Pre-Clinical Fixed Prosthodontics I

DR. Wassim Karzoun

DDS, MSc
Master of fixed Prosthodontics

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All ceramic Restorations
Veneers
On-lay
Crowns
In-lay
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High translucency
High esthetic
High
biocompatibility
Why all ceramic?
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Advantages
1. Its superior esthetics.

2. Its excellent translucency.

3. Its generally good tissue response.

4. Slightly more conservative reduction of the facial surface than is possible with the
metal-ceramic crown.
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Their chief disadvantage is their susceptibility to fracture, although this is
lessened by use of the resin bonded technique.

Disadvantages
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1. Reduced strength of the restoration because of the absence of a reinforcing
metal substructure.

2. Because of the need for a shoulder-type margin circumferentially, significant
tooth reduction is necessary on the proximal and lingual aspects.

3. Difficulties may be associated with obtaining a well-fitting margin when certain
techniques are used.

4. The "unforgiving nature of porcelain, if an inadequate tooth preparation goes
uncorrected, can result in fracture.

5. Proper preparation design is critical to ensuring mechanical success.


Disadvantages
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A. 9O-degree cavosurface angle is needed to prevent unfavorable distribution of
stresses and to minimize the risk of fracture
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Indications
indicated in areas with a high esthetic requirement where a more conservative
restoration would be inadequate.
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Contraindications
The ceramic crown is contraindicated when a more conservative restoration
can be used.
If occlusal loading is unfavorable like edge to edge relationship.
If it is not possible to provide adequate support or an even shoulder width of at
least 1 mm.
Close or heavy bite (Class 2 Div 2)
Bruxism or parafunction.
A young patient with a large pulp.
Teeth with short crowns

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Preparation
Armamentarium :
Narrow, round-tipped, tapered diamonds, regular and coarse
grit (0.8 mm)
Flat-tipped, tapered diamond, regular grit (1.0 mm)
Football-shaped diamond
Finishing stones and carbides
Mirror
Periodontal probe
Explorer
Chisels and hatchets

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Preparation
The preparation sequence for a ceramic crown is similar to that for a metal-
ceramic crown.


Incisal (occlusal) reduction:

The completed reduction of the incisal edge should provide 1.5 to 2 mm of
clearance for porcelain in all excursive movements of the mandible.
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1. Place three depth grooves in the incisal edge, initially keeping them
approximately 1.3 mm deep to allow for additional loss of tooth
structure during finishing.

2. Complete the incisal reduction, reducing half the surface at a time,
and verify its adequacy upon completion.

Preparation
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All-ceramic crown preparation
A. Labial view. B. lingual view

To prevent stress
concentrations in the ceramic,
all internal line angles should
be rounded.

The shoulder should be as
smooth as possible to
facilitate the technical aspects
of fabrication
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The uniform shoulder width of 1 mm on this
all-ceramic crown preparation
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Facial Reduction:

3. After placing depth grooves, reduce the facial or buccal surface and
verify that adequate clearance exists for 1 mm of porcelain thickness.
One depth groove is placed in the middle of the facial wall, and one
each in the mesiofacial and distofacial transitional line angles.
The depth of these grooves should be approximately 0.8 mm to allow
finishing.
4. Accomplish the bulk reduction with the flat-tipped tapered diamond
(which results in a heavy chamfer margin).
Be sure to maintain copious irrigation throughout.
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Lingual Reduction:

5. Use the football-shaped diamond for lingual reduction The reduction is
done in the same way as the other anterior tooth
Preparations until a clearance of 1 mm in all mandibular excursive
movements has been obtained .
5. Repeat the shoulder preparation, this time from the center of the
cingulum wall into the proximal, until the lingual shoulder meets the
facial shoulder. This margin should follow the free gingival crest and
should not extend too far subgingivally.

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Finish line preparation:

For subgingival margins, displace the tissue with cord before proceeding with
the shoulder preparation.
The ultimate objective is to direct stresses optimally in the completed
porcelain restoration. This is accoplished when the rounded shoulder
margin completely supports the crown; any forces exerted on the crown
are then in a direction parallel to its path of placement.
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A sloping shoulder results in unfavorable loading of the porcelain, with
a greater likelihood of tensile failure.

A 90-degree cavosurface angle is optimal.

The completed shoulder should be 1 mm wide, smooth, continuous,
and free of any irregularities.

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Finishing
Finish the prepared surfaces to a final smoothness. Be sure to round any remaining
sharp line angles to prevent a wedging action, which can cause fracture.

Perform any additional margin refinement as needed, using either the diamond or a
carbide rotary instrument of choice.

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Ceramic Inlays and Onlays
Onlay
Inlay
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Ceramic Inlays and Onlays
For patients demanding esthetic restorations, ceramic inlays and
onlays provide a durable alternative to posterior composite resins.

The procedure consists of bonding the ceramic restoration to the
prepared tooth with an acid-etch technique.

The bonding mechanism relies on acid etching of the enamel and the
use of composite resin, as seen in the resin-retained fixed dental
prosthesis technique. Bonding to porcelain is achieved by etching with
hydrofluoric acid and the use of a silane coupling agent.


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Indications
A ceramic inlay can be used instead of amalgam or
a gold inlay for patients with a low caries rate
requiring a Class II restoration and wish to restore
the tooth to its original appearance.

It is the most conservative ceramic restoration and
enables most of the remaining enamel to be
preserved.


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Contraindications
Because these restorations are time consuming and expensive,
they are contraindicated in patients with poor oral hygiene or
active caries.


Because of their brittle nature, ceramics may be
contraindicated in patients with excessive occlusal loading,
such as those with bruxism.

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Advantages
Ceramic inlays and onlays can be extremely esthetic
restorations.

The restoration wear associated with posterior composite
restorations is not a problem with the ceramic restoration.

Marginal leakage associated with polymerization
shrinkage and high thermal coefficient of expansion of
the resin is reduced, because the luting layer is very thin.




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Disadvantages
Accurate occlusion can be difficult to achieve with ceramic inlays and
onlays.

Because they are fragile, intraoral occlusal adjustment is impractical
before they are bonded to place. Therefore, any areas of adjustment need
careful finishing and polishing, which is a time-consuming procedure.

Wear of the composite resin-luting agent can be a problem, leading to
marginal gaps. These eventually allow chipping or recurrent caries.

So, accuracy is important with these restorations, because accurately fitting
restorations (marginal gaps less than 100 um) have been shown to reduce this
problem significantly.


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Finishing of the margins can be difficult in the less accessible
interproximal areas.

Resin flash or overhangs are difficult to detect and can initiate
periodontal disease.

Bonded ceramic inlays are a relatively new concept, and long-term
clinical performance is hard to judge.

Disadvantages
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Preparation
Armamentarium :
As for metal inlays, carbide burs are used in the preparation, but
diamonds may be substituted:

Tapered carbide burs
Round carbide burs
Finishing stones
Mirror
Explorer and periodontal probe
Chisels
Gingival margin trimmers
Articulating film
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Armamentarium for the ceramic inlay preparation
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Preparation..
Step by step procedure
Rubber dam isolation is recommended for visibility and
moisture control.

Before applying the dam, mark and assess the occlusal contact
relationship with articulating film.

To avoid chipping or wear of the luting resin, the margins of
the restoration should not be at a centric contact.

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Outline Form :

1. Preparation is generally governed by the existing restorations and caries and is
broadly similar to that for conventional metal inlays and onlays. weakened enamel
should always be removed. The outline should avoid occlusal contacts. Areas to
receive onlays need 1.5 mm of clearance in all excursions to prevent ceramic
fracture.


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Preparation..
Step by step procedure
2. Extend the box to allow a minimum of 0.6 mm of
proximal clearance for impression making. The
margin should be kept supragingival, which makes
isolation during the critical luting procedure easier
and improves access for finishing

3. Round all internal line angles. Sharp angles lead to
stress concentrations and increase the likelihood of
voids during the luting procedure.

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Preparation..
Step by step procedure
Caries Excavation :
4. Remove any caries not included in the outline form preparation
with an excavator or a round bur in the low-speed handpiece.

5. Place a resin-modified glass ionomer cement base to restore the
excavated tissue in the gingival wall.


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Preparation..
Step by step procedure
Margin Design :

6. Use a 90-degree butt joint for ceramic inlay margins. Bevels are
contraindicated because bulk is needed to prevent fracture. A
distinct heavy chamfer is recommended for ceramic onlay
margins.


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Preparation..
Step by step procedure
Finishing :

7. Refine the margins with finishing burs and hand instruments,
trimming back any glass ionomer base.
Smooth, distinct margins are essential to an accurately fitting
ceramic restoration.


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Preparation..
Step by step procedure
Occlusal Clearance (for Onlays) :

8. Check the occlusal clearance after the rubber dam is removed.
A 1.5-mm clearance is needed to prevent fracture in all excursions. This can be
easily evaluated by measuring the thickness of the resin interim restoration with a
caliper.

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Preparation..
Step by step procedure
Preparation for ceramic Inlays
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Preparation for ceramic Onlays
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