CLINICAL REPORT

Fixed dental prostheses with vertical tooth preparations

without finish lines: A report of two patients
Rubén Agustín-Panadero, DMD, PhD,a María Fernanda Solá-Ruíz, DMD, PhD, MD,b César Chust, CDT,c and
Alberto Ferreiroa, DMD, PhDd

Treatment with tooth-supported ABSTRACT

fixed dental prostheses (FDPs)
Tooth abutments can be prepared to receive fixed dental prostheses with different types of finish
remains one of the most lines. The literature reports different complications arising from tooth preparation techniques,
commonly applied options for including gingival recession. Vertical preparation without a finish line is a technique whereby the
replacing missing teeth and abutments are prepared by introducing a diamond rotary instrument into the sulcus to eliminate
offers good long-term clinical the cementoenamel junction and to create a new prosthetic cementoenamel junction determined
survival.1-5 However, FDPs can by the prosthetic margin. This article describes 2 patients whose dental abutments were prepared
suffer various complications, to receive ceramic restorations using vertical preparation without a finish line. (J Prosthet Dent
including gingival recession, 2015;-:---)
which may compromise es-
thetics in the anterior sector.6-8 The reasons for this type of This preparation protocol without a finish line offers
complication include the relationship between the prepara- several advantages. Clinicians can correct the position of
tion of dental abutments and chronic gingival inflammation the CEJ on both nonprepared and previously prepared
produced by inadequate marginal fit between the abutment teeth, the latter eliminating the preexisting finish line.
and FDP.4 At the same time, a new prosthetic CEJ is created by
Traditionally, when clinicians prepare dental abut- placing the prosthesis so as to leave the gingival margin
ments to receive FDPs, they create a finish line on the at the desired position (obtaining the optimal esthetic
tooth on which the prosthetic restoration rests.9,10 This outcome in cases of compromised esthetics). Addition-
can be located supragingivally or subgingivally, with the ally, this reorganization of the CEJ by means of the
latter being more likely to produce gingival inflamma- prosthesis increases gingival thickness and generates
tion.11-15 These finish lines can be classified into 2 main better soft tissue stability in the medium and long
groups: horizontal finish lines, which include curved term.7,16 The technique also improves prosthetic
chamfer, flat chamfer, and straight shoulder, or vertical
6
retention, allows optimal fit between the tooth and
lines, which include feather or knife-edge margins. An restoration, preserves dental structure, and simplifies
alternative for dental preparation without a finish line, the impression procedure as compared with dental
known as the biologically oriented preparation technique preparation with finish lines.7
(BOPT), can be used for FDPs. The clinician removes the
7
This clinical report describes 2 patients whose prep-
emergence of the anatomic crown, which coincides with aration to receive FDPs was performed using the vertical
the cementoenamel junction (CEJ), to create a new preparation protocol described by Agustín-Panadero and
prosthetic junction situated according to the desired Solá-Ruíz,16 reporting outcomes at 24 months after
location of the gingival margin. placement of the definitive restoration.

a
Associate Professor, Department of Stomatology, Faculty of Medicine and Dentistry, University of Valencia, Valencia, Spain.
b
Adjunct Professor, Department of Stomatology, Faculty of Medicine and Dentistry, University of Valencia, Valencia, Spain.
c
Laboratory technician, Valencia, Spain.
d
Associate Professor, Department of Buccofacial Prosthesis (Stomatology I), University Complutense of Madrid, Madrid, Spain.

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Figure 1. Preoperative intraoral view.
CLINICAL REPORT
Patient 1
A 45-year-old woman without medical problems came to
a private dental clinic hoping to correct esthetic prob-
lems. Intraoral examination revealed Grade III mobility of
the maxillary right lateral incisor (with a hopeless prog-
nosis due to periodontal disease), absence of the maxil-
lary right central incisor, and a thick gingival biotype
(Fig. 1). After intraoral examination, the treatment plan
was to provide a zirconia FDP from the maxillary right
canine to the maxillary left central incisor, to extract the
maxillary right lateral incisor, and to follow the vertical
preparation protocol without finish line for the abutment
teeth.
Initially, a double probing was performed first to
measure the depth of the gingival sulcus and then to
measure the bone level and locate the CEJ, as this de-
termines the limit of preparation of the dental abutment.
Determining the location of the bone is also essential, as
this must not be contacted during tooth preparation.
Tooth preparation began by reducing the incisal edge of
the dental abutments by 2 mm. The axial walls were
reduced by 1 mm with a chamfer diamond rotary instru-
ment (1.4 mm size) (ADO-881, G014; Ancladén SL)
(Fig. 2A). Then the internal wall of the sulcus and the
tooth were prepared at the same time with a conical
diamond rotary instrument (862.514.012 BOPT drills;
Sweden & Martina) with a particle size of 100/200 and a
diameter of 1.2 mm. The diamond rotary instrument was
introduced into the sulcus at an angle of 15 degrees
(Fig. 2B).16 The purpose of this first stage was to eliminate
1 mm from the emergence of the anatomic crown. Then,
in order to avoid creating a finish line, the diamond rotary
instrument was situated parallel to the tooth axis between
the root and crown so that it removed tooth structure with
the instrument’s body rather than the tip. Both the tooth
and gingiva were prepared at the same time (Fig. 2C).
During BOPT, the rotary instrument interacted with the
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internal wall or the internal sulcus and the gingival
epithelium up to the point where the CEJ was situated.
This preparation step aims to eliminate the emergence
area of the tooth crown while the soft tissues are prepared.
The CEJ is located approximately at the level of the
interface between the junctional epithelium and connec-
tive tissue. At this stage, the operator removed epithelial
tissue from a controlled area of the free epithelial sulcus
and junctional epithelium. In turn, the most coronal
connective tissue was also prepared to a depth of 0.3 mm
(Fig. 3). This procedure creates a blood clot at the apical
level of the preparation which stabilizes in the presence of
the interim restoration to stimulate fibroblast differentia-
tion and gingival tissue growth. This process forms a new
periodontal structure around the new emergence
morphology of the interim restoration and subsequently
around the definitive prosthesis (Fig. 4).16
Interim restorations fabricated by a dental laboratory
technician were relined and adapted. Using the interim
restorations, a CEJ was created with the new emergence
profile (Fig. 5). The interim restorations were located at a
depth of 0.5 to 1 mm into the sulcus, respecting biologic
width (Fig. 6). For this patient, an ovoid pontic was used
to remodel the soft tissues in the absence of teeth (Fig. 7).
After 8 weeks, the soft tissues had a healthy aspect, and
the interim restorations were removed (Fig. 8). Treatment
proceeded with a 2-step impression technique with
elastomers (Light Body and Virtual putty; Ivoclar Viva-
dent AG) and 2 gingival displacement cords (Ultrapack
#000; Ultradent Products Inc).
The definitive prosthesis was created on the basis of
the biologic and functional parameters of the interim
restorations. A zirconia framework (IPS e.maxZirCAD;
Ivoclar Vivadent AG) was fabricated by computer-aided
design/computer-aided manufacturing. After the zirco-
nium dioxide framework (IPS e.maxCeram; Ivoclar
Vivadent AG) had been placed, the esthetics, marginal
and internal fit, interproximal contacts, and occlusion
were evaluated at the bisque bake stage. Minimal
occlusal adjustments were required.
The internal surfaces of the zirconia FDP were
airborne-particle abraded with tribochemical silica-
coated 30 mm Al2O3 (CoJet Prep; 3M ESPE). A zirconia
primer was then applied for 5 seconds (Z-PRIME Plus;
Bisco) and air dried. The teeth were also treated with
35% phosphoric acid for 40 seconds, followed by a 30-
second application of a desensitizer (Gluma; Heraeus
Kulzer). The FDP was then cemented with dual-
polymerizing resin cement (RelyX Unicem 2 Automix;
3M ESPE) that was light polymerized. The patient was
instructed in oral hygiene and the care of the new
prosthesis.
Follow-up evaluations were made at 3, 6, 12, and 24
months after the placement of the definitive prosthesis.
No mechanical, esthetic, or biologic complications were
Agustín-Panadero et al
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Figure 2. Simplified protocol for BOPT preparation. A, Preparation with supragingival finish line. B, Elimination of first millimeter of anatomic crown
emergence (15 degrees’ angulation). C, Creation of vertical axial plane between crown and root.

Figure 3. Facial view of vertical abutment preparation. Figure 4. Occlusal view of vertical abutment preparation.

Figure 5. Interim prosthesis after 8 weeks of gingival healing. Figure 6. Facial view of gingival healing.

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Figure 7. Occlusal view of soft tissues with healthy status around dental Figure 8. Widening of gingival sulcus.
abutments.

noted (Fig. 9). The periodontal status of the tooth abut-

ments was assessed, showing probing depths within
accepted ranges of periodontal health no more than
3 mm), no signs of inflammation, and no bleeding at the
time of assessment.

Patient 22
A 40-year-old man was referred from a private dental
clinic to the University of Valencia dental clinic for
assessment before being treated with fixed prostheses in
the anterior sector. Clinical analysis observed extensive
composite resin restorations of the maxillary central in-
cisors with poor esthetics (Fig. 10). The patient presented
a thick gingival biotype. The treatment plan was to use
the vertical tooth preparation protocol to prepare dental Figure 9. Postoperative intraoral view.
abutments of the maxillary right central incisor and
maxillary left central incisor to receive 2 zirconia crowns. flowable composite resin (Filtek Supreme XTE flow; 3M
The procedure began with the double probing tech- ESPE) (Fig. 14). This union creates the interim restora-
nique as in patient 1. The teeth were prepared with a tion’s cervical emergence profile (Fig. 15).
conical diamond rotary instrument (862.514.012 BOPT After 8 weeks, when gingival tissue maturation was
drills; Sweden & Martina) with a 100/200 particle size almost complete, the interim restorations were removed
and a 1.2 mm diameter, which was used to penetrate the (Figs. 16-18).10 The soft tissues were evaluated before
gingival sulcus following the same preparation protocol
as in patient 1 (Fig. 11).16
After tooth preparation (Figs. 12, 13), interim resto-
rations were then adjusted and relined with an autopo-
lymerizable acrylic resin (Sintodent White; Sintodent).
Relining the interim prosthesis allowed the acrylic resin
to penetrate the gingival sulcus in an apical direction
pushing tissue outward to reproduce maximum sulcus
opening. This procedure reproduced 2 areas: a circum-
ferential line that determined the extension of the
gingival sulcus and an outer circumferential area that
marked the position of the gingival margin. Between
these areas, a groove is formed in the interim prosthesis,
with its depth depending on the distance between the
gingival margin and the margin-milling depth. The
groove created will be filled with photopolymerizing Figure 10. Preoperative intraoral view.

THE JOURNAL OF PROSTHETIC DENTISTRY Agustín-Panadero et al

- 2015
Figure 11. Vertical preparation with diamond rotary instrument angled
at 15 degrees in gingival sulcus.
Figure 13. Occlusal view of vertical abutment preparation.
making a 2-step impression with elastomers using 2
displacement cords (Ultrapack #000; Ultradent Products
Inc). Two zirconia crowns were fabricated, and bonding
was carried out in the same way as in patient 1.
The patient returned for assessment at 3, 6, 12, and 24
months after definitive crown placement (Fig. 19). No
mechanical, esthetic, or biologic complications were
noted. The periodontal status of the tooth abutments was
assessed, presenting probing depths of 1 to 3 mm,
without bleeding or signs of gingival inflammation.
DISCUSSION
This protocol aims to stabilize gingival tissue in the me-
dium and long term. In this technique, the restoration
margin is located at subgingival level, but several studies
have shown that restorations placed below the gingival
margin are associated with periodontal inflammation and
therefore possible gingival displacement.8,9 However, in
the present patients, this dental abutment preparation
protocol obtained good outcomes for soft tissue health
and esthetics, free of any signs of inflammation. This
Agustín-Panadero et al
5
Figure 12. Facial view of vertical abutment preparation.
Figure 14. Preparation sequence for interim restoration. Image on left
shows 2 lines obtained in clinical relining procedure; white arrow indi-
cates end of sulcus; yellow arrow indicates gingival margin. Central im-
age shows union of 2 lines with photopolymerizable flowable composite
resin. Interim restoration finished with knife-edge finish line, which is
introduced 0.5 mm into sulcus.
technique respects biologic width dimensions10 by con-
trolling the invasion of the sulcus without invading the
epithelial attachment. This avoids complications related
to the traditional preparation with finish line2-4 and
produces a good periodontal tissue response.
In this protocol for preparing dental abutments, the CEJ
is reorganized by means of the prosthesis, which permits
good management of new tooth contours. After tooth
preparation, the process begins with fibroblast stimulation
and their migration to the damaged area,11 which the
dentist promotes by means of the vertical dental prepara-
tion; placement of the interim restorations stabilizes the
resulting blood clot. The interim restoration is exploited
to guide gingival remodeling by overcontouring or
undercontouring the prosthesis. Overcontouring tooth-
supported restorations produce an apical displacement of
the margin, while undercontouring produces the opposite
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Figure 15. Facial view of cervical area of interim restoration and soft Figure 16. Facial view of dental abutments with good appearance of
tissues after 8 weeks. papilla.

Figure 17. Occlusal view of gingival healing. Figure 18. Widening of gingival sulcus.

effect.12 According to the particularities of the situation, the

dentist can add or remove material from the interim resto-
ration to guide soft tissue maturation. Furthermore, the
margin of the interim restoration can be shortened or
extended to reach different levels of the gingival sulcus. This
establishes the position of the gingival margin, which will
help balance soft tissue esthetics in terms of the margin
position and the zenith position.13 Several studies have
reported that overcontouring the restoration with a finish
line on the dental abutment can produce inflammation and
possible biologic complications.14 However, in spite of the
known association between excessive overcontouring and
gingival inflammation, no signs of inflammation were
registered in the present patients.
The technique is accompanied by increasing gingival Figure 19. Postoperative facial view.
tissue thickness, produced by reducing the dental abut-
ment in the buccolingual direction.7 The soft tissues deepithelizing the gingival sulcus. The increase in soft
occupy this space and increase in thickness. Increased tissues and increased vascularization also helps achieve
vascularization also takes place, decreasing the risk of long-term stability.15
gingival displacement, regardless of whether patients The vertical preparation technique without finish line
present thin or thick gingival biotypes. This situation is has drawbacks. The technique is complex and clinically
produced as a result of eliminating the CEJ and more time-consuming. Situating the line of the prosthetic

THE JOURNAL OF PROSTHETIC DENTISTRY Agustín-Panadero et al

- 2015
margin adequately is difficult because there is no dental
finish line to refer to. For the dentist or laboratory tech-
nician with little experience of the procedure, there is a
risk of uncontrolled invasion of the sulcus. Excess cement
is difficult to remove. The technique has not been backed
by scientific evidence, and no published research is
available.
In our experience, vertical dental abutment prepara-
tion without a finish line does not appear to increase the
risk of definitive prosthesis fracture. Using this protocol,
not only can metal ceramic restorations be used for the
definitive restoration but also zirconia and lithium dis-
ilicate crowns. Several studies have demonstrated that
these ceramic materials offer sufficient fracture resistance
to allow this type of vertical preparation without hori-
zontal support on dental abutments in the anterior
sector; they do not suffer mechanical complications.17
Furthermore, the technique adapts the crown to the
dental abutment well.
SUMMARY
Vertical preparation without a finish line on the teeth is
an alternative procedure for FDPs. It increases soft tissue
thickness, achieves good esthetic results, and promotes
healthy and stable soft tissues. No mechanical compli-
cations have been observed using this technique for
ceramic restorations. Nevertheless, clinical studies are
needed to confirm the results of these clinical reports and
to validate the technique.
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Corresponding author:
Dr Maria Fernanda Solá-Ruíz
University of Valencia
C/ Gascó Oliag, 1
46021 Valencia
SPAIN
Email: m.fernanda.sola@uv.es
Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
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