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Fixed Prosthodontics

Guidelines at CSU
Dr. Bilal El Masoud
BDS, GradDipClinDent(Melb), DCD(Melb),
FRACSD, FRACDS(Pros), ADC(Australia)
CSU

School of Dentistry and Health sciences

Case selection
General case selection
The following cases should not be managed in the
undergraduate student clinics:

Patients undergoing chemotherapy or radiotherapy.


Patients with severely impaired immunity.
Patients suffering from rare syndromes that require
specialist management.
Patients with active airborne infections (eg. active TB,
SARS, H1N1).
Patients with medical conditions that render them
incapable of withstanding lengthy dental appointments.

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Cases to avoid in Fixed Prosthodontics


Patients whose prosthodontic treatment plan has not
been approved. This is particularly important if a crown
is to serve as an abutment for a partial RDP.
Patients with unrealistic aesthetic expectations or
anatomical considerations that compromise aesthetics
(e.g. a high lip line).
Patients with significant loss of VDO, severe dental
attrition, short clinical crowns or an underlying
symptomatic tm joint condition (e.g. painful tm joint
locking or clicking).

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Cases to avoid in Fixed Prosthodontics


Patients best served by pre-prosthodontic surgery (e.g. crown
lengthening or alveolar ridge augmentation) or orthodontic
treatment. In such cases patients should be advised of their
treatment options and specialist referral pathways, and informed
consent must be received before proceeding with any alternative
management that is deemed within scope of practice in the
undergraduate dental clinic. Only rarely would an advanced (Year 5)
undergraduate student be permitted to manage a case requiring
referral for pre-prosthetic oral or periodontic surgery.
Patients best served by fixed prosthodontic treatment but where the
condition of any core material or remaining coronal tooth structure
has not been assessed or where the excavation of any caries prior to
core placement has not been recorded in the clinical notes.

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Rule
Once any prosthodontic treatment plan has
been approved, it is desirable (but not
always possible) that the student is
mentored through the treatment by the
same clinical tutor.

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Treatment commencement
Examination, diagnosis and treatment planning
forms are available and it is mandatory for the
students to fill the forms and obtain signatures
from the supervising staff before commencing
any treatment.
Lab forms need to be filled by the student and the
tutor needs to insure that all the appropriate
sections are filled and all the necessary
instructions are clear.

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Primary impressions: For any fixed pros treatment the


students must obtain primary impressions in order to
fabricate study casts. These are taken using a stock
tray in Alginate impression material. The impressions
need to be disinfected and poured as soon as possible
to minimise distortion, within 15 minutes to a maximum
of 1 h. If that was not achievable then the impression
must be repeated.
Primary bite registration: Wax bite material is used to
relate both casts together and face bow record is also
taken to mount the casts on an articulator.

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Assessment of the mounted casts, treatment


planning and diagnostic waxup is then
performed to re-establish the lost tooth structure. A
PVS PUTTY INDEX is then fabricated that will at
least cover one tooth on either side. In cases of
bridges a plastic tooth of suitable size is then used
to fill up the gap area and the index needs to cover
all abutments in addition to one tooth on either side
of the abutments.

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Fabrication of special trays (light cured or


self cure)

They need to be prepared at least a day

before and an adhesive layer is applied well


before the appointment (minimum 30
minutes).
For maxillary special trays the palate does not
need to be covered to reduce the chances of
gagging. (This is only for fixed pros)
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Tooth preparation steps:

Adequate anaesthesia if needed.


For All Ceramic Crowns a 1 mm shoulder with an internal rounded
angle (radial shoulder) is the recommended. In addition a 1.5-2mm
occlusal reduction is required for posterior teeth and a 1.5mm incisal
reduction for anteriors. PFM Crowns require a 1.2mm facial reduction
(shoulder) and 0.5-0.8mm lingual reduction (chamfer).
Check the amount of clearance from the opposing dentition at maximum
intercuspation and at excursions (Extremely important)
Post and cores require conservative preparation and should assure the
lack of undercuts. GP could be removed by heated instruments or
Gates Glidden. Para post drills ARE NOT to be used in handpieces and
should be utilized manually to create the post space. (PA should
always be taken to assess the remaining apical seal)

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Final impression

In cases of gingival recession and open embrasures please insure to


block these embrasures using CAVIT or WAX before taking the
impression.
Achieve a dry field and use a double retraction cord technique (single
retraction cord technique in aesthetic zones and thin biotype cases). Use
retraction cords in areas where the finish line is below the gingival
margin. Impregnation of the retraction cord using Aluminium Chloride is
according to the preference of the tutor.
Addition type PVS is the material to be used. At CSU we do not use
powdered gloves but in case you were using them do not mix the putty
material using your gloves.
The standard single stage impression technique is followed at
CSU.

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The material needs to remain inside the mouth for at least


5 minutes to insure that it has reached its final set.
Check the impression for air bubbles and that there are no
drags that could affect the accuracy of the impression.
(The tutor needs to sign off the impression)
Insure that all retraction cords are removed.
For Post/Core impressions please use the periodontal
probe to measure the length of the impression post sticking
out of the impression and compare it with the post space
depth inside the tooth before sending out the impression
for casting.
All impressions need to be disinfected.

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Bite registration is taken using a PVS


material if most of the teeth are available.
In cases were the crown is fabricated on
casts which cannot be made stable due to
minimal number of tooth contacts a
separate appointment for bite registration
is made using bite records. Take a face
bow record at this stage.
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Temporization is performed using a


BisGMA material. Insure that all the
margins are intact and that there are no
positive margins. Use TempBond as your
provisional cement, however if the final
restoration is going to be adhesively
bonded to the tooth structure you need to
use an Eugenol free temporary cement.
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Try in stage

On the cast, you need to check that the crown is fitting on the
die without any gaps or rocking. Check the emergence profile of
the crown and insure that it is not bulky. Also check the fitting
surface for any metal bubbles. Always check that the lab has
complied with your requests.
Always make sure that you have an untouched die that could be
used to perform a quality control step.
Once happy with the crown proceed to the clinical steps. Check
if the crown is fully seated. If not the first thing to check is the
contact points. If tight use graphite markers, articulating papers
or fit checking spray material to identify the tight spots. Adjust
them slowly until the shim stock can be withdrawn with
resistance. Also check that the lab has not damaged the die
margin and created a lip of metal that is not allowing the seating
of the crown.

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Try in stage

Then check the margins for fit (take a precementation PA) and
gaps and the crown for rocking.
Check the occlusion using a shim stock and articulating papers.
Check for shade and obtain consent for cementation from the
patient. Do any necessary adjustments or send it back to the lab
if needed.
Proceed to the cementation stage.

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Cementation stage:

Achieve a dry environment.


Do not over dry your preparation.
Use the appropriate cement for the crown type you are using:
PFM crown/ Metal crowns: use GI luting cement or Resin
Modified Glass Ionomer Cement (preferable)
Ceramic crowns and ceramic inlays and onlays: IPS e.max,
use an adhesive cement under rubber dam. (Dont forget the
need for HF acid etching)
Ceramic Zirconia crowns: use resin modified glass
ionomomer cement.

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Strictly follow the cementation steps provided by the

manufacturer as different cements need deferent


steps. (check what is available at your clinic before
your cementation appointment)
Insure the removal of all excess cement.
Recheck occlusion and take post cementation x-ray.
Provide post operative instructions.

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Review appointment:

Check oral hygiene


Check occlusion
Aesthetics
Excess cement.

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