Pre-Prosthetic Treatments &

The Principles of Tooth

Preparation
Introduction to Pre-Prosthetic Treatments

● Dental procedures are often done before fixed prosthodontics to prevent failure of
the prosthesis.
● These preprosthetic dental treatments are often required because the etiologic
factors which led to the need for fixed prosthesis are the same factors which also
cause caries and periodontal disease.
● For fixed prosthodontics to be successful, restorations must be placed on well-
restored teeth.
● A comprehensive treatment plan is essential to ensure that preparation of the
mouth for fixed prosthesis is done in a logical and eficient sequence.
● Patient education is a crutial part in preparing for treatment. Good oral hygiene
habits should be encouraged.
Aims of Preprosthetic Treatments

1. Relief of symptoms (Chief complaint).

2. Removal of etiologic factors (e.g., Caries removal, removal of plaque and

calculus deposits).

3. Repair of damage.

4. Maintenance of dental health.

Sequence of Treatment

1. Preliminary assessment
2. Emergency treatment of presenting symptoms
3. Oral surgery
4. Caries control and replacement of existing restorations
5. Endodontic treatment
6. Definitive periodontal treatment and preliminary occlusal therapy
7. Orthodontic treatment
8. Definitive occlusal treatment
9. Fixed prosthodontics
10.Removable prosthodontics
11.Follow-up care
Oral Surgery

● Soft tissue procedures

○ Abnormalities detected during clinical
or radiographic exam may require
referral to and oral surgeon for further
consultation or treatment.
○ Diagnosis of pathologic conditions can
be difficult and the general dentist
should refer to a specialist when there
is doubt.
○ Examples:
■ Alteration of muscle attachments
■ Increasing the vestibular depth
■ Modification of edentulous ridge
Oral Surgery

● Hard tissue procedures

○ Extractions should be performed
early in the treatment plan to
maximize time for healing and
osseous recontouring.
○ Impacted/ unerupted
supernumerary teeth should be
extracted if removal will be
atraumatic.
○ Other procedures include
reduction of bony tuberosities
when there is inadequate space
for prosthesis and ridge
augmentation procedures.
Oral Surgery

● Orthognathic surgery
○ Requires careful restorative
evaluation, to prevent dysfunction
between occlusion and facial
skeletal structure.

● Implant-supported Fixed
Prosthesis
○ Patients benefit from a team-
approach.
○ Case selection is important
○ Technique sensitive.
Caries and Existing Restorations

● Teeth being considered for fixed

prosthesis are often severely
damaged or have existing
restorations.
● Restorations should be carefully
evaluated for damage and recurrent
decay.
● Damaged or carious restorations
should be replaced to provide the best
possible foundation for the prosthesis.
Foundation Restorations

● This is a core of material used to build up a damaged tooth to ideal anatomic form
before it is prepared for a crown.

● The core should be contoured provide the patient with adequate function and be
finished adequately to facilitate good hygiene.

● The core build up should be prepared for a crown in the same manner as if it were
initially whole and intact.

● Various materials may be used for core restorations and selection depends on the
extent of tooth destruction, the treatment goals and operator preference.

● Retention features such as grooves or pinholes may be placed to combat the possible
loss of retention and resistance during crown preparation.
Foundation Restorations

● Amalgam:
○ Good resistance to microleakage.
○ Suitable for posterior teeth.
○ Recommended when the crown
preparation will extend less than
1mm beyond the junction of the tooth
and core material.
○ Higher strength than glass ionomers.
○ Functions well as an interim
restoration.
○ Pins, undercuts and slots can be
used for retention
○ Adhesive bonding is possible and
may reduce leakage.
Foundation Restorations

● Resin-modified Glass Ionomer Cement:

○ Suitable for small lesions.
○ Fast setting.
○ Adheres to dentin although
preparation should be undercut to
supplement retention.
○ Radiopaque formula should be used.
○ The presence of fluoride helps
prevent recurrent decay.
○ Low strength.
Foundation Restorations

● Composite Resin:
○ Fluoride releasing formulations are
available, thus resisting recurrent decay.
○ Does not require condensation.
○ Sets rapidly.
○ Material is bonded through dentinal
bonding agents.
○ Moisture sorption properties of
composite may cause delayed
expansion leading to axial binding of
crown.
○ Material is adversely affected by
exposure to zinc oxide eugenol
temporary cement.
Foundation Materials

● Pin-retained cast metal core:

○ Should be considered for
extensively damaged tooth.
○ Preparation requires careful
location and placement of
pinholes.
○ Laboratory fabricated.
○ Good preparation form.
Foundation Materials
Foundation Materials
Endodontic Treatment

● Initial examination of patient should include vitality testing of teeth.

● Vitality test may be done with an electric pulp tester, endodontic refrigerant spray. Or
heated gutta percha.

● Tenderness to percussion should also be assessed, as well as sensitivity, soft tissue

swellings, fistulous tracts or tooth discolouration.

● Conventional endodontic treatment should be done if possible. Surgical treatment is more

invasive and affects crown/root ratio.

● The need for a post + core should be evaluated.

● Elective endodontics may be considered in cases where the prognosis of an abutment tooth
is compromised or if additional preparation would jeopardize pulpal health.
Endodontic Treatment
Periodontal Treatment

● Proper diagnosis and treatment of periodontal disease is important for long lasting fixed
prosthodontics.
● If left untreated, prosthesis will fail.
● Gingival grafting procedures may be required to augment the amount of attached and
free gingiva. Ideally there should be 5mm of keratinized gingiva with 3mm being
attached.

● Crown lengthening may be indicated when the clinical crown of a tooth is too short to
provide adequate retention without the restoration impinging on the gingival attachment.
○ The biologic width is approximately 2 mm.
○ Any impingement by restoration may result in bone loss.
○ Crown lengthening increases the crown/root ratio
Periodontal Treatment
Orthodontic Treatment

● Even minor orthodontic movements can significantly improve the prognosis of any
restorative treatment being planned.
○ E.g. Uprighting a malpositioned tooth to improve axial alignment and direct
occlusal forces more favorably along its long axis.

● Orthodontic extrusion in conjunction with osseous recontouring of a tooth may be

considered when a fracture or carious lesion extends below the free gingival margin.

● Orthodontic treatment should be considered where abnormal tooth relationships or

diastemas occur.
Orthodontic Treatment
Occlusal Treatment

● Primarily done to relieve symptoms of occlusal dysfunction.

● Goal is to have maximum intercuspation coincident with centric relation and

remove eccentric interferences.

● Selective recontouring of the dentition must be carefully considered since

hard tissue is removed and it it limited by the thickness of enamel. If too
much is removed it cannot be put back on.
Occlusal Treatment
Introduction to Principles of Tooth
Preparation
● Teeth do not possess the ability to regenerate.

● Restorative materials are used to restore form and function when enamel and or dentin
is lost as a result of caries, wear or trauma.

● Teeth must be prepared in order to receive restorations.

● A good preparation is the foundation for a successful restoration.

Principles of Tooth Preparation

● The principles of tooth preparation can be categorised into :

○ Biologic - affects the health of oral tissues
○ Mechanical - affects the integrity and durability of the restoration.
○ Esthetic - affect the appearance of the patient.

● All three (3) factors should be considered simultaneously to increase the probability of
successful tooth preparation and subsequent restoration.
Principles of Tooth Preparation
Biologic Considerations

● It is important to avoid unnecessary damage to the surrounding living tissues during

tooth preparations.

● Try to prevent damage during tooth preparation to adjacent teeth, soft tissues and pulp.

● Adjacent teeth: Iatrogenic damage to adjacent teeth is common. A metal matrix band
may be placed around the adjacent tooth for protection.

● Soft Tissues : Careful retraction of soft tissues such as the tongue and cheeks can be
done using a mouth mirror or flanged saliva ejector.
● Pulp : Pulpal injuries should be prevented during fixed prosthodontics. Care must be
taken. Chemical irritation, microorganisms and extreme temperature can cause
irreversible pulpitis.
Causes of Injury to the Tooth

● Temperature :
○ Friction caused during the preparation of the tooth surface with the
rotary instrument generates heat.
○ Pressure applied as wells the speed and shape at which the rotary
instruments are used will alter the the amount of heat generated.
○ Water must be used while cutting the tooth to prevent overheating.

● Chemical : Chemical actions of some dental materials may be a pulpal

irritant.

● Bacterial :
Conservation of Tooth Structure

● Conserve as much tooth structure as possible.

● Preparation design should be consistent with mechanical and aesthetic principles.

.
● Tooth preparations in close proximity to the pulp should be avoided.
Conservation of Tooth Structure

● Aim for conservation of tooth structure by :

○ Use partial coverage restorations as opposed to full coverage.
○ Prepare teeth without over tapering axial walls.
○ Occlusal preparation should follow anatomic planes.
○ Avoid unnecessary apical extension of preparation.
○ Margin geometry should be conservative and compatible with tooth preparation.
Considerations Affecting Future Dental
Health
● This includes but is not limited to :
○ Axial reduction
○ Margin placement
○ Margin adaptation
○ Margin geometry
○ Occlusal considerations
○ Preventing tooth fracture
Margin Design
Margin Design
Margin Design Advantages and
Disadvantages
Mechanical Considerations

● Tooth preparations are governed by mechanical principles.

● Mechanical Considerations can be categorised into :

○ Providing resistance form
○ Providing retention form
○ Preventing deformation of the restoration
Retention Form

● Retention is the preparation quality that prevents restorations from being dislodged by
forces parallel to the path of placement.

● Adequate retention is determined after considering :

○ magnitude of the dislodging forces
○ geometry of the tooth preparation
○ roughness of the fitting surface of the restoration
○ materials being cemented
○ film thickness of the luting agent.
Retention Form - Retain these facts !

● Taper is defined as the convergence of two opposing external walls of a tooth

preparation as viewed in a given plane.

● Undercut is defined as an irregularity in the wall of a prepared tooth that prevents the
withdrawal or seating of a wax pattern or casting.

● Slight convergence is clinically desirable.

● Crowns with tall axial walls are more retentive than those with short axial walls.

● The type of luting agent affects retention in the case of cemented restorations.
Retention Form
Resistance Form

● This form consists of features that prevent dislodgement of a cemented restoration.

● Multiple resistance areas make up retention form.

● Adequate resistance depends on :

○ magnitude and direction of dislodging forces
○ geometry of the tooth preparation
○ physical properties of the luting agent.
Preventing Deformation

● A restoration requires sufficient strength to prevent deformation while functioning.

● Insufficient strength will result in failure.

● Failure typically occurs at the metal - porcelain interface or the restoration - cement
interface.

● Failure may be a result of :

○ Poor alloy selection
○ Inadequate tooth reduction
○ Poor margin design and/ or incorrect placement
Esthetic Considerations

● Esthetic expectation of the patient must be considered.

● Observe the patient’s smile.

● Esthetic restorations include :

○ Partial veneer crowns
○ Metal - ceramic restorations
○ All - ceramic restorations
References

1. Rosenstiel, S. F., Fujimoto, J., & Land, M. F. (2006).

Contemporary fixed prosthodontics. St. Louis, Mo: Mosby
Elsevier.
2. Shillingburg, H. T., & Sather, D. A. (2012). Fundamentals of
fixed prosthodontics. Hanover Park, IL: Quintessence Pub.
3. Google image search.