Fixed prosthodontics

90% of what you do in dentistry is prosthodontics .first we will start with the definition of prosthodontics. Its The dental specialty pertaining to the diagnosis, treatment planning, rehabilitation, and maintenance of the oral function, comfort, appearance, and health of patients with clinical conditions associated with missing or deficient teeth, and/or maxillofacial tissues using biocompatible substitutes. This definition is taken from Glossary of Prosthodontic Terms. So most of the time you deal with missing teeth ,or deficient teeth. Now fillings are part of prostho and it depends on the country, like if you study your speciality in USA, you have operative dentistry separate from prostho. if you study in Australia like the doctor :P, operative dentistry is part of prostho. Why do we need to replace missing teeth? 1- For function , mastication, some patients complain from missing posterior teeth and they cant chew correctly or they cant masticate very well, so when you replace their missing teeth their function is supposed to be improved. 2- Aesthetics, like some patients complains from missing upper interior teeth, from car accident for example, so you need to improve their Aesthetics. 3- Stability ,if the tooth is missing the adjacent tooth will start to move, and we call that in dentistry drifting , so when you replace this missing tooth you will maintain stability of the dental arch.

So basically three major functions for replacing a missing tooth: function, aesthetics and stability... if you are placing a posterior tooth you are placing function and stability. If you are placing an anterior tooth you are placing Aesthetics.

Now Prosthodontics: As a branch of dentistry we have: *fixed Prosthodontics *removable Prosthodontics *implant Prosthodontics (they still dont teach this in Jordan) *maxillofacial Prosthodontics (they dont teach it also, its left to specialist)

Fixed Prosthodontics:
The branch of Prosthodontics concerned with the replacement, and/or restoration of teeth by artificial substitutes that not readily removed from the mouth. The patient cannot take them out like the denture so its fixed. But the dentist can take them out in some cases, but in other cases he cannot until he cut the crown. This is why patients like fixed Prosthodontics much more the removable Prosthodontics, because they feel like its almost similar to their natural teeth. but the problem of fixed Prosthodontics that its much more expensive than removable Prosthodontics

We have two types of restoration in fixed prosthodontics:

* Intracoronal restorations, means that its in the tooth. * Extracoronal restorations, which means on the tooth or replacing a missing tooth.

Types of intracoronal restorations:

1- Direct restorations (fillings) We use a certain materials like Amalgam, Composite Resin, GIC (glass-ionomer cements), RMGIC (Resin-Modified Glass Ionomer Cements), Compomer.

amalgam fillings

composite fillings

Indirect restorations: Inlays: metal, ceramic, composite resin. The difference between inlays and fillings is that fillings we do them direct to the patients mouth. So we prepare the cavity, the nurse prepare the amalgam, and we insert it right away in the tooth (no need for lab), while inlays cannot be done right away, it needs a laboratory .Its not a direct filling. What is Inlays? It is a dental restorations made outside the tooth to correspond to the form of the prepared cavity by an impression (An impression is carried out by placing a viscous liquid material into the mouth usually in a customized tray. The material then sets to become an elastic solid, and when removed from the mouth retains the shape of the teeth), then the lab will bring the inlay back to the dentist which is then luted into the tooth.

Here in the pic its ceramic

Types of Extracoronal restorations:

1-Onlays: Metal, Ceramic, Metal-Ceramic. Only is a restoration that restores one or more cusps, and adjoining occlusal surfaces or the entire occlusal surface, and is retained by mechanical or adhesive means. Its simply inlay + cuspal coverage. Why do we need to cover the cusp? For many reasons one of them is to prevent fracture of the teeth .

This is from the lingual surface

Only part of the tooth is covered because if you cover the entire tooth it becomes a crown. *Incisor Onlay is not common at all because you need to have technician with very good skills to be able to construct such little restorations.

9 onlays

This is the patient mouth with onlays

2-Veneers: Ceramic, Composite Resin, Metal (veneers are very common) Its a thin sheet of material usually used as a finishing or ornamental facing.

In dentistry we have laminate veneers, and the most common one is porcelain because we use it in the facial surfaces in the upper anterior teeth. Porcelain laminate veneer: a thin bonded ceramic restoration that restores the facial or lingual surface and part of the proximal surfaces of teeth requiring aesthetic restoration. What is the advantage of veneers? Very conservative and its aesthetic if plant properly.

This patient complained of midline diastema .first thing to do is examination. Here she needed ortho treatment but she refused to take it so we went for restoration treatment to close the gab. Also her teeth had composite fillings so our doctor decided to veneer all of the incisors teeth, central lateral, central lateral plus closing the midline diastema : D Just he did very conservative preparation of the teeth, impression, send to the lab, the lab constructed the veneers.

And these are the veneers in her mouth... because they closed the midline diastema she had a wider central teeth but she was happy with that. So veneers are very conservative, less than 0.5 mm preparation you can achieve a very aesthetic result with very minimal preparation.

*another case where a patient had discolored teeth (in the lower interior teeth), we decided to do lower 6 veneers, and this design of veneer is called veneer with an overlap because it goes with lingual surface of the teeth.

The veneers in patient mouth

3-Crowns (the most widely used restorations after the fillings): Metal (not for anterior teeth), Ceramic, Metal-Ceramic . Crown is an artificial replacement that restores missing tooth structure by surrounding part or all of the remaining structure with a material such as cast metal, porcelain, or a combination of materials such as metal and porcelain.

It can cover the whole tooth and we call it a full coverage crown, or it can cover part of the tooth which we call it partial crown. But the most widely used is the coverage crown.

*We have different materials of crown :

*FGC: full gold crown and this is the most predictable treatment in prosthodontics and it has the best survival rate. But unfortunately for 2 reasons its not as common these days as before, gold is very expensive and patients dont like it these days because aesthetics. Some dentists prescribe golden crown if the patient accept to pay the extra fees for gold, because the lab charges us crown + gold weight.

*PFM: Porcelain fused to metal (the most used) Why do we use metal underneath the ceramic? Because ceramic alone is brittle compared to the metal, and metal alone is not aesthetic so we combine both. *Ceramic crowns (metal free): the strongest ceramic is zirconium, we have pressed ceramic, and Alumina ceramic . Ceramic crowns give us the best aesthetic results but the main disadvantage relative to PFM that they can break.

This is a case: patient came complaining of worn upper anterior teeth (damage in the anterior teeth) so already endo treatment done and have post and core (post are part of fixed prosthodontics) (the first pic ) *A post and core is a dental restoration used to sufficiently build-up tooth structure for future restoration with a crown when there is not enough tooth structure to properly retain the crown, due to loss of tooth structure to either decay or fracture. Post and cores are therefore referred to as foundation restorations. (its here the metal material, appears in the last pic from the lingual surface)

Now when the tooth does not have enough height to retain the final restoration of the crown. Then what can we do? In this case the tooth is not vital and needs endodontic treatment, then we just prepare through the canal and we cement a post or a pin. What happens ? The crown becomes longer or higher. Without these post and cores there is a high chance for the crown to be lost. *Note that its PFM crowns in the pic, and know that crowns are the mostly done procedure in prosthodontics.

4-Fixed Partial Denture (Bridge): Metal, Ceramic, Metal-Ceramic Is basically 2 crowns but they are replacing a missing tooth. For example a patient has one of his teeth missing, how can we restore his tooth ? 1- if the patient is happy then no treatment, you can leave it as it is ,like the eighth tooth or the seventh tooth for example its optional to replace them, unless we are worried about stability . 2- We can use a partial denture (removable prosthodontics) but its not a good option for every patient especially young patients. 3- We can use a bridge to replace a missing tooth or we just can replace it by implant

*The term fixed partial denture (FPD) is used in America and Canada while the term bridge is used in Australia and Britain. Fixed partial denture is Restoration that is securely retained to natural teeth to replace missing teeth.

Securely retained means that the patient cant take it out, it not like removable partial denture, its retained to the adjacent teeth to the missing tooth.

In this case for example a patient is complaining of missing the anterior tooth, to OUR DOCTOR, the best treatment is implant, because you dont sacrifice any tooth structure, plus the implant supported restoration have better success rate if planned properly better than bridge. In this case the patient couldnt afford implant therapy because its very expensive, so we decided to provide him with a bridge.

This is From the canine to the canine, we call it six unit bridge (each one is called a unit) and 6 unit bridge does not mean it replaced 6 teeth , in this case 6 unit bridge replaced three teeth so the number of units does not mean exactly the number of teeth to be replaced.

But usually when you have single missing tooth and you prepared the tooth interior and the tooth posterior, you will have three unit bridge, so three unit bridge replaces one missing tooth. And the way they charge you is: each one with the same cost (for example a unit costs 100 JD, so 3 Unit Bridge is 300 JD).

DONE by: SENDOS AL-JALAM LAMA KHALIL

Now ehda2 5as jeddan la Farah belal, AYAH Haj Yahya , Diana Alsardia, and Rawan Qashqoosh =D AND RAMADAN KAREEM FOR ALL =)