PROSTHO

III NOTES Annemijn Dijs

UNIT 1. GENERAL CONCEPTS IN FIXED PROSTHETICS

Concept of fixed denture
Fixed prosthesis Removable prosthesis
Can’t be removed (except by the dentist Can be removed by the patient in order to
cutting it) clean it
Requires a previous tooth preparation Doesn’t require a previous dental
preparation (excepts RPDs sometimes)
Requires cement between tooth and Doesn’t require cement
restoration
Materials: porcelain and/or metals Materials: acrylic resin and / or metals
Tougher and abrasive More flexible
Better hygiene Worse hygiene
More comfortable Foreign body sensation
Easily accepted by the patient Worse acceptance by the patient

Fixed Removable

Tooth supported Tissue supported

COMPLETE

Implant supported

Implant supported

Implant retained
(e.g. implant
overdenture)


Tooth supported Tooth supported
Tissue supported
PARTIAL Tooth-tissue supported


Implant supported

• They replace tooth structure
• They are inert (no biological reaction to them)
• Friction retention
• Cement only fills the space between restoration and implant/tooth

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Purposes of fixed dentures
• Therapeutic
- Correct some of the consequences of edentulism
- Help recover from muscular pain, TMJ pain... à even though we have to keep in
mind that only 20% of TMD’s are related to occlusal disorders
• Preventive
- Prevent the appearance of further occlusal pathology, periodontal pathology and
caries
• Restorative of lost function
- Mastication
- Phonation
- Aesthetics
Exam
Indications and contraindications
Indications Contraindications
• Psychological (irreversible)
• Psychological (easy to adapt to) • Systemic diseases
• Systemic disease • Poor oral hygiene
General • Prevention of tooth migrations • Lack of cooperation
• Periodontal reasons • Macroglossia
• Aesthetics • Age
• Oral function alteration • High cariogenicity
• General gingival hypertrophy
• Advanced periodontal disease
• Protection of weak teeth
• Replacement of lack of teeth • Bad prognosis for the abutment
Local • Recovery of space caused by teeth
migrations • Length of the edentulous space
• Tooth shape alterations • Shape of the edentulous space
• Tooth position alterations • Prosthetic space
• Colour alterations • Previous pathology
• Traumatisms

ü General indications
1. Psychological factors
• A fixed denture (FD) integrates immediately in the patient’s mouth (thanks to
temporary FD)

2. Systemic diseases
• Diseases that imply risk of chocking with removable denture
- Epilepsy à requires metal occlusal surfaces
• Hindered oral hygiene
- Low intelligence quotient à FDs retain less
dental plaque than RDs

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 3. Prevention of tooth migrations
• Performing a bridge right after the extraction of a 36 or 46
prevents the migration and rotation of a 37 or 47

4. Periodontal reasons
• A FPD can make the tooth receive axial forces instead of lateral
forces, which prevents occlusal trauma

5. Aesthetic reasons
• Even though a FD doesn’t replace soft tissue or bone loss

6. Oral function alteration
• Phonetics due to lack of teeth
• TMD’s related to occlusal instability

ü Local indications
1. Tooth position alterations
• To make teeth receive axial loads
• To provide a good path of insertion for RPDs

2. Colour alterations
• Intrinsic
• Extrinsic

O General contraindications
1. Psychological reasons
• The patient must be able to accept that FDs are irreversible treatments

2. Systemic diseases
• Cardiopathies
• Allergies
• Facial paralysis
• Parkinson’s disease
• Haemophilia

3. Age
• Very young patients
- Big pulp chambers
- Alternative to conventional FPD: Maryland bridge

• Very old patients
- Lack of cooperation
- Physical condition
- Alternative: preformed crowns

3
O Local contraindications
1. Bad prognosis of abutment teeth
• Crown
- The longer the better the prognosis
- Endodontic treatment à poorer prognosis
- Tooth mobility à very bad prognosis

• Root
- Radiolucent periapical images
- Root resorption
- Hypercementosis
- Crown-to-root ratio (minimum 1/1)
- Number, shape and location of roots

2. Length of the edentulous space
• Maximum 2 consecutive missing teeth
• Exception à lower incisors

3. Shape of the edentulous space
• The more curved the arch, the worse the prognosis
• Never splint the whole arch with FDs

4. Prosthetic space
• Increased à e.g. traumatism
• Decreased à e.g. tooth extrusion

5. Previous bone or soft tissue pathology

Types of fixed restorations

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Ø Multiple teeth restoration à bridges
• Consist of two retainers, one pontic which are connected
through the connectors

ü Retainers
- Full coverage crowns
- Partial coverage crowns
- Inlays / onlays
- Metal backing of Maryland bridges

ü Pontic
- Artificial teeth supported by the abutment teeth

ü Connectors
- Elements that join retainers to pontics
- Rigid
- Interlocks and attachments

Ø Implant supported fixed restorations
• Single tooth // multiple teeth
• Screwed // cemented

Selection criteria
1. Remaining clinical crown
• Central tooth structure loss à Inlays / Onlays
• Peripheral tooth structure loss à Crowns

2. Aesthetics
3. Plaque control
4. Economic considerations
5. Retention

Ø Intracoronal restorations
Small lesions Medium lesions Big lesions Aesthetic
concern
Metallic inlay YES YES NO NO
Ceramic inlay YES YES NO YES
Onlay NO YES YES YES

Ø Extracoronal restorations
• Full metal crowns
- Multiple axial walls missing
- Unaesthetic
- Conservative preparation

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 • Porcelain fused to metal crowns
- Multiple axial walls missing
- Aesthetic

• All-ceramic crown
- Medium to low occlusal load
- Maximum aesthetic needs

• Porcelain veneers
- No tooth destruction
- When there are colour, size, shape or moderate position alterations

Materials
1. Metallic materials
• High noble alloys (former precious alloys)
• Noble alloys (former semiprecious alloys)
• Titanium and titanium alloys
• Predominantly base alloys (former non-precious alloys)
Note: Zirconia is a white metal

2. Non-metallic materials
• Acrylic resins
• Porcelains

3. Combination of materials
• Porcelain fused to metal
• Metal-acrylic

Ø Desirable characteristics
• Rigidity and toughness
• Good fit
• Adequate hardness
• Wear resistance
• Low thermal expansion coefficient
• Good aesthetics
• Good colour stability
• Biocompatible
• Easy polish and handling
• Low cost

ü Pure gold
• Advantages
- Very tough
- Cushions occlusal loads
- Easy casting and burnishable (polijstbaar) à good fit
- No corrosion
- Low abrasiveness

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 • Disadvantages
- Bad aesthetics
- Cannot be bonded to porcelain
- Soft
- Easily abraded
- Cost

• Indications
- Prefabricated posterior crowns
- Posterior inlays / onlays
- No aesthetic concern

ü Metallic alloys
• High noble alloys
- Noble metals content; Au [Gold], Pd [Palladium], Pt [Platina] > 60%
- Au content > 40%
• Noble alloys
- Noble metal content 25-60%
- Usually alloys mainly made of Ag [Silver] and Pd [Palladium]
• Predominantly base alloys (non-noble alloys)
- Noble metal content < 25%
- Usually Cr [Chromium]-Ni [Nickel] alloys
• Titanium and titanium alloys
- Titanium content > 85%

O High noble and noble alloys vs. pure gold
• Harder
• More rigid
• More abrasion resistant

O High noble and noble alloys vs. non-noble alloys (advantages)
• Easier and more accurate cast à better fit
• Better polish
• Less corrosion
• Lower abrasiveness

O High noble and noble alloys vs. non-noble alloys (disadvantages)
• More expensive
• More flexible
- Is only a disadvantage for long bridges à veneering porcelain can fracture
- In a long bridge, we would use base metal alloy because they’re stronger (e.g. 4
incisor bridge)
• Coping should be thicker than for PFM crowns
- 0.5mm instead of 0.3mm
- Require slightly more tooth preparation

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• Conclusion
- Always use high noble and noble alloys, except for long bridges, where Cr-Ni alloys
should be used

Ø Indications of metal alloys in fixed prosthetics
• Inlays
- Type I and II gold
• Partial coverage crowns
- Type III gold
• Full metal crowns
• Porcelain fused to metal crowns
• Porcelain fused to metal bridges
• Cast post and cores
• Type III gold

ü Acrylic resins
• Advantages
- Easy to handle
- Allows adding more material at different times à allows
relines
- Good initial aesthetics
- Low cost
• Disadvantages
- Low biocompatibility
- Porous
- Low strength
- Low abrasion resistance
- Ages with time
- Low colour stability
- Relatively bad marginal fit
- No chemical adhesion to metals
• Indications
a) Provisional crowns and bridges
- Short term provisionals (5-10 days) à self-curing
- Long term provisionals (2-3 months) à heat-curing
b) Occlusal splints
c) Veneer crowns à in disuse nowadays

ü Porcelains
• Advantages
- Colour stability
- Low plaque retention
- High hardness à 400 Brinell scaled vs. 300 for enamel
- Good marginal fit
- Low thermal conductivity
- Biocompatible
- Highly aesthetic

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 • Disadvantages
- Fragile à Low resistance to flexion, tension and transversal forces
- Require deeper tooth preparations (even more than PFM)
- Not flexible
- Abrades enamel if not well polished
• Indications
a) Anterior and posterior single-tooth restorations
b) Porcelain veneers at anterior teeth
c) Posterior inlays / onlays
- More abrasive than composite resin ones
d) Anterior and posterior short bridges without high
occlusal load

ü Porcelain fused to metal (PFM)
• Advantages
- Good mechanical properties due to chemical bonding
• Disadvantages
- Require deep tooth preparations
- Not as aesthetic as all-ceramic restorations
- Expensive when made of high noble and noble alloys
• Indications
a) Crowns
b) Bridges

ü Metal-acrylic restorations
• In disuse
• Veneer crowns / bridges
• Insufficient mechanical properties à only suitable when
antagonist is acrylic resin

ü High-end laboratory composite resins
• E.g. Adoro
• Indirect (made at the lab)
• Light-curing resin composite with a later heat-curing stage
• Advantages
- Tougher than usual direct composite resins
- Highly aesthetic
- Low abrasivity
- Can be used with or without reinforcing metal
framework
- Can be repaired

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UNIT 2. TOOTH PREPARATION IN FIXED PROSTHETICS I

Concept
• “The process of removal of diseased and/or healthy enamel and dentin and cementum to
shape a tooth to receive a restoration” (GPT)
• In fixed prosthetics, it’s the preparation to receive a fixed denture
• Irreversible removal of tooth structure
• Usually with high speed diamond burs
• Over those teeth that will be abutments of the fixed denture

• Double purpose
1. Provide space for the restoration, so it complies with
- Aesthetics
- Function
2. Have such a shape that it provides to the restoration the following
- Retention
- Stability
- Structural strength
• Two kinds of preparation principles
1. Biological
- Condition the future health of the surrounding tissues
- Prevent harm to oral structures during and after tooth preparation
- Preservation of as much tooth structure as possible
2. Mechanical
- Condition the behaviour of the restoration
- Retention
- Stability
- Path of insertion
- Structural strength
- Finish line (next lecture)

Biological principles
1. Preventive requirements
• The preparation has to comply with them in order to preserve the health of the
surrounding tissues
• During tooth preparation
A. Protection of adjacent teeth
- Use metal matrix and wood wedge
- Don’t touch the adjacent tooth with the bur
B. Protection of the periodontium
- Retraction cord (contains vasoconstrictor, temporary ischemia, watch thin bioptype)
- Avoid touching the gingiva with the bur (sharp burs best, so not too much pressure)
- At first, preparation should be done supragingivally, in the end, place the margin at
the desired height (supragingival only in posterior, easier and more hygienic)
C. Protection of the pulp
§ Thermal harm
- Preparation can lead to irreversible pulpitis or even pulp necrosis
- Water refrigeration
- High speed (high speed handpiece at full throttle) and intermittent strokes
- New burs and seal dentin with adhesives and provisionals (provisionals provide
aesthetics, less sensitivity and maintain space)

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 § Mechanical harm
- It means getting into the pulp with the bur
- It’s very important to know its anatomy (depends
on tooth, age) and the diameter of the burs
- Pulp exposure more likely in rotated, inclined or
extruded teeth
D. Protection of the surrounding soft tissues
- Tongue, lips, cheeks
- With mirror, ejector and cotton rolls

• After tooth preparation
A. Biological seal
- Fit between the margins of the restoration and the
margins of the preparation
- It impedes cement from dissolving and bacteria from
penetrating the space between them (caries)
B. Adequate emergence profile
- The restoration must have a contour similar to that of the natural
tooth à not overcontoured nor undercontoured
- Otherwise, dental plaque gathers and caries and periodontal
disease may occur
C. Respect the biological width
- Margin of the preparation should be at least 2 mm away from the
crest of the bone
- Otherwise, there is a chronical inflammation of the gingiva
- It’s the connective tissue + epithelial attachment (2mm), so you can
only prepare up to 0.5 – 0.6 mm subgingival

2. Preservation of tooth structure
• It’s very important to preserve as much tooth structure as possible
• Especially important in vital teeth (anaesthesia needed in vital teeth for preparing)
• Objective à not harming the pulp
- With heat from the bur
- Chemical irritation produced by certain cements
• For non-vital teeth
- Preserving tooth structure weakens the tooth less
• Summary
- Preserve pulp vitality
- Not weaken the tooth
• Every restorative material has its own ideal thickness
• The depth of the preparation will vary depending on it
• Due to that, it’s important to know the diameter of the burs

Mechanical principles
1. Retention
• The quality inherent to the dental prosthesis acting to resist the forces of dislodgment
along the path of placement (GPT = Glossary of Prosthodontic Terms)
• Provided by friction between opposite walls of the preparation and the restoration e.g.
between facial and lingual surfaces
• It’s NOT provided by the cement (except for porcelain veneers)
• The cement ONLY seals the interface between tooth and restoration

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 - External retention
- Between external surface of the preparation and internal
surface of the restoration
- For extracoronal restorations (convergent walls)
- Internal retention
- Between internal surface of the preparation and
external surface of the restoration
- For intracoronal restorations e.g. inlay, cast post-and-
core (divergent walls)

• Factors that influence retention
A. Magnitude of dislodging forces
- Caution with sticky food if there is something that
decreases the retention of the restoration (short die)
B. Fit of the restoration
- The better the fit, the greater the friction hence the
retention (good marginal adaptation required)
- Provided by good impressions and the quality of the
laboratory procedure
C. Cements
- Increase friction
- Provide micromechanical bonding
- None or almost no chemical bonding
- Has to be chosen regarding its solubility and the material of the restoration
- Cementation technique has an effect on retention
D. Morphology of the preparation
- Together with a good fit, it’s the most important factor
- Regarding this, there are some more factors
1. Conicity / taper
§ Determined by the convergence angle of
the preparation
§ More conical à more angle à less
retention
§ Less conical à less angle (more parallel
walls) à more retention
§ The problem with too parallel walls à piston
effect
- Cement would prevent the restoration form
getting to its ideal position
§ A slight conicity
- Allows the restoration to seat correctly
- Provides a good retention
§ Ideal conicity
- Total of 6º, that is 3º per wall
- It can be done manually with parallel
wall burs or using tapered burs
vertically
§ If the tooth is big, an increased conicity may be acceptable à molars 20º
(10º-10º) and premolars 14º (7º-7º)

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 2. Amount of surface of the preparation
§ The more surface, also the more friction
§ The greater the surface, the greater the retention
§ Factors that determine the surface
- Height à the higher, the more retentive
- Diameter à the more diameter, the more retention
§ If a tooth is short, height can be maximized by
- Moving the finish line apically
- Preparing the occlusal surface as little as possible
- Build boxes and guiding grooves
§ If a tooth is narrow
- Build boxes and guiding grooves
- Note that boxes and grooves are very invasive /
aggressive and the CAD/CAM can’t read the tooth
properly when they have indents like that
3. Coverage of the preparation (full or partial)
§ Full coverage crowns have more retention than partial-
coverage crown
4. Path of insertion
§ Having one single path of insertion increases retention
§ Path of insertion is enhanced by conicity
§ The more conical, the more paths of insertion the restoration has (but the
less retention, so a single path of insertion is ideal)
§ Also influenced by the quality of the impressions and laboratory work (fit
of the restoration)

2. Stability
• “The quality of dental prosthesis to be firm, steady, or
constant, to resist displacement by functional
horizontal or rotational stresses” (GPT)
• Depends on
- Magnitude of the forces
- Direction of the force
- Geometry of dental preparation
- Physical properties of the cement
• Lateral forces are
- Mainly produced by eccentric movements
- Suffered more by posterior teeth
- Increased in bruxists
• Principles to increase stability
A. Adequate conicity
- Leads the rotation radius to lay into the restoration
- Thus, the axial wall of the preparation prevents the rotation of the restoration
- At the same time, it provides a single path of insertion
B. Lateral boxes
- They limit the range of possible movements, thus increasing
stability
- They should be parallel to the path of insertion and convergent
towards the occlusal surface (to allow correct path of insertion)
- Used especially for short and wide teeth e.g. molars

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 C. Length-to-mesiodistal width ratio
- Height greater than MD width à increased stability
- Height smaller than MD width à decreased stability

- If a tooth is short, the following can be done to increase stability
§ Minimal conicity
§ Preparing boxes / grooves at the axial wall
§ Performing a crown lengthening procedure
§ Moving the finish line apically
§ Preparing the occlusal surfaces as little as possible
§ Lowering MD and labio-lingual width

D. Length-to-faciolingual width ratio
- Ratio should be 0.4
- At least 4 mm high for every 10 mm width

3. Path of insertion
• “The specific direction in which a prosthesis is placed on the abutment teeth or dental
implant(s)” (GPT)
• In order to increase retention and stability, there must be only one possible path of
insertion
• The optimum path of insertion must be considered throughout all the
dental preparation
• If any boxes / guiding grooves are prepared, they must match the path
of insertion too
• Ideally, it should be parallel to the axis of the tooth
• For tilted teeth à should usually be perpendicular to the occlusal plane
• The restoration has to be capable of being seated over the preparation
- For that reason, there should be a certain conicity (6º)
- From an occlusal point of view, all the preparation must be visible
• When the preparation is for a bridge, all the abutment teeth must share
the same path of insertion
• When an abutment tooth at a bridge is inclined
- Follow the inclination of the abutments that are not inclined, which
may imply having to make an endodontic treatment
- Another option is to perform orthodontic treatment previously
• The path of insertion has to take adjacent teeth into consideration à avoid harm





• The path of insertion has to be correct
§ Facio-lingually
- Especially important for anterior teeth
- If too labial à thin crown, too opaque OR adequate thickness, overcontoured
crown
- If too lingual à too short a preparation (low retention) or possible pulp invasion
§ Mesio-distally
- Adjacent teeth may prevent the crown / bridge from seating
- Adjacent teeth may be harmed during preparation

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 • How to visualize it
§ From an occlusal point of view
- With one eye only
- The following have to be visible: all the axial walls (but a small amount because of
small conicity) and all of the finish lines
- Otherwise there will be undercuts
- With direct vision or with a mirror at 45º
- For bridges, the inclination of the mirror has to remain the same

§ From a lingual / facial point of view

- With direct vision or a mirror
- Asses conicity

4. Structural strength
• To prevent deformation of the restoration
• Providing enough space for the restoration under occlusal load
• Made during the dental preparation
• Will depend on the material of the restoration

• Occlusal reduction
§ Should provide enough space
§ Metal crowns
- Functional cusps à 1.5 mm
- Non-functional cusps à 1 mm
§ Porcelain-fused-to-metal crowns
- Functional cusps à 2 mm
- Non-functional cusps à 1.5 mm
§ All-ceramic crowns
- Functional cusps à 2 mm
- Non-functional cusps à 2 mm
§ Should be done in planes, following the anatomy
§ If not in planes, either too near to the pulp at the cusps or too little space for the
materials
§ The planes should not generate sharp angles
§ All the preparation must be smoothed down slightly
§ It’s very important to bevel the functional cusps (45º)
§ This bevel will let the crown to be thicker where it
bears more load
§ If there is no bevel
- The crown can break
- The crown can be pierced, exposing the tooth
- If it’s a PFM crown, metal can become visible
- Lead to prematurities

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 • Axial surface reduction
§ If there is enough space for the restoration
axially
- Tough enough restoration
- No overcontours
- Good aesthetics
§ If the reduction is too little
- Thin restoration à weakness
- Adequate thickness à overcontour
(periodontal problems due to plaque
gathering)
§ Suggested thickness of the preparation
o Golden crowns
- 1 mm (0.5 chamfer finish line)
o Anterior PMF crowns
- Labial reduction à 1.2 – 1.5 mm
- Lingual concavity à 1 mm
- Lingual reduction à 0.7 – 1 mm (chamfer of 0.5-0.7 mm)
- Proximal reduction à 0.7 – 1 mm (chamfer of 0.5-0.7 mm)
o Posterior PMF crowns
- Buccal reduction à 1.2 – 1.4 mm
- Lingual reduction à 1 – 1.5 mm (chamfer of 0.5 – 0.7 mm)
- Proximal reduction à 1 – 1.5 mm (chamfer of 0.5 – 0.7 mm)
o All-ceramic crowns
- Buccal reduction à 1.2 – 1.4 mm (1 – 1.2 mm shoulder)
- Lingual reduction à 1 mm
- Proximal reduction à 1.2 – 1.4 mm (1 mm shoulder)

Preparation procedure
1. Occlusal / incisal preparation
• Posterior teeth in planes
- To follow the anatomy
- Provides an even thickness to the restoration
- Lower risk of getting into the pulp

2. Labial / buccal preparation
• With a 6º conicity between opposite surfaces
- Usually in a direction perpendicular to the occlusal plane (generally it’s the axis of the
tooth)
- Trying to have the bur as parallel as possible to the axis
• After that à preparation of the occlusal / incisal third of these surfaces
- Following the inclination of the external inclines
- Thus, labial / buccal preparation is always done in two planes
(otherwise too near to the pulp)
• Cervical portion of the preparation has this 6º conicity
• Coronal portion of the preparation follows the anatomy of the tooth (external inclines)
• Doing so
- Maximum tooth structure is preserved
- Allows the insertion of the crown
- Provides maximum retention
• As a first approach, this preparation is made supragingivally

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3. Proximal surface preparation
• With a 6º conocity between opposite surfaces
• Making a smooth connection with facial surfaces

4. Preparation of the finish line
• Will depend on the material of the restoration and the
aesthetic needs
• Shoulder and rounded shoulder à less conservative
• Chamfer à more conservative
• The more apical its location, the more axial surface reduction too

Guidelines to allow a correct laboratory work
• Morphology of the preparation will condition the morphology and characteristics of the
restoration
• Adequate thickness
• Smooth preparation
- No sudden changes in direction
- Improves the fit
- Doesn’t mean it has to be polished
- Microgrooves produced by the diamond burs increase retention
• Neat and smooth finish line
- For an easier identification by the dental technician





















Questions
1. Why would an adequate thickness lead to an overcontoured crown in slide 51? And why would
too lingual lead to a short preparation?
2. What exactly is overcontouring? What surface does it effect in what plane? Slide 65

17
UNIT 3. TOOTH PREPARATION IN FIXED PROSTHETICS II (FINISH LINE)
Location of the margin of the preparation
• Non-gingival margin
• Gingival margin
- Supragingival
- At the level of the gingiva (juxtagingival)
- Subgingival

Advantages and disadvantages
1. Supragingival
• More hygienic
• Easier to prepare
• Over enamel
• More conservative
• Easier impression
• Easier to identify by the dental technician
• Easier to access at check-ups
• Every time it’s possible à supragingival
• Main disadvantage à aesthetics

2. Subgingival
• Hinder hygiene
• Risk of biological width invasion
• Maximum of 0.5 – 1 mm under gingival margin (remember need 2 mm
of connective tissue + epithelium over bone crest)
• Only with good oral hygiene and good fit (max 40-50 micrometer)
• More difficult to prepare
• More difficult to copy at the impression
• More difficult to assess at check ups
• Requires cast preparation
• Main advantage à aesthetics

Indications
• Consider
- Aesthetics
- Die height
- Caries location
- Caries propensity (likelihood)
- Height of tooth fracture

F Requirements for a subgingival margin
1. Deep enough sulcus to not invade biological width
2. Band of attached gingiva wider than 2 mm
3. Good fit of the restoration
4. Good oral hygiene
5. Gentle tooth brushing

Contraindications
1. Periodontal disease
• Wait 2-3 months after SRP (wait until the gum settles to see where the finish line should be)
• Wait 5-6 months after periodontal surgery

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2. Great gingival recession and high clinical crown
• Supragingival at non-aesthetic areas
• At the level of the gingiva in aesthetic areas
• Chamfer
• Furcation à concave preparation

Marginal integrity
• Marginal fit
- Maximum clinically acceptable 40-50 micrometer
- Checked at the lab with a microscope
- Checked at the office with an explorer (or probe) and x-rays
- Finish line should be neat and clear and should be transferred correctly to the working cast
- Thorough manufacturing of the restoration by the laboratory
- Horizontal over / under contour
- Vertical over / under contour

• Marginal strength
- Adequate thickness and shape of the restoration
- Emergence angle /
profile

• Biological width
- On average 2 mm

• Scalleped pattern of the
preparation

Characteristics
• Its design will depend on the kind of restoration
• Neat and clear (no irregularities)
• Deep enough to be identified easily
• Lay over healthy tooth tissue
• Follow the gingival scallop
• Conservative with tooth tissue

• Its thickness will have to be adequate for the material of the restoration
• Adequate shape for the material of the restoration
• Easy to do

Types
1. Chamfer
• Curved shape
• Depth à 0.5 – 0.7 mm
• Angle at the margin approximately 45º
• Very conservative

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 • Prepared with a torpedo-shape bur
• Tip of 1.2 mm (878-012) or half of 856
• The thickness is referring to the base (so a 016 is
010 at the tip and therefore we can make a
chamfer of 005)

• Only half of the bur works
• Needs metal at the end of the restoration
• Small angle at the margin increases fit
• Less stress at the cement

• Indications
1. Metal-end restorations (metal collar)
- Lingual (or buccal / labial surfaces) of PFM crowns
- Full metal crowns
- Veneers
- Monolythic zirconia crowns

2. Deep chamfer
• Angle at the margin of approximately 90º
• Inner shape has a smaller radius than that
of the normal chamfer
• Its depth depends on the material of the
restoration

• Indications
1. Full coverage crowns
- Lingual or buccal / labial surfaces of PFM crowns à
0.5 – 0.7 mm (metal collar)
- Buccal surfaces of posterior PFM crowns, when
aesthetics are not jeopardized (1.2 mm)
- Proximal surfaces of PFM crowns in the transition
towards buccal or lingual surfaces
- PFM crowns at long teeth (metal margin)
- Porcelain veneers (0.3-0.5 mm)
- CAD/CAM crowns that use a touch-probe scanner

3. Butt shoulder or straight shoulder
• Angle at the margin of 90º
• 1 – 1.2 mm deep
• Prepared with a flat-tip cylindrical bur
• Indications
1. Jacket crowns (full porcelain feldspathic)
2. Labial surface of PFM anterior crowns
• Disadvantages
- CAD/CAM scanners read it badly
- The least conservative
- 90º inner angel generates tensions and makes it
difficult for alloy casts or porcelain to fit well
• Not used anymore

20
4. Rounded shoulder (radial shoulder)
• Angle at the margin is 90º too
• Inner angle is rounded, as opposed to butt
shoulder
• Reduces the stress at the inner angle
• Allows the scanning of most of CAD/CAM
scanners
• Provides good space for porcelain
• More conservative than butt shoulder
• Prepared with a cylindrical bur with rounded edge at the tip (bur 847)

• Indications
1. Modern jacket crowns (1 mm) (full porcelain crowns)
2. Labial surface of upper anterior PFM crowns, or even posteriors
when aesthetics are jeopardized (1.2 – 1.5 mm)

5. Ceramic shoulder
• It’s the best option from an aesthetic point of view
• Acceptable fit (45 micrometer)








• Not for long span restorations à the metal framework can warp due to the additional
firing cycles

6. Metal margin
• Only 0.2 – 0.3 mm are showed labially
• To be placed subgingivally
• Doesn’t warp because of the bulk of metal at the
shoulder

7. Shoulder with bevel
• Increases marginal fit
• Suggested for PFM crowns
• The bevel can only be covered by metal
• Good fit
• Bad aesthetics
• Supragingival finish line
• For posterior crowns when there is no concern about aesthetics

8. Other finish lines
A. Feather edge (or knife edge)
• Obsolete
• It’s not a clear finish line
• Overcontours
• Thin material at the end

21
 B. 135º shoulder
• 1.2 mm thick
• Bur with a tip at 45º
• Labial surface of anterior PFM
crown
• Thin metal collar
• Not for ceramic shoulders

PFM CROWNS
Porcelain-metal 1.2 mm
Deep chamfer margin 0.4 mm
Small aesthetic metal collar
concern Shoulder with Porcelain-metal 1.2 mm
bevel margin 0.5 mm
Buccal metal collar
Medium aesthetic Rounded Porcelain-metal 1.2 mmm
concern shoulder margin 0.2 – 0.3
mm metal collar
High aesthetic Rounded Porcelain margin 1.2 mm
concern shoulder
Lingual Chamfer Metal margin 0.5 – 0.7 mm
Deep chamfer Metal margin 0.5 – 0.7 mm
Proximal Deep chamfer Metal margin 0.5 mm
Rounded Metal margin 0.5 mm
shoulder

ALL-CERAMIC RESTORATIONS
Full porcelain crowns Classical Butt shoulder 1 mm
Present Rounded shoulder 1.2 mm
Porcelain veneers Rounded shoulder 0.3 – 0.5 mm

• Adhesion is better over enamel than over dentin
• For anterior we can do a restoration like this à PFM in lingual a 0.5mm chamfer suprgingival,
in buccal we’ll have a 1mm round juxta or sub gingival finish line
• KR stands for “corner round”
• Full porcelain crowns are more expensive than PFM crowns
• Retention and aesthetics are better in ceramic shoulder because porcelain can be etched
unlike metal and will increase the marginal integrity and the retention (the disadvantage is that
it is less resistant)
• Usually when you make a ceramic shoulder you still make the finish line subgingival because
there’s a high aesthetic demand (you’re prepared for gingival recession)
• We don’t use shoulder with bevel, feather edge or 135-degree shoulder anymore

Instruments for dental preparations
• High speed hand piece
• Suction (not surgical)
• Burs
1. Medium grit
2. Red band
- Only tip is active
- All the bur is active

22
Preparation of full coverage crowns
• Before preparation
- Treatment planning
- Colour
- Putty silicone impression

• Preparation
1. Occlusal surface
§ Posterior teeth
- Metal crowns à 1 mm (1.5 at functional cusps)
- Full porcelain à 1.5 – 2 mm
- PFM à 1.5 – 2 mm
- PFM with metal occlusal surface à 1 mm (1.5 at functional cusps)
§ Anterior teeth
- Full porcelain à 1.5 – 2 mm
- PFM à 2 mm
2. Free surfaces
§ In two planes
§ Lower plane with 3º convergence
§ Smooth down the joint between planes
F Labial surface
§ Guiding grooves for labial surface
§ PFM anterior crowns (labial)
- 1.5 mm for noble alloys
- 1.3 mm for non-noble alloys
- Butt shoulder à 1.2 mm
§ 1.2 – 1.4 mm for full porcelain crowns (labial)
F Lingual / palatal surface
§ Gingival portion still with conicity
§ PFM à chamfer burs (metal collar) 0.5 – 0.7 mm
§ Full porcelain à rounded or butt shoulder burs (1 mm)
§ Less reduction than over buccal / labial surfaces
§ Anterior teeth à concave preparation
- Metal à 0.7 mm
- PFM à 1 – 1.2 mm
- Full porcelain à 1 mm
3. Proximal surfaces
§ Use metal matrix to protect adjacent teeth
§ First with a narrow and long bur
§ Then with the proper bur for the finish line
§ Keep conicity
§ Smooth transition with free surfaces
§ Respect gingival scallope
4. Check that morphology is OK
5. Finish the preparation
§ So far, finish line should be supragingival
§ Now, adjust its final level (max 0.5 – 1 mm subgingival)
§ Retraction cord if needed (don’t forget to remove it)
6. Polish the preparation

23
Questions
1. How does the inner shape have a smaller radius of a deep chamfer than a normal chamfer? Slide
38
2. What are additional firing cycles slide 51?
3. Can we go through all the shoulders again?
4. Is butt shoulder the same as straight shoulder?

24
UNIT 4. FULL COVERAGE CROWNS

Concept
• Fixed partial restoration that covers one single tooth completely, restoring its morphology and
function
• Most of the fixed restorations (90%)

Types of full coverage crowns
1. Metal
• Preformed
• Cast
2. PFM
• Veneer crowns
• Porcelain coverage with metal collar
3. All-ceramic
• Manufacturing method
- Layered
- Pressed
- CAD / CAM
• Material
- Feldspathic
- Aluminous
- Zirconia-based (Y-ZTP)
4. Acrylic resin
• Self-curing
• Heat-curing
• Polycarbonate
• Cellulose acetate

Metal crowns
1. CAD/CAM
2. Preformed
• Golden
- Small preparation (least invasive)
- Uncooperative patients
- Soft (doesn’t wear the antagonist)
- Malleable and biocompatible
- Have to be adapted
- Easy to handle but least aesthetic
• Steel or cobalt-chromium
- For provisional restorations

3. Cast
• Similar preparation as for PFM, but with less reduction
• 0.5 mm chamfer
• Noble alloy à 1 mm
• Non-noble alloy à 0.8 mm
• Good occlusal anatomy
• Good marginal fit

25
Porcelain-fused-to-metal crowns
• Thin layer of cast (or sintered/milled) metal (coping) in contact with the tooth
• Covered by feldspathic porcelain
• Metal provides toughness and fit
• Porcelain provides aesthetics
• Most versatile type, golden standard

1. Veneer crowns (PFM)
• Occlusal metal surface
• Buccal / labial porcelain layer
• Less aesthetic (but useful in epilepsy)
• Less occlusal preparation (prosthetic space)

2. Conventional PFM crowns
• Almost all the crown is covered by porcelain
• But a small collar at the lingual surface (hygienic,
when made with CAD/CAM not necessary)
• Require more occlusal preparation

All ceramic crowns
• High aesthetic results but least conservative
• Translucency and toughness will depend on the material that’s used
• Manufacturing method
- Layered
- Pressed
- CAD / CAM
• Material
- Feldspathic
- Aluminous
- Zirconia-based (Y-ZTP)

Acrylic resin crowns
• Self-curing (cure in the mouth)
- For short-term provisional dentures (2-3 weeks)

• Heat curing (not used nowadays)
- Made at the laboratory
- For medium to long term provisional dentures (2-3 months)
- More tough than self-curing
- Mild preparation of the cast
- Reline at the patient’s mouth (self-curing)

• Polycarbonate
- Preformed
- Relined into the patient’s mouth
- For provisional dentures

• Cellulose acetate

à Acrylic has the
shortest longevity

26
Preparation criteria
1. Create a space for the restoration
• Too little preparation à weak restoration
• Too great preparation à not conservative with
tooth structure
2. Keep the anatomical profile (emergence profile)
• Periodontal health
• Preservation of the integrity of the margins
3. Smoothen preparation
• Enhances waxing and casting (better fit)
• Forces spread out over a greater and even surface
à lower risk of restoration or tooth fracture
4. Neat finish line
• No undercuts
• Eases laboratory work
• Better fit à no marginal leakage
5. Two-plane preparation for convex surfaces
6. Vertical location of finish line
• According to the kind of restoration
• Each material has its own minimum thickness
• Every time it’s possible à supragingival
- Better for periodontium
- Eases preparation and impression taking
- Easier to control fit of the restoration at check-ups

Porcelain-fused-to-metal crowns
1. Parts
A. Metal coping (a.k.a metal core or framework)
• 0.5 mm for noble alloys (because they’re soft, need to be thicker)
• 0.3 mm for non-noble alloys
B. 3 layers of veneering porcelain (feldspathic) of 1 mm
• Opaque porcelain (opaquer)
- Hides colour of underlying metal framework
- Joins metal and the rest of porcelain layers
• Dentin porcelain
- Main part of veneering porcelain
- Provides the shade to the restoration
• Incisal / enamel porcelain
- Provides translucency
- Can be stained

2. Margin
A. Metal margin
• Metal collar at lingual surface
• 0.3 – 0.5 mm thick
• 2 – 3 mm high
B. Metal-porcelain margin
• Most commonly used
• Metal coping gets thinner as it gets near the margin
• Contraction of porcelain can put the coping out of fit

27
 C. Ceramic shoulder / chamfer
• Low fusing ceramic in contact with margin
• Foundation for feldspathic porcelain
• Good aesthetics
• Requires a thick enough preparation to
avoid fractures

3. Preparation
A. Occlusal preparation
• Functional cusps à 2 mm
• Non-functional cusps à 1.5 mm
B. Axial surfaces à 1.2 – 1.5 mm
C. Buccal / labial finish line à rounded shoulder (1.2 – 1.5 mm)
D. Lingual finish line à chamfer or deep chamfer of 0.5 mm
E. Margin placement à juxta or supragingival, except for
• Aesthetics
• Short teeth
• Cervical caries or restorations

4. General considerations
A. Age
• Young patients
- Teeth partially erupted
- Big pulp chambers
• Old patients
- Gingival margin over cementum
- Lack of cooperation
B. Edentulous space
• The longer, the greater the load over the abutment
teeth
C. Bone and periodontal support
• Occlusal trauma
• Crown-to-root ratio
• Periodontal health
D. Previous abutment tooth inclination
• Purpose à change inclination
• Guiding planes for RPDs
• Change amount of retention of a retainer
E. Metal occlusal surfaces
• Bruxists
F. Oral hygiene
• If bad à contraindication
• Crowded teeth à hinder hygiene
G. Pulp vitality
• Minimum preparation to achieve objectives
• Provisional dentures
• Endodontically treated teeth are weaker
H. Structural strength of the tooth

28
5. Indications
1. Single crowns to strengthen the tooth
• Teeth with several restorations that weaken their
structure
• Traumatisms
• Great tooth wear
• Hypoplasia
2. Single crowns to change the shape of the tooth
• To change the contour (crowding, conoid)
• Occlusal modification
3. FPD retainer
• Provide maximum retention
• Reinforce the abutment tooth
• Intermediate abutment tooth
• Tooth splinting
4. RPD retainer
• Improves path of insertion
• Control the amount of retention
• Reinforces the abutment tooth
• Prevent caries over abutment tooth
5. Combined prosthesis retainer

6. Laboratory procedure
F Coping
• Lost-wax procedure (waxing and casting)
• CAD / CAM
• CAD + laser sintering
F Veneering porcelain build-up

1. Cast preparation
• A die cast is made
2. Waxing
3. Investment
• Powder and liquid mixture
• 30-minute setting time
4. Oven
5. Centrifuge
6. Removal of the coping
7. Trimming and finishing

• Other techniques
- CAD/CAM vs laser sintering

29
 • Solutions for volume changes during casting
- Oversized wax pattern
- Correction of the crown
- Investment expansion (soft walls)

Notes
• Zirconia is a white metal
• PMMA is the acrylic used for relining, comes in powder and liquid
• If you have a sharp edge in your preparation à the plaster can’t copy it properly when casting
it, the crown is not going to fit inside
• The type of porcelain used for veneering is called feldspathic porcelain

• For a PFM, 3 appointments at least
1. Preparation, impression, mounting and provisional;
2. Metal try-in, the lab has to fill it with porcelain but without the glazing;
3. Bisquit try-in;
4. Final try-in with glazed crowns

• Try making overlays when a bruxist, instead of crowns, because the crowns will be too
aggressive

• Options to make PFM’s à lost wax techniques or CAD/CAM techniques (milling or sintering)
• Die spacer to make space for the cement

• Internal expansion happens when the cilinder is made of a very hard material, so the shape of
the metal framework is going to be smaller (preferable to make a cast post and core, otherwise
it won’t fit in the root canal)
• External expansion happens when the cylinder is made of a soft material, so the shape of the
metal framework is going to be bigger (preferable to make a crown, otherwise it won’t fit over
the preparation)













Questions
1. Are metal occlusal surfaces good for bruxists? Slide 49
2. Veneering porcelain build up doesn’t happen before waxing and investment etc. right? Slide 60
3. Just to be clear about the steps in a PFM, we first prepare the tooth of the patient, then take the
impressions with addition silicone and send these to the lab? And then there they start with
coping (which is?) and then waxing?

30
UNIT 5. ALL-CERAMIC CROWNS

Concept and types
• Ceramics
- “Compounds of one or more metals with a non-metallic element, usually oxygen. They’re
formed of chemical and biochemical stable substances that are strong, hard, brittle and
inert non-conductors of thermal and electrical energy”
• Porcelain
- “A ceramic material formed of infusible elements joined by lower fusing materials”
• Ceramic crown
- “A ceramic fixed dental prosthesis that restores a clinical crown without a supporting
metal framework”

Classic jacket crowns (all-ceramic) à obsolete / outdated
• Land (1903)
- Feldspathic porcelain fused over a platinum foil
• McLean (1965)
§ Aluminous porcelain coping (40% Al2O3)
- McLean 1967
- Platinum foil was left as coping
- A variant of the previous one
- Tougher but less elastic
§ Feldspathic veneering porcelain
§ Opaque coping
§ Low fracture toughness
• Current jacket crowns à reinforced to provide improved toughness and/or aesthetics

Dental ceramics
• Inert
• Metallic oxides
• Don’t pour ions into the mouth, unlike metals, and
don’t get corroded
• Highly biocompatible
• Vitreous matrix + mineral crystals
- Vitreous phase (amorphous) à provides
aesthetics (translucent and weak)
- Crystalline phase à provides toughness

Classification
A. Regarding chemical composition
3. Low strength feldspathic porcelains
3. High strength feldspathic porcelains
3. Aluminous
3. Zirconia-based ceramics

31
 1. Low strength feldspathic porcelains
• The first that appeared
• Composition
- Feldspar à translucency
- Quartz à crystalline phase
- Kaolin à plasticity
• Main current use à veneering porcelain (not strong
enough by themselves)
• Examples of FFC à Mirageâ, Optecâ, Duceramâ
• Low strength = glass = vitrous feldspathic porcelains
• Vitrous feldspatchic porcelains are aesthetic but weak
• Polycrystalline (aluminous and zirconia) porcelains are less aesthetic but stronger
• Layered porcelains are the most aesthetic ones

2. High strength feldspathic porcelains
A. Leucite-reinforced
• Leucite microcrystals
• Examples
- IPS Empressâ I
- Optec-HSPâ
- Fortressâ
- Finesseâ Allceramic

B. Lithium disilicate and lithium orthophosphate-reinforced
• Tougher
• Less aesthetic (more opaque)
• Require conventional veneering
• Example à IPS Empressâ II
• Good for an anterior full porcelain crown, because veneering is possible

C. Lithium disilicate-reinforced
• IPS e.maxâ CAD
- Varies from HT (high translucency) to HO
(high opacity)
- Typical blue initial colour
• IPS e.maxâ Press
- Varies from HT (high translucency) to HO (high
opacity)
• Very aesthetic, good cementation, which makes it
quite strong
• The more translucent, the more aesthetic

32
 3. Aluminous
• Aluminum oxide instead of quartz
• A polycrystalline porcelain
• Good mechanical properties
• Low translucency
• For FCCs copings

• VITA In-Ceramâ Alumina
- 99% aluminium oxide (Al2O3)
- Aluminum oxide is very resistant, but very
ugly
- Glass-infiltration that reduces porosity
- High flexural strength
- For single-tooth FPD and short FPD
- Not used anymore nowadays, since Zircona has made its comeback

• VITA In-Ceramâ Spinell
- Magensium + aluminum oxide (Spinell – MgAl2O4)
- High translucency
- Poor strength
- Copings for anterior single tooth FPD

• VITA In-Ceramâ Zirconia
- Alumina (67%) + zirconia (33%)
- Glass-infiltrated
- High toughness
- Single and multiple FPDs

• Proceraâ AllCeram (Nobel Biocare)
- 99,5% alumina
- Cold isostatic pressing + sintering at 1550 ºC
- High toughness
- Highly crystalline
- Photo of a contact scanner à

4. Zirconia-based ceramics
• Zr, number 40 in the periodic table, it’s a metal not a porcelain
• ZrO2 à zirconia
• Two phases à tetragonal and monoclinc
• 95% zirconium oxide + 5% yttrium oxide Y2O3 (yttria)
• Y-TZP (yttria stabilized tetragonal zirconia polycrystals)
• Totally crystalline
• Transformation toughening
(Gravie et al 1975)
• Once there’s a crack, changes
phase from tetragonal to
monoclinic à

33
 • Very tough à posterior full porcelain crown is better with zirconia than lithium disiilcate
• Very opaque à first types of Zirconia were very opaque, that’s why they needed to be
layered
• Most notable examples
- VITAâ In-Cearm YZ
- Proceraâ Zirconia (Nobel Biocare)
- Lavaâ (3M ESPE)
- IPS e.maxâ ZirCAD (Ivoclar)
- DC-Zirconâ (DCS)
- Cercon

• Aging à low temperature degradation
• Chipping in 15% of the cases after 24 months
• 25% of fractures after 31 months

• Under pressure the material will age, gets phase transformations spontaneously
• Zirconia is not abrasive on the antagonist tooth even though it’s very tough
(feldspathic is abrasive, but not tough)
• Increased aesthetics in zirconia, means less resistance
• Zirconia doesn’t achieve a high cement bonding to the tooth and therefore partial
coverage restorations e.g. veneers, inlays, onlays, overlays are best made with
lithium disilicate (because of adhesion!)

B. Regarding manufacturing method
1. Layered over investment cast
• In-Ceramâ Spinell
• Mirageâ II Fiber
• Optec-HSPâ
• Fortressâ

2. Pressed (lost-wax)
• Waxing of the framework or the whole restoration
• Increases toughness by reducing porosity
• Examples
- IPSâ Empress
- IPSâ e.max Press
• Zirconia and alumina cannot be pressed, lithium
disilicate however can be pressed

3. CAD / CAM
• Stands for Computer Aided Design & Computer Aided Manufacturing
• Examples
- Cerecâ (Sirona)
- Proceraâ (Nobel Biocare)
- Lavaâ (3M ESPE)
- DCSâ (DCS)
- Cerconâ (Dentsply)
- Everestâ (Kavo)

34
 • Intraoral digitizing

• Manufacturing
§ Full-contour
- All the volume of the restoration in one piece
- Stains
- E.max at posterior teeth should be like these
- Zironia shouldn’t be made in full-contour
(antagonist abrasion and phase danger)
§ Cut-back
- Milling of cervical 2/3 of the crown
- The rest is veneered with feldspathic porcelain
§ Milled coping + veneering porcelain
- For maximum aesthetic results

Selection criteria
1. Fracture toughness
• ISO 6872 à minimum of 100 MPa
• PFM à 400-600 MPa (golden standard)
• Types
- Low fracture toughness (100-300 MPa) à Feldspathic porcelains
- Medium fracture toughness (300-700 MPa) à Empress II, alumina, e.max
- High fracture toughness (> 700 MPa) à Zirconia

2. Marginal fit
• McLean and Von Fraunhofer à 120 micrometer
• Adequate à 40 – 50 micrometer
• Explorer cannot detect misfits lower than 120 micrometer

3. Aesthetics

35
4. Clinical survival
• Crowns
- In Ceram Alumina à 100% after 4 years
- In Ceram Spinell à 97.5% after 5 years
- Procera All Ceram à 96.7% after 5 years
- IPS Empress II à 100% after 5 years
- Metal-ceramic à 94% after 10 years
• Bridges
- Lava à 100% after 3 years
- In Ceram Zirconia à 94.5 % after 3 years
- In Ceram Alumina à 93% after 5 years
- IPS Empress II à 70% after 5 years
- Metal-ceramic à 87% after 10 years

5. General guidelines
A. Anterior crowns
• Assess colour of underlying tooth
• Light colour and enough prosthetic space (favourable occlusion) à high strength
feldspathic porcelains (e.g. lithium disilicate)
• Dark colour or unfavourable occlusion / space à aluminous or zirconia-based
porcelains (or PFM)

• Anterior tooth non bruxist à lithium disilicate that’s layered (for aesthetics)
• Bruxist anterior tooth à monolithic zirconia crown, monolithic disilicate veneer

B. Posterior crowns
• Assess fracture toughness needs
• Aluminous and zirconia-based are the toughest
• Zirconia based
- Chipping due to low wettability of veneering porcelain
- Resin cements spread stress
- Aging
- Abrasion of antagonist
• Full-contour e.max
- Adequate toughness for single PFDs

C. Anterior bridges
• E.max
• Zirconia
• Light colour and enough prosthetic space (favourable occlusion) à high strength
feldspathic porcelains (e.max)
• Dark colour or unfavourable prosthetic space à zirconia-based porcelains (or PFM)
• Unfavourable occlusion and lowered prosthetic space à contraindication

D. Posterior bridges
• Zirconia
• E.max (max three teeth)
• Light colour and enough prosthetic space (favourable occlusion) à high strength
feldspathic porcelains
• Dark colour or unfavourable prosthetic space à aluminous or zirconia-based
porcelains (or PFM)

36
Indications
1. Maximum aesthetic concern
• Tooth fractures
• Caries and restorations at anterior teeth
• Colour alterations (intrinsic or extrinsic)
• Diastema
• Tooth malformations
• Malpositions
F It’s necessary to have a good dental technician
2. Parafunctional habits
3. Limited prosthetic space (!!)
• Overbite
• Crossbite
• Edge-to-edge occlusion
4. Periodontal disease

Dental preparations
1. In-Ceram system
• Rounded shoulder of at least 1 mm
• Connectors à height 4 mm, width 3-4 mm
2. Procera system
• For contact scanners à deep chamfer of 0.8 mm minimum
• Connectors à height 4 mm, width 3 mm
3. IPS Empress and IPS e.max
• Rounded shoulder at least 1 mm
• Connectors à height 4-5 mm, width 3-4 mm for anterior, 4 – 4.5 mm for posterior
4. Lava system
• Rounded shoulder or deep chamfer of 1 mm
• 8º taper
• Connectors à height 4 mm, width 3 mm




Questions
1/ Is lithium disilicate reinforced the glass infiltrated one?
2/ Are high strength feldspathic polycrystalline? Or only zirconia and alumina?
3/ When you use CAD CAM for manufacturing, can it only mill? Or also laser sinter?
4/ Slide 34 says zirconia should be made in full-contour, but we do do this now, don’t we? We use
monolythic zirconia?
5/ what are the connectors we talk about in the last 2 slides?





• Posterior tooth à monolythic zirconia crown or monolythic disilicate partial restoration
• Monolythic restorations in general can be either milled or pressed, but pressing is only for
lithium disilicate and other aesthetic porcelains, but can’t be done for zirconia nor alumina; for
this only milling works

37
UNIT 6. LAMINATE VENEERS
Concept
• Definition
- “A thin bonded ceramic restoration that restores the facial surface and part of the
proximal surfaces of teeth requiring aesthetic restorations”

• Concept
- Extracoronal partial coverage single-tooth restorations made of porcelain

History
• 1938, Charles Pincus
• 1955, Buonocore (acid etch of the enamel)
• 1963, Bowen (BIS-GMA resins and resin composites)
• 1983, Simonsen and Calamia (adhesion to porcelain)

Characteristics
• Highly aesthetic porcelains
- Highly translucent
- Takes advantage of the optical properties of the underlying dentin
• Highly conservative restorations
- Minimal preparation
- Into enamel whenever possible
- 0.3 – 0.5 mm thick
- Excellent bond to enamel
• Low geometrical retention (very low friction)
- Adhesive bond

Indications
• When we seek maximal long-term aesthetic results and we have
- Healthy tooth structure (most of it)
- Minor colour, shape or position alterations
• For anterior teeth and premolars

1. Colour alterations
• Tetracycline stains
• Dental fluorosis
• Hypoplastic stains
• Tooth resistant to bleaching

2. Shape and size alterations
• Microdontia / conoid teeth
• Primary teeth
• Tooth fractures
• Broad cervical embrasures
• Dental erosions

3. Position alterations
• Diastema
• Mild crowding
• Minor malpositions (e.g. rotations)

38
Contraindications
1. Inadequate occlusion or position
• Deep overbite
• Parafunctional habits (e.g. bruxism)
• Severe crowding
2. Multiple restorations
3. Inadequate anatomy
• Short clinical crown
• Thin incisal portion of the tooth
• Highly triangular crowns
• Little enamel
4. Caries and/or bad oral hygiene
5. Erupting teeth
6. Untreated periodontal disease
7. Angle’s class II

Types
1. Type I à only buccal preparation
• The most conservative
• Requires thick incisal edge
• Allows less shape change
• Less toughness à more fractures

2. Type II à buccal and incisal preparation
• Thicker at the incisal edge
• Tougher
• Allow greater shape changes
• It’s been stated that has the same toughness as type III

3. Type III à buccal, incisal and lingual preparation
• Increases support of incisal porcelain
• Tougher under horizontal forces
• Increased retention and stability
• Increases adhesion surface
• Pascal Magne advises against this type

Preparation
• Minimal possible preparation
• Over enamel whenever possible, especially at the margin
• Always conditioned by the diagnostic wax-up
• Reduction
- 2/3 incisally à 0.5 mm
- 1/3 gingivally à 0.8 mm
• Guide grooves à special bur with 1.6 – 2 mm depth
• Preserve buccal curved morphology

1. Buccal preparation
• With a deep chamfer or rounded shoulder bur
• Keep buccal curvature
• Finish line 0.3 mm deep
• Height of finish line à juxtagingival or slightly subgingival

39
2. Proximal preparation
• Contact points
- P. Magne advises to preserve them (more conservative)
- Other authors open them (Sidney Kina) à impression doesn’t tear and it’s easier to
individualize dies at the lab
- Either way, they should end far from visible areas

3. Incisal preparation
• 1.5 – 2 mm
• It’s a high stress area
• Be careful with lower incisors (maybe class III veneer)
• Incisal preparation according to Sidney Kina (upper picture)

4. Lingual preparation
• 0.5 mm deep chamfer bur
• To provide better support for MI contacts
• Should preserve lingual concavity
• Should match buccal surface inclination
• Should continue evenly with proximal preparation

5. Finish of the preparation
• Remove edges / angles
• Open contact points with polishing strips (if desired)

F Variations from the standard preparation
• For dark tooth colour
- 0.4 – 0.5 mm preparation (gingival 1/3)
- 0.6 – 0.7 mm preparation (incisal 2/3)
• Malpositioned teeth
• Lateral incisor agenesis (upper picture)
• Premolars (lower picture)
• Diastema

Impressions
• Double retraction cord
- The second one you place is removed right before taking the
impression
- The first one keeps the gingiva away from the tooth
• Additional silicone
• Single-step or two-steps impressions

Provisionals
• Technique is complex (low retention of the preparation)
• Sometimes it’s not necessary
- All the preparation is over enamel
- Aesthetics are unaffected
• Types
- Resin composite direct provisionals
- Acrylic resin direct provisionals
- Acrylic resin indirect provisionals

40
Laboratory procedure
• Master cast is duplicated with investment material
• Individualization of dies
• Porcelain layering
- From the inside to the outside
- Mimics the different layers of the tooth
- It allows the veneer to be natural
- May have different opacities to cover underlying colour
- 2-3 firings and glazing

F Procera laminate veneers
• Zirconia coping
• Doesn’t allow etching with hydrofluoric acid
• Different cementation
• Feldspathic veneering porcelain

F IPS e.max veneers
• Lost-wax or CAD / CAM
• Lithium disilicate copings
• Allows acid etching
• Feldspathic veneering porcelain

Verification
• Individual fit
• Collective fit à contact points
• Colour verification à modification if needed
• General appearance

Cementation
• Enamel
• Etched enamel surface
• Dentin-enamel adhesive
• Composite luting agent
• Dentin-enamel adhesive
• Silane coupling agent
• Etched porcelain veneer

Postoperative instructions
• In the next 24-72 hours
- Avoid alcohol
- Avoid hard food
- Avoid food that can stain (coffee, wine, tea…)
- Careful mastication

Maintenance
• Check-ups every 6 months
• Thorough hygiene
• Avoid flour-rich substances
• Avoid parafunctional habits
• Mouthguard for sporty people

41
Failures
• Fractures
• Marginal leakage
• Loss of cementation
• Gingivitis























Questions
1/ Finish line 0.3 mm deep, means into the tooth or 0.3 into the gingival sulcus? If the first one, why
do we say we cut gingivally 0.8 mm? Could you explain slide 25 and 26?
2/ What exactly do we use zirconia for? Because slide 42 says we use it as coping but I though we
only should use it as monolithic?

42
UNIT 7. PARTIAL COVERAGE RESTORATIONS (INLAY, ONLAY, OVERLAY)
Concept
• It’s a conservative restoration that requires less destruction of tooth structure
• Used to reinforce the remaining dental structure in cases of caries and fractures
• They are considered minimally invasive restorations

Types of indirect restorations
• Inlay à partial direct restoration, without cusp covering
• Onlay à partial indirect restoration, covering at least one
cusp
• Overlay à partial indirect restoration, covering all cusps

Conventional direct restorations
• Many advantages when restoring cavities
• But also have limitations à especially due to the polymerization contractions
• Light curing shrinkage consequences
- Gaps, due to the curing contraction
- Secondary decay
- Cracks propagation
- Cusp fracture
- Postoperative sensitivity

• Factors influencing the polymerization shrinkage
- Cavity size
- Cavity shape
- Adhesive technique
- Material application à type of light, intensity, time, material used

• Light curing à when applying the light, there’s a 50% of polymerization
• Dark reaction à after the light curing, between 10 minutes and 48 hours, the materials still
polymerizing to a 100%
• That is why the ideal is to wait 48 hours before the polishing of the surface, or ideally wait 10
minutes so the polymerization process reaches a 75%

• The thickness reached by the light is 2mm
• The distance between the light and the composite should be 1 – 2 mm
• The minimal distance but without contacting

• Light curing units
F The emission spectrum is very important for the result
§ Halogen à 350 – 500 nm, cured the 3 catalysers
§ Plasma à 460 – 480 nm, only activates the camphorquinone compound
§ Laser à no use
§ LED à 430 – 490 nm, only activates the camphorquinone
§ New generation of LED à works with all the different activators
- Bluephase G2 430 – 490 nm
- Bluephase 20I 430 – 490 nm
- Valo Cordless 395 – 480 nm

43
Types
1. Inlay
• Used for smaller cavities
• No cusp coverage
• Can result more aggressive during the
preparation than a direct composite filling
• Still some controversy in class II MO / OD
• Porcelain, resins, hybrid materials

2. Onlay
A. Onlay
• Includes cusp coverage
• At least one cusp is covered
• Indicated for the restoration of big cavities
with remaining axial surfaces
• Porcelain, resins, hybrid materials
• Onlay subtypes à onlay, overlay, veneer onlay
/ overlay

B. Overlay
• A type of onlay
• Full cusp coverage

C. Veneer onlay / overlay
• Same as the onlay / overlay
• But covering the buccal surface
• High aesthetic needs

3. Endocrown
• Option for endodontically treated teeth
• Full cusp coverage
• No post nor pin
• Uses the pulp chamber for more adhesive surface and
more macro-retention
• More conservative option

Indications
Clinical situation Small cavity Big cavity
Class I Direct Direct
Class II MO / OD Direct Inlay / onlay / overlay
Class II MOD Direct / inlay Onlay / overlay
Destructed teeth Fiber post + overlay / Fiber post + overlay /
endocrown endocrown

• Recommendations for all full coverage of the cusps when
- Parafunctional habits
- Root canal treated upper premolars
- Less than 2 mm thickness of the wall

44
Build-up
• Filling the missing or inadequate areas
• With a nanohybrid composite (ideally e.g. filtek supreme XTE, Tetric Evoceram…)
• Purpose
- Eliminate retentive areas
- Lift the cavity floor
- Create a better access to the curing light
- Strengthen the cavity, often done after root canal treatment

Marginal relocation
• Consists in elevating the margin of the preparation away from the
gingiva before taking the impression, to control humidty etc.
• During the build-up step and with the same nanohybrid composite
• Indicated if
- No good isolation is possible
- A good impression can’t be taken (conventional / digital impression)

Design of the cavity
• In these types of restorations, the retention depends on the adhesion
• The shape of the preparation must be expulsive in order to admit a good
adaptation of the restoration
• The adhesion is between the internal surface of the tooth and the external
surface of the restoration, opposite to the crowns

Steps to follow for the preparation
1. Remove the pathological and decayed tissue
2. Build-up and relocation of the margin if necessary
3. Preparing the cavity for the final restoration

Preparation
• Minimal occlusal thickness for the restoration 1.5 mm
• Thickness at the base of the cusp, at least 1.5 – 2 mm if not à remove
• Residual surfaces of at least 2 mm, if not à remove
• Minimum width of the isthmus of 2.5 mmà to avoid fractures of
the restoration
• Rounded angles
• Expulsive shape of the cavity for a good insertion and settlement
• Taper of the internal walls of 6-10º
• Rounded angles
• The anatomical contour of cusps and sulcus
must be respected
• Always with smooth transitions
• Enough prosthetic space à 2mm of restorative
material is needed in the cusps area
• Contact points must be open àRecreate a good anatomy and
new contact point with the restoration
• The bigger the distance to the adjacent tooth, the bigger the
interproximal box should be to recreate correctly the anatomy
• When there are no remaining walls, during the preparation and build-up step à
create indices (always index your preparation, a little cavity or groove, so the
restoration won’t be able to move or rotate)

45
• Good restoration
- Rounded shapes
- No angles
- No abrupt changes of orientation
- Far from the pulp
- Leaving enough space for the restoration

Criteria for cavity approval
• Detailed sharp margins
• Absence of undercuts
• Accessibility of subgingival margins
• Absence of contact between the cavity and the adjacent teeth
• Adequate interocclusal space in centric and during lateral movements

Impressions
• Conventional with PVS (polyvinyl siloxane = addition silicone) à pouring the cast with plaster
- Layering
- Pressing
- Extraoral scanning: CAD / CAM
• Digital à CAD / CAM

F Conventional impression
• With addition silicon, PVS
• Putty + light body for the details
• The antagonist is needed for the occlusion
• No gingival retraction needed because of the supragingival
margins

F Digital impression
• CAD / CAM

Provisionals
• Complicated technique because we have no retention from the cavity
• We provisionalize to protect the tooth and avoid non-desirable movements

1. Option A
• Prepare a silicone key before the preparation
• With putty silicone
• Once we have the preparation and the impression
• Place Bis-acrylic resin into the needed area of the silicone key
• Place it into the mouth and wait for it to dry
• We gain some retention with one point of adhesive in the middle of the preparation

2. Option B
• Apply in the center of the preparation one point of adhesive
• Shape a bulk of composite over the preparation
- Specific light curing materials exist for these specific restorations
- E.g. Telio CS Inlay (Ivoclar) à used for provisional in class I and II

46
 Materials

• Partial coverage crowns are ALWAYS monolithic, because we always want resistance over
aesthetics in posterior regions
• Zirconia can’t be used for an inlay or onlay, because it has bad adhesion
• We normally use lithium disilicate for the partial coverage restorations
ü Composites à layered or milled
ü Ceramics à either pressed (lost-wax) or milled
ü Hybrid materials à only be milled

Resistance Elasticity Adhesion Aesthetics Indications Scientific Minimum
capacity long- spacers
term
evidence
Ceramics Conventional Inlay
silicates + ++ ++++ ++++ Onlay ++++ 1, 5 mm
Overlay
High Inlay 1 mm
resistance +++ + ++++ +++ Onlay +++ (inlay/onlay)
silicates Overlay 1,5 mm
Crown (crown)
Hybrid Infiltrated Inlay
materials ceramics + ++++ +++ ++ Onlay + 1,5 mm
with Overlay
polymers

F Ceramics vs hybrid materials
• Hybrid materials
1. Nanoceramic resin
- Resin nano-ceramic material
- Resists chipping and cracking during the milling
- No post firing step needed
- High luster
2. Ceramic with resin
- Hybrid ceramic, ceramic strengthened by a polymer
- High load capacity after bonding
- High elasticity module

47
 1. Vita enamic (nanoceramic resin)
• More aesthetic because of its ceramic composition
• The composite filling suffers a high level of wear
• The result is the exposition of the ceramic crystals
• Creating a more abrasive restoration
• Requires fluorhydric etching and silane

2. Lava ultimate (ceramic with resin)
• Advantage à elastic modulus similar to the dentin
• Disadvantage à high rates of wear, we can lose our
contacts and guidance easily
• Since 2015, not indicated for crowns, but indicated for
inlays, onlays and veneer restorations

Laboratory procedure










1. Layering technique
• Inherent errors similar as the direct technique
• The lab heat curing process provides better extraoral properties

2. Milling process
• The only contraindication for CAD/CAM according to the state of the
art technology is a full mouth rehabilitation (for any partial coverage
restoration it’s good)

3. Pressing
• As we’ve seen before in the chapter about full coverage crowns

F Cementation / bonding
1. Isolation
• Control of the operative field and humidity
• Provides security and optimization of adhesion
• Real 4 hands work

2. Surface conditioning
A. Preparation of the cavity
B. Dentin sealing
C. Cavity building and marginal relocating
D. Final dental preparation
E. Enamel conditioning
F. Restoration conditioning

48


F We seek for micromechanical retention or chemical adhesion between substrate and
restoration
F The restoration is either made of ceramic or hybrid materials
F The substrate is either enamel, dentin or composite, substrate conditioning:
1. Enamel
• Selective enamel etching ortophosphoric acid 37% for 30 seconds
• Rinse with water
• Absolute drying
• Adhesive (bonding) à last step before the bonding
- Don’t light cure the adhesive before placing the restoration, if you do, the
adhesive will get in some areas of the restoration that prevent it from fitting
correctly, the light will be powerful enough to get to the adhesive through
the restoration
2. Dentin
• Much more sensitive to the technique
• Follow the instructions
• Self-etching adhesive in 2 steps
- Les sensitive to the technique
- Good results
3. Composite
• First à sandblasting with aluminous oxide of 30-50 microns to create a
micromechanical retention
• Second à application of a bonding, the one that comes with the adhesive

Sandblasted Acid etch Self-etching adhesive Total etch 1 step
in 2 steps adhesive
Enamel No 30 sec No No
Dentin No No Yes No
Composite Yes 60 sec No No

Bonding Silane Photo- Dentin Enamel Composite
polymerized Self-etching Adhesive 1 step
adhesive in 2 steps total etch

Enamel Yes (without No No
polymerizing)

Dentin No No Yes

Composite Yes (without No No
polymerizing)

49

3. Cementation
• Requirements
- Marginal fit
- Low solubility in the oral cavity
- Radioopacity
- Working time
- Viscosity
- Aesthetic properties
• Types of cement
1. Microhybrid composites
- Preheated up to 55º (Z-100, tetric basic, Herculite XRV)
2. Light curing resin cements
- Variolink Esthetic, Relyx Veneer
- Watch out with the lamps
3. Dual curing cements
- Stains in the margins after years
Lamp Heater Ultrasound tip Excess removal
Self-curing None None No Difficult
resin cement
Dual resin Medium None No Difficult
cement potency
Light curing High potency None No Easy
resin cement

Microhybrid High potency Essential Preferably Easy

composite (1.000
mW/cm2)

Mechanical Aesthetic properties Working time
properties
Self-curing Good Good Very little
resin cement
Dual resin Good Good Little
cement
Light curing Good Good As you choose
resin cement

Microhybrid Very good Very good As you choose

composite

50

Clinical case

51


Semi-direct technique
• If anatomy is correct: good, otherwise wax up the
ideal anatomy
• Transparent silicone key (of ideal anatomy)
• Preparation of tooth
• Partial impression with alginate
• Filled with (putty) silicone to obtain partial model
• Stratification over the silicone model and shaped to the form of
the transparent silicone key
• Polymerize
• Oven + light polymerizing machine
• Characterization and make up if necessary
• Cementation protocol

à don’t forget to read the article on incrustation







Questions
1/ What are indexations slide 30?
2/ What’s the difference between putty, light-body and addition silicone? What do we see on the
picture? Slid 34
3/ Do we have to know slide 41?
4/ Slide 56, we say first that we do none with 1 step total etching and then all of the sudden at the
end of the table we say that both enamel and dentin are conditioned like that…
5/ What does punta de ultrasonido do? In slide 59
6/ Do we have to know slide 60?

Notes: 30sec etch for enamel, 15 sec for dentin

52
UNIT 8. TREATMENT OF ENDODONTICALLY TREATED TEETH
Introduction
• A great amount of severely destroyed teeth can be treated with fixed prosthetics
• Alternatives for the endodontically treated teeth (ETT)
1. Removable denture
- Tooth overdenture
- RPD
2. Fixed denture
- Large restoration with prefabricated post
- Cast post and core

Characteristics of endodontically treatd teeth
1. Dentin modification
• The dentin has inherent properties that help inhibit the crack progression
• It has fracture toughening mechanisms
- Dentin dehydration (increases fragility)
- Collagen fiber reduction and degeneration (also increased fragility)
• Consequence à dentin is less fatigue resistant
• Clinical situations with a degradation of the collagen fibers à endodontically treated teeth
- Less collagen fibers and more minerals
- Higher brittleness
- Higher fracture risk
2. Reduction of structural integrity
• Due to caries / old restorations / fractures
• Due to the effects of the endodontic treatment
• Due to the effects of the endodontic irrigants over the dentin (NaOCl, EDTA, Ca(OH)2)
• Always try to avoid unnecessary removal of tooth structure
• Opposing teeth tend to separate cusps of ETT (endontically treated teeth)
• Chance of vertical fracture
- Lower molars and upper premolars with MOD
restorations and endodontic therapy undergo vertical
fractures after 5 years in 50% of the cases
3. Reduction in sensitivity
• Reduced proprioception
• Higher pain threshold
• Lowered capability of recording stimuli
• Less control of the applied forces over it, needs twice the forces to react
• Leads to inadequate behaviour under high occlusal loads

Assessment of endodontically treated teeth
1. Must be a healthy tooth
• Clinically
- No fractures that extend beyond the boundaries of the restoration
- Periodontal health
- No infection (no fistulas etc.)
• Radiographically
- No root fractures
- No internal or external resorption
- Good apical seal
- No radiolucent periapical areas (must be assessed 6 months
after the endodontic therapy)

53
2. Quantity and quality of remaining tooth structure
• Big caries
• Amount of tooth structure lost
- No post just regular reconstruction
- Cast post and core à great destructions
- Prefabricated post à smaller destructions

3. Anatomy of the pulp canal
• Pulp canal section
- Cylindrical à cast post and core or prefabricated post
- Oval à cast post and core
• Pulp canal diameter
à Always into the largest and straightest canal
- Upper molars à palatal canal
- Lower molars à distal canal
- Premolars with two canals à palatal one
à The post has to adapt to the canal, not the other way around
• Direction of the canal relative to the occlusal plane
- If there is a great inclination à prefabricated post
- If not, depending on the canal: prefabricated or cast post and core

4. Biomechanical needs for the restoration
• The position and type of tooth
• The function of the future restoration à unitary or abutment for a
bridge
• Determine the flexural and compressive forces the tooth will bear
• Every posterior ETT will need a restoration that covers the cusps,
ideally onlay or crown, to reduce the risk fracture

5. Ferrule effect
• The crown has to embrace at least 1.5 – 2 mm of healthy dentin all around the
contour of the tooth
• 360º of healthy cervical dentin surrounding the tooth and extending 1.5 – 2 mm
coronal to the margin of the crown
• Why? à to optimize the biomechanical behaviour of the restored tooth
• It’s important / mandatory to respect it
- Better biomechanical behaviour
- Elevates the resistance of the crown
- Reduces and transmits the stress better
- Dissipates the forces that concentrate at the circumference of the tooth
- Stabilize the restored tooth
- Optimizes the resistance form
• The more ferrule height, the better prognosis
• The more uniform the ferrule in the whole circumference, the better and less risk of failure
• A correct ferrule needs 1.5 – 2 mm height
• A non-uniform ferrule is better than none, more important on palatal and buccal surface
• In case of no ferrule
- You will find different views in the literature, evaluate situation
- Not so long ago the option was CP&C, but today many authors prefer a prefabricated
post
- If not viable, extract and restore with an implant or bridge

54
6. Crown-to-root ratio
• The proportion between the length of the crown and the length of the root
• Minimally acceptable proportion is 1:1 to resist lateral forces, always and only if healthy
periodontium and controlled occlusion
• A 1:2 proportion will have a better prognosis

7. Subgingival destructions
• Depending on the amount and depth of the subgingival destruction
• What do we need to restore?
- 1.5 – 2 mm ferrule effect + respect 3 mm of biological width = minimum of 4.5 mm of
supra-alveolar tooth structure required
• Solutions for these situations will be
A. Surgical crown lengthening
§ Increase the crown / root ratio
- Reduces the effective root length
- Increases effective crown length
- Reduces the volume of root dentin
§ Evaluate the aesthetic outcome if it’s an anterior tooth
§ Good option for molars
§ Delays the treatment, 3-6 months

B. Orthodontic extrusion
§ When extrusion is performed à reduction of the bone support
§ It should be considered before the surgical option, because
- More favourable mechanical behaviour
- Preferable for premolars and incisors
§ Delay of the final treatment

C. Tooth extraction

8. Function and tooth position in the arch
• Patients with excessive occlusal wear or parafunction
- Higher risk of fracture
- Higher risk of debonding
- Higher risk of fracture of the composite core
• Try to establish contact points rather than areas of contact

9. Balance between the tooth reconstructions vs value of the tooth in the treatment plan
• If the prognosis of the tooth to restore is limited
- If the tooth has to act as an abutment for removable or fixed prosthesis à evaluate
the higher risk of fracture
- If the tooth is in a strategic position in a wider restoration plan à consider extraction
- If the tooth to restore is in between two implants à consider extraction and restore
with implants

10. Successful clinical outcome of ETT
• Adequate root canal treatment
• Adequate restorative treatment
- Good post and core system
- Luting agent and techniques
- Restoration type, full or partial coverage crown

55
Treatment planning
• What are posts used for?
- The retention of the core
- Optimization of the resistance
- Transfer and dispersion of the loads into the
root
- Even if still controversial à strengthen the
totality of the tooth and restoration (we don’t
only remove the Gutta Percha, but also the healthy hard tissues, so this is debatable, it
actually makes the tooth weaker)
• General indications for the placement of a post
1. Large defects requiring crowning
2. Large defects requiring partial coverage
3. Narrow abutment diameter
4. Immature root with a large root canal
• “Gutta-percha, MTA and composite are materials that do not have a reinforcing effect over the
tooth or the restoration”

1. ANTERIOR TEETH
• Intact tooth
- When there is no crown destruction, only the cavity access
- Sometimes no post is needed (e.g. only minor proximal cavities)
- Upper central incisor is three times tougher if it doesn’t have a
cast post and core (CP&C)
- Anterior teeth suffer more from flexural stress, the post helps increasing the rigidity
and biomechanical properties
• With loss of tooth structure
- Always take into consideration the translucency of the final restoration to
choose the restorative material
- Possible alternatives à prefabricated post + composite resin restoration or
CP&C
• Basically post only required when crown in anterior tooth

2. POSTERIOR TEETH
• Shillinburg recommends cusp coverage
• Minor tooth structure loss
- Crown
- Onlay
- Endocrown
• We can use the pulp chamber to increase the retention and adhesion of the restoration
• Moderate tooth structure loss < 50%
- E.g. big occlusal or proximal caries
- Increased severity if there are also cervical lesions
- Treatment à prefabricated post + composite resin
restoration (PP&CRR) + crown/onlay
• Severe tooth structure loss > 50%
- If more than 50% of the structure is compromised
- Two or less walls left
- The post is recommended
- E.g. MOD caries or cusp loss
- Options à CP&C + crown or prefabricated post + crown

56

• Always remember that you should have ferrule effect
• If there is no ferrule effect
- Crown lengthening + CP&C + crown
- CP&C with additional post

A. Premolars
• Smaller teeth mean less structure
• Smaller pulp chamber to use to increase retention and adhesion
• Subject to lateral forces during mastication
• The post is usually indicated

B. Molars
• The post is more indicated when
- The coronal structure is totally missing
- Small pulp chamber that will not allow us to gain retention and adhesion

3. CONSIDERATIONS FOR TEETH THAT WILL BE ABUTMENTS OF DENTURES
• ETT must not be abutment teeth or free-ended RPDs
- Four times more risk of fractures
• ETT must not be used for cantilever bridges
- High risk of fracture or failure
• ETT used as abutments of bridges suffer fractures twice as often as teeth without
endodontic treatment or single-tooth FPDs
- Even with ferrule effect
- The use of ETT as abutments for bridges with more than one pontic is questionable

4. CLINICAL PERFORMANCE OF THE RESTORED ETT
• Will depend on the entire complex
- The post and core material
- The luting agent and technique
- The overlying crown
- The ferrule effect
- The functional occlusal loads

Prefabricated posts
• Classification according to material
- Metal posts
- Aesthetic posts
• Classification according to shape
- Cylindrical
- Tapered
• Classification according to surface
- Threaded
- Unthreaded

57
1. Classification
F Regarding their material
A. Metal posts
• Very rigid
• Indicated more for posterior teeth
and/or crowns
• Not really used anymore

ü Stainless steel
- Still used successfully
ü Ni-Cr alloy
ü Titanium alloy
- Appeared to avoid corrosion
- Low radioopacity
- Low toughness when small diameter

B. Aesthetic posts
ü Carbon fiber
- 8 micrometer fibers parallel to the axis of the post
- Epoxy resin matrix
- Radiolucent
- Biocompatible
- Elasticity 21 GPa (dentin GPa)
- Disadvantage à dark colour
ü Glass fiber
- Translucent
- Favourable colour
- Transmit light (cements)
- Similar elasticity to the dentin
- Their flexibility can lead to microleakage and fracture if
there isn’t an adequate ferrule effect
ü Quartz fiber
ü Zirconia
- Prefabricated or custom-fitted
- High compression strength
- Very rigid
- Almost impossible to remove
- Require more pulp canal preparation
- Cannot be etched
- Better not to be used
- Quartz and zirconia both have bad adhesion, so they’re not really used as posts

à The good posts nowadays are the carbon fiber and the glass fiber posts

F Regarding their shape
A. Cylindrical
• Greater retention (more friction)
• Create a weaker area of the root at the tip of the post
B. Tapered
• Fit the pulp canal better, but low retention
• “Wedge effect” if not deep enough

58
 F Regarding their surface
A. Threaded
• Risk of fracture
• Creates high tension over the residual walls
• Don’t use
B. Unthreaded
• Lower risk of fracture of the root

à Tapered are more conservative, cylindrical more retentive, so we always use tapered
ones, because we care more about preservation of the tooth
à We use unthreaded tapered post, for the same reason
à We prefer fracture of the post, rather than a fracture of the root canal

2. Purposes
• Intraradicular retention
• Doesn’t reinforce the tooth perse
• Nowadays we can find in the literature authors that state that the post helps
with the reinforcement of the tooth, but actually the crown is what really
reinforces the tooth
• Retention will depend on à the design of the post and the cement
A. Length
- Minimum crown height à around 8 mm
- 2/3 of the working length or root length
- Leave at least 4-5 mm of apical seal
B. Shape and surface
- Best shape à not cylinder but tapered
- Most retentive surface à threaded but high risk
- Prefabricated posts are usually fluted (grooves or ridges)
C. Diameter
- The greater the diameter, the greater the retention
- Not greater than 1/3 of the diameter of the root
- At least 1 mm of root wall thickness
- Always try not to weaken the tooth
- The post must be adapted to the canal, not the canal to the post

3. Procedure
• Drills are coded according to the shape and size of the post
• Colours of the stripe drills change depending on the brand
• Before these burs, glate gliddens burs number 2 and number 3
(and then when using these burs, e.g. when red one, step wise,
first use white, yellow and then red)

1. First, take a radiograph of the tooth
2. Confirm apical seal and performance of the endodontic treatment
3. Calculate working length (4-5mm of apical seal)
4. Removal of endodontic sealing material (gutta percha) with Gates-Glidden drills
5. Shaping of the pulp canal with drills
- Increasing diameter
- Contra-angle hand piece
- Up to the desired width
6. Clean the post with alcohol

59
 7. Get the post into the canal and take a radiograph
- Fit of the post
- All the gutta-percha has been removed
8. Check that there is enough space for the antagonist tooth
9. Cement the post
ü Fiber posts are cemented with composite resin cements
- Translucent post à dual cure cements
- Opaque post à self-cure cements
ü Metal posts are cemented with either zinc phosphate or glass-
ionomer cements
ü For both, we place the self-curing adhesive on the post and then we put the cement on
top and place it in the root canal
10. Build up the core
11. Crown preparation
12. Impression taking
13. Provisional restoration
14. Cementation of the crown

Cast posts and cores
1. Concept
• Single tooth FPD that restores totally or partially the ETT
• Cast in one piece (core and post are joined)

2. Characteristics
• Used for ETT
• For highly destroyed teeth
• Requires placement of a crown afterwards
• Design à not too short

3. Clinical procedure
• General guidelines
- Independent from the final restoration (crown, bridge)
- Its fit and adjustment is independent from the fit of the restoration
- Must be made of a noble alloy (nobel alloy to avoid corrosion, we
make them in gold, but this is very expensive)
- Must be made of the same alloy as the final restoration (corrosion)
- Length of the post into the root below the bone level to prevent
fractures à a very short post will break the neck of the tooth / the
root at that place
- At least 1 mm diameter
- Flat supporting surface
- The margin of the final restoration must end over healthy
dentin
- Thus, the crown must surround the
CP&C completely (doubles its
strength)

• Pulp canal preparation
- Same as for prefabricated posts
- Conical drills should be used after Gates-Glidden drills
- Width of no more than 1/3 of the diameter of the root

60
 • Coronal preparation
- A small slot must be made to prevent rotation
- Surface must be flat to provide support
- Remove any undercuts in the coronal area (check direction of the pulp
canal)

• Summary clinical procedure
F Indirect pattern
- An impression is taken
- The dental technician designs and
manufactures the CP&C at the lab
- Light body silicone is poured into the pulp
canal
- A bolt is placed right afterwards à it must
have a retentive end
- The rest of the impression is taken
- A wax pattern is made over the cast
- It’s cast later


F Direct pattern
- The pattern of the CP&C is made at the office, directly into the
patient’s mouth
- Made of acrylic resin
- Sent to the lab for casting
- The canal must be lubricated with Vaseline (petroleum jelly)
- A plastic bolt is used as support for the resin
- Acrylic resin is prepared and pushed into the
canal with a lentulo and the bolt
- The acrylic core is built with a brush and a
plastic instrument
- When acrylic resin is set, the tooth is prepared for a crown with its final shape
- The dental technician casts the CP&C






F Overcastable post
- A noble alloy prefabricated post is put into the canal
- The rest of the core is built with acrylic resin
- The dental technician overcasts the CP&C

F Multiple canals
A. First option
- A second canal is used to increase retention
- The widest pulp canal is prepared in the usual way
- The preparation of the second canal is shallower

61
 B. A second option is to build a telescopic CP&C
- Overcastable post in the main canal
- Prefabricated post in the secondary canal
- Core build with acrylic resin
- The abutment preparation can also be designed at the
laboratory

Conclusion
The use and indication of the post placement and the type of post is still a controversial subject.
Analysing all the determinant factors will help increase the good prognosis to our restoration. To
sum up:
1. No post and composite core building
• Molars and small destructions
• It’s enough taking advantage of the anatomy of the pulp chamber
2. Fibre post
• When at least 50% of the structure is lost
• Two surfaces or less are present
• Incisors and premolars à studies on premolars demonstrated less fractures when posts
are placed
• Molars, if crown structure is missing and insufficient pulp chamber
3. Need of pre-restorative treatment
• Crown lengthening
• Orthodontic extrusion
4. Cast post and core
• Big destruction
• No ferrule
• Patients insisting on trying to save the tooth
• Acceptable results
5. Extraction
• When the tooth has no viability
• Because of the planification the extraction makes more sense








Questions
1/ What’s the boundary of the restoration? Slide 12
2/ Why if there’s a great inclination we would use a prefabricated post?
3/ Can you draw the ferrule effect + biological width = required tooth structure?
4/ For both moderate and severe tooth structure loss the post is recommended? Slide 40/41
5/ I wrote I my notes that we start with Gate Glidden burs number 2, but don’t we start with number
1?
6/ Could you just explain the direct and indirect pattern of cast post and core? I’m not sure what a
bolt is slide 99

62
UNIT 9. BRIDGES

Definition of dental bridge
• It’s a fixed dental prosthesis used to replace a missing tooth / teeth
• The missing tooth is restored by a structure called the pontic
• Pontic comes from the Latin pons which means bridge
• It’s fixed to the adjacent teeth of the missing piece

Advantages
• Firm attachment
• Aesthetics
• Comfort for the patient
• Better hygiene than RPDs
• Better load transfer to abutment teeth than RPDs

Parts











Types
1. Fixed bridge
• Most common type of bridge
• Retainers are cemented onto the abutment teeth
• Rigid connectors
2. Cantilever bridges
• The pontic has a connector and a retainer only on one side
• Less use due to the implants rehabilitation
• Occlusion overload of the abutment teeth
• Need to be careful with occlusion
• Need to be careful with the periodontal attachment
• Always have Ante’s law in your mind
• Indications
A. Upper lateral incisor missing
- Abutments à canine and first premolars
- Watch for à crown-to-root ratio and eccentric
movements
B. First premolars
nd st
- Abutments à 2 premolar and 1 molar
C. First molars
st nd
- Abutments à 1 and 2 premolars
st nd
- Short pontic à half mesiodistal distance from 1 to 2 premolar

63
3. Maryland bridges
• Metal “wings” over abutment teeth
• Cemented with resin cements
• Rely on adhesion to stay in place
• Very small preparation on the lingual surface of abutment teeth
(over enamel)
• Indications
A. Provisional restorations
- During implants healing
- Young patients

4. Bridges with interlocks
• Seldom used
• Cannot be removed, it’s fixed
• It’s a non-rigid connector
• Used as broken-stress mechanical union
• Two parts joined by an attachment (interlock)
- Patrix (male) à should be at the mesial surface of the pontic
- Matrix (female) à should be at the distal surface of the retainer
and will be cemented to the abutment
- Movement will seat the key into the keyway
- Mesial direction of the movements when vertical forces are applied, which can unseat
the key
• Placed in the middle abutment
• If placed in the terminal ones, pontic acts as lever arm
• Situations of long bridges or edentulous pieces on both sides of a tooth
• Frequent intrusion of one of the parts, usually the matrix
• Indications
- Unparalleled abutment teeth
- Rarely used because of the intrusion produced
- In this case, the non-rigid connector is placed over the premolar to avoid further
increasing the tilting of the molar

5. Removable bridges
• Seldom used
• Large ridge defects
• Friction retention
• Retentive devices
A. Bar
B. Telescopic crowns
§ For badly aligned teeth
§ Primary copings
- Cemented to the abutment teeth
- 3-6º taper
- Adequate height
§ Secondary copings
- Joined to the removable part
- Not cemented to the primary copings

64
6. Bridges with hygienic pontics
• Seldom used
• Pontics are 1-3 mm from the gingiva
• Indications
- Periodontitis with poor oral hygiene
- Handicapped patients
- Epilepsy à gingival hypertrophy
• Check that there is enough prosthetic space
• Rigid alloy

Pontics
1. Hygienic
• Good access for oral hygiene
• Poor aesthetics
• Separated from the ridge
• At least 3mm gap, minimum of 1mm gap from the
edentulous ridge
• Volume of at least 3 mm
• Very weak pontics, need length to compensate the rigidity
• Zero aesthetics
• Not comfortable

2. Ridge lap (saddle)
• Aesthetic
• Very difficult to clean
• Concave shape, surround the ridge bucally and lingual /
palatal
• Intimate adaptation to the gingiva
• Produces inflammation and possible bone resorption
• Difficult hygiene
• Very aesthetic
• Not recommended

3. Modified ridge lap
• Good aesthetics
• Moderately easy to clean
• Extends over the buccal surface
• Does not surpass the bone ridge lingually
• Good hygiene (less than the conical)
• Good aesthetics, the design creates the illusion of a real tooth

4. Conical
• Very hygienic
• Poor aesthetics
• Shape of an inverted pyramid
• Just one contact point with the gingiva
• Convex shape M-D and B-L
• Not very comfortable
• Indicated in posterior areas over thin ridges
• Not to use on the upper jaw, creates phonetic problems

65
5. Ovate
• Superior aesthetics
• Moderately easy to clean
• The pontic goes into the concavity created in the gingiva
- Firstly, shaped with the provisional right after the
extraction
- Creating the concavity with a rounded bur, then placing the
provisional so the tissues heal with the shape
• It is the most aesthetic, it emerges from the gingiva
• Preserves the interdental papilla or creates it
• The provisionalization step is key for it to succeed
• Only anterior sector with high aesthetic needs

Connectors
F Part that joins the retainer to the pontic
1. Rigidity
• Adequate diameter, minimal
2
- Metal à 4mm (2x2mm)
2
- High strength ceramic à 16 mm (4x4)
2. Correct shape
• The more resistant is the triangular shape, where the vertical axis is the biggest
3. Width
• 1/3 to ½ of the B-P diameter
• Also depends on the length and alloy material
4. Height
• Far from the papillae to create embrasures for the hygiene
• Joins at the medium third, slightly below the fossae of the
retainers

F Depending on the connector we can classify the bridges as
1. Fixed-fixed
• Classical à rigid connectors, cemented
• Cantilever à in extension
• Fixed removable à cemented retainers, removable structure on top over telescopic
crowns or a bar
• Adhesives (Maryland)
• Hygienic
2. Fixed-removable (combined)

Retainers
1. Intracoronal retainers
• Inlays
2. Extracoronal retainers
• Full coverage crowns (provide better protection to abutment teeth)
• ¾ crowns (infrequent use), picture à
• Reverse ¾ crowns (infrequent use)
• 7/8 crown (infrequent use)

66
Treatment planning
For a good treatment planning
• Good diagnosis
• Clinical history
• Visual inspection
• Radiographs
• Mounting diagnostic cast on the articulator
- Prosthetic space
- Mesializatios
- Occlusion
- Lateral guidance

1. ASSESSMENT OF ABUTMENT TEETH
A. Pulp vitality
• Optimum situation à vital tooth, without caries or restorations
• If the tooth has an endodontic treatment
- Can be used for fixed prosthetics
- But ferrule effect is even more important
- Bridges fail twice as much as when teeth are vital
• Some people state that every abutment teeth has to undergo an endodontic treatment
when doing bridges, but that’s false
• Endodontic treatment will be done when
- It can be foreseen that preparations will get into the pulp
- Accidental pulp exposure
- Signs or symptoms of irreversible pulpitis after preparations
B. Condition of the clinical crown
• Integrity
- Ideally à no caries, abfractions, erosions, abrasions or restorations
- If previous restorations are not in a good condition à redo them
- Remember that every tooth has to be able to retain its restorations individually à
consider posts whenever necessary
• Morphology
- The morphology should not be expulsive
- Because of no survey line
- Survey line below the gingiva (e.g. gingival hyperplasia) is a bad situation, consider
crown lengthening
• Size
- Ideally A > B
- Too short clinical crowns will provide little retention
- The bigger (higher) the crown the better the retention
• Position
- Ideally abutment teeth shouldn’t be inclined and without rotation
- If all abutment teeth are straight, a good path of insertion can be achieved
- Tooth preparation can correct inclination to a certain degree
• Relationship between clinical and anatomical crown
- Usually clinical crown is shorter à enamel below the gingiva
- Finish line over enamel whenever possible
- If clinical crown is longer (over-erupted / gingival recession), options:
§ Supragingival finish line if possible
§ Metal collar (when aesthetics are not critical)
§ At aesthetic areas à over cementum (try to achieve maximum fit)

67
 C. Periodontal condition of the abutment teeth
• Bridge abutment teeth will bear more load than normal teeth
• Periodontal condition is even more important
- No gingivitis
- Not more than 3mm probing depths
• If periodontal treatment has to be performed
- Wait at least 2 months to get to a stable gingival level after
a root scaling
• Larger teeth have greater surface à better ability to support
forces
• At least 2mm of attached gingiva à makes it easier to keep a healthy situation
• No furcation defects
• No mobility

• The surface of the pontics cannot exceed the surface of the abutment
retainers
• Ante’s law
- The surface of the second premolar and second molar is bigger than
the tooth to restore à good prognosis
- The surface of the retainers and the pontics are equal (middle
picture)
- The missing teeth surpass the surface of the retainers à bad
prognosis and poor choice to go with
• Radiological assessment should yield images with
- Even periodontal ligament
- No bone resorption à a small horizontal bone loss can be acceptable, but no
occlusal trauma signs
- Adequate crown-to-root ratio
- No periapical radiolucency’s
- No root resorptions
- No cementomas or hypercementosis

D. Root(s) condition
• Crown-to-root ratio
- Assess radiographically
- Measure from bone crest level
- Ideally à 1:2
- Minimum acceptable à 1:1
• Crown-to-root ratio has to be considered together with
- Antagonist arch (complete denture, fixed denture)
- Periodontal condition of the antagonist arch
- Length of the edentulous space
• Morphology of the roots
§ Single rooted teeth
- Oval section ones are better than round section roots e.g. upper lateral incisors
are not good teeth
- Better if they are slightly curved
§ Multi-rooted teeth
- More than one root, better behaviour and retention
- Divergent roots are better than fused ones
- Better periodontal support

68
 • Root surface
- Always note that it can be diminished due to
§ Root resorption because of orthodontic treatment
§ Periodontal disease
- Radiographs are very important

2. ASSESSMENT OF EDENTULOUS SPACES
• Will determine number of abutment teeth used, type of pontic, bridge biomechanics which
depends on
- Alloy used
- Thickness of the pontics
- Type of connectors

A. Length
• The longer, the greater the load
• Ante’s law
- The total periodontal membrane area of the abutment teeth must equal or exceed
that of the teeth to be replaced
- It cannot be taken as the only rule
- Consider this together with all the other data
• Number of missing teeth
- 1 tooth à very good prognosis
- 2 teeth à good prognosis
- 3 teeth à unfavourable prognosis
- 4 teeth à not indicated (except lower incisors)
• Failure of long bridges
- Periodontal ligament overload
- Failure of the materials
- Misfit at distal margins

B. Shape of the space
• Straight spaces
- Favourable
• Curved spaces
- Unfavourable
- E.g. upper front teeth
- May require using more teeth

C. Shape of the edentulous ridge
• Will condition the kind of pontic
1. Normal ridge (convex and not so much bone loss) è modified ridge flap or conical
2. Thin ridge, but still convex à conical
3. Flat and wide ridges à ovate pontics (higher aesthetics), the hole can either be
done with provisionals or surgically
4. Ridge with defects à may need a surgical procedure to
modify it, Siebert classification
- Class I à horizontal
- Class II à vertical
- Class III à combination

69
 D. Location of the space
• Whether it’s an upper or lower space
- If it’s upper à occlusal load will tend to spread abutment teeth
- If it’s lower à occlusal load will tend to gather abutment teeth, this is more
favourable (better prognosis)

E. Prosthetic space
• Sometimes the edentulous space will be invaded
- Extrusion of the antagonist
- Mesial migration of the adjacent teeth
• Mounting the models for previous study and diagnosis is required
• Some previous treatment might be needed

3. BIOMECHANICAL CONSIDERATIONS
• Occlusal load will bend the bridge towards the ridge
• This will lead to
- Tension over retainers à torque over abutments, which
will tend to separate retainer and abutment
- Lever effect on curved edentulous spaces à luxation of abutment teeth
• Occlusal forces of the bridge can cause
- Deflection
- Torque over the abutment
- Lever arm, increased effect over the anterior
- Luxation

A. Factors that condition how much the bridge bends (deflection)
1. Length of the bridge
• Bending is directly proportional to the cube of
the length (the dentulous span)
• The longer à the more bending of the bridge à
the higher the risk of failure
2
• For example, if the length is double, there is eight more times deflection (2 ), if the
3
length is triple there is 27 more times deflection (3 )

2. Thickness of the bridge
• The thickness will reduce the degree of deflection
• Occluso-gingival thickness is the one that matters
• Inversely proportional to the cube of the
thickness
• To reduce deflection àincrease the O-G thickness of the pontic
and the used material
• For example, a bridge that is half as thick will deflect eight times
more

3. Curvature of the bridge
• The curvature of the arch has an effect on the stress over the
fixed partial denture
• When pontics are away from the line that joins the retainers
(more lever arm) à higher risk of torque
• It will produce a lever action over the abutment teeth
• The longer the lever arm, the more torque and luxation

70
 • Example to replace upper incisors
- Pronounced curvature
- To offset the torque à gain retention on the opposite direction of the lever
arm
- Only if good retention of the premolars because of the tensile forces they will
have to support
• Example to replace canines







B. How to minimize torque over abutments
1. Thicker pontics (occluso-gingivally)
• Thicker framework of the pontics à for PFM crowns,
gingival or occlusal surface of the pontic made of metal
• Modifying the antagonist arch if necessary
2. More rigid alloys (Ni-Cr and Zr)
• Predominantly base alloys, they’re the most rigid
• If not, noble alloys
• Last resort à high noble alloys, the least rigid
3. Using more than one abutment tooth
• Especially when abutment teeth don’t have an optimum
crown-to-root ratio
• Teeth further away from center are the ones that suffer more torque
• The conditions of the secondary abutment must be equal to the primary
- Crown-to-root ratio à equal or bigger than the first
- Bone support à equal or bigger than the first
- Periodontal health à equal of better
- Retentive capacity à equal or higher
• The secondary abutment will have to support
tensile forces when the pontic flexes
• Low embrasures between retainers must allow a
correct hygiene

4. INFORMATION TO THE PATIENT
• Inform the patient about the condition of his or her mouth
• Inform about the different options
- Legally mandatory
- Not only one option
• Tell him/her about the option you think is best
• Risks
• Inform about the time it will take to do the treatment
- Approximate number of appointments
- Check-ups
- Future maintenance

71
5. POSSIBLE OPTIONS BASED ON WHAT TEETH ARE MISSING
1. SIMPLE BRIDGES
• Replace one tooth only
A. One incisor missing
B. First premolar missing
- Using 3 and 5
- Group function
- A cantilever option could be used but not
recommended
C. Second premolar or first molar missing

• Replace two teeth when those teeth are:
D. Central and lateral incisors missing
- Maryland bridge or conventional
E. First and second premolars missing
F. Second premolar and first molar missing

2. COMPLEX BRIDGES
• Two or more pontics (except the ones previously seen)
• Space in a more committed (compromising?) location
• More demanding regarding
- Toughness of retainers
- Abutments
- Periodontal support
• Four pontics only when replacing lower incisors
• When bridge is not possible à RPD or implants
rd
• 3 molar as abutments à can be used but usually present
some problems
- Incomplete eruption
- Short and fused roots
- Mesially inclined
• Secondary abutments
- Abutments that are not right next to the space
- All abutments must have the same retention (if
not, secondary abutments are necessary)
- When not à secondary abutments
- Also, when there is a reduced periodontal
support

a. Canine missing
- Difficult because of canine guidance
- Group function occlusion
- Both incisors must be included as abutments

72
 b. Upper central and lateral incisor
c. Lower central and lateral incisors
d. Upper central incisors

e. First and second premolars








f. Second premolar and first molar







g. Lateral incisor and canine
- Group function occlusion
h. Canine and first premolar
- Group function occlusion

i. More than 2 incisors missing
j. Both premolars and first molar missing
- Bridge only if abutments are in perfect condition
- Canine guidance
- Rigid alloy (Ni-Cr)

73
 3. SPECIAL BRIDGES
A. Intermediate abutments
• There are two spaces next to a tooth
• Intermediate abutment suffers more
• Thus, it’s important that abutment teeth of these
bridges are periodontally sound and have plenty of
healthy tooth structure
• Formerly, interlocks were used, but nowadays these are obsolete
B. Inclined abutment teeth
nd
• Especially lower 2 molar
• Very difficult to get a common path
of insertion
• Endo post might be needed
• Ortho treatment, telescopic crowns
or partial coverage crowns are also
options

C. Canines involved
• Canine and one more tooth missing à group function
• Canine + 2 more teeth missing à RPD or implants
D. Cantilever bridge
• A pontic is connected only on one side to a retainer
- First premolar missing
- Upper lateral incisor missing à lateral incisor
shouldn’t participate in canine guidance
- First molar missing à option to avoid, if no other
choice then at least reduce it MD






E. Splinting
• Should be avoided whenever possible
- Hindered hygiene
- All the treatment can be committed because of one tooth
• Only three reasons
- Periodontal reasons
- Tooth with very short clinical crown
- Combined prosthesis

74
 F. Full mouth rehabilitations
• Splinting as one single bridge should be avoided
- It’s difficult to achieve a good fit
- Hindered hygiene
- All the treatment can be committed because of one tooth
- Mandible bending movement
• Try to divide the bridges in sectors
- Anteriors on one side
- Posteriors on the other

All-ceramic bridges
1. Low resistance
• Feldspathic
• Aesthetics
• Veneering layers
• 70 – 90 Mpa
• More translucency

2. Moderate resistance
• Lithium disilicate
• Monolithic or with veneer layer (pressed / CAM)
• 360 – 400 Mpa
• Moderate translucency

3. High resistance
• Zirconia
• Monolithic or with veneer layer (pressed / CAM)
• 900 Mpa
• Low translucency

Masticatory forces
• Forces that the material must support without fracturing
• Over molars à 300 – 800 N
• Anterior sector à 60 – 200 N
• Parafuction à 1000 N

Full ceramic bridges options
1. Lithium disilicate
• Only for anterior bridges
• Higher aesthetics than resistance

• Mostly indicated for anterior bridges
• Bridges of max 3 pieces until the second premolar
• It can be pressed CAM or monolithic
2
• Require 16 mm volume connectors (4x4), more than zirconia
• The pressed has better mechanical properties (Emax-Press vs Emax-CAD)
• The monolithic present a better survival rate

75
2. Zirconia
• High resistance
• Less aesthetic
• New options against chipping
- Zirconia core + aesthetic veneer has a high risk of chipping (main failure reason)
- New alternative à monolithic zirconia à no chipping, solidity, strength thus suited for
bruxists
• Posterior bridges
• Discoloured or edodontically treated teeth
• Not ideal in anterior because of high opacity (new shades and translucencies are available)
• Zirconia options
1. Monolithic ZR à strong and resistant, full contour crowns
§ Indication
- For teeth and implants
- Unitary
- Anterior bridges (limited aesthetics)
- Posterior bridges
§ High strength
§ Biocompatibility à less risk of allergies (Ni, Pd)
§ Good and accurate marginal fit
§ Reduces hypersensitivity (resistant to temperature changes)
§ Radioopacity
§ No corrosion
§ Good estimated clinical longevity

§ Les tooth preparation required
§ Better aesthetics than with PFM
§ Lithium disilicate has better aesthetics, but there are new ZR with different shades
and opacities
§ They can mask underlying dark subtract colours
§ No chipping à indicated for bruxists
§ Less prosthetic space needed
§ Not highly abrasive when correctly polished
§ Reduction of the working time

2. HT ZR à high translucencies, good aesthetics for anterior
3. Layered ZR core à feldspathic veneer, not for posterior

• Zirconia bridges
§ For Zr bridges not only the tooth preparation requires a lot of volumes, also
O Connectors require a minimum volume à full-ceramic require more connector
volume (most frequent point of fracture)
O Connectors dimensions are directly related to the flexural resistance and the
resistance to fracture
O Thickness of the connector
§ Abutment – pontic
2
- 7 mm for anterior bridges
2
- 9 mm for posterior bridges
§ Bridges with more than one pontic (the intermediate pontic)
2
- 12 mm

76
 • Preparation
§ Average volumes needed, it can vary depending on the brand or position of the
preparation (unit vs bridge / anterior vs posterior)
§ Finish line à rounded shoulder or chamfer
§ Finish line of 0.8 – 1.2 mm
§ Occlusal reduction 0.6 – 1.5 mm
§ Avoid sharp edges, angles or discontinuities
§ Round and smooth transitions
§ Posterior bridges à connectors of 9 mm2
§ 12mm2 when in between pontics à subject to the higher loads and stress


























Questions
1/ Volume of what has to be 3mm, the pontic or the ridge, or the space between? slide 29
2/ What does because of no survey line mean in slide 44?
3/ slide 50, would you say that if the combined surface of the retainers and pontics is equal to the
surface of the abutment teeth, the bridge is still a good option? Meaning, is that the limit?

5/ Slide 102 says all the abutments must have the same retention, but in slide 62 of the short version
it says if not, then secondary abutments. So, which is it, when you don’t have enough retention in
the first one, you take a second one? Or when you take a second abutment tooth, both the first and
the second need to have the same amount of retention?
4/ Canines and one more teeth missing is mentioned under complex and special bridges, which one
is it? Slide 109/110 and 117
5/ Is it supposed to be anterior guidance? Because the lateral incisor is never supposed to be
participating in canine guidance, right? Slide 119

77
UNIT 10.1 AETIOLOGY OF THE FUNCTIONAL DISORDERS OF THE MASTICATORY SYSTEM

The masticatory system
• Okesson à “The more complex a system, the more probability of breakdown”
• Disturbances of the masticatory system can be as complicated as the system itself
• The masticatory system is made up primarily of
- Bones à maxilla, mandible and the temporal bone
- Muscles
- Ligaments
- Joints
- Teeth
• Movement is regulated and coordinated by an intricate neurological control system composed:
- Brain
- Brainstem
- Peripheral nervous system
• Movement is coordinated to
1. Maximize function
- Chewing
- Speaking
- Swallowing
- Role in breathing
2. Minimize damage to any structure
• Precise movement of the musculature is required for the movement of the mandible in order
to move the teeth efficiently during function
• Components
1. Teeth
• 32 teeth
• Different functions
- Incisors à incise or cut the food
- Canines à cutting, ripping or tearing
- Premolars à begin the breakdown of food
- Molars à grinding and chewing before swallowing
2. Periodontal ligament
• Attaches the tooth to the bone socket
• Dissipates the applied forces over the teeth
• Functions as a natural shock absorber
3. Bones
• Maxilla à two bones fused in the mid-palatal surface
• Mandible
- U-shaped, suspended to the skull (no bones attachment) and mobile
- At the end of the ascending ramus, two processes à the coronoid process
(anterior) and the condyle (posterior)
• Temporal bone à part of the base of the cranium, the condyle articulates in the
concavity of the squamous portion
4. Muscles (they hold and move the skeletal components)
• Masseter à elevation of the mandible, chewing and protruding
• Temporalis à depending on the portion of the fibers that contract, the mandible
follows the direction, elevation
• Medial pterygoid à elevation, protrusion and mediotrusion, depending on the area
that contracts

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 • Lateral pterygoid à divides in two muscles of
opposite functions
- Inferior lateral pterygoid à lateral movements
and lowering of the mandible, protrusion
- Superior lateral pterygoid à high relation with
the articular stability of the TMJ, activates when
forcing intercuspal position
• Digastric à depression of the mandible, opening and
swallowing
5. Temporomandibular joint (TMJ)
• Articulation between the mandible and the temporal bone of the cranium
• Considered one of the most complex joints of the body
• Provides the capacity of hinging and gliding
• The mandibular condyle fits into the mandibular fossa of the temporal bone,
separated by the articular disc
• Two distinct systems
- One system is the tissues that surround the inferior synovial cavity; the disc is tight
to the condyle (condyle-disc complex), rotational movements
- Second system is the condyle-disc complex functioning against the fossa, the disc is
not attached to the articular fossa, there is a sliding between surfaces, translation
movements
• The disc is always between the condyle and the fossa
• Mouth opening
- Teeth separated 20 – 25 mm à the condyles do not move from the fossae
- Wider opening à ligaments are fully extended, condyles move downward and forward out
of the fossae
- It’s called the second arc of opening
- When the patient opens its mouth, check with 4 fingers to see how far, if you try and open it
more and the patient can it’s a muscle problem, when they can’t it’s a skeletal problem
• During the diagnosis, it’s important to distinguish between a patient with a disorder and a
patient adapted to the alteration à treatment plans vary
- There are different possibilities to adapt to new situations: either grinding the teeth at
night, or changing the mandible to another position, to where it works à compensating
patient
- The adaptation capability of the muscles of a bruxist patient, is not going to be the same,
they don’t adapt so there will be problem finding a new position and grinding will be
painful too (she’s more likely to come back with pain in the masseter / temporal muscle or
will develop pulpitis in the lower 6)

Temporomandibular disorders: aetiopathogeny
1. Occlusal conditions
• Having a type of condylar position (THIOP / MIOP) has nothing to do with TMD, the only
occlusal important factor is to have occlusal stability
• Prematurities and interferences are not big factors for TMD’S
• Interferences are worse in the non-working side
2. Emotional stress
3. Parafunctions
• Patients that bite their nails are quite prone to TMDs
4. Trauma
5. Deep pain (central nervous system excitation)

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• Predisposing factors à they increase the risk of appearance of the disorder
• Precipitating or activating factors à they activate the process
• Perpetuating factors à they prolong the situation

F For Maria, a bruxist à Activating factor = filing, perpetuating factor = bruxism
F For Juan, a healthy student à Activating (precipitating) factor = exam stress, predisposing
factor = filling, perpetuating factor = overactivated mandible that was trying to adapt

• How do TMD symptoms develop?
- Normal function + event (local alteration or systemic alterations)
- Physiological tolerance is surpassed
- In response à signs and symptoms of TMD

1. Regular function à nociceptive stimuli
• Basic functions are controlled by the neuromuscular system
• The brainstem regulates the function through engrams that are selected depending on the
sensitive stimuli
• When unexpected sensitive stimuli are received, protective reflexes are created to reduce
the muscular activity

2. The event
• During the normal function of the masticatory system, disorders or alteration can occur
and modify the function
• We can differentiate between two types of alterations
A. Local alterations
1. Changes of the sensory / proprioceptive input
- Fracture of a tooth
- Severe occlusal factor à a crown restoration with inadequate occlusal
contacts
- Chewing hard food or chewing-gum
- Excessive mouth opening à yawning
2. Tissue trauma
- Injection of local anaesthetic
- Excessive mouth opening (luxation or dislocation)
- Excessive or non-usual use of the masticatory system à bruxism
3. Constant deep pain input
- Alters the muscular function by way of the central excitatory effects
B. Systemic events
1. Emotional stress
- The global effect of the emotional stress is generally a muscular hypertonicity
- Fight response à increased tension and activity of the muscles
- An increase of the tone of the muscles of head and neck
- An increase of the non-functional muscular activity (teeth grinding, bruxism)
2. Systemic factors
- Genetic factors
- Gender
- Diet
- General health of the patient, chronic disease, acute disease
- Physical condition of the patient
• There’s no single cause that accounts for all signs and symptoms

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3. Physiological tolerance
• When exceeded the system begins to reveal changes
• Orthopaedic stability
- Optimal articular and functional position (CR) of the teeth in maximal intercuspation
- Disocclusion of the posterior teeth in eccentric movements
• Orthopaedic instability
- Lack of harmony between the CR and MI
- Lack of occlusal stability
- Alterations related to the occlusion à undesirable dental contacts
- Alterations related to the TMJ à anatomical factors, disc displacement, arthritic
condition
• When in a situation of orthopaesic stability, the masticatory system is best capable to
tolerate local and systemic events
• When there is orthopaedic instability, it’s frequent that an event (local or systemic) can
exceed the physiological tolerance disrupting the system function
• The physiological tolerance is different for each patient, the threshold of pain and
resistance vary depending on each patient

4. The response
• Symptoms of TMD appear when the event is bigger than the tolerance
• Each component of the masticatory system has its own structural tolerance
• The initial breakdown starts in the weakest structure of the chain
• “A chain is as strong as its weakest link”
• Symptoms
A. If the lowest structural tolerance is in the Muscles
- Muscle tenderness
- Pain
- Limited jaw movements
B. If the lowest structural tolerance is in the TMJ
- Joint tenderness
- Pain
- Articular sounds à clicking or grating, however (double) clicks are not pathological
C. If the lowest structural tolerance is in the Teeth
- Mobility
- Wear
- Pulpitis
- Fractures
D. If the lowest structural tolerance is in the Periodontium
- Tooth pain
- Tooth mobility

Temporomandibular disorders: temporomandibular disorders
F There are five principal aetiological factors in the apparition of TMD, a good diagnosis of the
etiological factors is the basis of therapeutic success

1. OCCLUSAL CONDITION
• General dentist à prevention and treatment of the TMD, iatrogenicity can cause a TMD
• Not all the TMD’s are due to occlusal factors (actually, almost none)
• A specific occlusal factor doesn’t always cause a disorder, the physiological tolerance will
have to be exceeded
• Occlusion is still an important factor in the TMD genesis (no it’s not)

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 • Optimum occlusion
- “Even and simultaneous contact of all possible teeth when the condyles are in their
most supero-anterior position (resting over the posterior slopes of the articular
eminences with the discs properly interposed)”
- “Each tooth should contact in such a manner that the forces of closure are directed
through the long axis of the tooth”
• Types of early (undesirable) contacts
A. Prematurity’s
- Happen when going from CR to MI
- A premature contact avoids the ICP (maximum intercuspation) in a retruded
position
- E.g. one tooth has occlusal contact before the others
B. Interferences
- Undesirable contact during eccentric movements
- Ideally for a dentate patient à mutually protected articulation
- Worst situation à NWS interferences
C. Protrusion
- When the mandible moves forward from the ICP (MI)
- The predominant protrusive contact should be between the anterior teeth
D. Laterotrusive mandibular movements
- During a lateral movement, the right and left mandibular posterior teeth move
across their opposing teeth
- Working side à laterotrusive movement (most function occurs on this side)
- Non-working side à mediotrusive movement

A. Static occlusal factors (predisposing occlusal factors)
• Musculoskeletal anterior open bite
• Displacement (deviation) from CR to MI of more than 2 mm
• Absence of anterior guidance à interferences
• Overjet greater than 4 mm
• 5 teeth or more missing

B. Orthopaedic instability of the jaw à most important factor
• Dynamic occlusal factors like the prematurities, forces a sliding to reach the intercuspal
position (MI)
• Overexertion of the lateral (external) pterygoid and intracapsular disorder of the TMJ,
especially when subject to higher forces (e.g. bruxism)
• Discrepancies of 2 to 3 mm are one of the principal factors involved in a TMD

C. Acute changes in the occlusion (acute occlusal interferences)
• They increase the muscular tone and its hyperactivity can lead to symptoms of the
elevator muscles due to a protective co-contraction
• Muscles can develop a new way of working together to avoid the interferences
• The patient generally adapts to the new situation
• If it becomes a chronical occlusal situation associated to the stress factor, a
parafunctional activity can appear
• Slepep bruxism is more associated to the stress and sleep alterations than to the
apparition of acute interferences

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 D. Chronical changes in the occlusion
• Occlusal interferences due to the migration of teeth adjacent /antagonist to a gap /
edentulous ridge
• The apparition of a small interference, maintained over time, can also be converted
into a chronic one
• Adaptation à the musculature system tends to adapt to avoid the nociceptive
(adaptive) reflex, this happens more frequently when not associated to stress
• TMD à a parafunction is developed by the patient due to an increase of emotional
factors (stress), that leads to the typical muscular hyperactivity associated to bruxism
• In those cases, there is a failure of the proprioceptive defensive system that was used
to avoid the interference
• In those situation, the mandible does not try to avoid the interferences, but
unconsciously grinds the area creating the subsequent wear

E. Types of occlusal interferences
• Prematurity’s causing more than 2mm discrepancies
- The factor that is mostly associated to TMD, it creates an overloading of both
pterygoid muscles or one of them
- Pain during the palpation and functional manipulation of the inferior external
pterygoid muscle
• Interferences in protrusion and the working side
- Less influence over the apparition of muscular symptoms
- Increase muscular activity of the elevator muscles of the side of interference

• The important thing will be to try to correlate the pain symptoms with a specific interference
to consider its elimination with selective grinding
• Less pathogenic conditions
- When the mouth is closed, condyles are in their most supero-anterior position, resting on
the posterior slopes of the articular eminences with the discs properly interposed
- All tooth contact provides axial loading of occlusal forces
- Adequate tooth guided contacts on the latero-trusive (working) side and disocclusion of
the medio-trusive (non-working) side à the most desirable is the canine guidance
- In protrusion, anterior guidance to disocclude posterior teeth immediately
- In the upright head and feeding alert position, posterior contacts are heavier than the
anterior ones

2. TRAUMA OVER THE STRUCTURES OF THE MASTICATORY SYSTEM
• A trauma can cause functional disorders
ü TMJ à more likely affected
- Intracapsular disorders
- Disorders of the condyle-disc complex
ü Muscular disorders
• We can distinguish between 2 types of trauma
1. Macrotrauma
§ Intense and sudden force
§ Intracapsular disorders
§ Elongation of the ligaments and disc displacement
§ Due to
- Accidents, practicing sports, a fight etc.
- Iatrogenic trauma à intubation during general anaesthesia, complex tooth
extraction

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 2. Microtrauma
§ Small repetitive forces over the same structures during a long period of time
§ E.g. grinding teeth, bruxism
§ If associated to orthopaedic instability in the IPC (MI) à high risk of elongation of
the ligaments

3. EMOTIONAL STRESS
• Stress increasing can disturb the muscular function
- Increase of the muscle tone of the masticatory muscles, and a more sensitive spindle
muscle during distensions and stretching
- Increase of the non-functional activities such as bruxism
- Reduction of the physiological tolerance related to the increase of the sympathetic
nervous system
• Emotional stress is very common and frequent in our day to day routine
• High variability depending on the patient
- Clear situation caused by a displeasing and annoying event
- Small and daily displeasure that can create anxiety and are not always easy to detect
• The individual reaction
O External mechanism of liberation (fight or physical excercise)
O Internal mechanism of liberation
- More repression
- More psychosomatic disorders
- More muscle tone
- Sleep bruxism can be considered as it

4. DEEP SOURCE OF PAIN
• Any type of deep and constant pain can cause alterations or disorders in the muscle tone
• This deep and constant pain mostly affects the muscular function due to the excitation of
central mechanisms of the nervous system, it excites the brainstem
• The central excitatory effect is a phenomenon that suggests that the neurons carrying
nociceptive stimuli into the CNS can excite other interneurons
• This type of pain is caused by constant pain and sources that lie in deep structures
(musculoskeletal or visceral structures)
• Clinical sign in response of the nervous excitation
1. Referred pain à the pain is located away from the injured or involved organ
- An example a deep pain in the trapezius muscle can cause deep pain in the TMJ
• Alteration of the motor response
2. Trigger points à hypersensitive and localized areas of the muscles
- They can be spontaneously painful or painful under compression
- The trigger point area presents a few contracted motor units, if the totality of the
fibers contract the muscle will shorten and we will be facing a myospasm
- Direct relation with the myofascial pain, the pain arises due to the trigger points
- The trigger point would be in the trapezius muscle, the referred pain in the angle of
the jaw, ears or temple
- Another example: a trigger point in the occipital belly of the occiptiofrontalis
muscle produces referred headache pain behind the eye
3. Protective co-contraction (limitation of the muscular movement) à due to any
proprioceptive or sensory input change
- When prolonged over time, may lead to muscle symptoms and get pathological
- The purpose of it is to protect the threatened area right after the event
- E.g. if placing a high crown, any deep pain input, emotional stress

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 - The protective co-contraction is a body response (in the form of a trismus) to limit
the use of the injured area, the following all limit mouth opening
O Tooth ache
O Sinus ache
O Cervical ache
- The relief of the pain should allow the normal function to be restored again

5. PARAFUNCTIONAL ACTIVITIES
• Parafunction activities are the ones with no functional purpose
- Bruxism à involuntary clenching or grinding between the teeth, with intensity,
frequency and persistency, often not aware (unconscious)
- Biting à nails, cheeks, pencils or other objects
- Chewing ice
• Hyperactivity and hypertonicity of the muscular system
• Example: it’s quite common to find patients with massive dental wear but no pain in
comparison to young patients with a beginning wear in some teeth. The difference is
generally the hypertrophic development of their muscles. New bruxers or just a couple
nights, tend to be in more pain because their muscles are less adapted to the situation

Aethiopathogenesis of bruxism
• The glossary of prosthodontic terms (GPT) defines bruxism as parafunctional tooth grinding
habit consisting of involuntary rhythmic or spasmodic non-functional gnashing, grinding or
clenching the teeth
• Different theories and hypotheses about the aetiology
- Chronic occlusal interferences à less likely
- Psychological factors (stress, anxiety) à most important
- Sleep disorders (going from the deep to the light sleep) or disorders in the CNS

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1. Diurnal parafunctional activity (during the day)
• Consists of clenching (more than grinding) during the day
• It can relate to the existence of prematurities in a centric
relation position à centric bruxism
• Unconscious habit that can be seen in patients very
concentrated in a specific task, performing a demanding or
stressful activity
• The patient is generally not aware of them, when recognizing
it, he can start decreasing the frequency and intensity

2. Nocturnal parafunctional activity (during the night)
• Eccentric bruxism à parafunctions during sleep seems to take the form of single episodes
and rhythmic contractions of the muscles, creating eccentric movements with tooth
contact
• The majority of the episodes tend to happen while going from deep to light sleep
• The patient is generally unaware of the clenching and bruxing, the partner is usually the
person that highlights it
• The duration of the episodes is about 5 – 10 seconds, but can also last up to 20 – 40
seconds
• The frequency of the episodes varies greatly as well, the studies show different results
- 25 times all along the night, the sum will be around 5 min per night
- 38 minutes in one night
• For muscular pain to appear on jaw muscles, a clenching of 20 – 60 seconds is enough
• Bruxing events can induce symptoms in some individuals but not necessarily in all of them
• A higher frequency of bruxist episodes tend to occur in stressful periods of the patient
• The direction of the applied forces is horizontal and not axial (more risk of occlusal trauma)
• The position of the jaw during eccentric movements tends to create orthopaedic instability
of the TMJ
• The type of muscular contraction is isometrical
• During the night, the reflexes of protective co-contraction are decreased

Oral treatments of TMDs
• Should be reversible whenever possible and conservative
• Occlusion is not proven to be the cause
• In general, TMD’s treatment consists of
- Education of the patient and home care
- Relaxation and stress control
- Pharmacotherapy (don’t prescribe benzodiazepine, their ability to relax the muscles is not
as good as of ibuprofen [600 mg every 8 hours for 15 days] and the suicide rates are higher)
- Physiotherapy (always)
- Occlusal splints
- Occlusal equilibration à last option (only done when the patient has proven to have a lack
of stability, occlusal disorder)
• Of all that, what’s within reach of dentists are occlusal splints
• Occlusal equilibration should be avoided because it’s irreversible and non-conservative

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F Occlusal splints
• Any removable artificial surface used for diagnosis or therapy
affecting the relationship of the mandible to the maxilla
• Might be used for occlusal stabilization, treatment of TMDs
and/or to prevent wear of the dentition
• It’s a reversible treatment
• Objectives
1. Relax muscles of the stomatognathic system
2. Provide orthopaedic stability to TMJs
3. Lower grinding / parafunctional activity
4. Protect periodontium from occlusal trauma
5. Prevent wear of the dentition

• Characteristics of the splint
- Must cover all teeth (prevent extrusions)
- Should provide occlusal stability at CR
- Should increase VD about 1.5 – 2 mm
- Flat and polished occlusal plane (freedom of movements) à only occlusal contact
points at MI / CR
- Occlusal scheme à mutually protected articulation

• You increase the VD 2 mm when placing a mouthguard, they think that’s one of the reasons
that mouthguards work, it provokes an elongation of the muscles that provokes relaxation
(just a hypothesis, not proved yet)
• The wax record has to be taken in centric relation (always when you try to change the VD)
• Typical exam question: “Can you change the incisal pin in a semi-adjustable articulator?”
- We usually use arbitrary facebows so NO, we shouldn’t change the incisal pin
- Only if you use a kinematic facebow, which we use for fully-adjustable articulators, you
can change the incisal pin
- If we want to increase the VD of a patient, we need to do the increase in the mouth,
with wax and transfer the final VD from the mouth to the articulator with the wax
record, no touching the pin!

• Regarding referred pain à anaesthesia test to locate the location of the pain, the referred
pain will stop








Questions
1/ How is the protrusion an early contact? The other two describe undesirable contacts, but in
protrusion the predominant protrusive contact should be between the anterior teeth right?
2/ Why are the perfect conditions on slide 53 called less pathogenic conditions?

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UNIT 10.2 DENTAL SIGNS AND MANIFESTATIONS OF THE OCCLUSAL PATHOLOGY
Dental signs in tooth and periodontium
• Dental wear
• Cervical erosion
• Tooth mobility
• Gingival recessions
• Dental migrations
• Parafunction
• Alveolar bone exostosis

1. WEAR FACETS
• More frequent sign of dental pathology with an occlusal origin
• More frequent sign of disorders of the stomatognathic apparatus
• Due to parafunctions
• No symptoms during first stages of the wear
• Flat, plain and shiny surfaces
• Non-physiological à diagnose checking centric and eccentric movements and their
relation with the wear areas
• Localization
- Diurnal bruxism à postero-inferior sectors, starting from the higher point of the cusps
- Eccentric nocturnal bruxism à antero-superior sectors in
protrusive and lateral movements, in posterior sectors more
over the inferior NWS sector
• Causes
- Occlusal problems à non-desirable contacts, interferences
- Nutritional problems à generalized and excessive facets in
palatal surfaces of the superior arch
- Other parafunctional habits à tend to be over the anterior sector without
abnormalities
• Classification of wear facets
1. Type I
- Over limited areas
- Smooth flat and shiny surfaces
- Only over enamel
- Over slopes and borders
- Exploration with a mirror and reflected light
2. Type II
- Islets of dentin surrounded by enamel
- Concavities or plain
- Incisal borders and the vertex of the cusps
- On the occlusal surfaces of molars, frequent to see a
combination between different lesions
3. Type III
- Almost on all of the occlusal surface yellow secondary dentin
- Enamel layers of 1 – 2 mm
- The morphology of the occlusal surface is lost, completely plain or in shape of a
cup
- Palatal surface with destructed areas and exposed dentin
- Reduction of the clinical crown à less vertical dimension
- Pulp hypersensitivity

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 - Patient has porcelain fused to metal crown in
the upper, so wear in the lower teeth; can’t put
crowns in these teeth because too close to the
pulp
- Veneer / onlay / overlay better option, because
we don’t have to remove the enamel in that
case, we will use lithium disilicate
- Feldespathic is the most abrasive porcelain
(lithium disilicate and zirconia are less abrasive)

- Patient is an eccentric bruxist
- We should try to make sandwich veneers, but in
this case probably need RCT, P&C (post and
core) and crowns

- Patient suffers from erosion due to external
acids, shiny, 11 and 12 have composite
restorations that got really stained


2. CERVICAL EROSIONS à DENTAL ABFRACTIONS
• Wedged-shaped injuries
• Located in the cervical area, buccally
• Due to occlusal overloading
• Combination between acidic catabolites from the sulcus
and mechanical traction à creates cervical destruction
• Rare to find over palatal surfaces thanks to the natural
autoclisis, even when contact on the NWS (sometimes
seen, not completely uncommon)
• They start as plain and then start having a wedging shape, in advanced cases the pulp can
be seen through the transparency of the structures
• Anterior teeth, because of eccentric bruxism à when contacts in protrusion
• Posterior teeth, because of eccentric bruxism à with contacts on the NWS
• Different from the abrasions associated to the brushing technique
• The first treatment is a mouthguard, occlusal adjustment last option, you can use
chlorhexidine high concentration to increase adhesion and place a composite restoration
(but not a good prognosis, as you can see in this left picture)

• We differentiate between three types
1. Type I à affects only the enamel
2. Type II à affects enamel and dentin
3. Type III à almost gets to the pulp chamber

• In the picture below, the antagonist is made of layered feldespathic ceramic and there’s a
passive eruption of anterior teeth, which happens
especially in patients with attrition, abrasion or
erosion, because the occlusion is trying to stabilize,
searching for tooth contacts, and the bone follows
the teeth

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3. INCREASE OF THE MOBILITY
• Due to a failure of the structures supporting the tooth
• Two main reasons
O Loss of periodontium due to bacterial causes
- If the periodontal disease is associated to abnormal forces,
there will be more mobility, and this is non-reversible
O Abnormal forces (intensity and orientation) over a healthy
periodontium
- Periodontal ligament widening, reversible when correcting
the forces

4. GINGIVAL RECESSION
• Signs of periodontal disease with or without occlusal trauma
• Can have a bacteriological origin or can happen because of
trauma (unfavourable and intense forces)
• Palatal surface of the molars on the NWS
• Buccal surface
- Anterior à protrusive
- Posterior à WS
• Attrition that provokes abfraction à

5. DENTAL MIGRATIONS
• Change of the physiological position of the tooth due to the periodontal disease or trauma
• Antero-superior teeth tend to spread buccally when associated to eccentric bruxism and
previous periodontal disease

6. PARAFUNCTION
F Noises while clenching teeth (centric bruxism)
• Parafunction
• Unconscious reflex of clenching and grinding with different but high intensity
frequency and resistance
• Highly associated to an increased level of stress and to orthopaedic instability
• Can be seen in patients very concentrated on a specific task, realizing a demanding or
stressful activity
• More clenching than grinding

F Nocturnal parafunction activity (eccentric bruxism)
• Unconscious, during sleep, single and rhythmic episodes
• The patient is generally unaware of the clenching and bruxing, the partner is usually
the person that highlights the habit

7. ALVEOLAR BONE EXOSTOSIS
• Overgrowth of bone
• Bone prominence, growth of the bone as a protection against overloading forces
- Midpalatal union à palatal tori
- Buccal maxilla à associated to erosions (of the skin)
- Lingual area of inferior premolars à mandibular tori
• No treatment is needed if they do not interfere with the
function and do not create too many ulcerations
• If they need to be removed à surgery

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Clinical symptoms (manifestations of occlusal disorders over teeth and periodontium)
1. HYPERSENSITIVITY AND/OR PULP PAIN
• Anomalous contacts in some of the teeth
• Exposition of the dentin tubules caused by the wear
• Consequences
- Spontaneous pulp pain
- Pain to cold (reversible)
- Pain to heat (irreversible)
- Aseptic pulp necrosis due to ischemia

2. PERIODONTAL PAIN
• Vague and unclear pain
• Discomfort and unusual response to percussion
• Different from the periodontal abscess, which is a localized and a more intense pain
• Because of the intrusion of the tooth it compresses the vascular system

3. SENSATION OF TOOTH LOOSENING
• It’s considered as a subjective feeling
• Real mobility is considered a sign
• Can be related to the widening of the periodontal ligament space due to occlusal trauma
• Can be restored when reducing the trauma
• The patient will say: “Noto los dientes flojos” meaning my teeth feel loose

Radiological signs
1. WIDENING OF THE PERIODONTAL LIGAMENT SPACE
• Bone resorption caused by intense forces that squeeze and compress the PDL
• X-ray à the space of the periodontal ligament looks wider
• Radiolucent image around the root in its coronal portion (more frequent localized, it can
be more generalized too)
• Mobility
• Normal PDL space is 0.15 – 0.21 mm, but this may decrease with age









2. THICKENING OF THE ALVEOLAR CORTICAL BONE
• Osteosclerosis à bone condensation as a defence mechanism against traction
• X-ray à narrow, longitudinal and radiopaque area
• Strong periodontium à wear facets can be found on the crown of the tooth
• Weak periodontium à no wear facets, the tooth is lost before their apparition

3. LOOSENING OF THE INTERALVEOLAR RIDGE
• Alteration of the lamina dura, between the bone sockets à early sign of dental trauma
• The bone ridge is lost or fracture

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4. RESORPTION OF THE ALVEOLAR BONE
• Very frequent sign
• Caused by a periodontal disease or occlusal trauma
• Two types of bone loss
1. Horizontal à cases of periodontal disease, tend to be more generalized
2. Vertical à cases of occlusal trauma, often located around the damaged area
§ Wedge shape mesial or distal of the root (diagnosis through radiographs)
§ Because of the contacts that tend to happen, the wedge resorption is generally
associated to
O Prematurities (protrusion)
- Distal superior
- Mesial inferior
O Interferences in retrusion
- Mesial superior
- Distal inferior

§ Concave, cup shape
- Interferences on the WS
- Concave defects on the buccal surface
- Interferences on the NWS

5. RHIZOLYSIS
• Disappearing and loss of the root
• Caused by
- Occlusal trauma
- Iatrogenicity (orthodontics, bridges etc.)
• Not frequent, but happens especially in patients with orthodontic
treatment, in which the tooth movement occurs rapidly
• Unfavourable root response

6. HYPERCEMENTOSIS
• Excess of cement deposit, thick layer of cementum surrounding the root
• Proliferative response against occlusal trauma
• Ankylosis
• Not frequent, but important in case of
restoration with fixed prosthesis
• Radiographic mass at the root of the apex
• Contraindicated to restore with bridges

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7. PULP STONES
• Compact masses of calcified tissues
• Can be found in the pulp chamber and the root canal
• A tooth can respond negative to vitality test due to pulp stones,
even though they are probably vital (they can try and remove
them with ultrasound if the tooth needs a root canal, if the tooth is
vital we can just leave it)

Signs and symptoms over the musculature system
1. PAIN ON PALPATION
• Frequent sign of TMD
• The patient doesn’t have to have a specific pain
• The tenderness points are found during the masticatory muscles
examination
• Exploration of the masseters from behind
• The medial pterygoid is palpated inside the mouth or
by clenching under the angle of the mandible

2. MYALGIA
• Highly related to parafunctions, stress and anxiety
• Diffuse tenderness of the muscles
• Facial and around the auricular pavilion localization
• Described as erratic (onberekenbaar, onvast) and recurring

3. LIMITED MOUTH OPENING à MUSCULAR CAUSE
• Caused by a protective co-contraction against muscular pain
• A limited mouth opening is considered when
- Wide opening less than 40 mm
- Lateral movements less than 7 mm
• The path while opening can be affected, deviated from its regular trajectory
• Soft end feel à when applying a gentle passive force, the patient increases his opening (if
the patient can’t, it’s called hard end feel and that’s a skeletal problem)

4. MUSCULAR HYPERTROPHY
• In centric bruxism à the masseters

5. FACIAL ASYMMETRY
• In eccentric bruxism à hypertrophy of one side can lead to asymmetries

6. TENSION HEADACHES
7. MUSCULAR PAIN OF THE SPINAL COLUMN
• Trapezius and the sternocleidomastoid muscles

Articular signs and symptoms
1. ARTICULAR PAIN
• Arthralgia à pain located in a joint
• The articular surfaces present no innervation; the pain is originated in structures that
present nociceptors
- Discal ligament and capsular ligaments à elongation (leading to pain)
- Retrodiscal tissues à compression (leading to pain)

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 • It’s complicated to differentiate between the different structures where arthralgia occurs
• The pain tends to be localized in the area in front of the ear
• Differentiate with ear or muscular disorders
• When at rest, the pain tends to resolve

2. ARTICULAR NOISE, JOINT SOUNDS
• Joint sounds are one of the most common signs of TMD
• Becomes a symptom when the patient perceives them
• They appear when the patient opens and/or closes the mouth
• Associated to the disruption of the normal condyle-disc movement:
- The condyle moves forward
- The disc rotates posteriorly on the condyle
- The superior retrodiscal lamina elongates
allowing the condyle-disc to (completely)
translate out of the fossa
- The muscles maintain the limitation of the
displacement

• Two main sounds
ü Click (not pathological)
- Single event of short duration
- If we talk loud, sounds like a pop sound
- Wrong coordination between the condyle and the articular disc during movement
- Appears when there is a condyle-disc disorder (discal luxation)
- There’s a functional displacement of the structures
- Can occur at any time during the opening
- Less harmful at the beginning of the movement
- Produced by an abrupt movement of the disc over the condyle, into the normal
condyle-disc relationship
- Once the joint has clicked à a normal relationship between the disc and condyle is
re-established and maintained during the movement
ü Reciprocal clicking
- Occurs when there is also a morphological change of the disc at the area where the
condyle rests
- It’s a second click during the closing movement
- When the condyle is going to its rest position
- Happens near the closed or intercuspal position (MI)
ü Crepitation (pathological)
- Multiple, rough, gravel sound-like
- Grating and complicated
- Due to a friction between the articular surfaces
- Possible osteoarthrosis pathology

3. LIMITED MOUTH OPENING, ARTICULAR CAUSE
• Less than 40 mm opening
• Hard end fell à restrictions in mouth opening that occur at 25 – 30 mm that cannot be
opened wider even with gentle passive force
• Suggest a joint problem (or skeletal?)

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 A. Functional dislocation with reduction
- A dislocation (luxation) of the disc happens
- The patient can move his jaw in different directions and resolve the locking
- The disc comes back to his position
- When resolved with no help à disc dislocation with reduction
- Click or reciprocal click
- Not always painful, it depends on the severity, duration and structures affected
during the lock or catch
- Pain can be associated to the ligament elongations or if they break and loose
innervation due to the forces over retrodiscal tissues
B. Functional dislocation without reduction
- This happens when the patient cannot return the dislocated disc to the normal
position over the condyle
- A mouth opening limitation occurs due to the non-translation of the dislocated disc
à the condyle only rotates
- Also create a modification of the opening mandibular pattern, the other joint
works correctly
- Midline deflected to the affected side when open
- Lateral movements are possible over the affected side, not the unaffected side
(because the NWS has to slide for a lateral movement)
- The patient generally remembers the moment of the locking
- Not always painful
- Caused by elongation of the ligaments or thinning of the disc
C. Luxation
- Dislocation where the clinician needs to reduce the dislocation to normalize jaw
movement
D. Subluxation
- The malposition of the complex can be reduced by the patient
- The disc-condyle complex positioned anteriorly to the articular eminence

4. OTORYNOLARYNGAL (ORL) DISORDERS
• Symptoms associated to the ORL area can appear
- Tinnitus à noise sensation, only heard by the patient
- Deafness à loss of hearing
- Vertigo à the sensation of feeling off balance

Treatment options for TMD
1. OCCLUSAL EQUILIBRATION
• Irreversible and non-conservative treatment
• Consists of the elimination of prematurities and interferences
• First of all à occlusal analysis on the articulator mounted in CR and eliminating the
contacts on the cast
• If more than 4 contacts to eliminate à not recommended, hard to reproduce in the
patient’s mouth

2. PHYSIOTHERAPY
• For the relaxation of the muscular system
A. Massages à, increases the heat and helps eliminating toxins during the contraction
B. Therapeutic exercises à help recover the function (limited movements opening/closing)
C. TENs à Transcutaneous Electrical Nerve stimulation, reduce pain and stimulate muscle tone
D. Infrared light à creates heat that improves blood-flow, oxygenation and relaxes muscles

95
3. PHARMACOKINETICS
• Objectives
- Reduce the psychological tension
- Relax the muscles
- Enable treatment manoeuvres
• Types
- Muscle relaxant (Robaxisal or Myolastan)
- Sedative and tranquilizer can help the doctor reduce the pain, benzodiazepines (NO!!)
- Analgesic, not very useful to relieve acute pain, better paracetamol
- Anti-inflammatories
- Vasoactive drugs for vascular migraines
- Infiltrations in the affected areas

4. EXTERNAL AGENTS
• As a contributing factor for the treatment
ü Heat
- Can create changes over the neuromuscular system, increase of the blood-flow and
the capillary permeability
- When muscular tension, pain and rigidity of the joints
ü Cold
- Anaesthetic effect, reduces spasms and blood-flow, reducing the local
inflammatory response, oedema and haemorrhage
- When the jaw movements are limited associate to active therapy

5. PSYCHOLOGICAL FOLLOW-UP
• Patients with high stress and anxiety
• A follow-up with a psychologist can help

6. OCCLUSAL SPLINT
• Any removable artificial occlusal surface used for diagnosis or therapy affecting the
relationship of the mandible to the maxilla
• Might be used for
- Occlusal stabilization
- Treatment of TMDs
- Prevent wear of the dentition
• Reversible treatment
• Therapeutic objectives
1. Relax muscles of the stomatognathic system
2. Provide orthopaedic stability to TMJs
3. Lower grinding / parafunctional activity
4. Protect periodontium from occlusal trauma
5. Prevent wear of the dentition

• Characteristics of the splint
- Must cover all teeth (prevent extrusions)
- Should provide occlusal stability at CR
- Should increase VD about 1.5 – 2 mm
- Flat and polished occlusal plane (freedom of movements) à only occlusal contact
points at MI / CR
- Occlusal scheme à mutually protected articulation

96
Questions
1/ What exactly are we summing up here? These are consequences of what? Because bruxism is one
of them…
2/ Why does it say mesial in maxilla in protrusive on slide 66 and the next slide says that it’s
retrusion?
3/ Why does it say hard end feel suggest a joint problem, not a skeletal in slide 95?
4/ Why would you want to stimulate muscle tone? Slide 103 under TENs?
5/ We don’t use benzodiazepines right? Sldie 104


Extra class on CadCam – 16/10/2018
• Workflow: impression taking à casting the impression à trimming and cutting the cast to make
a die cast à lost wax technique
• CadCam: 2 types of extraoral scanners that are used in the lab à optical scanner and contact
scanner
• STL file = Standard Tessellation (mozaïekwerk) or Triangulation Language (image you get in
CadCam)
• Remember sprouts in the non-active casts
• CAD = Computer Aided Design // CAM = Computer Aided Manufacturing
• Milling (fresado) or laser synthering is how you can manfucature teeth with CadCam
- Milling is a substractive method, we have a block and remove material until it has the final
shape, more expensive, because you waste quite a lot of material and it takes much longer
than synthering, but it is more accurate than synthering
- Laser synthering is a constructive method, we build op the tooth from scratch, cheaper
option and takes less time and in addition to that it is better in copying organic structures,
and we can obtain more retentive surfaces
• Implants will always be milled
• Teeth: frameworks will be laser synthered when chromium cobalt but milled for those materials
that can’t be done with laser synthering (e.g. zirconia, lithium disilicate porcelain)
• Then we have the frameworks and then we can layer the porcelain on it
• Zirconia that is being layered will chip, nowadays we use monolytic restorations with zirconia, in
which we mill the complete final restoration of zirconia
• With CadCam we can scan the impression or the cast, but the cast is much easier to scan
• Cranberry and lemon juice are really really acidic, even more than coca cola
• Veneers, ways of manufacturing
- Monolytic technique à most resistant (also called staining technique, because after we
stain the surface to make it look more natural)
- Layering technique à most aesthetic
- Cut back technique à somewhere in between
• For full mouth rehabilitation, it’s not good to use a intraoral scanner to take CadCam
impressions, because the scanner is small and the mouth is big, so the scanner takes a lot of
pictures and then puts them together, but not in the most accurate way, so better to use
CadCam for restorations, not full mouth rehabilitation

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UNIT 11 DIAGNOSIS IN FIXED PROSTHETICS

• Evaluation of
- Medical history
- Extraoral examination
- Intraoral examination
- Muscular examination
- Joint examination

• Treatment planning is the keystone to succeed
- Good clinical history and examination
- Good diagnosis
- Good treatment plan
- Restore functional needs
- Restore aesthetic needs

Medical history
• Directed by the professional
• Reasons for consultation (chief complaint)
- What happens to you?
- Since when?
- What do you think the reason is?
• Personal data
- Name
- Age (be careful with too young or too old patients)
• General diseases that might influence the treatment
- Hypertension
- Hepatopathies
- Cardiopathies
- Diabetes
- Allergies
- Previous surgical procedures
- Pregnancy
- Coagulopathies
• Pathologies that might make us modify the treatment
1. Epilepsy
- Metal occlusal surfaces
- Short appointments
2. Allergies
1. Ni, acrylic resins, alginate
3. Xerostomy
2. Higher caries incidence
4. Diabetes
3. Higher incidence of periodontal disease
5. HIV
4. Higher incidence of periodontal disease
6. Hydantoin treatment
5. Gingival hyperplasia
7. Sjögren syndrome

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Extraoral examination à Facial examination
• Look for
- Asymmetries
- Muscular hypertrophy
- Scars
- Old trauma’s
- Paralysis
- VD (decreased, maintained)
• Facial fistulas
• Areas of alopecia
• Facial profile
• Lip support
• Smile line
• Lip seal

• Cranio-cervical palpation
- Adenopathies
- Thyroid gland
- Salivary glands

Intraoral examination
1. Dental formula
• Count teeth
• Horizontal and vertical migrations may occur
• Assess the migrations carefully à preprosthetic
treatments may have to be done
- If you anticipate a pulp invasion, schedule
an endodontic treatment prior to the dental
preparation
- Consider other possible options
2. Dental pathology
• Wear facets
• Abrasion
• Erosion
• All may indicate parafunctional habits
3. Clinical crown length
• Crown lengthening may be required
4. Periodontal assessment
• Probing
• Bleeding
• Calculus
• Tooth mobility
• Plaque index
• Attached gingiva around teeth
• Percussion
5. Re-evaluate previous dental treatments
6. Evaluate pulp vitality
7. Asses aesthetics
• Tooth colour
• Tooth shape
• Tooth position

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8. Soft tissue assesment
• Soft tissue lesions
• Exostosis (torus)
9. Assessment of the edentulous space
• Morphology
• Extension
• Date of last tooth extraction
• Relation with nearby teeth
• Straight spaces have a better prognosis than curved spaces
10. Assessment of the occlusion
• To see if the present occlusion is correct and can be kept
• If the occlusion is correct à keep it
• If the occlusion is wrong à modify it with the treatment or before the treatment
• Static occlusal relationships
- MI (is it stable?)
- Overbite, overjet
- Cross bite
- Cusp-to-cusp occlusion
- Uniformity of the occlusal plane
- Midline
• Dynamic occlusal relationships
- Disocclusions (protrusion and literal movements)
- Look for prematurities and interferences

Muscular examination
• Some patients may present muscular pain
• Sometimes related to parafunctional habits
- Stress
- Occlusion
• Parafunctional habits may lead to
- Muscular pain
- Spasms
• Muscular examination can reveal problems that can be otherwise unnoticed

1. MUSCULAR PALPATION
• Purpose à find painful muscular points
• Pain is usually intense and localized (except trigger points)
• Helkimo test à sum of points through a test
- 0 à No TMDs
- 1 à Mild TMDs (1-4 points)
- 2 à Moderate TMDs (5-9 points)
- 3 à Severe TMDs (10-25 points)
• Palpation is done
- Into the bulk of the muscle
- Against a hard plane (some bone nearby)
- At the insertion of the ligament
• Easier the more superficial the muscle
• Pain threshold of the patient
- Palpate mastoid process
- Or vertex

100
 A. Temporal muscle
• Palpation along muscular fibers
• From front to back
• Tendon palpation
- With the index finger over
the ramus of the mandible
from inside the mouth
- Towards coronoid process

B. Masseter muscle
• Deep part à 15 mm in front of
tragus, below zygomatic arch
• Superficial part
- Over the ramus of the
mandible
- From back to front
- Craniocaudally
• Intraoral palpation à one finger intraorally and another one
extraorally
• Bilateral pain usually indicates clenching
• Unilateral pain may be due to an interference

C. Lateral pterygoid muscle
• Usually the first muscle affected by TMDs
• Can sometimes pull from the disc, displacing it
• Palpation with the little finger at the bottom of the upper
vestibule, behind retromolar process

D. Medial pterygoid muscle
• Palpation is difficult
• Only lower insertion, below the border of the
angle of the mandible

E. Sternocleidomastoid muscle
• Easily palpated along the muscle

F.Posterior belly of digastric muscle
• Palpation with the litttle finger between
posterior border of the ramus of the mandible
and the sternocleidomastoid muscle
• Head of the patient to the front and
downwards

2. FUNCTIONAL EXAMINATION
• Muscular pain occurs either at
- Maximal stretching of the muscle (e.g. maximum mouth opening)
- Maximal contraction
• Protrusion and laterality against resistance
• Clenching
• Biting a saliva ejector laterally
• Protrusion against resistance with a unilateral saliva ejector

101
 • Apart from painful muscular points, assess
- Muscle hypertrophy
- Facial asymmetries
- Muscle hypertonicity
- Spasms
• Functional limitation of muscular movements
1. Maximum mouth opening
§ Less than 40 mm interincisal opening
§ Due to pain and spasm of elevator muscles
§ Protrusion and lateralities
- Usually not limited (8mm) due to muscles
- Unless lower lateral pterygoid is highly affected
ü Soft end-feel
- Muscles allow 2 mm stretching
- The opening can be increased when applying some force over the jaw
- Painful
ü Hard end-feel
- Articular problem, not muscular
- The mandible can’t be opened more, even when a gentle force is applied
- The opening cannot be forced

2. Opening-closing path
§ Muscular problem à variable deviated path
§ Articular problem à always the same path

Joint examination
• Articular pathology is less frequent than muscular pathology
• Most frequent articular pathology is intracapsular pathology

102
1. Articular pain
• Usually not from the articular surfaces, but from the surrounding tissues
• Two kinds of palpation
1. External (laterally)
§ Palpation of the lateral part of the
condyle
§ Index and middle fingers in front of tragus
§ Pain usually indicates capsulitis or
synovitis
2. Internal (posteriorly)
§ With the little finger into the external auditory canal, pushing
forward
§ Pain usually indicates
- Retrodiscisitis (very common for disc-condyle disorders)
- Posterior capsulitis or synovitis

2. Articular sounds
• Clicks à single explosive noise
- Disc-condyle incoordinaton
- During disc recapturing
ü During opening
- Indicate anterior functional displacement of the disc
- Milder stage the nearer to the MI point
ü During opening and closing
- Reciprocal click (or clicking)
- Indicated disc dislocation with reduction
- Early on opening, late on closing usually
- More advanced stage
ü During mediotrusion
- Indicate mesial disc dislocation
• Crepitus à continuous “grating” noise
- Due to wear of the articular surfaces
- TMJ osteoarthrosis
- X-ray to see this à Schüller’s transcranial radiography
• Heard with the bell of the phonendoscope
• While performing opening-closing or eccentric movements
• Are the most frequent sign
• Can also be noticed during lateral palpation

3. Movement limitation
A. Maximum mouth opening of less than 40 mm with hard end feel
- Articular problem
- Probably an anterior disc dislocation without reduction
B. Mediotrusion of less than 8 mm
- Probably an anterior disc dislocation without reduction
C. Lateral deflection of the mandible during protrusion
- Deflection towards the affected side (DDWOR)

103
 D. Deflection during opening-closing movements
- More than 2mm deflection is considered a pathological sign
- If there is reduction, the deflection is during the opening path
and ends again at the midline
- If there isn’t reduction, the deflection doesn’t get back to the
midline, the affected condyle only rotates and there will be
deflection towards the affected side

Preprosthetic treatment
à The purpose of it is to eliminate pathological conditions, uncertainties and risks
1. Urgent treatments (has to be done quickly but not right now, which would be an emergency)
2. Tooth extractions
3. Initial periodontal treatment
4. Occlusal equilibration
5. Endodontic treatment
6. Restorative treatment
7. Orthodontic treatment
8. Surgical periodontal treatment
9. Treatment of TMDs

1. URGENT TREATMENTS
• Urgencies are pathologies that require fast treatment, but not right now this second
• As opposed to emergencies (risk to life)
• In general, every process that presents pain or infection
• Pathologies that require urgent treatment
A. Acute pulp disease (pulpitis)
B. Periodontal abscess
C. Tooth fractures
D. Acute TMDs (trismus)

104
 • Also includes some malocclusions that require immediate treatment
- Fremitus
- Any occlusal contact clearly harmful to the patient
• Fine adjustments will be done at the end of the treatment

2. TOOTH EXTRACTIONS
• We extract when the tooth is too damaged to be restored, with a high degree of mobility
or for a better treatment planification
• If an anterior tooth or teeth needs to be extracted
- A provisional immediate denture (fixed or removable) has to be prepared in advance
- Options à Removable denture, Maryland bridge or provisional bridge

• Regarding third molars
- Hardly ever have attached gingiva at buccal and lingual surfaces
nd
- Tend to produce periodontal problems to the 2 molars
- Usually fused or conical roots
- Tend to have inadequate positions, inclination or lack of eruption
nd
- Can produce root resorptions to the 2 molar
• Conclusion
- Extract the third molar next to bridges unless they’re in perfect condition or there’s a
high risk to touch the inferior alveolar nerve etc.
rd
• When extracting 3 molars, possible extrusion of the antagonist can cause
- Prematurities
- Inadequate contact point à food impactation
rd
- Thus, when extracting a 3 molar à extract opposing one too

• How long should we wait after a tooth extraction?
§ From 6 months to 1 year
§ Less than that, bone resorption (remodelling) is happening
- Gingival level migration
- Separation between pontic and gingiva
§ More than 1 year
- Tooth migrations
§ Meanwhile
- Temporary RPD
- Immediate provisional bridge

• For extrusions with no options to restore the edentulous space à extrusion is needed

3. INITIAL PERIODONTAL TREATMENT
• Stages of periodontal treatment
1. Initial treatment
- Hygiene instructions
- Motivation
- Dental prophylaxis
- Scaling and root planning
- Correction of overcontoured margins of restorations and other iatrogenic irritants
2. Surgical treatment (if needed)
3. Maintenance

105
 • Two months after SRP à re-evaluation and decision
- Surgical treatment
- More SRP
- Prosthetic treatment
• During these 2 months
- Evaluation of the commitment of the patient with its oral health
- Stabilization of the gingival tissues
- Very important for any prosthetic treatment to succeed

4. OCCLUAL EQUILIBRATION
• Irreversible and non-conservative treatment
• Consists of elimination of prematurities and interferences
• First of all à occlusal analysis on the articulator mounted in CR and eliminating the
contacts on the cast
• If more than 4 contacts to eliminate à not recommended, hard to reproduce in the
patient’s mouth
• Eliminating one contact can lead to the apparition of another one
• Not recommended
• When?
- Only for occlusal contacts clearly harmful to the patient
- Fremitus
- Extrusions that might interfere with the denture
- Unevenness of the occlusal plane
- Lack of occlusal stability

5. ENDODONTIC TREATMENT
• Only when needed, required and justified
• Endo therapy when necrotic tooth
• Fistula and abscess treatment
- Wait 6 months before performing the prosthodontic treatment
- Be sure of the remission of the pathology
• Endo therapy of vital teeth
- When cast post-and-core is needed (retention)
- Extrusions
- Great tooth inclination
- Wait 1 month
• Apicectomy
- Evaluate crown-to-root ratio
- Wait 6 months for a full healing
- Disadvantages
§ Low crown-to-root ratio
§ Unaesthetic scar
§ Sometimes increases tooth mobility

6. RESTORATIVE TREATMENT
• Remove and restore any caries
• Trim and polish overcontoured restorations
• Repeat any restorations that are not in
optimum conditions over abutment teeth
• In case of doubt, repeat the restoration

106
7. ORTHODONTIC TREATMENT
• Objectives
- Improve periodontal health
- Improve occlusion
- Remove and prevent occlusal trauma
- Ease prosthodontic treatment (inclinations, extrusions)

• Options
- Distalize teeth
- Extrude teeth to increase ferrule effect
- Align crowded teeth
- Achieve a good anterior guidance (overjet, overbite)

8. SURGICAL PERIODONTAL TREATMENT
• For aesthetic purpose
• For periodontal reason
• Re-evaluation after 2 months
• Important to obtain a good stability and healing of the periodontal tissues
• If during surgery
- Only gingiva have been touched à 1 – 3 months
- Gingiva and bone à 6 months

• After any surgery à wait 2 – 3 months
• Having done the initial treatment has these advantages at this point
- No plaque, no calculus (better visibility)
- No inflammation (better handling of tissues)
- Less posterior inflammation
- Patient already motivated
• Patients with bad plaque control
- May have to consider other treatment options and / or prosthetic designs

9. TREATMENT OF TMDS
1. Physiotherapy à for the relaxation of the muscular system
A. Massages à, increases the heat and helps eliminating toxins during the contraction
B. Therapeutic exercises à help recover the function (limited movements
opening/closing)
C. TENs à Transcutaneous Electrical Nerve stimulation, reduce pain and stimulate
muscle tone
D. Infrared light à creates heat that improves blood-flow, oxygenation and relaxes
muscles

107
 2. Pharmacotherapy
• Objectives
- Reduce the psychological tension
- Relax the muscles
- Enable treatment manoeuvres
• Types
- Muscle relaxant (Robaxisal or Myolastan)
- Sedative and tranquilizer can help the doctor reduce the pain, benzodiazepines
(NO!!)
- Analgesic, not very useful to relieve acute pain, better paracetamol
- Anti-inflammatories
- Vasoactive drugs for vascular migraines
- Infiltrations in the affected areas

3. External agents
• As a contributing factor for the treatment
ü Heat
- Can create changes over the neuromuscular system, increase of the blood-flow
and the capillary permeability
- When muscular tension, pain and rigidity of the joints
ü Cold
- Anaesthetic effect, reduces spasms and blood-flow, reducing the local
inflammatory response, oedema and haemorrhage
- When the jaw movements are limited associate to active therapy

4. Psychological support
• Stress and anxiety are a cause and a consequence of TMDs
• Psychologist
• Psychiatrist

5. Education of the patient
• Soft diet
• Voluntary avoidance; disengage teeth contact
• Avoid parafunction and other oral habits
• Avoid stressful activities

6. Occlusal splint
• Any removable artificial surface used for diagnosis or therapy affecting the
relationship of the mandible to the maxilla
• It alters the mandibular position and contact pattern of the teeth
• It hasn’t been proved what makes them work, but it has been stated that it is because
it resets the neuromuscular patterns
• Synonymous of occlusal device
• Indications
1. Relax muscles
2. Helps reducing the pain
3. Allow to handle the patient during the treatment
4. Treatment for TMDs
5. Occlusal stabilization
6. Prevent the occlusal trauma
7. Reduce tooth wear

108
 • Very effective at reducing muscular pain
• Poorly effective to reduce joint sounds
• Objectives
1. Relax muscles of the stomatognathic system
2. Provide orthopaedic stability to TMJs
3. Lower grinding / parafunctional activity
4. Protect periodontium from occlusal trauma
5. Prevent wear of the dentition

• Procedure
1. Take the cranio-maxillary record with the facebow
2. Occlusal record at final VD in CR position (the purpose is to
take the condyle-disc-fossa to an optimum position)
3. Mount the casts with the wax record in between
4. Sometimes physiotherapy and pharmacotherapy are
needed before doing the splint, to be able to handle the patient
5. When it’s impossible to record CR
§ Approximate CR
§ Posterior adjustment to the splint or new splint
6. Manufacturing
§ Heat-curing acrylic resin
- Good mechanical properties
- Allows adjustments
§ For night-time bruxism à upper splint
§ For day-time bruxism à lower splint
§ Anyway à arch where it’s more stable or stabilizes more the dental arches
7. Design
§ Retention à survey line
§ Avoid contact with periodontium (plaque gathering)
§ Flat occlusal surface
§ Mutually protected occlusion (soft canine and anterior guidance)
§ Even contacts
§ No tooth without occlusal contact à to prevent extrusions
§ Minimum possible VD (not making the splint weak) à to prevent myotatic
reflex
8. Time of use
§ Will depend on the pathology of the patient
§ Bruxist patient à forever
9. MI at CR
§ Rarely achieved the first time
§ Adjustments to the splint
10. Monthly appointments
11. Avoid soft splints à increase parafunction and stimulates chewing



Questions
1/ What’s the retromolar process that we have to palpate? Slide 38?
2/ What does DDWOR mean?

109