DDS

YEAR 4
Fixed Prosthodontics

Wednesday
25/September/2013
Overview of
Fixed
Prosthodontic
Procedures
History taking, examination and diagnosis,
primary impression
. Articulated Study casts, diagnostic wax-up
Shade matching
Tooth preparation
Gingival retraction and tissue management, Final
impression making
Bite registration
Provisional coverage (interim restoration)
Laboratory prescription
. Laboratory procedures include: definitive cast and die fabrication,
wax-Up, investing and casting, porcelain build-up (for PFM
restorations)
Clinical try-in and Adjusting
. Laboratory procedures include: Polishing and glazing for porcelain.
Cementation
Home care instructions






MOUTH
PREPARATION
Mouth preparation refers to the dental
procedures that need to be accomplished
before
fixed prosthodontics can be properly
undertaken.
Rarely are crowns or fixed partial dentures
provided without initial therapy of a
multidisciplinary and often extensive nature,
because the etiologic factors that lead to the
need for fixed prosthodontics also promote other
pathologic conditions (caries and periodontal
disease are the most common).

These must be corrected as an early phase of
treatment.
Comprehensive treatment planning will ensure
that mouth preparation is undertaken in a logical
and efficient sequence aimed at bringing the teeth
and their supporting structures to optimum health.

Equally important is the need to educate and
motivate the patient to maintain long-term dental
health through meticulous oral hygiene
practices.
the following sequence of treatment procedures in
advance of fixed prosthodontic should be
adhered to:
1. Relief of symptoms (chief complaint)
2. Removal of etiologic factors (e.g., excavation of
caries, removal of deposits)
3. Repair of damage
4. Maintenance of dental health
Sequence of Treatment:
Preliminary assessment (A)
Emergency treatment of presenting symptoms (B)
Oral surgery (C)
Sequence of Treatment:
Caries control and replacement of existing restorations (D)
Endodontic treatment (E)
Definitive periodontal treatment, possibly in conjunction with
preliminary occlusal therapy (F)
Sequence of Treatment:
Orthodontic treatment
Definitive occlusal treatment
Fixed prosthodontics (G, H)
Removable prosthodontics (I)
Follow-up care
ORAL SURGERY

SOFT TISSUE PROCEDURES
Any soft tissue abnormalities that may require
surgical intervention should be recognized
during the initial or radiographic examination.
Elective soft tissue surgery may include alteration
of muscle attachments, removal of a wedge of
soft tissue distal to the molars, increase of the
vestibular depth, or modification of edentulous
ridges.
Soft tissue surgery to correct unfavourable edentulous ridge.
HARD TISSUE PROCEDURES
Simple tooth removal is the most common surgical
procedure involving hard tissue.
It should be performed as early during treatment
as possible for maximum healing time and
osseous recontouring.
Other procedures may be: extraction of impacted
or unerupted supernumerary teeth, tuberosity
reduction and removal of maxillary or
mandibular tori.
CARIES AND EXISTING
RESTORATIONS
Any restoration on such teeth must be carefully
examined and a determination made regarding
its serviceability. If doubt exists, the
restoration should be replaced.
Even on caries-free teeth, an existing restoration
may not be a suitable foundation.
Preparation design is different for a foundation
than for a conventional restoration, particularly
regarding the placement of retention.
Generally, when a crown is needed, the dentist
should plan to replace any existing
restorations.
FONDATION RESTORATIONS
A foundation restoration, or core, is used
to build a damaged tooth to ideal anatomic
form before it is prepared for a crown.
It should provide the patient with adequate
function and should be contoured and finished to
facilitate oral hygiene.
Subsequent tooth preparation is greatly simplified
if the tooth is build up to ideal contour.
Selection of the foundation material depends on
the extent of tooth destruction, the overall
treatment plan, and operator preference.
Adhesive retention may be helpful in preventing
loss of the foundation during tooth preparation.


The placement of a foundation restoration depends on the extent of damage to the tooth
and should always be designed with the definitive restoration in mind. A, Cement. This is
suitable when damage is minimal. B, Amalgam. C, Pin-retained amalgam. D, Cast gold.
E, Post-and-core.
DEFINITIVE PERIODONTAL
TREATMENT
Unless a patient's existing periodontal
disease has been properly diagnosed
and treated, fixed prosthodontics is
doomed to failure
Certain specific periodontal procedures may be
indicated to improve the prognosis of a
restoration:
Mucosal Reparative Therapy
Free Autogenous Gingival Graft
Laterally Positioned Pedicle Graft
Coronally Positioned Pedicle Graft
Subepithelial Connective Tissue Graft
Crown- Lengthening Procedures
CROWN- LENGTHENING PROCEDURES
Surgical crown lengthening or extension may be
indicated to improve the appearance of an
anterior tooth or when the clinical crown is too
short to provide adequate retention without the
restoration's impinging on the normal soft tissue
attachment or biologic width.
The term biologic width refers to the combined connective
tissue-epithelial attachment from the crest of the
alveolar bone to the base of the gingival sulcus
This attachment averages approximately 2 mm in width,
and any restoration that impinges on it may cause bone
loss because of the effort of the host to maintain the 2
mm distance.
If impingement occurs in an interproximal area, it can
lead to problems with plaque control and possible
osseous resorption.
DEFINITIVE OCCLUSAL
TREATMENT
Mouth preparation often involves
reorganization of the patient's occlusion,
typically to make intercuspal position
coincident with centric relation and remove
eccentric interferences
When selective reshaping of the natural dentition
is being considered, it is important to remember
that this is a purely subtractive procedure (tissue is
removed), and it is limited by the thickness of the
enamel. Obviously, before any irreversible
changes are made in the dentition, a careful
diagnosis must establish whether restorations
will be needed.
Two sets of articulated diagnostic casts are
required for diagnostic occlusal adjustment.

Occlusal adjustment needs to be undertaken in
a logical sequence to avoid repetition and
improve the efficacy of treatment.

1. Elimination of Centric Relation interferences
2. Elimination of Lateral and Protrusive
Interferences.
TREATMENT
PLANNING
Treatment planning consists of formulating a
logical sequence of treatment designed to
restore the patient's dentition to good
health, with optimal function and
appearance.
The plan should be presented
in written form and should be discussed in
detail with the patient.
Successful treatment planning is based on
proper identification of the patient's needs.

Treatment is required to accomplish one or
more of the following objectives: correcting
an existing disease, preventing future
disease, restoring function, and improving
appearance.
Selection of Abutment Teeth
Assessment of Abutment Teeth

Radiographs are made, and pulpal health is
assessed by evaluating the response to
thermal and electrical stimulation.
The ability of the abutment teeth to accept applied
forces without drifting or becoming mobile must
be estimated and has a direct influence on the
prosthodontic treatment plan.

These forces can be particularly severe
during parafunctional grinding and clenching.
Endodontically Treated Abutments.
If a tooth is properly treated endodontically, it can
serve well as an abutment with a post and core
foundation for retention and strength.
Care is needed to obtain maximum retention for
the post and core.
Sometimes it is better to recommend removal of a
badly damaged tooth rather than to attempt
endodontic treatment.
Definition
A post and core is a dental restoration for
an endodontically treated tooth used to
sufficiently build-up tooth structure for
future restoration with a crown when there
is no enough tooth structure to properly
retain the crown.
Post and cores are therefore referred to as
foundation restorations.
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Root Surface Area
The root surface area of potential abutment
teeth must be assessed when planning
treatment for fixed prosthodontics.
Ante's law
Ante suggested in 1926 that it was unwise
to provide a fixed partial denture when the
root surface area of the abutment was less
than the root surface area of the teeth
being replaced.
Authors have confirmed that abutment teeth
with limited periodontal bone can
successfully support fixed prostheses.

Antes law is useful for determining the
prognosis of fixed partial denture.
Root Shape and Angulation
the shape of the roots and their angulation should
be considered.
A molar with divergent roots will provide better
support than a molar with conical roots and little
or no interradicular bone.
Similarly, a well-aligned tooth will provide better
support than a tilted one.
Periodontal Disease
After horizontal bone loss from periodontal
disease, the PDL-supported root surface
area can be dramatically reduced potential
abutment teeth need very careful
assessment where significant bone loss
has occurred.
In general, successful fixed prostheses can
be fabricated
on teeth with severely reduced periodontal
support, provided the periodontal tissues
have been returned to excellent health,
and long-term maintenance
has been ensured.
SEQUENCE OF TREATMENT
TREATMENT OF SYMPTOMS
Discomfort can be due to one or more of the
following: a fractured tooth or teeth, acute
pulpitis, acute exacerbation of a chronic pulpitis,
dental abscess, an acute pericoronitis or
gingivitis, and myofascial pain dysfunction.
STABILIZATION OF DETERIORATING
CONDITIONS
The second phase of treatment involves stabilizing
conditions such as dental caries or periodontal
disease by removing the etiologic factors,
increasing the patient's resistance, or doing
both.
DEFINITIVE THERAPY
When the stabilization phase has been completed,
successful elective long-term treatment aimed at
promoting dental health, restoring function, and
improving appearance can begin.
Usually oral surgical procedures are
scheduled first, followed by periodontics,
endodontics, orthodontics, fixed
prosthodontics, and finally, removable
prosthodontics.
FOLLOW-UP
A specific program of follow-up care and regular
recall is an essential part of the treatment plan.
The aim is to monitor dental health, identify the
signs of disease early, and initiate prompt
corrective measures as necessary.
REFERENCES
Rosenstiel, S.F., Land, M.F., and Fujimoto, J.
(2006). Contemporary Fixed Prosthodontics. 4
th

Ed. Mosby.
Shilingburg, H.T. (2003).Fundamentals of Fixed
Prosthodontics. 3
rd
Ed. Quintessence Pub. Co.
Jacobs D.J, Steele J. G. and Wassell R. W.
Crowns and extra-coronal restorations. Part 3:
Considerations when planning treatment. BDJ.
2002; 192(5): 257-67

Dr. Maan Ibrahim Al-Marzok 2013

At the end of the lecture,
students should be able to:

1. Discuss the importance of mouth preparation to control
oral environment for long term success of crowns and
bridges.
2. Describe the steps for case selection and proper referral
for mouth preparation.
3. Discuss the preparation of foundation restoration
biologically and biomechanically for crown and bridge
work.