Fixed

Prosthodontics
Crowns and bridges lec 1
18.02.09
It is the art and science of restoring damaged teeth with
1)
cast metal, 2)metal-ceramic or 3)all ceramic restoration and
replacing missing teeth with fixed prostheses(cemented or
screwed-in). Cemented means using cement : conventional
cement, Glass Inomer cement, RMGI or Resin cement. But it has
to be luted , cemented or screwed-in, this is why we call it
fixed, the patient can not remove it and sometimes the dentist
can not remove it. So it is fixed because it has been screwed to
the structure underneath it either by screws or cements.
Restoration in this field could be the finest service (you can give
excellent service to the patient if your work is excellent) or
could be the worst disservice (if you are bad), usually fixed
prosthodontics lead us to irreversible outcome if goes bad.

The scope of this field can range from the restoration of a

single tooth to the rehabilitation of the entire occlusion. Which
means, the patient may complaine of a bad broken tooth and
you need to restore it with a crown which is a fixed
prosthodontic and he might come to your clinic with no teeth
and you need to rehabilitate him with fixed prosthodontics
which could include implants. So it is a wide range of treatment
from single tooth to rehabilitation of the entire occlusion.

The restoration of single teeth (which they are there but

damaged) could be: 1- Intra-coronal: means within the
confines of the tooth(within the anatomy of the tooth), it is like a
filling but it is not, because it is cemented or screwed-in {this is

Page | 1
the deference between Intra-coronal fixed prosthodontics and
Intra-coronal conventional operative
works(amalgam,composite,GI)}. 2- Extra-coronal: it’s a
restoration that covers the outer surfaces of the tooth(cover
part of the tooth or all the tooth). Both Intra-coronal and Extra-
coronal are fixed because they are looted to the tooth structure.

Crown: one of the most common Extra-coronal restoration.

It is an artificial replacement that replace missing tooth
structure (if it is replacing missing tooth then it is bridge or
fixed partial denture)by surrounding part of the tooth( we call it
partial crown) but if surrounding the whole tooth (it’s called
complete or full crown) with a material as 1)cast metal,
2)
ceramics or 3)combination of both. Advanced material could be
used.

**Partial Crowns: surround one surface or more but they don’t

surround the whole tooth structure.

**Complete/Full Crowns: surround the whole tooth structure.

The crown could be made of ceramic or metal or

combination of them or other material.

From design point of view, they are either Partial Crown or

Complete Crown. From material point of view, 1)they could be
cast (cast restoration is the restoration where you need to
fabricate a mold usually out of wax and this will be replaced
later on with molten material which could be metal or ceramics )
2)
they could be only ceramics, or 3)combination metal and the
top of that a ceramic layer.

The picture below explain what we mean by partial crown

which covers mesial, distal and the palatal surfaces, but the
labial surface is off.

Page | 2
 This picture below is complete crown which surround the
whole surfaces of the tooth, if you look there, you can notice
that the palatal surface is metal and the labial surface is
ceramic, this is combination of metal and ceramic, it could be
metal by it self or ceramic by it self or
combination of both.

For Intra-coronal restoration it is unlikely to be a

combination, it is either metal or ceramic or other material, it
can not be combination for certain consideration which will be
explained later on.

Inlays and onlays: are intra-coronal restoration (within

the confined of the tooth) artificial replacement that restore
missing tooth structure. The former( which is inlays) restore
mild to moderate lesions while the latter restores more
extensive lesions with occlusal coverage.

If you have Intra-coronal restoration and it covers part of the

occlusal surface like the picture below:

Here we have MOD that covers the palatal cusp, this is

called Onlay. And Onlay in dentistry means “cover the top”, for
that reason called Onlay. The other type is the Inlay which
restores mild to moderate lesions without occlusal coverage.

Page | 3
These Inlays or Onlays could be made out of metal or ceramic or
other materials and unlikely to have two layers metal and
ceramic, so unlikely to have combination of these materials.

This is Inlay, but it could be Onlay if we cover the mesiobuccal

cusp.

So the point is covering the occlusal surface: if it is covered

so it is Onlay but if not it is Inlay.

The difference between the Inlays and the operative work of

class II is: usually the lesions are bigger, difficult to create a
contact point or proper contour, so you can not reproduce it
with amalgam or composite then you have to think about
something that could be build up properly with the contour and
the contact area, and that can be done only in the lab, if you
need it to be fabricated in the lab you have to take an
impression and have a wax up mold then replace it with metal,
so the only difference is that in the conventional operative work
you do the filling inside the clinic, but in the Inlay you do it in
the lab, and the reason is that you can not reform the tooth
structure properly using the conventional plastic material like
amalgam, composite, and GI. You need something with
impression, so you give the chance for the technician to build it
up as properly as he can, because he is working in a model not
in the patient mouth.

**Not every class II is going to be an Inlay, because class II

could be done easily and properly within a certain range of
tooth destruction within the patient mouth but if the destruction
is big enough and you can not restore the function and
form(because the lesion is too extensive) then you need to think
about the Inlay. If you can not restore with the Inlay so you have

Page | 4
to think about some thing more which is the Onlay, if you can
not, then you go for a crown. So we start with a filling then we
go to fixed prosthodontics branch.

Note: by the end of the lecture you have to know what we

mean by fixed, Intra-coronal, Extra-coronal, Inlay, Onlay, Crown,
Bridge.

Another restoration used in fixed prosthodontic is called

laminate veneers, laminate means very thin, veneer means
cover. Laminate veneers usually made of ceramic so we call
them all ceramic laminate veneers or facial veneers. These
facial veneers are extra-coronal restorations because they cover
part of the tooth, used mainly to improve the aesthetics of
anterior teeth using a thin layer of ceramic bonded to the facial
surface of a tooth which otherwise sound. For example: a lady
came to your clinic complaining of microdontic teeth(small
teeth) and you need to build them up, you can build them up in
you clinic with composite but it is better to build them up with
ceramic, but to build them up with ceramic you need to have an
impression, than send it to the lab and fabricate veneers to
restore the aesthetics. Usually these teeth are sound, there is
no caries, no fractures, and the problem is in the way they look
like, for example: stain, space, crowded, so you can improve
them by using laminate veneers.

All what we talked about before is restoration of damaged teeth.

Now we will deal with other branch of fixed prosthodontics

which is replacing missing teeth.

Page | 5
Bridge(fixed partial denture): Bridge is the British
name, and fixed partial denture is an American name. A bridge
partial denture that is cemented or otherwise securely retained
( it is retained either by cement or something else) to natural
teeth, tooth roots and/or dental implant. The structure which
support this bridge is called abutment that furnish the primary
support for the
prosthesis.

Here we have a missing lower 6, this lower 6 will be replaced

by H(artificial tooth), this is called pontic, this pontic is
connected to the adjacent teeth by small area called
connectors, these connectors are connected to a natural teeth
via an extra-coronal restoration (which is usually a crown)which
is called retainer, the retainer is usually a crown if it is for a
single tooth, but for a bridge we call it retainer. So we have
retainer, connector, pontic, connector then another retainer.
The tooth it self or the root (could be a root, tooth, implant) is
called abutment. The abutments are the teeth which furnish the
support for the bridge. The retainer is usually extra-coronal
restoration( usually a crown) but we don’t call it crown in case of
bridge, we call it retainer, because it retains the bridge in. The
retainers should have a common path of insertion, we have one
retainer on 2nd premoler and one on 2nd molar, if they don’t have
a common path of insertion then you can not seat them on the
abutments. The abutments should be parallel. In fixed
prosthodontics we should have one way of
insertion(parallelism).

Page | 6
 Do I need a retainer all the time?!! No, not every
abutment will be used as a retainer and we will take that in the
lecture of designing a bridge.

If we have teeth that are not parallel to each other(originally

they should be parallel to each other), and we should have one
way of insertion so we have to cut more tooth structure from
one tooth than the other(usually more from the mal aligned
tooth) so the bridge work is more destructive than crown work.

The saddle is the area where the tooth has been missed, so
the missing tooth area called the saddle. The last thing you
need to understand is the Unit. Every bit of the bridge is called a
unit. Pontic is a unit, retainer is a unit.. so this bridge is a three
units bridge or a three units fixed partial denture.

Reaching a Diagnosis:
Your patient came to your clinic complaining of certain things,
in any part of dentistry, crown and bridge is as any other dental
special, you have chief complaint, history, examination, special
investigations, diagnosis and prognosis.

Chief complaint: patient comes with broken tooth, missing

premolar or what ever.

History: routine history of chief complaint for example when the

pain starts, Medical history, Dental history.

Examination: extra oral examination, intra oral examination

Intra-oral examination:
*You have routine oral examination.

*Periodontal assessment: this is very essential in fixed

prosthodontic and include gingivae and periodontium, there is
something called CPITN. Not for every patient you need to do
full periodontal charting, is it true?!! You have to do full
periodontal charting, Gingival Index, pocket depth, plaque Index
for your perio patient. So there should be an easy way to

Page | 7
assess the periodontal status of the patient without loosing a bit
of time in your clinic.

CPINT stands for Community Periodontal Index of Treatment

Need.

When your patient come to the clinic you can have

something called WHO periodontal probe, it is a simple probe
with spherical ended tip diameter 0.5 mm and the color band
extending from 3.5 to 5.5 mm, we use this and walk through the
whole dentition quite rapidly, when you start using it, you will
not take more than few minutes, and you will score the teeth,
but not for every tooth, you will score a areas, you will divide
your teeth into 6 areas : lower left posterior, lower anterior,
lower right posterior, upper left posterior, upper anterior, and
upper right posterior. You have 6 areas, You will walk through
the highest score for each area will be recorded, according to
certain Index. When you record the whole areas, there is a Gide
lines where you need to refer this patient, you need to treat this
patient, you skip the perio stuff so this is just for your
restorative work, we don’t use it for perio clinic, we use it for
prostho, cons, surgery, you can use this just to have an idea
about periodontal status of your patient .

This is epidemiological tooth, uses just to have an idea,

screen your patient, have an idea, we don’t want to fabricate a
bridge for a patient who needs later on extraction of the tooth,
so this is very essential,(the doctor will ask us about it).

*Dental charting: fillings, caries, etc.

*Occlusal examination: in fixed prosthodontics occlusal

examination will be essential. In occlusal examination there are:

1. Initial tooth contact: which include ICP (Inter-Cuspal

Position),RCP(Retroted Contact Position), and slide between
them. All these you need to examine them.

Page | 8
 2. General alignment: you look for crowding ,rotation ,
spacing, supra-eruption, overjet , overbite, saddles,
tilting and drifting.

3.Lateral and protrusive movements: type of guidance

and interferences. You record the whole stuff before
fabrication your prosthesis.

Special Investigations:
Special Investigations are extremely important for fixed
prosthodontics, nobody ask any of us in prosthodontic stuff in
the clinic to see the patient before considering what the special
Investigations you need. You have to tell the doctor what the
special investigations you need for your patient before he come
and look at the patient. The special Investigations include:

1.Vitality testing: you can not fabricate any fixed prosthesis

without checking the vitality, this is starting from Intra-coronal,
Extra-coronal, Crowns, Bridges. The teeth should be checked for
the vitality using thermal, electrical or whatever. This test is
essential (should be done for every single tooth which will be
involved in the fixed prosthodontics) together with percussion
for the involved tooth/teeth in fixed prosthodontics. Percussion
we use it to check crack, fracture.

2.radiographic assessment: it is a must, you have to have

your periapical radiographs for the tooth/teeth involved in your
prosthesis. This is to assess caries, periodontal bone, pulp, root
number and form, or any pathology. You can not ask the doctor
to come to your unit before having your vitality test done and
your X-rays asked for, but you have to get X-rays for the tooth
involved in your procedure.

3.Diagnostic casts: it is a must in fixed prosthodontics

specially in bridge cases.(MCQ)[diagnostic cast possibly
requested for a crown, for Extra crown restoration, mostly for
bridge cases, all are true]. They must have an accurate

Page | 9
reproduction of the arches. They should be mounted on a semi-
adjustable articulator( because they simulate tooth movements
and oral movements better than average value articulator). We
need fixed prosthodontics to be more accurate than removable
because whatever your accuracy in removable your bases are
mobile, you have mucosa, but in fixed prosthodontics you have
rigid bases which are teeth, so you need accurate reproduction
of the movements (of your oral movements). Diagnostic cast is
used for :

a.Occlusal assessment: you check the occlusion inside

the patient mouth, see drifting, rotation and all what we said
before and you can see some of these using your diagnostic
cast.

b.Diagnostic wax-up

c.Fabrication of provisional restorations

Here
you use see your diagnostic cast to fabricate a provisional
restoration, which is in this case acrylic partial denture. The
doctor’s plannig later on to use implant . Right pic is where you
can see a diagnostic wax-up, patient comes to your clinic and he
needs veneers to improve his aesthetics, you can not make the
veneers immediately in one step, you need a step in between
called diagnostic wax-up where the technician build the wax to
his best quality regarding the form and shape of the teeth. With
this wax-up you can ask the patient are you happy to go
through this procedure and end up with the look like this?! This
is one of the benefits of using wax-up. The other thing you can
use it for temporary restoration, how do we use it? We have to
make a crown and you want to fabricate the temporary

Page | 10
restoration( the best temporary restorations are those which
based to have the shape and form of final restoration) we can
do a matrix or a night guard. Diagnostic wax-up could show to
the patient the outcome, could be used for temporary
restoration, or the same diagnostic cast could be used for
temporary restorations or provisional.

4.Shade selection: this is could be done at this stage or

could be done in the treatment plan stage. But you have to
make it before starting drilling the teeth. The shade is the color
of the tooth, and you have to choose it before commencing your
treatment, so you will keep the shade of the original teeth
better than if you prepare it.

Diagnosis

Your diagnosis could be dental caries, gingivitis, tooth

fracture, missing teeth. You have diagnosed your patient, he
could need endo, surgery, prostho, operative. You reach the
diagnosis for every tooth. After that you jump to prognosis.

Prognosis

If you diagnosed a tooth with dental caries and mobility (lets

say a grade III mobility), then what is your prognosis? Could
need extraction, could be restored, you need to tell the patient
about the prognosis which is the likely course of a disease
and this depend on:

a.General factors: age, general disease..

b.Local factors: occlusal load, impactions, mobility..

imagine that you have a grade III mobility for a 75 years old
patient, you have two options, either you to fire it out or to refer
him to a periodontal treatment for a couple of years to stabilize
it. Defiantly considering the age you will get it out, so general
factors and local factors will determined the prognosis for each
tooth. If you decided what is your diagnosis and prognosis you
will end up with a treatment plan, this treatment plan for every
tooth and for the whole dentition.

Page | 11
 Done by: Shahd Qeadan..
Imp. Note: Exam will be on 18.4.09 11:00-12:00
10H1+10H2

Page | 12