IntroductionIntroduction to to

Fixed ProsthodonticsFixed Prosthodontics

Dr. William MorganDr. William MorganClinical ProfessorClinical Professor

UCLA School of DentistryUCLA School of DentistryApril 3, 2007April 3, 2007

FacultyFaculty Dr. William Morgan, Course Co-ChairDr. William Morgan, Course Co-Chair Dr. Richard Stevenson, Course Co-ChairDr. Richard Stevenson, Course Co-Chair

Dr. Esteban BonillaDr. Esteban Bonilla Dr. Lillian ChengDr. Lillian Cheng Dr. Donald FisherDr. Donald Fisher Dr. Michael GritzDr. Michael Gritz Dr. Sue SpackmanDr. Sue Spackman Dr. Jay WatsonDr. Jay Watson Dr. Andy WongDr. Andy Wong

Course RequirementsCourse Requirements Attend lecture & lab each weekAttend lecture & lab each week Complete all projects on timeComplete all projects on time Pass midterm & final practical examinationsPass midterm & final practical examinations

One makeup examinationOne makeup examination Average 75% or better on all written Average 75% or better on all written

examinationsexaminations Each question on quizzes & examinations count the Each question on quizzes & examinations count the

samesame Quizzes each week on reading assignmentQuizzes each week on reading assignment Drop one quiz at end of quarterDrop one quiz at end of quarter Examinations cover material since last examinationExaminations cover material since last examination Fall & Winter final examinations are cumulativeFall & Winter final examinations are cumulative

TerminologyTerminology

ProsthodonticsProsthodontics The dental specialty concerned with the The dental specialty concerned with the

making of artificial replacements for missing making of artificial replacements for missing parts of the mouth and jaw. Also prosthetic parts of the mouth and jaw. Also prosthetic dentistry or prosthodontia.dentistry or prosthodontia.

Fixed ProsthodonticsFixed Prosthodontics Gold crowns-full and partial veneerGold crowns-full and partial veneer Inlays-gold and all ceramicInlays-gold and all ceramic Porcelain-all porcelain and PFMPorcelain-all porcelain and PFM Fixed partial denturesFixed partial dentures

Replace one or more missing teethReplace one or more missing teeth

Restorative DentistryRestorative Dentistry Restorative dentistry covers the range from Restorative dentistry covers the range from

simple direct restorations to complex full simple direct restorations to complex full mouth rehabilitation. This will include class mouth rehabilitation. This will include class I & class II direct restorations, simple I & class II direct restorations, simple indirect restorations like inlays, crowns & indirect restorations like inlays, crowns & veneers, to replacing missing teeth with veneers, to replacing missing teeth with fixed partial dentures & finally to complete fixed partial dentures & finally to complete rehabilitation with indirect restorations rehabilitation with indirect restorations throughout the mouth. Esthetics & function throughout the mouth. Esthetics & function must also be considered.must also be considered.

Operative DentistryOperative Dentistry Fixed ProsthodonticsFixed Prosthodontics Esthetic DentistryEsthetic Dentistry

RestorationsRestorations

Full Veneer CrownsFull Veneer Crowns

Gold casting covers all external walls of the tooth & reinforces remaining tooth structure

Partial Veneer CrownPartial Veneer CrownMOL Gold Inlay/OnlayMOL Gold Inlay/Onlay

Healthy tooth structure is preserved

Partial Veneer CrownPartial Veneer CrownMOL Gold Inlay/OnlayMOL Gold Inlay/Onlay

Minimal facial extension preserves esthetics

Partial Veneer CrownPartial Veneer CrownMOD Gold OnlayMOD Gold Onlay

Restoration reinforces remaining tooth & leaves tooth structure at gingival area

Gold InlaysGold Inlays

Conservative preparation & finishing of the gold margins can provide a restoration that will last many years

All Ceramic OnlayAll Ceramic Onlay

Esthetic restoration but is subject to fracture

All Ceramic Inlay/OnlayAll Ceramic Inlay/Onlay

Porcelain Fused To Metal Porcelain Fused To Metal Crown (PFM)Crown (PFM)

Porcelain is baked to a thin cast metal coping

Porcelain Veneers &Porcelain Veneers &Fixed Partial DentureFixed Partial Denture

Porcelain Veneers & Porcelain Veneers & Fixed Partial DentureFixed Partial Denture

Porcelain Veneers

Fixed Partial Denture

Fixed Partial DentureFixed Partial Denture

Porcelain is baked over a cast metal framework

Fixed Partial Denture Fixed Partial Denture (PFM)(PFM)

Metal framework for strength & porcelain for esthetics

Fixed Partial Denture Fixed Partial Denture (Gold)(Gold)

Fixed Partial DentureFixed Partial DenturePier AbutmentPier Abutment

Pontics

Fixed Partial DentureFixed Partial DentureImplantsImplants

FPD attached to implants

DiagnosisDiagnosis HistoryHistory

Physical/Emotional HealthPhysical/Emotional Health PremedicatePremedicate AllergiesAllergies Medications Medications Physician ConsultPhysician Consult

DiagnosisDiagnosis TMJ/Occlusal EvaluationTMJ/Occlusal Evaluation

Within Normal Limits?Within Normal Limits? Maintain Occlusal RelationshipMaintain Occlusal Relationship

Frequent Head, Neck or Shoulder Frequent Head, Neck or Shoulder Pain?Pain? Evaluate Muscles & TMJEvaluate Muscles & TMJ

Referral? Referral?

DiagnosisDiagnosis Intraoral ExaminationIntraoral Examination

General Oral HygieneGeneral Oral Hygiene Soft TissueSoft Tissue Periodontal HealthPeriodontal Health

Probing/Chart PocketsProbing/Chart Pockets MobilityMobility

CariesCaries Examine Old RestorationsExamine Old Restorations

Serviceable or failing?Serviceable or failing?

DiagnosisDiagnosis Diagnostic Casts-required for all Diagnostic Casts-required for all

indirect restorationsindirect restorations Mount With Facebow & Bite RecordsMount With Facebow & Bite Records Occlusal EvaluationOcclusal Evaluation Diagnosis/Treatment PlanDiagnosis/Treatment Plan Diagnostic Wax-UpDiagnostic Wax-Up Stents For TemporizationStents For Temporization

DiagnosisDiagnosis Full Mouth RadiographsFull Mouth Radiographs

Caries-Interproximal & RecurrentCaries-Interproximal & Recurrent Periapical Lesions?Periapical Lesions? Quality of Previous EndodonticsQuality of Previous Endodontics Periodontal Health & Alveolar Bone Periodontal Health & Alveolar Bone

LevelsLevels Crown/Root RatioCrown/Root Ratio PathosisPathosis

Treatment OptionsTreatment OptionsIntracoronal RestorationsIntracoronal Restorations

Glass IonomerGlass Ionomer Composite ResinComposite Resin Simple AmalgamSimple Amalgam Complex AmalgamComplex Amalgam Gold FoilGold Foil Gold InlayGold Inlay Ceramic InlayCeramic Inlay

Treatment OptionsTreatment OptionsExtracoronal RestorationsExtracoronal Restorations

Ceramic OnlayCeramic Onlay Gold OnlayGold Onlay Partial Veneer Crowns (3/4, 7/8)Partial Veneer Crowns (3/4, 7/8) Full Gold CrownFull Gold Crown Porcelain/Metal Crown (PFM)Porcelain/Metal Crown (PFM) All-Ceramic CrownAll-Ceramic Crown Ceramic VeneerCeramic Veneer

Treatment OptionsTreatment OptionsReasons For Extracoronal Reasons For Extracoronal

RestorationsRestorations Previous restoration and/or caries Previous restoration and/or caries

undermines tooth structure, requiring undermines tooth structure, requiring reinforcement that comes from an reinforcement that comes from an extracoronal restorationextracoronal restoration

Discoloration present and patient desires Discoloration present and patient desires esthetic improvement and tooth has been esthetic improvement and tooth has been weakenedweakened

Occlusal modifications Occlusal modifications

CastingCasting

Full Gold Crown

Casting/Crown Casting/Crown FabricationFabrication 1. Tooth Preparation, Including Caries 1. Tooth Preparation, Including Caries

Removal & Build-UpRemoval & Build-Up 2. Temporization (Ready before impression)2. Temporization (Ready before impression) 3. Impression3. Impression 4. Model (Cast) and Die Fabrication4. Model (Cast) and Die Fabrication 5. Wax-Up (Exact shape & size of desired 5. Wax-Up (Exact shape & size of desired

crown)crown) 6. Investing and Casting6. Investing and Casting 7. Crown Adjusting and Polishing7. Crown Adjusting and Polishing 8. Clinical Try-In and Cementation8. Clinical Try-In and Cementation

Tooth PreparationsTooth Preparations

Full Gold Crown Full Gold Crown PreparationPreparation Indicated when Indicated when

restoration or caries restoration or caries significantly significantly weakened tooth weakened tooth

All external walls All external walls covered-occlusal & covered-occlusal & axial with minimal axial with minimal taper of axial wallstaper of axial walls

Gingival finish line Gingival finish line may be subgingival or may be subgingival or supragingivalsupragingival

Adequate reduction to Adequate reduction to provide bulk of goldprovide bulk of gold

Porcelain Fused to Metal Porcelain Fused to Metal (PFM)(PFM)

Indications same as Indications same as FGC but patient FGC but patient desires more desires more estheticsesthetics

All walls covered All walls covered similar to full gold similar to full gold crowncrown

Additional reduction Additional reduction necessary on facial to necessary on facial to accommodate metal accommodate metal & porcelain without & porcelain without being overcontouredbeing overcontoured

3/43/4 Gold CrownGold Crown Facial wall unpreparedFacial wall unprepared Facial cusp minimally Facial cusp minimally

reduced occlusallyreduced occlusally Grooves placed to Grooves placed to

prevent lingual prevent lingual displacement of crowndisplacement of crown

Minimal facial extension Minimal facial extension interproximallyinterproximally

Fixed Partial DentureFixed Partial Denture Anterior crown Anterior crown

preparation preparation (abutment) is a (abutment) is a PFMPFM

Posterior crown Posterior crown is a full gold is a full gold crowncrown

Ceramic OnlayCeramic Onlay Restoration is all Restoration is all

ceramic with no ceramic with no metalmetal

It is bonded to the It is bonded to the toothtooth

Weaker than Weaker than restorations with restorations with metal & can fracture metal & can fracture during masticationduring mastication

Build-UpsBuild-Ups Done to replace missing tooth Done to replace missing tooth

structure & provide retention for structure & provide retention for final restorationfinal restoration

TypesTypes Pin Retained Amalgam or CompositePin Retained Amalgam or Composite Preformed Posts Retaining BuildupPreformed Posts Retaining Buildup Custom Cast Post and CoreCustom Cast Post and Core

Build-Up (Pin retained)Build-Up (Pin retained) Pin holes drilled Pin holes drilled

into vital toothinto vital tooth Pins threaded into Pins threaded into

tooth & retained in tooth & retained in dentindentin

Missing tooth built Missing tooth built up with amalgam up with amalgam or non tooth or non tooth colored compositecolored composite

Build-Up (Pre-formed Build-Up (Pre-formed post)post)

Endodontically Endodontically treated tooth is treated tooth is missing significant missing significant amount of tooth amount of tooth structurestructure

One or more canals One or more canals are shaped & pre-are shaped & pre-formed post is fit into formed post is fit into the canal & cementedthe canal & cemented

Chamber may also be Chamber may also be used to provide used to provide additional retention additional retention for buildupfor buildup

Build-Up (Pre-formed Build-Up (Pre-formed post)post)

After post is After post is cemented, the tooth cemented, the tooth is built up with is built up with amalgam or amalgam or compositecomposite

Walls of preparation Walls of preparation must extend beyond must extend beyond the build up to the the build up to the tooth structuretooth structure

Build-Up (Custom Cast Dowel Build-Up (Custom Cast Dowel Core)Core)

Single rooted Single rooted endodontically endodontically treated tooth treated tooth with significant with significant amount of tooth amount of tooth structure missing structure missing or undermined-or undermined-not enough to not enough to retain a crownretain a crown

Build-Up (Custom Cast Dowel Build-Up (Custom Cast Dowel Core)Core)

Canal is shaped & sized Canal is shaped & sized with a reamerwith a reamer

Resin pattern is made Resin pattern is made that is an exact that is an exact impression of the canal impression of the canal & created the desired & created the desired coronal “tooth coronal “tooth structure”structure”

Pattern is cast into goldPattern is cast into gold

Build-Up (Custom Cast Dowel Build-Up (Custom Cast Dowel Core)Core)

Cast dowel core is Cast dowel core is cemented into the cemented into the canal in the rootcanal in the root

Dowel core & tooth Dowel core & tooth are reshaped into final are reshaped into final crown preparationcrown preparation

Impression made of Impression made of preparation & crown preparation & crown fabricated, adjusted & fabricated, adjusted & cemented onto toothcemented onto tooth

Provisional RestorationsProvisional Restorations(Temporaries)(Temporaries)

Custom made acrylicCustom made acrylic Relined polycarbonate crownsRelined polycarbonate crowns Pre-formed metal crownsPre-formed metal crowns

Provisional RestorationProvisional Restoration (Custom Made Acrylic) (Custom Made Acrylic)

Rough provisional Rough provisional crown causes crown causes gingival irritation & gingival irritation & difficulty in taking a difficulty in taking a final impressionfinal impression

Provisional Provisional restoration smoothed restoration smoothed & polished with much & polished with much better tissue better tissue response after only a response after only a few daysfew days

Provisional RestorationProvisional Restoration (Custom Made Acrylic) (Custom Made Acrylic)

Final restorations

Provisional Restorations Provisional Restorations (Relined Polycarbonate (Relined Polycarbonate

Crowns)Crowns) Pre-formed Pre-formed

polycarbonate crown polycarbonate crown selected & adjustedselected & adjusted

Polycarbonate crown Polycarbonate crown relined with acrylic, relined with acrylic, adjusted, polished & adjusted, polished & cementedcemented

Provisional Restorations Provisional Restorations (Preformed Metal Crowns)(Preformed Metal Crowns)

Pre-formed soft Pre-formed soft metal crown metal crown selected & adjustedselected & adjusted

Metal crown relined Metal crown relined with acrylic, with acrylic, adjusted, polished adjusted, polished & cemented& cemented

ImpressionsImpressions Full arch impressionsFull arch impressions Double bite impressionsDouble bite impressions Quadrant impressionsQuadrant impressions

Full Arch ImpressionFull Arch Impression

Impression of whole arch using light & heavy body impression material capturing detail with no bubbles

Double Bite ImpressionDouble Bite Impression Impression Impression

of of preparation, preparation, opposing opposing dentition as dentition as well as well as intercuspal intercuspal bitebite

Model (Cast) andModel (Cast) andDie FabricationDie Fabrication

Cast & Die FabricationCast & Die Fabrication

Full arch impression is used to fabricate full arch cast with removable dies

Cast & Die FabricationCast & Die Fabrication Double bite Double bite

impression is impression is used to fabricate used to fabricate mounted casts mounted casts with either a with either a separate die or a separate die or a removable dieremovable die

SeriesSeriesCrown PreparationCrown PreparationCasting FabricationCasting Fabrication

Full Crown Prep #30Full Crown Prep #30

Impression & Cast Impression & Cast FabricationFabrication

Inspect impression for completeness & fabricate cast

Wax Pattern Wax Pattern FabricationFabrication

Fabricate a wax pattern exactly like the desired crown, checking details with the stereo microscope

Invest & Cast CrownInvest & Cast Crown

Finished wax pattern is placed inside ring & investment flowed around it. Pattern is burned out in oven & molten gold flowed into the void in the ring, creating the casting as shown above

Crown CementationCrown Cementation

Crown tried in, adjusted & cemented