The second part of lecture #1: PFM bridges overview

# Note before starting: Focus on any material/technique that is used in our clinics!

In the second clinical visit, and after you’ve finished the preparation, you need to provide your patient with a
temporary bridge. There are basically two ways to fabricate a temporary bridge, the one that we will be using in our
clinic is the “Direct “technique, there is another way that is called the “indirect” technique, both have some
advantages and disadvantages:

Direct technique Indirect technique

# This technique is done chair-side using an index that # This technique is done in the lab where the technician
has been prepared over the diagnostic cast with the prepared a temporary bridge on the cast, finishes it,
wax-up, we simply fill the index with temporary bridge polishes it and send it back to your clinic for
materials and place it over the teeth, finish, polish and cementation.
cement.
# Advantages:
# Bis-acryl composite resin is used in our clinics • Stronger
• More accurate
# Alternative resins are Polyethyl methacrylate, • More aesthetic
Polyvinylethyl methacrylate, and VLC urethane • protects the pulp from the setting reaction of
dimethacrylate the materials “ heat release and residual
monomers”
# Polymethyl methacrylate must be avoided in direct • Stronger materials can be used
technique because it releases heat “exothermic
reaction” and can irritate the pulp with the free residual # Disadvantages:
monomers • Require more time
• More expensive
# Advantages:
• takes less time to fabricate and it’s
more practical.

# Disadvantages:
 • Less accurate
• Can expose the pulp to heat and residual
 monomers while the material is setting
• If you wait till the material sets to remove the
index the material will shrink and gets locked
in the undercuts and the interproximal spaces


# The reasons why we should provide the patient with temp. Bridge:

• To prevent any occlusal instabilities like drifting, tilting and supra eruption

• To Cover the exposed dentine “if there’s any” and to protect the prepared tooth tissue until the final
 restoration is ready
• Aesthetic and function

• Extra note: Make sure that your temporary bridge is well made, finished, polished, accurate and of good
fit, because if it was not of a good fit it can lead to gingival inflammation and make isolation for the final
impression hard due to bleeding.

# Question: What to do if you only finished preparing one tooth during your clinic? How to temporize this?

• You can block out the pontic space with utility wax and only fill the impression where you’ve finished
preparing and you’ll end up with a temporary crown instead of a bridge! :D
# How do we cement our temporary bridge?

• Since the bridge will be removed in weeks’ time then we need a material that is not very strong to make it
easy to remove the bridge for treatment continuation, the one that we use in our clinics is Zinc-oxide
eugenol (Temp Bond) cement. Make sure to check the occlusion and to remove any excess cement from
between the teeth

# Important note: If you are doing an all-ceramic restoration DO NOT use any cement that contains eugenol
because it will inhibit the polymerization of the resin-based permanent cement. Make sure that you use eugenol-
free if you’re using such materials for your final restoration.

After the cementation of the bridge the second clincial step should be over, with that we will move to the second lab
steps as shown in this table:

# After the final impression is sent to the lab the technician will pour it using a strong material such as high
strength type IV or V stone. The die system that we use in our centre is called (Pindex system), which is a
removable die system attached to the working cast.

# To make things clear we should differentiate between a die and a working cast, a working cast: is the cast that
is mounted on an articulator and is used in the fabrication of wax pattern but a die: is a model of the individual
prepared teeth on which the wax pattern is initially built (coping) and margins are finished

# The next step will comprise of the same steps for any metal restoration:

1- wax build up to form a wax bridge

2- spruing “Multiple spruing” meaning a sprue for each tooth
3- investing
4- burning out
5- casting metal
# As a quick revision of what each step of those mean read the following definitions:

• Investing: surrounding the wax pattern with a material that can accurately duplicate its shape and
anatomical features “will give a negative replica of the wax pattern after the burn out of the wax”

• Burnout: removal of the wax pattern so that a mould (space) is created into which the molten alloy can
 be placed
• Casting: introducing the molten alloy into the previously created mould (space) by burnout

# As mentioned in the previous clinical and lab steps table the following thing to do is metal frame work try-in, it
is a common mistake for a lot of practitioners to skip this step, but why is it a bad practice to skip it?

• Simply: if you skip the metal framework try in and you end up with a faulty restoration, you will not be able
to figure out what went wrong, was it the metal or the porcelain? And even if you could identify in which
component the problem was, fixing it will not be as easy as you think! So it is always to

individually check the metal framework, to exclude any mistakes in it and if there
were any, fixing them would be a lot easier!

# What to check in the metal framework try-in clinic?

• Metal framework should fully seat on prepared abutments with precise marginal fit
(no gaps) and no rocking

• Retention and resistance should be satisfactory, what are the problems that can lead
to bad retention or resistance? * over tapered or a very short preparation. OR:
excessive relief die spacer during the restoration fabrication

• Occlude spray can be used to check for porosities or pressure points that might
 prevent full seating, this material works such as pressure indicating paste,
but for metal , the material will be displaced in areas of high
pressure “please be familiar with how the can of this spray looks
like as you might be asked about it in VIVA exams”

• Ideally, thickness of framework should be 0.5 mm to allow for
sufficient thickness of porcelain, How do we check that? Using
a metal caliber (gauge), you use it as shown in the picture, the

circled part is the part of the instrument that is placed on the bridge thickness “there will be a question
 about this instrument in the midterm exam. Make sure that you don’t over trim the metal, w minimally need
0.4mm, below that it’s not accepted

• Check there is enough clearance for porcelain occlusally, there should be no occlusal contacts on the metal
framework in occlusion

• If you did not articulate the casts yet then take a wax registration “in the reality, it too late to do wax
registration in this step, ideally it should be done when casts are articulated before the framework
fabrication, this is why you can see articulation in more than one step”

# The next step is shade selection, which is a very wide topic but it will be covered shortly in this lecture:

• Ideally speaking; shade selection should be done early before teeth preparation because teeth will be
dehydrated and look whiter. Plus, the more late you are the more tiered your eyes will get, thus you won’t
be able to see colours correctly. As you previously know, shade selection should be done in natural day
light for more accurate matching. Make sure that you don’t “stare” at teeth, try to do short quick looks and
to always involve the patient in selecting shades. Providing the technician with photos or old records can be
 very helpful.
• We use Vita classic shade guide in our clinics
 • Vita classical shade guide comprises four different hues A, B, C, & D, each group is divided in different
 chroma degrees:
 1- A1 - A4 (reddish-brownish)
 2- B1 - B4 (reddish-yellowish)
 3- C1 - C4 (greyish shades)
4- D2 - D4 (reddish-grey)

• Commonly using this shade, A2 is suitable for younger patients, A3 is suitable for middle aged patients,
 A3.5 is suitable for older patients
• Other guides are arranged according to value and subdivided according to hue

# Next step: Porcelain addition

• We should do heating of the metal coping in order to form oxides

(oxidation) to bond with oxides in opaque porcelain (chemical
 bonding)
• Metal coping is covered with three layers of porcelain:
1- Opaque porcelain: conceals the metal underneath, initiate the
development of the shade, important for development of the bond
between ceramic and the metal
2- Dentin or body porcelain: makes up the bulk of the restoration,
providing most of the colour, or shade
3- Enamel or incisal porcelain: imparts translucency to the restoration

# After completing the layering we move to Porcelain surface treatment (glazing and polishing)

• Chairside stain might be requested, if so, then the final glazing will be postponed until bridge is evaluated in
 patient mouth. The doctor prefers that staining is done in the insertion visit.
• There are two ways to glaze the bridge:

1- Natural or auto-glaze: Porcelain has the ability to glaze itself when held at its fusing temperature under
 air for 1 to 4 minutes
 2- Applied overglaze: A low fusing clear porcelain is used
• We then do polishing, which is used on relatively small areas of adjustments

# The final clinical step: Evaluation of final bridge and cementation

• You should re-check everything like full seating with no gaps, Retention and resistance, Proximal contact
areas should be flossable “not tight and not opned” Check the occlusion, shade and aesthetics.

• One of the MOST IMPORTANT things to look at is the proximal areas because technicians usually trim the
surrounding teeth on the cast to be able to work properly.

# How to adjust the occlusion before cementation?

• Articulating papers can be used


• Occlusion should be checked in ICP and excursions, patient can easily feel high restorations in the ICP
 position
 • Check for displacement of the restoration in an excursion, because this is indicative of interferences
• Occlusal contacts should be checked with shimstock or mylar strip

• Make sure to check the occlusion and contact on the bridge side and the opposing side, checking only the
 bridge is a common mistake
 • Occlusal stability should be checked – centric stops and adequacy of contacts points
 • Suitable mounted stones or diamond burs can be used for adjustments
• Porcelain can be finished with mounted points or discs Cementat
# Cementation of the final bridge

• Some consider temporary cementation of the final bridge in case of any problems just as a try-in period of
 the final restoration
• For permanent cementation, glass ionomer (ketac Cem) cement is used in our clinics

• Alternatives are zinc phosphate, zinc polycarboxylate, resin-modified glass ionomer, and resin-based luting
 cements
• Teeth should be dry before cementation

• Powder and liquid are mixed according to manufacturer instructions and applied into the fitting surface
 of bridge
• Bridge is seated and finger pressure is applied

• Remove excess cement and floss proximal contacts areas after initial set of cement (finger pressure should
 be maintained, don’t stop, because the cement is not yet fully set so the bridge can still move in this step)
• Recheck occlusion before POI and discharge of patient



# Done and edited by: Raneem Malkawi