,
should be exaggerated in extent and angulation in order to involve adjacent wear
facets and root surface defects or root surface anatomical anomalies.
3. The preparation for a cast restoration should incorporate a variety of skirts,
secondary flares, and reverse secondary flares to eradicate peripheral marginal
undercuts created by the taper of any exposed root portion of the tooth.
4. Avoid placing any margin in the furcation. Maxima the margin may be at the
very occlusal limit of its occlusl flutes. To involve the furcation will create a
restored tooth a doubtful cariogenic and periodontal prognosis. When ccefronted
with margins that will end in the furcation proper. dee to the extent of destruction, it
is necessary; to think of otbc
5. restorative modalities, e.g., hemisectioning or bicuspidization, as alternatives.
6. For all types of restorations, the preparation walls and floors in place of a flat,
concave dr fluted root surface areas should follow the same configuration as the
replaced root surface. This is to avoid involving or encroaching on the root canal
system, to create an even thickness of the restorative material, and to facilitate a
definite surface termination at the margins.
7. A tooth preparation for a cast restoration that involves rootsurface concavities
or flutes, besides having its walls (axial surfaces) replace these anatomies with the
same configuration (concave or fluted), should have the established imitating con -
figuration of these walls (axial surfaces) over the entire surface occiuso-
gingivally. This is necessary to assure absence of undercuts in the path of the
preparation, and to facilitate a definite marginal termination gingivally.
8. For amalgam restorations the gingival floor will almost always be one-planed
axio-proximally (facially or lingually).
 9. For amalgam restorations proximally there are a number of indications for
Class II, Designs 4 and 5.
10. The gingival floor margins and finishing lines that come close to a furcation
should follow the apico-occlusal curvature of the furcation in the horizontal
direction (Fig. 36).
11. Gingival floor or finishing lines immediately occlusal to a furcation should
have an apical inclination (divergence) so as to dissipate and eliminate forces
accumulation.
12. II. Gingival floors immediately occlusal to a furcation should be
accompanied by mesial and distal (facial and lingual) flat ledges or gingival
floors away from the furcation ( Fig. 36). These flat-planed areas should have an
inclination which is at right angles to the occluding forces (long axis of the tooth),
so that no forces will concentrate stresses in the furcation tooth structures.
12. To facilitate plaque control in fluted areas of the root or inlets to the furcation,
a simple widening of the flutes without restoration can be done. if the flute is to be
produced in the restoration, but on a wider scale than originally present, the
preparation wall (axial surfaces) at the fluted areas should have the same curvature
and flare as the contemplated restoration, and not as the original flute.
B. Proximal contact and axial contour of the restoration
The final restoration for periodontally treated teeth, espe
cially those previously involved in an advanced periodontitis situation, should have
certain modifications in their axial contour.
Oceluso-apically, the contour should be less pronounced than usually found in teeth not
previously affected with periodontitis. This is more applicable to the facial and
lingual axial contour than to the proximal ones, and it should not interfere with the
contour of the unrestored areas of the tooth. This configuration will improve the
plaque control around the periodontium.
The surface configuration of the root anatomy, whether it is a concavity, flatness, or
flute, if involved in the preparation, it should be reproduced with the same
configuration in the final restoration. Furcation flutes, if reproduced in the final resto-
ration, should involve the entire surface apico-occlusally to assure proper plaque
control at the critical furcation area. Restorations involving part of the cemento-
enamel junction, but away from the furcation, should have a flat surface area occlusal
to the CEJ in a horizontal direction to assure the integrity of the area.
The horizontal axial contour of the restoration should follow the same contour as the
replaced tooth surface to assure the biologic integrity of the adjacent periodontium. As
mentioned before, replacing the tooth contour in these directions is more biologically
important than replacing it in occluso-apical directions. Contact areas, too, should be in
the most physiologic location, replacing any created facets there with the proper
convex configuration.
C. Occluding surfaces and control of occlusal forces
After periodontal therapy, there usually are ungained bone losses compromising the
ability of involved teeth to comply with physiologic occlusal loading. To add to the
problem. many of the proprioceptive nerve endings within the periodontium are lost
reducing the ability of the neuro-muscular mechanisms to recognize overloading on
the invested tooth and to react accordingly. if this is the case with the tooth (teeth)
being restored, certain modifications in restorative design must be considered.
If the restoration is to replace all occluding surfaces, the width of the occlusal table
should be reduced, minimizing the amount of forces to be received by the tooth. The
heights and inclinations of cuspal elements should also be reduced, to minimize lateral
forces on the tooth.
If it is practically possible, .the crown:root ratio should be decreased to improve the
root resistance features of the tooth (e.g.. in extruded teeth). This resistance is also
enhanced by controlling parafunctional habits through occlusal splints, removal of
interferences, and by building the restoration without excursive or centric
interferences. Finally, if it is proven that the tooth (teeth) with this presented bone
support cannot stand anticipated occlusal loading without failure, splinting should be
considered in the restorative design.
XII. Splinting
Teeth splinting should be designed so that bone support of the splinted teeth is shared.
Sometimes even the resistance and retention capability of the splinted teeth is shared. It
is always advantageous to include a corner tooth with a long root in the splinting
assembly and the splint should be designed so that the stronger tooth will receive
the applied forces before the
veakcr. This will assure the weaker tooth is being indirectly loaded. The decision
to splint can be controversial, and there are many factors involved:
I. If tooth mobility exceeds three to four degrees, endangering the integrity of
the periodontal ligament and attaching bone and placing the tooth in a traumatic
location, splinting should he considered.
2. If the tooth is required to play a major mechanical role in the dentition,
e.g., if it is going to be an abutment for a fixed prosthesis or partial denture, and
it has lost more than 1/3 of its bone support, it should be splinted to a stronger
tooth. The same thing should be done if the tooth is going to be included in a
disclusion mechanism of the mandible, etc. Usually, splinting should be considered
in any overloading situation where the teeth have less than one-half to one-third of
the maximum bone support remaining.
3. As part of periodontal therapy, if the tooth is to be immobilized to assure
periodontal healing, it should be splinted.
4.A tooth may be splinted to improve resistance and retention form.
5. A tooth may be splinted to prevent further movement after orthodontic
and/or periodontic therapy.
6. Several teeth may be splinted in order to create a restorative splint with a
greater or lesser number (or dimensions) of teeth for functional or cosmetic
reasons.
The number of teeth to be splinted will be decided upon by the numbei of teeth
that need additional support (splintee) and, most importantly, the nature of needed
bone support. This can be arrived at by determining the amount, location and type
of supporting bone for the teeth (tooth) that need splinting (splintee). Accordingly,
one can obtain the same information about the lost bone. From this calculated data
one can locate &e needed nature of the bone support in adjacent teeth (splinters-For
example, two splintees may need one splinter or one sp- tee may need two
splinters, depending on the availability I the type, location and extent of the
indicated supporting be= in the splinter.
Whether the splintee tooth should he between two spliw-: or peripheral to them is
decided upon by the availability of splinter tooth. The first arrangement can be
ideal but it cam= be fulfilled in every case, depending on the factors previmestt
mentioned.
The type and amount of resistance and retention feam:-ei :r the splinter and
splintee should be designed so that the sr
will have most of the share of locking and resisting. This affect the number of
teeth to be involved as certain number splinters may not take care of the
resistance-retention needs the splintee(s).
The splint should be designed to immobilize the teeth in the three possible
directions. Adequate plaque and readily accomplished maintenance should be
assured the choice and in designing of the splint. A choice different types of
splinting modalities can be arrived as describing the available types and their
indications.
Types of Teeth Splints
A. Provisional splints (Fig. 37)
1. Removable types
a. Occlusal splints, usually used for occlusal therapy. have. an attached facial arch
wire to support the tooth t in the labio-lingual direction. The splint itself will i
the tooth in the mesial, distal, and occluso-apical direction. It is ideal if the splint
is needed in conjunction with occlusal therapy. The main disadvantage of this
removable splint is that its action is not continuous, except when the patient is
wear-. ing it.
b. The Hawley appliance with splinting facial arch wire is a regular Hawley
appliance with a similar facial arch wire as in the occlusal splint. It produces the
same action as the occlusal splint, with a possibility of more disengagement of the
upper from the lower teeth during the immobilization period.
2. Fixed types
a. Intracoronal
MOD amalgam restorations condensed together in the involved teeth, making a
one piece amalgam
Prior to condensation, all involved teeth are matriced and wedged at the same
time. Then sufficient length and width of the intervening band material is cut
(scissors or burs). so as to create bulky junctions between restorations. The
remaining band material interproximally. together with the wedges and the
matrixed gingival margin of the preparation, should not be disturbed in order to
assure the creation of a physiologic gingival embrasure with adequate marginal
adaptability. After condensation, the splinting amalgam should be carved to con-
firm adequate embrasures. especially gingivally.
Amalgam and stainless steel wires
This intracoronal splint is similar to the confluent MOD amalgams. but after
partially condensing the amalgam restoration over part of the proximal portion and
covering part of the pulpal floor. stainless steel wires, in the diameter of 0.050" 1)r
more. arc laid mesio-distally across the preparations occlusal to the condensed
amalgam. More amalgam is then condensed over the wires.
i. Amalgam-wire and resin intracoronal splints
These are usually indicated if amalgam restorations are ul ready present or
separate MOD amalgam restorations are to be built for the individual teeth. A
fissure bur is used to cut a mesio-distal groove in the amalgam restoration, not
involving all the contact areas. Then, with a 33 1/4 or '4 bur, cut facial and lingual
undercut retention in the created groove on the entire occlusal amalgam, mesio-
distally. A wire is laid into the created groove and covered with composite resin.
ii. Another similar intracoronal splint involves placement of composite resin
and wires in cut grooves, with or without acid etching (Fig. 37).
These grooves are cut at the mesial and distal aspects of a tooth, preferably
away from occluding areas. The grooves should not cross the whole tooth mesio-
distally (3-4 mm horizontal involvement is adequate). and they should be at
least 2 mm deep with their lateral walls undercut. If enamel is available, it
should be conditioned as mentioned before. Pieces of 0.050" diameter wire are cut
to fit these grooves connecting between the indicated teeth. Composite resin is
mixed and some is introduced into the grooves, but not to fill them completely.
Then the pieces of wire are inserted. Additional composite is then added to cover
the wire and completely fill the grooves. The composite is then finished and
polished in the usual way.
iii. Fitting a wire chain within a continuous groove on the lingual surfaces of
adjacent teeth
The chain may be stretched and stabilized using threaded pins to hold it against
underlying dentin. The anchored chains
are then covered with composite resin to complete groove obliteration.
These five techniques provide very stable splints, but they require regular
adjustment, finishing, and polishing. In addition, plaque control is fairly difficult
there, so it should be continuously emphasized to the patient.
h. Extracoronal
i. Many of the extracoronal provisional splints are very similar in that they
involve acid etching of either facial or lingual enamel of adjacent teeth and
imbedding either stainless steel bars (rectangular in cross-section), stainless steel
wire mesh, or round stainless steel wire (.050" in diameter), within composite
resin bonded to the etched enamel. In fact, on anterior teeth with minimal
displacing occlusal loading, composite alone, bonded to facial or lingual
enamel, may suffice as a provisional splint.
ii. Orthodontic bands, properly fixed to involved teeth, may he
soldered together and then cemented to serve as a provisional splint.
ii. Orthodontic brackets may be bonded to acid etched enamel with composite
resin. Attaching an orthodontic wire to the brackets, either with elastics or with
ligature wires, creates a provisional splint holding the involved teeth together.
iii. Finally, nylon line, which is similar to, but thicker and more rigid than
fishing line, may be imbedded in composite resin that is bonded to acid-etched
enamel facially or lingually.
B. "Permanent" splints
1. Extracoronal
"Permanent," extracoronal splints take the form of full or partial veneer crowns
soldered together, or cast together.
 2. Intracoronal
"Permanent" intracoronal splints take the form of inlays or onlays soldered or
cast together.
Both types of permanent splints can have horizontal threaded or cemented pins to
improve their attachment to the involved tooth. The joints between any splinting
castings should be deviated occlusally. This facilitates a larger gingival embrasure
for better plaque control. Between visits during the construction of a permanent
splint, temporary or provisional restorations should be splinted together to assure
tooth immobility during the cast fabrication.
The choice between these numerous types of splints is a matter of clinical
evaluation and judgement. However, the following guidelines may be applied in
the process of this evaluation:
a. If the involved teeth are intact and splinting is to be only
temporary (e.g., a matter of months), in order to create the proper
stability of the weaker teeth, the removable types of splints are most
indicated.
b. Of course, provisional types of splints should be considered
before the. permanent ones if at all possible. This will facilitate
evaluation of results and a decision about the validity of the entire
idea of splinting for the particular situation. This is an especially
valuable technique because splinting sometimes aggravates the
periodontal situation more by complicating plaque control measures
and by depriving the clinician from one of the most important
diagnostic tools, i.e., tooth mobility.
c. Intracoronal provisional splints are the most stable of all
provisional splints. They do not interfere with occlusion or normal
architecture and maintenance of the oral and paraoral tissues.
Furthermore, they can be used for several years.
 a.Intracoronal provisional splints do require tooth structure removal (cavity
preparation), which is, of course, a permanent change. This is the reason why they
are the most indicated splints when there is already a restoration or lesion in the
involved areas.
b.Extracoronal provisional splints are reversible, i.e., they do not necessitate
any loss of tooth structure. However, they may interfere with normal activities of
the cheek, lip and tongue and, to some extent, plaque removal and maintenance
measures.
c.Intracoronal provisional splints can be the most inconspicuous splints,
especially if formed out of composite resin.
d.The permanent intracoronal types of splints are the least irritating to the
periodontium.
e.All permanent types of splints are the final restorations that the splinted teeth
should have, if splinting is to be part c: the restorative treatment plan for the life
of these teeth.
 f. Teeth splinted with provisional fixed splints should be evaluated after
varying periods of time (one year or more physically and radiographically, to
ascertain the involve.: teeth's support and stability. If, after this evaluation, the
involved teeth prove to be self-supporting, the splints should be removed and the
teeth restored individually. If, however, sic-port does not improve, permanent
splints should be constructez and cemented, provided the clinician is convinced
that splint; is performing a positive action, periodontally.
g.Usually, provisional removable splints are all tha: needed. However, if
after the designated time (e.g.. months) the objectives of splinting are not
fulfilled, or if the individual teeth migrate back after not using the splint fix 1
while, a fixed provisional splint should be built for the indica teeth befOre a
decision is made to permanently splint.
XIII. Foundations Versus Restorations
In many situations of badly broken down teeth, the ::.ac needs a foundation
made either of amalgam or sometimes composite resin. Following that, a
permanent restorat made of a cast material. The tooth preparation for an . foundation
is exactly the same as its preparation for an arm restoration. However, the tooth
preparation for a fina restoration of the tooth with a foundation is a little dif - ,
from the tooth with no foundation. These differences v. :e elucidated later.
Indications for a Foundation
(Build-Up) Prior to a Reinforcing-
Protecting Cast Restoration
A foundation, or build-up may be indicated in one or meet. of the following
situations:
I. Root canal treated teeth with one or more of their gina or crossing ridges
involved
2. In a tooth with all non-functional and/or half or the functional cusps to be
replaced
 3. A tooth to he used as an abutment for a fixed
above average loading situation) with MOD or more involvement, including
crossing ridges, with a width averaging 2/3 and more of the intercuspal distance
5. A tooth with the occlusal half (or more) of one of the axial angles of the non-
functional side and/or the occlusal half (or more) of both axial angles on the
functional side are lost, together with the adjacent cusps
6. A tooth with a deep axial cervical lesion facially and/or lingually, involving
more than two of its axial angles and 2/3 or more of its occluso-apical dimension
7. If 60% or more of the tooth structure is lost and has to he replaced
87 For teeth That have some of their forming components cross-linked together
with pins
9. For cracked teeth, teeth showing signs and symptoms of cracked-tooth
syndrome, or teeth with multiple unlimited crazing (microcracks), to avoid further
cracking or thinning of remaining tooth structures due to instrumentation, the tooth
is built up in the most conservative preparation with an amalgam foundation. Then
a cast restoration is used to cover (reinforce) and bind together the separated tooth
segments, usually in an extracoronal fashion.
9. Amalgam foundations for the badly broken down tooth can function as a
provisional restoration for very young patients, in dentitions with uncontrollable
caries, or other situations when cast restorations are contraindicated. The foun-
dation will serve as a provisional restoration until a more appropriate age and
cariogenically controlled conditions occur. Then a cast restoration may be
indicated.
I i . For short or shortened teeth, in which it is biologically and mechanically safe
to lengthen them with a foundation build-up prior to a cast restoration
12. In tilted teeth, when orthodontic uprighting is not feasible, crown portion
uprighting can be done through foundations made of a cast alloy or amalgam,
involving the whole crown. A cast restoration can be used over them, which, most
of the time, is part of a fixed prosthesis, going in the insertion path direction of that
prosthesis.
In all of these situations, build-ups are advisable for the following reasons:
a.Teeth with such destruction unavoidably accommodate multiple undercuts in the
path of a preparation for cast restoration. Trying to eliminate these undercuts can
lead to unnecessary loss of vitally needed sound tooth structures in such an already
weakened tooth. Building the tooth up with an amalgam foundation can safely
obliterate such undercuts, while pre,6erving sound tooth structure.
b.Foundation material will occupy some of the space created by the lost tooth
structure, thereby minimizing the amount of casting material (especially expensive
noble metals) for the covering restoration.
c.Amalgam, or any foundation material, will be in direct contact with the
weakened tooth structure to be covered with the cast restoration. When this
composite structure (tooth + foundation + restoration) is loaded during function,
weakened tooth structure's will be stressed the least, as forces will be indirectly
delivered to them through the amalgam or any other foundation material used.
d.In badly broken down teeth indicated for cast restorations, with deep involvement
axially and pulpally, amalgam
as a foundation material will seal the avenues to the pulp chamber and root canal
system. This is facilitated by its good adaptability, minimal leakage, and improved
sealability with age, especially in the presence of a cast alloy over it. These
advantages cannot be exhibited by a cast restoration alone.
a. In deep cavity preparations indicated for cast restorations, amalgam as a
foundation external to the proper intermediary basing (subbase plus base or
varnish), can incorporate two or more insulating media to different environmental
shocks. This includes the cementing media of the cast restoration, as well as the
amalgam itself, as an insulating medium.
b.Using amalgam (or any other material) to build-up lost cusps or axial angles of
a tooth will establish ideal reciprocal retention forms for a cast restoration covering
them.
c.With amalgam (or any other material) as a build-up material, axial surfaces
and other components of a tooth will work as auxiliary retention forms for the
covering cast restoration.
Both situations mentioned in (f) and (g) are not realized if the tooth is to be
restored directly by a cast restoration alone.
d.In situations when the bucco-lingual width of an occlusal involvement of a
tooth to be restored in cast restoration exceeded 3/4-4/5 the intercuspal distance,
the remaining cuspal elements are so thin that directly capping the cusps with cast
restorations will be impossible without completely losing them together with the
axial length of the preparation. This, in turn, will decrease the resistance and the
retention forms. Building the tooth in amalgam first will facilitate keeping all or
part of these cusps. Where the lost part is replaced in amalgam, the tooth
preparation for the casting is not deprived of its needed axial length and its vitally
required cuspal tooth structures.
e.In deep, wide, cervical lesions involving multiple axial angles, amalgam
foundations can minimize axial depth for the cast preparation, eliminate distorting
axial cavities and minimize trauma to the very close pulp tissues.
f. By building-up badly broken down teeth to a fairly regularly shaped tooth with
an amalgam foundation, the tooth preparation design for a cast restoration and its
execution can be greatly simplified, with little modification from the norm. This
saves money, time and effort, in addition to assuring more possibilities of success.
g.If marginal failure occurs to the final cast restoration in the future, the
foundation might still be intact, so deep re-entry to the cavity preparation may not
be necessary, minimizing irritation (Fig. 38).
h.I. In restoring some extensively destroyed teeth, pins and other prepared or
premade retention modes may be necessary. Incorporating them in an amalgam
foundation to be covered by a pinless (postless) cast restoration is more feasible
and practical than involving those premadc retention modes in the cast restoration.
This is because a cast restoration without pre-made retention modes is much easier
to fabricate. Also, these pinless (postless) cast restorations are, mechanically, better
tolerated by the tooth than pin-containing (post containing) cast restorations
without a foundation.
i. XIV. Design Features of a Tooth Built-Up in an Amalgam Foundation (or Any
Other Material) Prior to a Protecting/Reinforcing Cast Restoration
j. In addition to the different features for preparations, for cast restorations
already described in detail, the following should also be fulfilled:
k.No intracoronal preparation should be performed into an amalgam foundation,
i.e., if the amalgam foundation involves the entire occlusal surface or part of it,
preparing it for a casting restoration should be in the form of surface occlusal
reduction, like preparations for full veneer restorations ( Fig. '39). Do not prepare
external boxes, internal boxes, or grooves in the amalgam foundation. Any of these
can create thin amalgam walls, reducing the bulk of amalgam and subjecting it to
stress concentration beyond its tolerance (Fig. 40).
l. The margins for the cast restoration should be located on sound tooth structure,
2 mm or more apical to the gingival margin of the foundation (Fig. 41). This will
facilitate adequate finishing lines or other types of termination for the cast res-
torations. Furthermore, it will assure minimal ion and electron transfer back and
forth between the amalgam and the cast alloy. Such galvanic current is of some
clinical significance. The resulting corrosion and accelerated deterioration of
underlying amalgam could leave vacancies in the immediate area (e.g. open
margins), resulting in increased microleakage. Locating the casting margins on
sound tooth will also allow the resto ration's lateral resistance and retention modes
to directly involve this strong, unattacked part of the tooth structure. This.
m. in turn, results in a maximum ferrule effect. Furthermore. locating casting
margins on sound tooth structure imposes only one interface marginally, as
opposed to two or more interfaces.
n. In addition to having a direct contact with tooth structures marginally, it is
preferable for the cast restoration to have two pairs of opposing flat planes in tooth
structure at right angle to occluding forces and the long axis of the tooth ( Fig. 42).
' These can he in the form of ledges, floors, tables, or combinations of these.
Besides giving the advantages mentioned previously, flat planes can make most of
the occluding forces delivered directly. to the intact, strong, better part of the un -
derlying tooth structure. This minimizes loading on the foundation. At least 1.5
mm amalgam thickness should he left under the cast material, especially over
tables. ( Fig. 43) and pins (Fig. 41), to provide self-resistance.
o. Under no circumstances should the amalgam foundation accommodate
boxes, grooves, or any other intracoronal retentioe modes for the cast restoration
(Fig. 40). As a result of preparing the two pairs of flat opposing planes mentioned
above, intracoronal lateral walls in amalgam may be produced as a byproduct. In
this case, the internal and external peripheries ce these walls should be extremely
rounded (Fig. 42).
p. An amalgam foundation should never be used as a locaticv_. for a premade
retention mode, e.g., pins. It should be reemphasized that the only retention the
foundation should supplti is reciprocal and auxiliary retention through its surface
area and lateral frictional locking as a whole.
q. In preparing finishing lines or flat planes in tooth structus beyond an
amalgam foundation, clear the margin of amalven (composite) creating a ledge
(underhang). Then extend tic preparation axially (for flat plane), or apically (for
bevels a finishing lines, etc.)
r. From all of these design features it should be evident rl-lz the use of a
foundation preceding a cast restoration must tv planned ahead. The decision to
build-up a foundation sho-_:1.: not be made after restoring the tooth, when the
need for reinforcing/protecting restorative modality is recognized.
Anterior Teeth

In restoring badly broken down anterior teeth ( Figs. 44 and 45) many of the
same design features mentioned for posterior teeth will be utilized. In anterior
teeth, restorations should be done using tooth-colored materials, with the exception
of three situations in which metallic, non-tooth-colored materials may be used.
These situations are the distal of the cuspids, foundations for reinforcing cast
restorations, or as a substructure for a porcelain superstructure.

The following are the suggested sequences in which badly broken down
anterior teeth are evaluated, prepared and restored:
A.First, evaluate the status of the P-D organ and the attaching periodontium, as
mentioned before.
B. Second, clear surrounding walls of irreparably attacked and unwanted
enamel and dentin and apply the appropriate intermediary base.
C. Mechanically evaluate remaining tooth structure.
Because of the limited tooth volume in anterior teeth, their peculiar loading
situation (anterior determinant of mandibular movement), esthetic requirements,
etc., thorough mechanical evaluation of the remaining tooth structure as well as the
contemplated restoration is essential. This evaluation should take into
consideration one of the following three restorative pos
Can the tooth be restored with direct tooth colored materials or amalgam?
I. Can the tooth be restored directly with a cast or cast-based restoration?
What type?
I. Must the tooth be first built up with a foundation before being restored with a
reinforcing/protecting cast or cast-based restoration?
Of the above-mentioned choices, of course, the one affording maximum
restorative benefit with the least amount of tooth involvement should be the
restorative plan. All of these decisions should be made after comprehensive
evaluation of the loading situation (both static and dynamic), together with re-
calling probable stress patterns in anterior teeth (see Chapter 10). All of this must
be correlated not only to the remaining tooth components, but also to the areas to
be replaced.

The correlative evaluation of anticipated stress patterns should emphasize

certain salient features:
a.Stress concentration areas of anterior teeth include lingual marginal ridges,
incisal angles and ridges, axial angles, lingual concavities, cervical areas, and the
distal surface of canines
b.Transverse and vertical components of force during static and dynamic
contacts of upper and lower teeth
c.Weakened areas, e.g., undermined enamel and incisa angles, especially when
destruction approaches these areas
d.Partially vital or non-vital tooth or parts of a tooth
e.Types, points of application, and direction of possible displacing forces on
the contemplated restoration (Figs. 46 and 47)
f. The possibility of creating a gingival floor
s. This is the most important resistance feature in a proximoincisal restoration
(foundation) for an anterior tooth. It is essential to pre-operatively evaluate:
whether the gingival floor will consist of enamel and dentin, or just dentin; its
proximity to the area of application of forces; the amount of dentinal bulk available
for retention modes; the location of the floor relative to surrounding anatomy; and,
finally, the location of the gingival floor relative to the C.E.J.
a. Overlapping of teeth, which sometimes aggravates stress situations, and
other times prevents any loading whatsoever
In addition, overlapping changes the carogenic susceptibilit of involved
surfaces.
t. Cracks and crazing, which are managed exactly as in posterior teeth (Fig.
48)
u. Tooth thickness labio-lingually at the incisal ridge and angle
The higher this measurement, the greater the resistance capability of the entire
tooth.
v. The dimensions of destruction relative to the dimensions of remaining
tooth structure
The higher that this rating is, the more favorable becomes the third restorative
option. i.e., a foundation to he covered with a casting or a casting based
restoration.
D. Esthetic concerns
Before restoring any anterior tooth, it should be evaluated esthetically for design
features with the best cosmetic results. Any surface discoloration beyond the
major defect should he examined to see its extent and to determine if bleaching is
feasible, or if it is necessary to include in the tooth preparation. In many
circumstances, a complete veneering with a cast-moldable ceramic or cast based
porcelain crown is indicated.
Usually, the esthetic concern for the upper teeth is greater than for the lower. In
addition. cosmetic problems are more obvious and demanding on the mesial
aspects of these teeth than the distal. Of course. labial destruction is more
disfiguring cosmetically than at any other location on the tooth.
Lip lines, during both speaking and singing, define the conspicuous areas of the
teeth. In fact, their location can definitely affect the location of margins. An open-
mouth smile should be observed, as well, to ascertain the number of teeth
displayed and the predicted conspicuousness of a restoration.
The possibility of improving esthetics by extending, over-contouring, or otherwise
changing the configuration of the tooth should be considered and enter into the
overall plan of treatment. This should also include esthetic reshaping of adjacent
teeth, to be undertaken prior to or after restorative treatment. The possibility of
making the upper incisor ridge line parallel to the top of the lower lip to improve
esthetics should also be considered. All of these esthetic considerations must. of
course, not compromise the phonetic, anatomic, or anticariogenic necessities of
the tissues involved.
E. Phonetic considerations
It is a well established fact that speech impairment can result from some loss of
anterior tooth structure. The degree of impairment should be identified and
corrective restorative measures undertaken, specifically using the following:
I . Evaluate "F" sounds, during pronunciation of which the incisal edges of the
upper incisors touch the vermillion border of the lower lip.
,Evaluate "V" sounds, during pronunciation of which the incisal edges of the upper
incisors touch the inner side of the lower lip, just within the vermillion border.
Evaluate "S" sounds, during pronunciation of which the incisal edges of the lower
anteriors come into the closest possible proximity of the lingual surfaces of the
upper anteriors that is short of actual contact.
Phonetics, likewise, should not compromise esthetic, anatomic. or anti-cariogenic
requirements of the involved teeth.
Planning the Restorative Treatment Design
At this stage the amount and nature of remaining tooth structure can he positively
recognized and/or predicted. and the operator should have adequate data to choose
between the three possible routes for restoring the tooth (teeth) in question.
I. Build the Tooth Up with a Foundation Form (Substructure) to be
Covered with a Reinforcing/Protecting Restoration (Superstructure) (Fig.
49)
Usually, a ceramic or porcelain fused to cast veneer restoration is the superstructure
of choice. It is indicated in the following situations:
1. A root canal treated tooth, if any proximal surface is involved
2. Loss of the two incisal angles together with more than half the proximal
surfaces of the tooth
3. Loss of more than 50% of the tooth structure (Fig. 50)
4.Loss of more than one axial angle to a depth more than the anticipated axial
reduction for the reinforcing/protecting restoration (Fig. 50)
5.A cracked tooth or one with multiple. unlimited crazing in its enamel, and/or with
defects at axial depths deeper than the axial reduction for the veneering crown
6. A shortened tooth due to the nature of the destruction or to the removal of
undermined undesirable tooth structures
7.A tooth to be used as an abutment for a fixed prosthesis or partial denture and
whose defect involves one or more of the stress concentration areas to a depth more
than the usual reduction for the moldable ceramic or cast based porcelain restorations
8.Multiple defects (Class III, IV, and V) in the same tooth (Fig. 50), having depths
more than the axial reduction of a veneer crown and having a lot of undercuts
9.Remaining tooth structure accommodating multiple undercuts, the elimination of
which could be detrimental to self-resistance of the remaining tooth structures
As previously pointed out for posterior teeth, foundations are the ideal solution to
obliterate them.
1. Similar indications as for posterior teeth, especially for the distal of the cuspid
Anterior foundations, too, are preferably made in amalgam. but sometimes in
composite resins and rarely in cast alloy. Despite the material, they should have
internal dentinal retention forms (refer to the chapter on pin- and post-retained res-
torations and the chapter on cast restorations). Enamel etching (conditioning) should not
be used as a primary means of retention here.
The choice of amalgam as a foundation is the most preferable. for the same reasons
mentioned for posterior teeth. The foundation design features, too, are very similar to
those mentioned for posterior teeth.
II. Reinforcing/Protecting Restoration Without a Foundation or Build-Up
A moldable ceramic casting or porcelain fused to cast crown is, again, the treatment of
choice. It is indicated in the following situations:
1.In all situations mentioned for Choice 1. where the depth of the defect does not
exceed the regular axial reduction depth for the contemplated cast or cast based
porcelain restoration
2.Remaining tooth structure with the necessary axial length to retain the reinforcing-
protecting restoration
3. In all situations mentioned for Choice I where the defects
do not create multiple undercuts that cannot be eradicated by the preparation for the
protecting-reinforcing cast or cast based porcelain restorations
4.In situations where permanent discoloration in tooth structures is beyond the
resolving limit of conservative restorative modalities, i.e., direct tooth color
restorations with or without acid conditioning, or bleaching, or laminated veneering,
etc. Complete veneering tooth-colored restorations will be the only indicated
restorative modality.
5.Both labial and lingual walls are completely lost bilaterally, plus the incisal
angles and the remaining tooth structures have insufficient enamel to be conditioned
for proper retention
6.Lost tooth structure replacement in direct tooth-colored material can only be
retained with auxiliary means of retention
7.Distal of a cuspid destruction indicated to be restored in cast material
III. Restoration with Direct Tooth-Colored Materials
It is indicated for situations not necessitating aforementioned choices I and II.
The following should be done:
1. Recognize the access direction. This decision is dictated by esthetics (lingual)
and the extent of the destruction (either labial or lingual), as mentioned before.
2. Recognize the nature of the remaining enamel. As enamel can be used for
retention in some direct tooth-colored material restorations, its absence will dictate
other types of retention. If enamel is present, its thickness, configuration. and
undermined nature should be noted, especially around the defects. The existence of
hypoplasia and/or hypocalcification must he evaluated. If permanently and
conspicuously discolored enamel is to be eliminated, the operator must weight the
removal of such discoloration against the possibility of loss of retentive ability (see
Chapter 10).
3. The operator must strive to create a gingival floor in keeping with the
specifications previously mentioned (see chapter on direct tooth-colored materials).
The gingival floor must be prepared as pronounced, surfacewise, as possible. and at
a right angle to the long axis of the tooth, if possible (Figs. 46 and 47). It may he
prepared at different levels with different segments, if the destruction will not allow
only one level. The gingival floor must be placed as close to the loading location as
possible. It should contain the most locking retention means as possible, as it will be
in a location to best resist displacing forces. If the adjacent gingival enamel is
amenable to etching, the operator should create hollow-ground beveis to provide
more surface area for etching.
1. An effort to keep the incisal angle should be made. The loss of this angle will
drastically complicate the mechanical problems of the restoration. Maintaining the
viability of the angle is possible if the operator can at least keep part of it. refrain
from putting incisal retention if the incisal margin is close. and does not make any
angulation in the incisal wall that may undermine the incisal zingle or accentuate the
incisoaxial angle if it comes close to the incisal angle.
If possible. the operator should create a labial anc.For lingual wall, a vitally important
criterion for the retention and resistance of the restoration (if it is intracoronali as well as
for
the remaining tooth structure. The possibility of these walls should be evaluated
according to the following criteria:
Could the 'preparation have both labial and lingual walls or only one? If it can only have
one, will it be at the occluding or non-occluding side? Of course, two walls are
preferable to one. But if only one is possible, it is preferable to have it on the occluding
side rather than on the non-occluding side. In both preferred situations, it will be
possible to have occluding forces indirectly delivered to the restoration. Accordingly, the
presence of these walls dramatically improves the resistance and retention forms.
Can the wall(s) he one- or two-planed? Of course, two planes with one of them at a right
(acute) angle to the axial wall are more resisting and retaining than one plane
diverging proximally. A one-planed wall at a right qacute) angle to the axial wall will be
the most advantageous, but it may be impossible to prepare because of anatomic and
cariogenic limitations.
The more that the anticipated axio-proximal dimensions of the walls are, the better will
he the resisting and retaining capability of these walls.
The more that the anticipated inciso-gingival dimensions of the walls are, the better will
he their retaining capabilities.
An increased percentage of undermined enamel in the wall will increase retention form,
but will concurrently reduce the resistance capability .)f the replacement—tooth
structure cotnplex.
The larger that the angle at which the labial and lingual walls meet incisally is. the better
will be the resistance form of the restoration (foundation). This is because they will ac-
,commodate bulkier material there. In addition, there will be a greater possibility of
accommodating a bulky incisal retention form within this angle.
The more right or acute-angled that the junction is between the labial and lingual walls
with the axial wall, the more will be the retention form.
As the area of the anterior tooth just incisal to the ccmento-enamel junction is the
bulkiest portion of this tooth. if the labial and lingual walls involve part of this bulky
area, they can accommodate a sizable retention form.
Similarly, the amount of dentin the labial and lingual walls contain affects the size of
retention grooves that can be placed • in each without undermining any enamel,
If it is necessary to create better labial and lingual walls. extend the gingival floor
apically, involving sound tooth structures to accommodate at least short labial and
lingual walls. Every surrounding wall in any dimension will add to the resistance-
retention of the restoration-tooth structure complex.. Furthermore, their effect is
cumulative.
The labial and lingual walls should create rounded line and point angles with the axial
walls.
Prepare and condition the enamel circumferential to the destruction (preparation) in the
way described in a chapter on direct tooth-colored restorations.
With the exception of enamel etching. these items can be applied when preparing the
tooth for a foundation prior to the reinforcing protecting restorations.
The rest of the principles arc as described for posterior
teeth, and arc in the chapters on direct tooth-colored restorations.
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Charbenear et al.: Principles and practice of operative dentistry. Philadelphia, Lea and
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Gilmore, H.W., et al.: Operative Dentistry. 3d ed. St. Louis. The C.V. Mosby Co., 1977.
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