Fixed Prosthodontics

(Principles of tooth preparations)

22 pages

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 Principles of tooth preparations
The principles of tooth preparation for a fixed restoration may be divided
into five principles:

1. Preservation of tooth structure

2. Retention and resistance

3. Structural durability

4. Marginal integrity

5. Preservation of the periodontium

6. Aesthetics.

1. Preservation of Tooth Structure

In addition to replacing lost tooth structure, a restoration must preserve
remaining tooth structure.

This must be balanced with the criteria for retention and resistance and
structural durability.

It must be design restoration to reinforce and protect remaining tooth

structures.

Tooth structure is conserved through adherence to the following guidelines:

1. use of partial-coverage rather than complete-coverage restorations.

2. Preparation of teeth with the minimum practical convergence angle
(taper) between axial walls.
3. Preparation of the occlusal surface so that reduction follows the
anatomic planes to give uniform thickness in the restoration.
4. Preparation of the axial surfaces so that at maximal thickness of
residual tooth structure surrounding pulpal tissues is retained. If
necessary, teeth should be orthodontically repositioned.

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 5. Selection of a margin geometry that is conservative and yet
compatible with the other principles of tooth preparation.
6. Avoidance of unnecessary apical extension of the preparation. Apical
extension of the preparation can necessitate additional tooth reduction
because coronal diameter becomes smaller.

2. Retention and Resistance

For a restoration to accomplish its purpose, restoration must stay in place on
the tooth.

Retention: Certain forces (e.g., when the jaws are moved apart after biting
on very sticky food) act on a cemented restoration in the same direction as
the path of placement.

Retention prevents removal of the restoration by such forces parallel to the

path of insertion or the long axis of the tooth preparation.

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Resistance prevents dislodgment of the restoration by forces directed in an
apical or oblique direction and prevents any movement of the restoration
under occlusal forces.

Retention and resistance form depends on the following factors:

1. Taper of opposing walls

2. Freedom of displacement
3. Length of opposing walls
4. Circumference of the tooth
5. Auxiliary Retention
6. Path of insertion

1. Taper of opposing walls

Because a cast metal or ceramic restoration is placed on or in the prepared
tooth after the restoration has been fabricated in its final form, the axial
walls of the prepared tooth must taper slightly to permit the restoration to
seat; ie, in the occlusal direction, two opposing external walls must gradually
converge or two opposing internal surfaces of tooth structure must diverge.

The terms angle of convergence and angle of divergence (taper) can be

used to describe the respective relationships between the two opposing walls
of a preparation.

The relationship of one wall of a preparation to the long axis of that

preparation is the inclination of that wall.

A tapered diamond bur will impart an inclination of 2 to 3 degrees to any

surface it cuts if the shank of the instrument is held parallel to the intended
path of insertion of the preparation (or the long axis of the tooth).

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Two opposing surfaces, each with a 3-degree in the clination, would give the
preparation a 6-degree taper.

A, diamond is tipped away from the path of placement, resulting in an

undercut; B, the diamond is tipped into the tooth too far, leading to an
excessively tapered preparation.

The more nearly parallel the opposing walls of a preparation, the greater
should be the retention. The most retentive preparation should be one with
parallel walls.

Indeed, parallel walls are impossible to create in the mouth without

producing preparation undercuts.

Preparation walls are tapered to:

1. allow their visualization,

2. prevent undercuts,
3. compensate for inaccuracies in the fabrication process,
4. and permit more nearly complete seating of restorations during
cementation.

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 As taper increases, retention decreases.

2. Freedom of displacement
Retention is improved limiting number of paths of insertion. Maximum
retention is achieved when there is only one path. A full veneer preparation
with long, parallel axial walls and grooves would produce such retention.

On the opposite extreme an overtapered preparation would be without

retention because the restoration could be removed along an infinite number
of paths.

3. Circumference of the tooth

A full crown preparation is more retentive on a molar than on a premolar,
because the molar preparation has greater surface area.

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4. Length of Opposing Walls
Occlusogingival length is an important factor in both retention and
resistance. Longer preparations will have more surface area and therefore
will be more retentive.

The longer the wall the greater the retention if all other factors are equal.

Because the axial wall (occlusal to the finish line) interferes with
displacement, the length and inclination of that wall become factors in
resistance to tipping forces.

For the restoration to succeed, the length must be great enough to interfere
with the arc of the casting pivoting about a point on the margin on the
opposite side of the restoration (Fig a). The shorter wall does not afford this
resistance (Fig b). The shorter the wall, the more important its inclination.

The walls of shorter preparations should have as little taper as possible to

increase the resistance. However, even this will not help if the walls are too
short. Minimum length of opposing axial walls is 3 mm.

It may be possible to successfully restore a tooth with short walls if the tooth
has a small diameter. The preparation on the smaller tooth will have a short
rotational radius for the arc of displacement, and the incisal portion of the
axial wall will resist displacement (Fig a). The longer rotational radius on
the larger preparation allows for a more gradual arc of displacement, and the
axial wall does not resist removal (Fig b).

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5. Auxiliary Retention
Resistance to displacement for a short-walled preparation on a large tooth
can be improved by placing grooves, boxes, or pinholes in the axial walls. In
effect, this reduces the rotational radius, and the portion of the walls of the
grooves near the occlusal surface of the preparation will interfere with
displacement.

6. Path of insertion
The path of insertion is an imaginary line along which the restoration will be
placed onto or removed from the preparation.

It is determined mentally by the dentist before the preparation is begun, and

all features of the preparation are cut to coincide with that line.

It is of special importance when preparing teeth to be fixed partial denture

abutments because the paths of all the abutment preparations must parallel
each other.

The correct technique must be used to survey a preparation visually because

if the center of the occlusal surface of a preparation is viewed with one eye
from a distance of approximately 30 cm (12 inches), it is possible to sight
down the axial walls of a preparation with a minimum taper.

However, it is also possible to sight down the axial walls of a preparation

with a reverse (ie, undercut) taper of 8 degrees when both eyes are open. If
both eyes are open when the preparation is viewed, undercuts may remain
undetected.

Preparations in the mouth are viewed through a mouth mirror. It is held at an

angle approximately ½ inch above the preparation, and the image is viewed
with one eye.

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The path of insertion must be considered in two dimensions: faciolingually
and mesiodistally.

The faciolingual orientation of the path is roughly parallel with the long axis
of the teeth.

The mesiodistal inclination of the path must parallel the contact areas of
adjacent teeth. If the path is inclined mesially or distally, the restoration will
be held up at the proximal contact areas (ie, locked out).

3. Structural Durability
A restoration must contain a bulk of material that is adequate to withstand
the forces of occlusion. This bulk must be confined to the space created by
the tooth preparation.

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Only in this way can the occlusion on the restoration be harmonious and the
axial contours normal, preventing periodontal problems around the
restoration.

I. Occlusal reduction

One of the most important features for providing adequate bulk of metal and
strength to the restoration is occlusal clearance.

I. Full metal:
A. 1.5 mm functional cusp
B. 1.0 mm nonfunctional cusp
II. Metal-ceramic:
A. 1.5 - 2.0 mm functional cusp
B. 1.0 - 1.5 mm nonfunctional cusp
III. All-ceramic: 2.0 mm of clearance

The basic inclined plane pattern of the occlusal surface should be duplicated
to produce adequate clearance without overshortening the preparation.

A flat occlusal surface may overshorten a preparation that is already of

minimal length to provide adequate retention.

A. Inadequate clearance makes a restoration weaker.

B. In addition, inadequate reduction under the anatomical grooves of the
occlusal surface will not provide adequate space to allow good
functional morphology.
C. The restoration also will be much more easily perforated by finishing
procedures or by wear in the mouth.

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II. Functional cusp bevel

An integral part of the occlusal reduction is the functional cusp bevel.

A wide bevel on the palatal inclines of the maxillary palatal cusps and the
facial inclines of mandibular facial cusps provides space for an adequate
bulk of metal in an area of heavy occlusal contact.

If a wide bevel is not placed on the functional cusp, several problems may
occur.

Lack of a functional cusp bevel can cause a thin area or perforation

in the casting.
I. If the crown is waxed and cast to normal contour, the casting will be
extremely thin in the area overlying the junction between the occlusal
and axial reduction. To prevent a thin casting when there is no

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 functional cusp bevel, an attempt may be made to wax the crown to
optimal thickness in this area.

Lack of a functional cusp bevel may result in overcontouring and

poor occlusion.

II. An overcontoured restoration will result, and a deflective occlusal

contact is likely to occur unless the opposing tooth is reduced.

Overinclination of the facial surface will destroy excessive tooth

structure and lessen retention.

III. If an attempt is made to obtain space for adequate bulk in a normally

contoured casting without a bevel,
A. the result will be an overcut axial surface.
B. In addition to the unnecessary destruction of tooth structure,
C. the severe inclination of the surface renders it useless for
retention.

III. Axial reduction

Axial reduction also plays an important role in securing space for an

adequate thickness of restorative material.

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If restorations are made with normal contours over preparations with
inadequate axial reduction:

o they will have thin walls that will be subject to distortion.

o Laboratory technicians often attempt to compensate for this by
overcontouring the axial surfaces.
o While this intended solution to the problem strengthens the
restoration, it can have a disastrous effect on the periodontium.

Inadequate axial reduction can cause thin walls and a weak restoration (a)
or a bulbous, overcontoured restoration (b).

4. Marginal Integrity
The restoration can survive in the biologic environment of the oral cavity
only if the margins are closely adapted to the cavosurface finish line of the
preparation.

Finish line configurations

1. Knife Edge
2. Chamfer
3. Heavy Chamfer
4. Shoulder (Classic shoulder)
5. Modified Shoulder (Radial shoulder)
6. Radial shoulder with a bevel

The configuration of the preparation finish line dictates;

a. the shape and bulk of restorative material in the margin of the

restoration.
b. It also can affect both marginal adaptation
c. and the degree of seating of the restoration.
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Advantages and disadvantages of finish lines
Knife Edge
Acute margin of metal.

Its advantage is conservative of tooth structure and less destruction of tooth

structure.

Disadvantages

A. does not provide sufficient bulk of restorations

B. Lack of axial reduction:

1. results in overcontour of final restoration which leads to periodontal

inflammation,
2. or a casting that is very thin and weak, susceptible to distortion under
occlusal forces.

C. Location of margin difficult to control:

- The thin margin of the restoration that fits this finish line may be difficult
to accurately wax and cast.

Indications

I. Not recommended
II. Sometimes on tilted teeth. Indicated only on axial wall toward tooth is
tipped-preservation of tooth structure.

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Chamfer
a. Cavosurface angle is a 90-degree
b. with a rounded internal angle
c. Chamfer depth is from 0.3-0.7 mm
d. Even axial depth
e. Follow gingival contours

It can be cut with the tip of a round-end tapered diamond (1.2 mm) (Tapered
torpedo finishing diamond) while the axial reduction is being done with the
side of that instrument.

Advantages

1. Conservative type when compared with shoulder finish line.

2. Distinct margin
3. Adequate bulk
4. Easier to control
5. This finish line exhibit least stress to the underlying cement (Minimal
stress within cement film).

Disadvantages

I. Care needed to avoid unsupported lip of enamel. This unsupported

enamel is very easily fractured during or after cementation of the
restoration.
a. It can be cut with round-end tapered diamond with diameter 1.2
mm at the tip.
b. Tip of a round ended diamond with simultaneous axial
reduction.

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 (a and b) Lip formation.

Indications

1. Ideal for all metal restorations,

2. lingual margin of metal-ceramic crowns.

Heavy chamfer (Deep chamfer)

a. It is used to provide a 90-degree cavosurface angle
b. with a large-radius rounded internal angle.
c. Its depth is from 1.0- 1.2 mm
d. Even axial depth
e. Follow gingival contours.

It can be cut with the tip of a round-end tapered diamond (1.6 mm) while the
axial reduction is being done with the side of that instrument.

Advantages

1. It provides sufficient bulk for a ceramic crown

2. Support of the ceramic with a stress-reducing.

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Disadvantages

I. It can create a lip of enamel at the cavosurface.

II. Less conservative of tooth structure.

Indications

1. For all-ceramic crown. It provides better support for a ceramic crown

than a chamfer,
2. But it is not as good as modified shoulder.

Shoulder (Classic shoulder)

a. 90-degree angle at cavosurface and internal angel
b. depth from 1.0-1.2 mm
c. Even axial depth
d. Follow gingival contours

It is accomplished with flatend tapered diamond (1.4 mm).

Advantage

Bulk of restorative material

Disadvantages

1. Stress concentration at the 90° internal line angle.

2. Less conservative of tooth structure
3. Not for all metal restorations
4. Not for all ceramic restorations.

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Indications

Used for

I. Facial of PFM crowns ( porcelain fused to metal crowns) where

maximum esthetics desired
II. Metal inlays and onlays.

Modified shoulder (Radial shoulder)

a. A small rounded internal angle.
b. The cavosurface angle is 90-degees.
c. It is accomplished with flat- end tapered diamond,
d. depth from 1.0-1.2 mm
e. Even axial depth
f. Follow gingival contours

It is accomplished with flatend tapered diamond (1.6 mm), with a small-

radius rounded internal angle.

Advantages

1. Stress concentration is less in the tooth structure than with a classic

shoulder,
2. and support for ceramic restoration walls is good.

Disadvantage

- less conservative of tooth structure.

- The destruction of tooth structure required for this configuration is not
significantly less than that required for a classic shoulder.

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Indications

I. For all ceramic restorations

II. and for metal ceramic restorations.

Not :
For all- ceramic crown preparation:

Deep (heavy) chamfer

- Provide 90- degree cavosurface angle

- With large radius rounded internal angle.

Modified (Radial) shoulder

- Provide 90- degree cavosurface angle

- With small radius(rounded) internal angle.

Radial shoulder with a bevel

Adding a bevel to a shoulder creates acute edge of metal at the margin.

Shoulder with a bevel on the occlusal shoulder of an MOD onlay.

Indications

I. It is utilized as the gingival finish line on the proximal box of

inlays and onlays and for the occlusal shoulder of onlays

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 II. and mandibular three-quarter crowns.
III. This design can also be used for the facial finish line of metal-ceramic
restorations where gingival esthetics is not critical.

Advantages

1. Excellent crown
2. Strength
3. Less stress than classic shoulder

Disadvantages

1. Destructive of tooth
2. More stress than chamfer
3. Poor esthetics (necessitates metal collar)

5. Preservation of the Periodontium

The placement of finish lines has a direct bearing on the ease of fabricating
a restoration and on the ultimate success of the restoration.

The best results can be expected from margins that are as smooth as possible
and are fully exposed to cleansing.

Whenever possible, the finish line should be placed in an area:

a. where the margins of the restoration can be finished by the dentist

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 b. and kept clean by the patient.
c. In addition, finish lines must be placed so that they can be duplicated
by the impression, without tearing or deforming the impression when
it is removed past them.

Finish lines should be placed in enamel when it is possible to do so.

In the past, the traditional concept was to place margins as far subgingivally
as possible, based on the mistaken concept that the subgingival sulcus is
caries free. The practice of routinely placing margins subgingivally is no
longer acceptable. Subgingival restorations have been described as a major
etiologic factor in periodontitis.

The deeper the restoration margin resides in the gingival sulcus, the greater
the inflammatory response.

Caution should be exercised if conditions require that the finish line be

placed any closer to the alveolar crest than 2.0 mm, which is the combined
dimension of the epithelial and connective tissue attachments.

Placement of a restoration margin in this area probably will result in gingival

inflammation, loss of alveolar crest height, and formation of a periodontal
pocket.

Crown lengthening may be performed to surgically move the alveolar crest

3.0 mm apical to the location of the proposed finish line to guarantee the
biologic width and prevent periodontal pathology. This will allow space for
the connective and epithelial attachments and a healthy gingival sulcus.

Marginal geometry
For evaluation, the following guidelines for margin design should be
considered:

o Ease of preparation without overextension or unsupported enamel.

o Margins should be smooth and fully exposed to a cleansing action.
o Ease of identification in the impression and on the die. Margin
placement must allow duplication during impression procedures
without tearing or deforming the impression when it is removed.
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 o A distinct boundary to which the wax pattern can be finished.
o Sufficient bulk of material of the crown margins.
o Margins should be placed where the dentist can finish them and the
patient can clean them.
o Supragingival placement of finish lines whenever possible!
o Finish line should be placed in enamel if possible.
o Subgingival finish lines 2.0 mm from alveolar crest (combined
dimension of epithelial and connective tissue attachments).

Many situations in which sub-gingival margins are unavoidable.

Subgingival margin is justified if any of the following depend on:

1. Dental caries, cervical erosion, or restorations extend subgingivally,

and a crown-lengthening procedure is not indicated.
2. Additional retention and /or resistance is needed.
3. The margin of a metal-ceramic crown is to be hidden behind the
labiogingival crest (Esthetics).
4. Root sensitivity cannot be controlled by more conservation
procedures, such as the application of dentin bonding agents.
5. Modification of the axial contour is indicated. Such as to provide an
undercut to provide retention for the clasp of a partial removable
dental prosthesis.
6. Extension of previous restoration.

The advantages of supragingival margins include the following:

1. They can be easily finished without associated soft-tissue trauma.

2. They are more easily kept plaque free.
3. Impressions are more easily made, with less potential for soft tissue
damage.
4. Restorations can be easily evaluated at the time of placement or at
recall appointments.
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