Today we are going to talk about crowns and bridges.

So when we have edentulous areas, we have to plan the treatment for missing teeth. Today I want all of you to appreciate that the dental arch is a dynamic entity. There is occlusion; the teeth come together to grind food, help in speech and patients dont like gaps. When there is a tooth missing; for example, when a patient extracts a tooth, what happens? Teeth distal to the space may drift bodily or tilt mesially. Opposing teeth may supra-erupt to fill the gap. Q: Why do teeth drift mesially, not distally? Due to the inclination of the teeth, specifically the occlusal surface (the cusps) they are tilted mesially. This is called mesial drift. So when you grind your teeth together, you push them mesially towards the midline. Now concerning opposing teeth; upper and lower teeth are in an equilibrium state, there are forces pushing the upper teeth upwards and the lower teeth downwards, these forces cancel each other out. So if one of the teeth is missing, the opposing tooth will supererupt. Fixed Partial Denture: the definition of this is a prosthesis replacing 1 or more teeth that cannot be removed by the patient; if they are removed by the patient it is called a removable prosthesis or RPD. This requires substantial tooth preparation. The appliance usually requires no more space than the original dentition. We place a pontic to replace the missing tooth but we need support from adjacent teeth. To replace a missing 6, for example, we need 2 abutments. In this lecture we will talk about ideal abutments and contra-indicated abutments. We will talk about occlusion, missing teeth, abutments, gap, then we will talk about factors; the patient, the mouth, the teeth. In general, we need all of these to make a comprehensive picture of the case so we can say if this case is suitable for bridgework or not. Q: what is the disadvantage of a fixed partial denture? There is substantial tooth reduction. This in itself may be dangerous to the tooth of the patient. Selection of the type of prosthesis: RPD or FPD. If you do not take the case for a bridge, refer it to the prosthetics department to make a removable prosthesis. Several factors must be weighed; periodontal, biomechanical, esthetic and financial. Do not complicate the case; only 1 tooth missing for you as undergraduate students. More missing teeth will make it complicated at the try in stage. "Always take the simple cases and you will have a happy life; this is not taught in the books, I am giving you important advices." Give a recommendation that serves the patient's needs and still be reasonable to accomplish.

Removable partial denture is generally indicated for edentulous spaces greater than 2 posterior teeth or anterior spaces greater than 4 incisors. I am giving you this information just to complete the lecture but if this clashes with the information you learned in your prosthodontics lectures, forget it, just follow the prosthetics department lectures; my main objective is to tell you about the fixed partial dentures. Conventional tooth-supported fixed partial denture: What do we want? We want periodontally sound abutments. Why are short crowns not good abutments? Surface area is small and hence retention is less. Retainers should be well designed and executed. No gross tissue defect in the ridge or coronal structure on abutments. Absence of moisture is not good for FPD. One kind of FPD is the tooth-supported or resin bonded bridge. We use these in anterior segment of the mouth. They are conservative, they dont destroy teeth and they replace single missing tooth. On the palatal surface, we acid etch and we fix 2 wings on abutments and a pontic will fill the edentulous space. If we dont have teeth to support the bridge, we put an implant which will act as an abutment for the bridge. This is for implant supported FPD, used when we have insufficient number of abutments or insufficient strength in the abutments to support a bridge. In a short span bridge, abutments will be at the ends (implants) and in a long span bridge the abutment is used as pier. What do we do if abutments are tilted? Simple! It is not a student case BUT ideally what is the solution? We can do orthodontic uprighting, so that its long axis is vertical; this treatment will last months. Otherwise we can use telescopic crown or a proximal half crown. The story of a bridge: you have a gap, mesial and distal abutments are prepared, a bridge has been manufactured and then it is fitted.

A dental bridge is fabricated by reducing the teeth on either side of the missing tooth or teeth by a preparation pattern determined by the location of the teeth and by the material from which the bridge is fabricated. Now are you going to use metal alone or metalceramic crowns or ceramic alone? This determines the amount of reduction. If metal alone, reduce between 0.5-0.7 mm. Now if using porcelain fused to metal, reduce 1.5 mm; 0.5 for the metal and about 1 mm for the porcelain. Reduction of the teeth is determined by the bridge design. For example, when your supervisor asks you about the bridge you will do, you need to answer: I am going to design this bridge so that on the posterior abutment I use metal and on the anterior abutment I will use PFM so this way you explain how much reduction you will do on each tooth. Note: if you read this lecture and understand it carefully, this is all you need to know for your final oral exam (VIVA) on fixed partial dentures. When are dental bridges needed? When do you need a dental bridge? Dental bridges are recommended when there is one or more teeth missing that affect: -First of all and most important thing is your smile and appearance, life becomes brighter ,you have more confidence everything is nice . Your bite, you want to enjoy food ,I talk to people who has nothing to do with dentistry and they tell me I just want to enjoy food this is the only thing I enjoy in my life please doctor fix my teeth ,so I can be able to eat chew food and enjoy it , when you give him/her a bridge he/she will be able to eat properly and enjoy food ,now if he/she does not grind the food very well poor stomach will have to fight with this food and he/she will have stomach problems, so notice the sequence of the problem it will be transferred from a problem in the mouth to a problem in the GIT , so you make your patient bite and eat properly . when you have a missing tooth especially anteriorly this will affect Speech ,when you have a tooth properly designed you can articulate the talk properly and you give a very good speech like what Im doing right now , if I had two missing centrals I wouldnt be able to talk to you the way Im talking to you right now , so there is a sense of security you feel secure, you feel complete you feel you are on the top of the world there is nothing missing in you , its like you have one finger missing , if you have one finger missing its a problem if two its a bigger problem and so on, when you have five fingers you are confident you can catch you can write you can do whatever you like. Shape of the face ,some of you will come and ask doctor can we make a bridge when the first premolar is missing ?

My reply Yes, you can but you have the canine and you are going to use the canine as an abutment since the canine is a strategic tooth ,and it is a corner its like a pillar and if he worked on the canine and get it exposed then RCT, then we get it extracted what will happen? The whole side of the face here will collapse , so over years experience accumulated and then we stopped students from working on canines because we dont want to jeopardize the canine to any danger , you might be preparing the canine it needs a special preparation if you damage it then the patient loss will be costly , canine should stay in its corner so that the contour or the shape of your face remains intact . The rates of gum disease and tooth decay ,as a result of food accumulation in the gap when there is a gap food will accumulate , plaque will accumulate we need to restore the area so all of this will be eliminated .

Must missing teeth be replaced? Of course YES, missing teeth should be replaced so that you can: - Improve the appearance. - To reduce the strain on the teeth at either side of the missing tooth. - To prevent the neighboring teeth from leaning into the resulting gap and altering the bite. - then preventing gum disease and tooth decay due to accumulation of food in the gap. So what are the parts of the bridge ? Here comes a very popular MCQ and ViVa exam question An abutment is a tooth or implant to which a bridge is attached. What is a retainer ? A retainer is a crown or other restoration that is cemented or screwed to the abutment. Then the abutment is a tooth sturcture , the original tooth , the cover rest on it is called a retainer, so the retainer is a part of the mouth or the bridge ?? The Bridge , dont mix them together very important . So, what is a pontic ? A pontic is an artificial tooth as a part of a bridge. Then what are the parts of the bridge ? Pontic Retainer

And in between them connector or joint. If I asked what are the parts of the bridge and you answered Abutment this is wrong ! Abutment, is not part of the bridge , an abutment is a tooth that is supporting the bridge , now you have an abutment here and an abutment here and in between them you have a saddle , now the abutments wearing a cap which is a retainer and in between the pontic , the pontic is connected to the caps by a joint or connector so the parts of the bridge are : -Pontic -Retainer - Connector

In the jaw what do we have? Abutment and another abutment and in between we have saddle, now where is the pontic going to fit? In the saddle.

Dr , Asked one of the students to repeat what he just said Part of the mouth we have the abutment saddle and another abutment. Part of the bridge we have the retainer the pontic connected to the retainer by a connector, so abutment and abutment and between we have saddle.

So, the saddle is the area of the edentulous ridge over which the pontic will be found, a unit of bridge its either a pontic or a retainer, now the unit is very important to you why? Because you want to charge the patient according to the number of units , single tooth missing its three units , two teeth missing its a four unit bridge because now you have a retainer and a retainer and two pontics , so this is four unit bridge in this case how much the patient has to pay ? lets assume the cost for one unit is 150 JD , he has to pay 600 JD , when one tooth is missing he has to pay 450 JD , because one single missing tooth needs two retainer and one pontic that is three units , thats a connector connecting a pontic to retainers or two retainers to each other . The diagram above showing the abutments , the edentulous ridge and the abutment has been prepared and the retainer is going to fit on the abutment , the other retainer will fit on the molar between them we have a pontic and what is connecting between the pontic and the retainer is the connector , I think we are done with the advantages, but what are the disadvantages of replacing missing teeth ? Actually, every treatment has its advantages and disadvantages , especially when the operator doesnt know what he is doing ,so if you have a bridge case today you must have read about bridges and bridges preparation the night before ,so please prepare your self before you ask the patient to come to the clinic for a bridge work , read the procedures and get your self ready otherwise during the preparation there might be a damage to the tooth and pulp exposure , especially when you are preparing the distal surface of the seven or you might do over reduction and jeopardize the pulp, if there is pulp exposure there is no point of bridge you need to do RCT, you do pulp extirpation you break the Barbed broach in the tooth this is a further complication , no good RCT after six months a peri apical lesion will form then extraction ! What was a single tooth missing now is two teeth missing, you need to prepare another distal abutment and the same might happen , there was a student six years ago it was a very minor class I caries on upper six molar, the poor girl she was eighteen years old the guy was preparing did a pulp exposure , so he starts doing RCT while he was doing the RCT he perforated the chamber ,he did another perforation laterally , started as pulp exposure second complication chamber perforation third complication root perforation RCT failed whats the next step ? Extraction , fractured root turned to Minor Oral Surgery , the girl spent two weeks going back and forth to the DTC all because of a careless student mistake so , please always make it simple . Disadvantage of replacing missing teeth Damage to tooth and pulp Secondary caries Failures

Effects on the periodontium Discomfort and Cost, Bridge work is costly. Discomfort, now I cant rememeber one single bridge case that has gone without any problems , bridges fixed and problems do occur packing of food between the retainers and the adjacent teeth and tooth sensitivity , when you have a bridge and you cant enjoy food no sour dirnks no cold drink no ice creams and if you are an ice cream lover you will not enjoy life , this sensitivity is produce by the bridge ,so bridges do have disadvantage therefore i want you to explain to your patients the consequences of placing a bridge and do not push them or make the bridge case for them very attractive the choice has got to be theirs, they must say please i want a bridge please help me and make a bridge for me ,otherwise if you say to them a bridge is good a bridge is ..etc you make a bridge and complications will occur the patient will keep coming to the clinic nagging all the time that you gave me something that i didnt like , I didnt even ask for and the responsibility is always going to be yours and you should hold this responsibility for a year may be , so take this adivce . Now Factors influencing the selection of patients: The patient The mouth The teeth

If the patient is old, are you doing to do a bridge for a 70 years old man who cant sit properly on the chair? Especially if he has a kidney failure or something like that? Attitude and Keenness ,a patient who doesnt care about his natural teeth he is not going to care about his bridge or artificial teeth this is a rule. Alternatives, did you explain to the patient the alternative is a RPD he may like the RPD. and then you have to explain to the patient the cost and time how many visits four visits at least and the time required, if he works in a company or a bank the company will not allow him to come every week for 2 or 3 hours to do a bridge he has to know , so he has to organize his time and come to you .

So, Old people, Poor manual dexterity You expect the patient to has meticulous oral hygiene and if the patient is old and brush his teeth with a wriggling hand he is not going to clean his teeth properly, so leave this poor patient leave him , without a bridge because you are going to put a bridge and there might be a secondary caries due to bad Oral Hygiene and there will be halitosis and dentine sensitivity, you will make his life miserable after placing a bridge for him, so we have to think about everything .

End of the lecture you have to study the remaining slides that Dr.Zakaria didnt talk about in the lecture

Amr Mahderbashi Aseel Mukbel