Readings

8 Types of bridge
The appliances used to replace missing teeth attachment is made by an adhesive resin material,
were defined in Chapter 7. Some of the terms retained by the acid-etch technique to the enamel
used for bridges are also used in relation to and by other means to the metal. These bridges
partial dentures. can be used only when the abutment teeth have
sufficient intact enamel.
The saddle is the edentulous alveolar ridge
where a tooth/teeth are to be replaced.
An abutment is a tooth to which a bridge (or
partial denture) is attached. Basic designs, combinations and
A retainer is a crown or other restoration variations
that is cemented to the abutment. The terms
retainer and abutment should not be There are four basic designs of bridge, the differ-
confused or used interchangeably. ence being the type of support provided at each
A wing is a term sometimes used for a ends of the pontic. The same name is given to
minimum preparation retainer. the design, however many pontics there are in
A pontic is an artificial tooth as part of a the span and abutment teeth splinted at one end
bridge. of the span (Figure 8.1).
A span is the space between natural teeth that The four basic designs are the same whether
is to be filled by the bridge. the bridge is a conventional or a minimum-prep-
A pier is an abutment tooth standing between aration type. It is possible to combine two or
and supporting two pontics, each pontic being more of the four basic designs and to combine
attached to a further abutment tooth. conventional and minimum-preparation retainers
A unit, when applied to bridgework, means in the same bridge (the hybrid bridge see page
either a retainer or a pontic. A bridge with two 204).
retainers and one pontic would therefore be a Of the four basic designs, the first three may
three-unit bridge. be either conventional or minimum-preparation
A connector (or joint) connects a pontic to types. Minimum-preparation versions of the
a retainer, or two retainers to each other. spring cantilever bridge are rarely made and
Connectors may either be fixed or allow some conventional spring cantilever bridges are only
movement between the components that they made very rarely. There are better alternatives.
join. However, some patients still have spring
cantilever bridges which need to be maintained,
so dentists need to recognise them.
Conventional and minimum-

preparation bridges
The four basic designs (Figure 8.1)
Conventional bridges involve removing tooth
tissue, or a previous restoration, and replacing it Only the first three designs are still made.
with a retainer. This may be destructive of tooth
tissue and will certainly be time-consuming and
expensive. The alternative, minimum-preparation
Fixedfixed bridge
bridge involves attaching pontics via a metal wing
to the unprepared (or minimally prepared) lingual A fixedfixed bridge (Figure 8.1a) has a rigid
and proximal surfaces of adjacent teeth. The connector at both ends of the pontic. The
197
198 Types of bridge
Figure 8.1
Four basic designs of conventional bridges.
a Fixedfixed: both upper and lower bridges will be
fixedfixed, the lower retained by complete crowns on
the canine tooth and central incisor (see Figures 7.11c
and 3.17h for the preoperative condition and the
preparations). The upper bridge will be retained by the
canine teeth only (see page 227 for the rationale for
this design). The bridge was made before implants were
generally available but if they had been, a considerable
amount of bone grafting would have been necessary.
b Fixedmovable: a DO inlay in the lower second

premolar and full crown on the molar tooth. This
bridge has been present for 20 years in fact so long
that the occlusal surface of the crown has worn
through (see Chapter 14). The movable joint can be
seen between the pontic and the minor retainer. It
would not normally be as obvious as this.
c Cantilever: these are the two metalceramic bridges

made for the case shown in Figure 7.11dh.
d Occlusal view of the bridges in place.
e Spring cantilever: the first molar tooth is the

abutment tooth. There is a midline diastema, and a
diastema between the lateral incisor and canine on the
side of the missing central incisor. Any other bridge
design would have involved closing one or both of
these spaces. Today a single-tooth implant would be
the preferred solution to the problem.
Types of bridge 199
Figure 8.2
An unsatisfactory design for a fixedfixed bridge.
A conventional fixedfixed bridge should have all the

occluding surfaces of the abutment teeth protected by
the retainers. Otherwise an occlusal force directed at
the unprotected area will depress the abutment tooth
in its socket while the retainer is held by the bridge
and the other abutment tooth. This will break down
the cement lute, causing leakage. The retainer is held
in place by the bridge, and so secondary caries devel-
ops rapidly (see Figure 14.8).
abutment teeth are therefore rigidly splinted The fixedfixed design should be avoided if at
together, and for a conventional bridge must be all possible for minimum-preparation bridges. A
prepared parallel to each other so that the bridge, number of success and failure surveys have
which is a minimum of three units, can be shown that the cantilever design of minimum-
cemented in one piece. The retainers should have preparation bridges with one abutment tooth is
approximately the same retention as each other more successful with anterior bridges and a form
to reduce the risk that forces applied to the of fixedmovable design is preferred for posterior
bridge will dislodge one retainer from its bridges (see later).
abutment, leaving the bridge suspended from the At one time it was thought that the support
other abutment. for the abutment teeth at each end of a
To minimize this risk, it is also important for fixedfixed conventional bridge should be similar.
the entire occluding surface of all the abutment In other words, the root surface area of the
teeth for a conventional bridge to be covered by abutments should be approximately the same.
the retainers. The opposing teeth cannot then Today this is not considered necessary (see
contact the surface of an abutment tooth, depress Chapter 10).
it in its socket and break the cement lute. If this
should happen, the retainer will not appear loose
since it will still be held in place by the rest of
Fixedmovable bridge
the bridge.
However, oral fluids will enter the space A fixedmovable conventional bridge (Figure
between the retainer and the abutment prepara- 8.1b) has a rigid connector, usually at the distal
tion, and caries will rapidly develop (Figure 8.2). end of the pontic, and a movable connector that
For example, linking a full coverage crown to a allows some vertical movement of the mesial
simple DO inlay would quickly result in dislodge- abutment tooth. The movable connector should
ment of the inlay with consequent caries devel- resist both separation of the pontic from the
oping underneath. retainer and lateral movement of the pontic
This rule does not apply so much to minimum- (Figure 8.3a and b).
preparation bridges in which the bond between Occasionally the fixed and movable connectors
the retainer and the abutment tooth is much are reversed, but this has a number of disadvan-
stronger. However, it is sometimes not strong tages. The retainer with the movable connector
enough, and debonding occurs as a result of a (the minor retainer) is smaller and less visible and
mechanism similar to that shown in Figure 8.2. so is better in the more anterior abutment tooth.
200 Types of bridge
Figure 8.3
Fixedmovable bridges.
a A conventional bridge with an MOD gold inlay as the

minor retainer and a full gold crown as the major
retainer.
b Acrylic burn out patterns for movable connectors.

The blue is very tapered, the red more parallel-sided.
c and d A minimum-preparation fixedmovable bridge.
c Shows the minor retainer in place with a depression,

rather than a slot, in the distal rest. The preparations
for both the major and minor retainers are within
enamel.
d Shows the finger from the pontic resting on the

minor retainer. This will resist axial forces on the
pontic which would tend to tilt the molar abutment
tooth forwards. It does not resist lateral forces but
these can be made insignificant by contouring the
occlusion of the pontic.
Posterior teeth commonly tilt mesially, and this it need full occlusal protection. Occlusal forces
tends to unseat distal movable connectors, but is applied to the tooth surface not covered by the
resisted by mesial ones. retainer will depress the tooth in its socket, and
The movable connector can be separated there will be movement at the movable joint
before the bridge is cemented, and so the two rather than rupturing of the cement lute (Figure
parts of the bridge can be cemented separately. 8.2).
The abutment teeth do not therefore have to be A fixedmovable minimum-preparation bridge
prepared parallel to each other and the retention cannot have a large, dovetailed shaped movable
for the minor retainer does not need to be as connector (Figure 8.3a and b) without over-
extensive as for the major retainer. Neither does preparing the minor abutment tooth. Instead the
Types of bridge 201
Figure 8.4
a All-ceramic cantilever bridges. The lateral incisor

teeth were congenitally missing and the deciduous
canine teeth remained with good long roots. They
were therefore used as abutments for these cantilever
bridges until such time as the deciduous canine teeth
are lost. The patient is in her early twenties and this
may not be for a decade or two when implants will
probably be the treatment of choice but will have to
last for less time than if they were placed now.
b and c A minimum-preparation cantilever bridge

replacing the lateral incisor retained by the canine
tooth.
d A similar cantilever bridge but this time retained by

the central incisor tooth.
202 Types of bridge
Figure 8.5
A large splint/bridge with cantilevered pontics.
a The working dies.
b The metal framework, showing two cantilevered

pontics on the right of the picture.
c The completed restoration in the mouth

(photographed in a mirror so that the cantilevered
pontics are shown on the left).
design, which is shown in Figure 8.3c and d, is to Cantilever bridge

allow some movement of both abutment teeth,
thereby reducing the risk of debonding, and to A cantilever bridge (Figure 8.1c and d) provides
resist axial forces on the pontic. The design does support for the pontic at one end only. The
not resist lateral forces on the pontic or forces pontic may be attached to a single retainer or to
tending to distract the pontic from the minor two or more retainers splinted together, but has
retainer. It should therefore only be used for no connection at the other end of the pontic. The
relatively short spans in the posterior part of the abutment tooth or teeth for a cantilever bridge
mouth. However, in these circumstances it is now may be either mesial or distal to the span, but for
the preferred option. small bridges they are usually distal.
Types of bridge 203
Figure 8.6
A hybrid bridge with a conventional retainer (an inlay in the premo-

lar tooth carrying a movable connector for a fixedmovable bridge).
The other retainer on the canine is of the minimum-preparation type.
Hybrid bridges should only be made fixedmovable and with the
movable joint in the conventional retainer.
Two conventional cantilever bridges are shown of the soft tissues of the palate so that excessive
in Figures 8.1c and d. The central incisors needed leverage forces did not disturb the abutment
to be crowned and so a convential rather than a teeth. They were made when the teeth either
minimum-preparation design was used. Also see side of the gap were sound.
Figure 8.4. Spring cantilever bridges are no longer made
and have been superseded by minimum-prepar-
ation bridges and single-tooth implants. However,
a number of patients still have spring cantilever
Spring cantilever bridge
bridges and so dentists should be able to recog-
Spring cantilever bridges (Figure 8.1e) were nise them.
restricted to the replacement of upper incisor
teeth. Only one pontic could be supported by a
spring cantilever bridge. This was attached to the
end of a long metal arm running high into the Combination designs
palate and then sweeping down to a rigid connec-
tor on the palatal side of a single retainer or a The four basic designs can be combined in a
pair of splinted retainers. The arm was made long variety of ways. In particular, the fixedfixed and
and fairly thin so that it was springy, but not so cantilever designs are often combined. In larger
thin that it would deform permanently with bridges additional cantilever pontics may be
normal occlusal forces (i.e. exceed the elastic suspended from the end of a large fixedfixed
limit). Forces applied to the pontic were absorbed section (Figure 7.5). Similarly, it is possible to
by the springiness of the arm and by displacement combine fixedfixed and fixedmovable designs.
204 Types of bridge
It is possible to combine a bridge or splint with made so that they can be removed by the
a removable buccal flange that replaces lost alveo- patient. The advantage of this is that cleaning
lar tissue (Figure 7.8). around the abutment teeth and under the pontics
is much easier. The bridge has to withstand
handling by the patient, and so it is usually made
with acrylic facings (Figure 7.2). The acrylic
Hybrid design facings are less liable to chip if the bridge is
dropped. They can also be replaced without the
This term refers to a bridge with a combination risk of distorting the framework as would be the
of conventional and minimum-preparation retain- case with porcelain.
ers. There are three different hybrid designs:
Fixedmovable with the minimum-preparation

retainer carrying the movable connector. Advantages and disadvantages of the
Fixedmovable with the conventional retainer four basic designs
carrying the movable connector.
Fixedfixed with one conventional and one A comparison of conventional fixedfixed,
minimum-preparation retainer. fixedmovable and cantilever bridges is shown on
page 206. Spring cantilever bridges are not
The third design should not be used and the included.
second only rarely. In either case, if the minimum- A comparison of minimum-preparation
preparation retainer becomes debonded then it fixedfixed, fixedmovable and cantilever designs
will not be possible to re-cement it without is shown on page 207.
removing the conventional retainer, which may
well involve destroying the bridge.
The first design is one of choice given circum-
stances in which one of the abutment teeth Choice of materials
already has a restoration that could be replaced
by means of an inlay or other conventional Metal only
retainer and the other abutment tooth is
unrestored or the restoration does not involve Many posterior bridges, both conventional and
the surfaces to be covered by the minimum- minimum-preparation, can be made entirely of
preparation retainer (Figure 8.6). These circum- cast metal, whether they are fixedfixed,
stances occur surprisingly often, and so this fixedmovable or cantilever. If the retainers or
design of bridge is now common. pontics do not show when the patient smiles and
speaks then an all-metal bridge is the best choice
with conventional bridges the material necessi-
tates the least destruction of tooth tissue and
Variations may be the least costly. The margins are also
easier to adapt to the preparations.
Removable bridges
All the designs described so far are permanently
cemented in the patients mouth. With large Metalceramic
bridges there are disadvantages in permanent
cementation in that the maintenance and further When the strength of metal is required together
endodontic or periodontal treatment of with a tooth-coloured retainer or pontic,
abutment teeth is difficult, and if something goes metalceramic is the best material.
wrong with one part of the bridge or with one A range of composite crown and bridge facing
of the abutment teeth, usually the whole bridge materials is now available, but it is too early to
has to be sacrificed. For this reason, larger say whether these have an advantage over
bridges, including full arch bridges, are sometimes metalceramic materials for permanent bridges.
Types of bridge 205
Figure 8.7
Typical temperature ranges for the metalceramic

process. These vary according to the metal, porcelain
and solder used, and with the type of furnace, in partic-
ular its rate of temperature rise.
Ceramic only fracturing if the bridge receives a blow. It is not

uncommon for patients who lose a tooth as a
The traditional all-ceramic bridge was limited by result of an accident to have a further accident,
its relatively poor strength to two-unit cantilever either because of their occupation or sport or
bridges or three-unit fixedfixed bridges but they because, with a Class II Division I incisor relation-
were popular at one time and some patients still ship, their upper incisors are vulnerable to
have them. With improvements in metalceramic trauma. A broken bridge is better for the patient
materials, these all-ceramic bridges fell into than broken roots.
disuse. However, with the development of
stronger ceramic materials (see Chapter 1 and
Figure 8.4), there is a resurgence of interest in
all-ceramic bridges.. Combinations of materials
One advantage of the all-ceramic bridge is the
fuse-box principle (see Chapter 2). All-ceramic Many combinations are possible, but two deserve
bridges, if properly designed and constructed, special mention:
have sufficient strength to survive normal
functional forces, but will break if subjected to A metalceramic retainer and pontic with a
excessive forces. This potential for fracture may movable connector to a gold inlay or other
save the roots of the abutment teeth from minor retainer.
206 Types of bridge
COMPARISON OF CONVENTIONAL BRIDGE DESIGN

ADVANTAGES DISADVANTAGES
Fixedfixed Fixedfixed
Robust design with maximum retention Requires preparations to be parallel, and
and strength this may mean more tooth reduction than
Abutment teeth are splinted together; this normal, endangering the pulp and reduc-
may be an advantage, particularly when ing retention; the strength of the
teeth are uncomfortably mobile following prepared tooth may also be reduced
bone loss through periodontal disease Preparations are difficult to carry out,
The design is the most practical for larger particularly if several widely separated
bridges, particularly when there has been teeth are involved; the preparation is slow
periodontal disease and the parallelism has to be constantly
The construction is relatively straightfor- checked, or alternatively (and wrongly)
ward in the laboratory because there are the preparations are over-tapered to
no movable joints to make ensure that there are no undercuts and
so retention is lost
Fixedmovable All the retainers are major retainers and
Preparations do not need to be parallel to require extensive, destructive prepara-
each other, so divergent abutment teeth tions of the abutment teeth
can be used Has to be cemented in one piece, so
Because preparations do not need to be cementation is difficult
parallel, each preparation can be designed
to be retentive independently of the other Fixedmovable
preparation(s) Length of span limited, particularly with
More conservative of tooth tissue mobile abutment teeth
because preparations for minor retainers More complicated to construct in the
are less destructive than preparations for laboratory than fixedfixed
major retainers Difficult to make temporary bridges
Allows minor movements of teeth The major retainer needs to be able to
Parts can be cemented separately, so provide the support for pontics with
cementation is easy longer spans
Cantilever Cantilever
The most conservative design when only With small bridges the length of span is
one abutment tooth is needed limited to one pontic because of the lever-
If one abutment tooth is used, there is no age forces on the abutment teeth; if more
need to make preparations parallel to each teeth are to be replaced with a cantilever
other; if two or more abutment teeth are bridge, a large number of abutments widely
used, they are adjacent to each other, so it spaced round the arch must be used
is easier to make the preparations parallel The construction of the bridge must be
Construction in the laboratory is rigid to avoid distortion
relatively straightforward Occlusal forces on the pontic of small
Most suitable in replacing anterior teeth posterior bridges encourage tilting of the
where, if the occlusion is favourable, there abutment tooth, particularly if the
is little risk of the abutment tooth tilting. abutment tooth is distal to the pontic and
Easier maintenance and cleaning is already predisposed to tilting mesially.
Types of bridge 207
COMPARISON OF MINIMAL-PREPARATION BRIDGE DESIGNS

ADVANTAGES DISADVANTAGES
Fixedfixed Fixedfixed
A large retentive surface area Because part of the occlusal surfaces of
A single casting and so relatively simple in both abutment teeth are usually opposed
the laboratory by teeth in the opposing jaw, there is a
Can be used to retain post-orthodontic tendency for them to be dislodged from
cases as well as replacing teeth the retainer, thus debonding the bridge.
As the bridge will be retained there is a
Fixedmovable risk of caries developing under the failed
Independent tooth movement is possible, wing
particularly for the minor abutment tooth With tilted abutments it is sometimes diffi-
(with the movable joint). The major cult to achieve an adequate retentive sur-
retainer can be designed for optimum face without substantial tooth preparation
retention, sometimes incorporating intra- The retention of both retainers should be
coronal as well as extra-coronal elements approximately equal. This is difficult to
replacing restorations achieve when one retainer is a molar
The retention of the minor retainer need tooth and the other a premolar
not be substantial, particularly if the movable
joint consists only of a rest seated in a seat Fixedmovable
on the minor retainer. In this case there are Not suitable for anterior bridges
few displacing forces on the minor retainer More difficult to make in the laboratory,
The retention of the two retainers can be requiring two separate castings
very different, usually with the major retainer Not suitable for longer-span bridges,
distally and the smaller, minor retainer where a conventional fixedmovable
attached to a premolar tooth. The retainer bridge would be satisfactory. This is
can be made very small, and its appearance because the movable joint is seldom large
is similar to a small amalgam restoration enough to resist lateral forces on the
Prevents a posterior abutment tooth pontic, but will only resist axial forces by
tilting as is sometimes the case with a means of the rest on the minor retainer
cantilever bridge. The movable joint
merely acts to prevent this rather than to Cantilever
provide any retention for the bridge Relatively small retentive area, and
vulnerable to debonding through torquing
Cantilever forces
The most conservative of all designs, Seating of the bridge may be difficult to
usually only involving a single minimal- ensure on cementation as there may be
preparation retainer little guidance from the tooth preparation
Ideal for replacing upper lateral incisors,
using the canine tooth as the abutment,
provided that the occlusion is favourable
Suitable posteriorly when the span is short
Easy for the patient to clean with floss
passed through the contact point between
the pontic and the unrestored adjacent
tooth
No need to align preparations
Easy laboratory construction
208 Types of bridge
Figure 8.8
a This patient presented with periodontal disease and

gross calculus. As an initial phase in his treatment,
following removal of the calculus, the mobile lower
incisor was splinted to the adjacent teeth with acid-
etch retained composite. However:
b it was decided that the prognosis was hopeless and

the root was resected. This simple and very cost-effec-
tive treatment kept the appearance reasonable while
periodontal treatment continued and the socket
healed. It also kept the longer-term replacement
options open.
Figure 8.9
A Rochette bridge replacing one central incisor. The

porcelain or composite facing is yet to be added to the
pontic. The palatal spur is a handle which will be
removed in due course. Conventional composite is
often used as a luting cement as it is stiff enough to fill
the holes. This design is still used for provisional splints
and bridges because it is less traumatic to remove. The
composite is drilled out of the holes to release the
retention.
An all-metal retainer (a crown or minimum- abutment for a metalceramic crown would be

preparation retainer) towards the posterior end simple and would not require soldering but it
of the bridge with anterior metalceramic units. would be more destructive. Alternatively, the all-
metal retainer can be cast in metalceramic
An example is where a complete all-metal material so the whole casting can be in one piece.
retainer would be ideal for a posterior abutment The solder joint is made in a low-fusing solder
to conserve tooth tissue but the pontics will be after the porcelain has been added, and the bridge
visible and need to be of metalceramic material. cannot be returned to the furnace for further
If the design is fixedmoveable with the moveable adjustments to the porcelain after it has been
joint mesially then the all-metal molar retainer made. Figure 8.7 shows the range of tempera-
will need to be soldered or laser welded to the tures of the various components in the
metal ceramic pontics. Preparing the molar metalceramic system.
Types of bridge 209
Figure 8.10
a A scanning electron micrograph (SEM) of a cast

nickelchromium metal surface grit-blasted with 50 mm
aluminium oxide particles. The surface has no physical
undercuts but is irregular. This is the recommended
metal finish for the chemically adhesive cementing
resins.
b An SEM of a cast nickelchromium metal surface

etched in the laboratory (the Maryland technique). The
surface is very retentive but delicate.
Types of minimum-preparation tooth. This can often be done as a simple and

bridge rapid way of replacing a tooth lost through
injury (which cannot be reimplanted) or which
Direct bridges (Figure 8.8). These may be has to be extracted urgently. Sometimes metal
made using the crown of the patients own mesh or wire is added to the lingual surface to
210 Types of bridge
increase strength, but this is not always neces- Advantages of minimum-preparation

sary. If the natural crown of the tooth is not bridges in general
available or is not suitable, an acrylic denture
tooth can be used in the same way. The pulp is not put at risk from the preparation.
Macro-mechanically retentive bridges. The technique is mostly reversible and if the
The earliest version of the minimum-prepara- bridge eventually fails it is possible to proceed
tion bridge was known as the Rochette bridge with alternative ways of replacing the missing
after its developer who, in fact, developed the tooth.
technique for periodontal splinting. They are Temporary restorations are not required.
still sometimes used for this purpose because The technique is generally less expensive than
they are less retentive than newer types of conventional bridges.
minimum-preparation bridge and so can be
removed more readily. In other words they are
used for provisional restorations and no longer Disadvantages of minimum-
made for permanent use. They have large preparation bridges in general
undercut perforations through the cast metal
plate, through which the luting composite As the metal plate is added to the surface of
flows. These holes are cut in the wax or acrylic the tooth or only replaces part of it, the thick-
pattern with a bur and are then countersunk ness of the tooth is increased, and may (for
(Figure 8.9). example in a normal Class I incisor relation-
From the time of Rochette to the present ship) interfere with the occlusion unless space
day there have been a series of techniques is created orthodontically or by grinding the
developed. The best known of these was the opposing teeth (see Chapter 11).
Maryland technique (developed at the The margin of the retainer inevitably produces
University of Maryland) involving etching the a ledge where plaque can collect. This is a
non-precious metal surface either electronically problem, especially in the replacement of lower
or with hydrofluoric acid. These techniques incisors. Here plaque and calculus deposits are
have now been superseded. The term common on the lingual surface towards the
Maryland bridge should therefore not be used gingival margin, and the presence of such a
as it is inaccurate for the modern type of ledge can only make it more difficult for the
minimum-preparation bridge. patient to clean in this area.
Chemically adhesive (resin-retained) It is difficult to predict the longevity of mini-
bridges. With current techniques the non- mum preparation bridges and clinical studies
precious metal surface is simply grit-blasted generally agree that although success rates are
(sandblasted), preferably immediately before improving, in some patients their outcome is
bonding (Figure 8.10a). A comparison with the poor. Patients can be provided with spare
etched (Maryland) metal surface, at the same dentures in case the bridge should become
magnification is shown in Figure 8.10b. The dislodged. Minimum preparation bridges can
chemically active resin cement chemically usually be re-cemented if they de-bond but
bonds to the metal and the resin component patients will understandably lose faith in the
micro-mechanically bonds to the roughened bridge if this should happen regularly and alter-
metal and the etched enamel surface. native treatment should be considered.
9 Components of
bridges: retainers,
pontics and
connectors
Each part of the bridge should be designed where the occlusion is favourable (Figure 8.3c
individually, but within the context of the overall and d).
design. This chapter should therefore be read in
conjunction with the next, since in practice the
two processes designing the bridge and its
Complete crown (full crown), partial
components are done together, although it is
crown, intracoronal or minimum-
clearer to describe them separately.
preparation retainers?
The choice between complete and partial crown
Retainers retainers for posterior conventional bridges should
always be considered and will depend upon a full
Major or minor assessment of all the circumstances of the case. It
should not be made from habit. It will be found that
As described in Chapter 8, all fixedfixed and even after a full assessment, 8090% of conven-
cantilever bridges have only major retainers. tional bridge retainers will be full crowns, but for
Fixedmovable bridges have a major retainer at the remaining 1020% there are sound reasons for
one end of the pontic and a minor retainer choosing a partial crown. (See Chapter 2 for a
(carrying the movable joint) at the other. comparison of complete and partial crowns.)
Major retainer preparations must be retentive Intracoronal retainers are used only as minor
and, with conventional bridges, must cover the retainers except for very retentive MOD
whole occluding surface of the tooth. It is impor- protected cusp inlays/onlays.
tant to recognise the difference between the With the reduction in caries and with a more
occluding and the occlusal surface. conservative approach to cavity preparation, an
increasing number of potential abutment teeth
A major retainer for a conventional posterior have sufficient enamel available for minimum-
bridge should not be less than an MOD inlay with preparation retainers to be considered. When
full occlusal protection. For incisor teeth it is this is so, they are usually the retainers of choice,
usually a complete crown. provided that the other conditions for their use
are met (see later). This is because they are the
Minor retainers do not need full occlusal most conservative retainers, and it is wise to
protection: a minor retainer may be a complete preserve as much natural tooth tissue as possible.
or partial crown, or a two- or three-surface inlay When an anterior tooth is intact a minimum-
without full occlusal protection (Figures 8.1b and preparation retainer is more conservative of
8.3). Minimum-preparation minor retainers are tooth tissue than a complete crown, and so is the
also used for minimum-preparation bridges preferred choice whenever possible.
211
212 Components of bridges: retainers, pontics and connectors
Materials Figure 9.1b shows an example of where a distal-

palatal inlay would produce the best appearance.
Minimum-preparation retainers are usually made Figure 9.1c also shows an example of metal shine-
in base metal alloys because they are strong in through, which sometimes occurs with minimum-
thin sections and they bond well to adhesive preparation retainers.
luting resins when they are freshly grit-blasted. Of When several teeth are to be crowned or
the conventional retainers, an all-metal retainer is replaced as pontics, there is an aesthetic advan-
the most conservative of tooth tissue, and the tage to the bridge retainers and pontics being
simplest and usually the least expensive to made in the same material (usually metal
produce. When appearance permits, this should ceramic), giving consistency of appearance.
be used in the posterior part of the mouth. In the
anterior part of the mouth metalceramic is the
most suitable material. The condition of the abutment tooth
Frequently a minimum-preparation or partial
crown retainer cannot be used because of the
Criteria for choosing a suitable presence of caries or large restorations involving
retainer the buccal surface, or because of the loss of the
buccal surface from trauma or other cause. In
In some cases the type of retainer will be obvious. these cases a complete crown retainer is chosen.
For example, if a root-filled tooth that already has
a post crown is to be used as a bridge abutment,
there is little choice but to use another post- Conservation of tooth tissue
retained crown, whether as a major or minor
retainer. In other cases, the full range of choice There is a natural reluctance to remove sound
is available, and the decision on the type of buccal enamel and dentine from a healthy intact
retainer cannot be divorced from the decisions tooth. This weakens the tooth, destroys its
on the overall design and which abutment teeth natural appearance and sometimes endangers the
to use. These three sets of considerations are pulp. Therefore minimum-preparation retainers
dealt with separately (in Chapters 8, 10 and here), should be used whenever possible. However, if
but in reality the decision-making process is not there are sound indications for a complete crown,
so clear-cut, and thoughts on possible abutment the operator should not allow his or her clinical
teeth, retainers and the overall design intermingle judgement to be influenced by an overprotective
in the operators mind and influence each other attitude to dental enamel.
until a final decision on all three emerges.
The criteria for selecting a particular retainer
will include: Alignment of abutment teeth and
retention
Appearance
Condition of abutment teeth When the abutment teeth are more or less paral-
Conservation of tooth lel to each other and a fixedfixed conventional
Alignment of abutment teeth and retention bridge is being considered, complete crown
tissue retainers can be made. If the abutment teeth are
Occlusion not parallel (Figure 9.2), complete crown retain-
Cost ers with a common path of insertion are not
feasible. They could not be made independently
retentive without one or other of the teeth being
devitalized.
Appearance The solution will usually be to employ a
In some cases a complete crown will have a better minimum-preparation bridge or a design other
appearance than a minimum-preparation retainer. than fixedfixed so that the teeth do not have to
Sometimes neither will be completely satisfactory. be prepared parallel to each other.
Components of bridges: retainers, pontics and connectors 213
Figure 9.1
The appearance of retainers.
a The canine tooth has a partial crown retainer that is

barely visible from the front. The bridge has been
present for many years.
b The upper canine tooth has an extensive incisal wear

facet and pronounced buccal striae. The buccal surface
would be difficult to reproduce in porcelain if a
complete crown retainer were used and the occlusion
was unfavourable for a minimum-preparation bridge.
The design of the bridge in this case was therefore
fixedmovable with a distal-palatal gold inlay in the
canine tooth. An implant could also be considered.
c The upper central incisors both have minimum-

preparation retainers. Blue metal shine-through can be
seen. The incisal edge of the upper left central incisor
has been restored with composite, which is beginning
to lose its polish. Metal shine-through can be reduced
by finishing the retainer short of the incisal edge, but
this also reduces its retention. The problem can be
minimized by using opaque luting cements.
Figure 9.2
Non-parallel abutment teeth. It would not be possible

to make a conventional fixedfixed bridge with
complete crowns on the central incisor and canine,
although it would be possible to make a minimum-
preparation bridge. As the canine and central incisors
are all intact the design of choice would be two
separate minimum-preparation cantilever bridges; one
retained by the canine and the other retained by the
two central incisors splinted together, or perhaps just
one central incisor depending on the occlusion and
periodontal health. This would be comparable to the
bridges shown in Figure 7.1c and d.
It is impossible to give in absolute terms the The compromise often necessary between cleans-
amount of retention necessary for any one ability and appearance will also vary in different
retainer. It is reasonable to assume that the reten- parts of the mouth.
tion for a bridge retainer should be at least as great
as for a similar restoration made as a single unit.
Cleansability
Occlusion All surfaces of the pontic, especially the surface
adjacent to the saddle, should be made as cleans-
In some cases the abutment teeth are sound but able as possible. This means that they must be
there is insufficient space for a minimum-prep- smooth and highly polished or glazed, and should
aration retainer. The choice therefore is between not contain any junctions between different
creating space by reducing the opposing teeth, materials. In a metalceramic pontic the junction
preparing part way through the enamel of the between the two materials should be well away
abutment teeth, moving the abutment teeth from the ridge surface of the pontic.
orthodontically or a combination of these It is important too that the embrasure spaces
approaches. Often the best way to achieve a small and connectors should be smooth and cleansable.
amount of axial tooth movement is to use a fixed They should also be as easy to clean as possible.
Dahl appliance (Figure 4.6). If none of these Access to them and the patients dexterity should
methods are acceptable then a conventional be taken into account in designing pontics.
retainer will be necessary. When a conflict exists between cleansability
and appearance, priority should be given to
cleansability.
Cost
Complete metal crowns and partial crowns may
be less expensive than metalceramic crowns Appearance
(see Chapter 2), and minimum-preparation retain-
ers are the least expensive. When there are no Where the full length of the pontic is visible, it
other overriding factors affecting the choice, this must look as tooth-like as possible. However, in
is obviously important. the premolar and first molar region it is often
possible to strike a happy compromise between
a reasonable appearance for those parts of the
pontic that are visible and good access for clean-
Pontics ing towards the ridge.
Principles of design
Strength
Pontics are designed to serve the three main
functions of a bridge: All pontics should be designed to withstand
occlusal forces, but porcelain pontics in the
To restore the appearance anterior part of the mouth may not of course be
To stabilize the occlusion expected to withstand accidental traumatic
To improve masticatory function. forces.
The longer the span, the greater the occlusal
In different areas of the mouth the relative impor- gingival thickness of the pontic should be.
tance of these will alter. The principles guiding the Metalceramic pontics are stiffer and withstand
design of the pontic are: occlusal forces better if they are made fairly thick
and if the porcelain is carried right round them
Cleansability from the occlusal to the ridge surface, leaving
Appearance only a line of metal visible on the lingual surface
Strength. or none at all (Figure 9.3a and b).
Figure 9.3
The strength of metalceramic pontics.
a The central incisor pontics in this case have no metal

visible on the palatal surface.
b When the palatal reduction of the abutment teeth is

only sufficient for a layer of metal, this is often carried
along the pontics as well, leaving an occluding surface
entirely in metal. The porcelain, however, is carried
right under the pontics so that only porcelain contacts
the ridge.
The surfaces of a pontic is required for functional purposes rather than

appearance and is most useful in the lower molar
A pontic has five surfaces: region.
The ridge
The occlusal Dome-shaped (Figure 9.4b and c)
The approximal
The buccal or labial This is the next easiest to clean and is used where
The lingual or palatal. the occlusal two-thirds or so of the buccal surface
of the pontic show, but not the gingival third. It
Some of these will be similar to the natural tooth is commonly used in the lower incisor and
being replaced; others will be very different. premolar regions and sometimes in the upper
molar region.
This has also been described as torpedo-shaped
or bullet-shaped, but the less aggressive term,
The ridge surface dome-shaped, is preferred.
This surface of the pontic is the most difficult to

clean, and yet it also has a considerable influence Ridge-lap and modified ridge-lap (Figure
on appearance. There are four basic designs of 9.4d, e and f)
ridge surface (Figures 9.4 and 9.5).
The principles of this design are that the buccal
surface should look as much like a tooth as poss-
ible right up to the ridge, but the lingual surface
Wash-through (Figure 9.4a)
should be cut away to provide access for clean-
Other terms used for this type of pontic are ing. Ideally the pontic should have a completely
hygienic and sanitary, but the term wash-through convex lingual surface, making only a line contact
is more descriptive and less suggestive of vitre- along the buccal side of the ridge. However, this
ous china bathroom fittings. The wash-through is often impractical because of the shape of the
pontic makes no contact with the soft tissues and ridge, and so the modified ridge-lap pontic, which
so is the easiest to clean. It is used where a pontic has minimum contact with the ridge from the
Figure 9.4
The four designs of pontic ridge surface.
a A wash-through pontic with a concave mesio-distal

contour.
b and c Dome-shaped pontics. b A molar dome-shaped

pontic with the male part of a movable connector and
a lingual handle which will be removed after the bridge
is tried in. c An acrylic provisional bridge fitted as an
immediate replacement for the lower left central and
lateral incisors, showing an application of the dome-
shaped pontic.
d and e Ridge-lap pontics. d This bridge has been satis-

factory, but the patient complains of food impaction
under the single lateral incisor pontic. She can sweep
the other side clean with her tongue since the span is
longer. e A modified ridge-lap pontic with contact over
the buccal half of the ridge but cut away lingually. The
bridge has failed because of a fractured solder joint (see
Chapter 14).
f Typical ridge-lap pontics on another failed bridge.

This time the failure was due to loss of retention.
Despite the design and the smooth porcelain surface,
the ridge beneath these pontics was moderately
inflamed.
g Saddle-shaped pontics with well-contoured, cleans-

able connectors
point of contact on the buccal side up the crest, contact and must be removed in all cases, the
is often used (Figure 9.4e). emphasis in pontic design has shifted. Accessibility
These designs, particularly if the pontic is fairly for cleaning and patient comfort and convenience
narrow mesio-distally, as in the case of an incisor are the important criteria, rather than the size of
or premolar pontic, are sometimes unpopular area of contact. Many patients prefer the saddle-
with patients because they find that food impacts shaped pontic since the lingual surface feels more
into the space on the lingual side and cannot be like a tooth than any other design. With modern
readily removed with the tongue (Figure 9.4d). cleaning aids, such as superfloss, the ridge surface
Besides, considerable manual dexterity is needed of properly designed and constructed saddle
to manoeuvre dental floss, tape or other cleaning pontics is relatively easy to clean. This also
aid, holding it first against the pontic and then in requires less manual dexterity by the patient than
a secondary cleaning movement against the ridge ridge-lap pontics (Figure 9.5d).
(Figure 9.5). A saddle pontic should closely follow the
These pontics were designed at a time when contour of the ridge but should be smooth on
there was a lot of concern about the effect of the under surface. It should not displace the soft
pontics on the soft tissues but before the signifi- tissues or cause blanching when it is inserted, but
cance and nature of plaque were as well under- should make snug contact.
stood as they are today. They are still commonly
used, perhaps through habit and convention.
Other designs should also be considered and are
often better. The effects of pontics on the ridge
Sometimes when bridges are removed the area
Saddle of the ridge that was in contact with the pontic
has a red appearance. Biopsy studies have shown
The saddle pontic is so named because of its that there are always some chronic inflammatory
shape. It has by far the largest area of surface cells in this region, but the main explanation for
contact with soft tissue, and so, although it was the redness is probably the reduction in
popular in the early days of bridgework, it keratinization. The surface does not have the
became much less so as dentists became more normal stimulation from food and the tongue that
concerned about the effects of pontics on ridges. stimulates keratinization elsewhere. Unless clearly
Now that it is recognised that plaque can cause inflamed or ulcerated, the redness is of little clini-
inflammation however small the surface area of cal consequence (Figure 9.6).
a b
c d
Figure 9.5
Four sectioned casts of the same patient, showing the profile of the midpoint of a lower molar edentulous area
where a bridge is to be made. The profiles of four pontics are shown.
a A wash-through pontic with no contact with the ridge very cleansable but poor appearance.
b A dome pontic making point contact on the tip of the ridge still cleansable and with a better appearance
buccally towards the occlusal surface.
c A partly modified ridge-lap pontic with a buccal surface resembling a natural tooth but with minimum ridge
contact. The difficulty of cleaning the lingual aspect near the ridge is obvious.
d A full saddle pontic that, if well polished or glazed on the gingival surface, would be cleansable with superfloss.
This design has the best appearance and feels more natural to the tongue.
Figure 9.6
a Mucous membrane reactions under pontics. This area

of reduced keratinization under a pontic produced no
symptoms. There was no ulceration or bleeding on floss-
ing under the pontic. Although inflammation requiring
treatment at the gingival margin of the abutment teeth
is present, it is doubtful whether the changes in the
remainder of the ridge have had any real significance.
b A much more serious case, with ulceration and a

very inflamed mass of granulation tissue. This must
clearly be treated in the first place by removal of the
bridge. In fact no further treatment was necessary. The
inflammation resolved over a 3-week period.
Figure 9.7
Well-contoured open embrasure spaces.
Figure 9.8
Sections through both the lateral incisor areas of the

same patient. Left: the lateral incisor is present. Right:
it is missing and the alveolus has resorbed. The profile
of the resorbed side has been superimposed on the
other to show the extent of the resorption and three
ways in which a pontic might be modified to overcome
this problem.
Figure 9.9
Buccal ponticridge relationships.
a A pontic replacing an upper canine, where the neck

of the pontic has been curved inwards to meet the
resorbed alveolar ridge at the correct vertical position.
The incisal two-thirds of the buccal surface have been
contoured in line with the adjacent teeth so that all the
compensation for the missing alveolar bone is in the
gingival buccal third. (Note the excessive amount of
gold shown by these two partial crowns, in contrast
with those in Figure 9.7.)
b The same compromise has not been made with this

lower premolar pontic, which instead looks too long.
This would also create difficulty in cleaning under the
pontic.
The occlusal surface connector and the gingival tissue be as open as

possible to ensure that there is good access for
The occlusal surface of the pontic should resem- cleaning, particularly if the pontic is a ridge-lap or
ble the occlusal surface of the tooth it replaces. saddle pontic (Figure 9.7). The gingival side of a
Otherwise it will not serve the same occlusal movable joint is more difficult to leave entirely
functions and may not provide sufficient contacts smooth, and so it is again important that there
to stabilize the occlusal relationships of its should be good access for cleaning. A balance has
opponents. to be achieved to ensure that there is adequate
In some cases, when occlusal stability is less metal present to provide sufficient strength and
important (for example when the pontic is rigidity for the connector as well as allowing open
opposed by another bridge), the pontic may be embrasures for cleaning.
made narrower bucco-lingually to improve access The approximal surface of a cantilever bridge
for cleaning. Other arguments for narrowing on its free side will simply make normal contact
pontics are less convincing (see Chapter 10). with the adjacent tooth, or in some cases there
may be a diastema with no contact. Occasionally,
where the span is very short, a cantilever pontic
may be made to overlap the adjacent tooth to
The approximal surfaces improve its appearance. In this case the pontic
surface in contact with the natural tooth should
The shape of the mesial and distal surfaces of the be as smooth as possible, although it may be
pontic will depend upon the design. With slightly concave. If the patient is taught to clean
fixedfixed bridges the approximal surface will with dental floss, the natural tooth surface should
consist partly of a fixed connector. It is impor- not be any more susceptible to caries than with
tant that the embrasure space between the a normal contact point.
Figure 9.10
An acceptable appearance for a bridge or is there

more than one bridge?
The buccal and lingual surfaces number of proprietary pontic facings. These have
not been used for many years but some patients,
The buccal surface of a wash-through or dome- with long-standing bridges, still have proprietary
shaped pontic does not resemble the shape of a pontic facings. They are easy to recognise in
natural buccal surface, particularly gingivally. With contrast to metalceramic pontics.
ridge-lap and saddle pontics the buccal surface is
intended to look as much like a tooth as possible
for its entire length. The problem is that when a
tooth is missing, so also is some of the alveolar Connectors
bone that supported it. This means that the alveo-
lar contour where the pontic touches the ridge Fixed connectors
never looks entirely natural, and the pontic must
also be shaped unnaturally to meet the resorbed There are three types of fixed connector:
ridge. Figure 9.8 shows, by means of sections
through a study cast, how the ridge contour in a Cast
resorbed saddle area necessitates a compromise Soldered or laser welded
pontic appearance. Figure 9.9a shows an example Porcelain.
of this where an upper canine is missing. Figure
9.9b also shows an example of a case in which Cast connectors are made by wax patterns of
this compromise has not been made. The the retainers and pontics connected by wax being
aesthetic result is not good and there is greater produced so that the bridge is cast in a single
difficulty than necessary in cleaning. piece. This has the advantage that a second
No ridgepontic relationship can ever appear soldering operation is not required. But the more
entirely natural, even when the ridge has not units there are in the bridge, the more accurate
resorbed significantly or where it has been the casting must be. Minor discrepancies in the
augmented see Figure 7.9. But at the normal compensation for the contraction of molten
distance from which teeth are seen, the illusion metal that may be acceptable for single-unit
that the tooth emerges from the gum can be suffi- casting become unacceptable when magnified
ciently convincing: which are the pontics and several times.
which are the retainers in Figure 9.10? Cast connectors are stronger than soldered
The lingual surface of a pontic will be designed connectors, and also it is sometimes possible to
as a result of deciding the ridge surface. With disguise their appearance more effectively. For
ridge-lap pontics, the lingual surface should be these reasons, multiple-unit bridges are often cast
smooth and convex. in several sections of three of four units divided
through the middle of a pontic. The split pontics
are then soldered with high-fusing solder before
Materials the porcelain is added, so that all the connectors
are cast. The solder joint produced in this way is
The choice for pontics is the same as for retain- strong both because it has a larger surface area
ers. At one time there was also the choice of a than if it were at the connector and because it is
Figure 9.11
Creating a fixedfixed design with non-parallel

abutments.
a The central incisor could not be retracted sufficiently

to be parallel to the other abutment teeth even if
devitalized and with a post and core fitted. It would
interfere with the occlusion.
b and c The bridge is made in two parts with separate

paths of insertion, and the divided pontic connected in
the mouth by cement and a screw attachment.
covered by porcelain, stiffening it. Laser welding separately. This is necessary when they are made
is an increasingly popular way of linking compo- of different materials, for example a complete
nents of bridges together. The welds achieved are gold crown retainer with a metalceramic pontic.
stronger than soldering and the technique is quick
and simple, although the equipment required is Porcelain connectors are used only in conjunc-
complex and expensive. tion with all-porcelain bridges. The details of their
construction are beyond the scope of this book,
Soldered or laser welded connectors are but the same principles of accessibility and cleans-
used if the pontics and retainers have to be made ability still apply.
Movable connectors in the wax, the retainer is cast and with a groove,
the shape is refined with a tapered bur. The
Movable connectors are always designed so that pontic is then waxed-up with a finger or ridge to
the pontic cannot be depressed by occlusal fit into the depression or groove. This is cast and
forces. This means that the groove or depression the two parts of the movable joint are fitted
in the minor retainer must always have a good together before the bridge is taken to the chair
base against which the male part of the attach- side for trying in (Figure 8.3a).
ment can seat. Sometimes, with small pontics and In some cases a depression or groove may be
short spans, this is the only force that needs to prepared in an existing cast restoration in the
be resisted, and therefore the female part of the mouth and an impression taken of it together
attachment, in the minor retainer, need only be with the other prepared abutment tooth or
a shallow depression (Figure 8.3c). This is the teeth.
commonest design for fixedmovable minimum- Acrylic burn out patterns are available that may
preparation bridges. be incorporated into the pontic and minor
However, with longer-span bridges the retainer so that the whole bridge can be waxed-
movable joint must also resist lateral forces up in one operation and the minor retainer and
applied to the pontic and (assuming the movable remainder of the bridge invested and cast
joint is mesial) distal forces on the pontic, which separately (Figure 8.3b, page 200).
would separate the components of the movable Proprietary groove-and-ridge precision attach-
connector. In these circumstances the connector ments in metal may also be used as movable
is designed as a tapered dovetail-shaped slot so connectors, but are generally too retentive and
that the pin can move up and down a little and there is the risk that they will not permit suffi-
yet seat firmly against the base of the slot, but it cient movement. When precision attachments are
cannot move laterally and the connector cannot used, the minor retainer should have more reten-
separate. Examples of this type of connector are tion to its abutment than would be necessary if a
shown in Figure 8.3. less retentive connector were used.
There are different ways of producing movable Screw precision attachment connectors may be
connectors. In the freehand method a wax used to produce a fixedfixed bridge by connect-
pattern is produced for the minor retainer with ing two retainers that cannot be prepared paral-
a shallow depression or tapered groove prepared lel to each other (Figure 9.11).
7 Indications for
bridges compared
with partial
dentures and
implant-retained
prostheses
The number of bridges made in the UK National ent things. The word bridge itself is used in the
Health Service (NHS) increased nearly 20-fold in UK to describe a fixed appliance only, whereas in
the decade between 1980 and 1990. Since then parts of the world it also includes certain tooth-
the numbers have fallen although the average borne removable appliances.
dentist working in the NHS still makes 34 bridges The following names will be used for the
a year. Evidence from Commercial Dental various appliances. The terms in parentheses are
Laboratories shows that there is considerable those commonly used in the USA, although
growth in the number of bridges being made American terminology is rather variable.
privately, although detailed national figures are
not available. It is probable that the overall A conventional bridge (fixed partial
number of bridges being made is still rising. Large denture) is an appliance replacing one or more
increases are also reported in many other teeth that cannot be removed by the patient
countries. (Figure 7.1a). The general term fixed bridge is
Clinical experience suggests that patients who, avoided since it implies one of the specific
in the past, would have been prepared to wear a designs of bridge (see Chapter 8). Substantial
small partial denture are now reluctant to do so tooth preparation is necessary for a conven-
and ask for a bridge or implant-supported prosthe- tional bridge. The bridge usually occupies no
sis. Implants are not available under the General more space than the original dentition.
Dental Services of the NHS and are generally more A minimum-preparation bridge (resin-
expensive than bridges. The result is that at bonded bridge, adhesive bridge,
present in the UK many more bridges are being Maryland bridge) is attached to the surface
made than implant-supported prostheses. of minimally prepared (or unprepared) natural
teeth and therefore occupies more space than
the original dentition (Figure 7.1b).
A removable bridge is very much the same
General terminology as a bridge in that it is retained by crowns, is
entirely tooth-supported, does not replace soft
The terminology used for bridges is sometimes tissue and, unless it is examined closely,
rather loosely applied, and in different parts of the appears to be the same as a bridge. However,
world the same terms are used to describe differ- it can be removed by the patient (Figure 7.2).
177
178 Indications for bridges compared with partial dentures and implant-retained prostheses
Figure 7.1
Bridges.
a A conventional bridge replacing the upper right
lateral incisor with a single artificial premolar tooth
filling the space between the canine and first molar
teeth. The bridge has just been cemented. The gingival
condition around the molar abutment is good, but
around the canine it is inflamed buccally as a result of
irritation from a broken temporary bridge in this area.
b and c A cantilever minimum-preparation bridge

replacing a central incisor tooth.
d and e Two separate minimum-preparation cantilever

bridges replacing two lower incisor teeth. One is
supported by the canine and the other by the two
remaining incisors splinted together. This design is
likely to have a much better prognosis than a
fixedfixed design which would not allow any
movement of the abutment teeth. The bridges had
been in place for 9 years when this photograph was
taken.
Indications for bridges compared with partial dentures and implant-retained prostheses 179
Figure 7.2
A removable bridge.
a Cast copings permanently cemented to the remain-

ing teeth. The external surfaces of these are milled
parallel to each other in the laboratory.
b The removable bridge, which the patient can take

out himself.
Figure 7.3
Partial dentures.
a A precision-attachment retained partial denture. In

this case the two premolar teeth on the right of the
picture are splinted together and an intra-coronal
precision attachment is incorporated into the distal
surface of the second premolar. The first molar on the
left is an artificial tooth part of a bridge and it too
contains a precision attachment. The partial denture
retained by these two attachments can be removed by
the patient.
b A conventional cobalt-chromium partial upper

denture that is tooth-supported with rests, clasps and
a major palatal connector. None of the metal work is
visible from the front of the mouth.
Figure 7.4
a A cross-section through a typical implant. Systems vary and so this

one will not be described in detail but it is typical in having four
elements: from the top down the coarsely threaded screw is the
implant which is screwed into a tapped hole in the bone and then
covered to osseo-integrate; the transmucosal abutment is smooth-
sided and retained into the osseo-integrated fixture by the middle-
sized screw; the small screw at the bottom holds the restoration (the
prosthetic elements) to the implant. There is now a wide range of
prosthetic elements which will not be described here.
b, c and d A single tooth implant replacing the upper

right lateral incisor.
b Shows the stage after the second surgical procedure

to expose the fixture and to place the healing
abutment. The healing abutment is in place and the
incision line mesial and distal to it can still be seen.
c The healing abutment has been replaced by the trans-

mucosal abutment (TMA).
d A crown has been fitted to the TMA.
e Four fixtures in the lower jaw.
f A three-unit bridge has been attached to the three

implants on the left and on the right, a three-unit
cantilever bridge retained by the natural canine tooth
and the implant has been extended with a cantilever
premolar pontic.
g A three unit bridge retained by two fixtures showing

the screws which can be undone if necessary by the
dentist. These are covered with composite until it is
necessary to gain access to the screws.
A partial denture may be rested entirely on General advantages and

teeth, or be supported by the soft tissues, or disadvantages of replacing missing
by a combination of both. Rest seats are
commonly used, but otherwise it is usually not teeth
necessary to prepare the natural teeth exten-
sively. Partial dentures are retained by clasps, It is not always necessary to replace missing
by adhesion to the soft tissues, or by dental or teeth, and in some cases there are positive disad-
soft tissue undercuts (Figure 7.3b). vantages in doing so. At one time there was a
A precision-attachment partial denture is rather naive, simplistic view that the mouth was
retained by proprietary attachments and is a functioning machine and that if part of it was
removable by the patient. Soft tissue elements missing, it was rather like a tooth or teeth missing
are replaced and the appliance usually has from a cogwheel in a piece of machinery such as
structures that pass across the oral tissues, for a car gearbox. This is not the case because the
example across the palate or around the lingual human body is much more adaptable and flexible
alveolus. Natural teeth have to be prepared than machinery engineered by man. In fact there
and crowns or other restorations made for is reasonably good evidence that, with a modern
them, incorporating part of the precision diet, it is perfectly possible to function with no
attachment (Figure 7.3a). molar teeth at all provided that the first and
An implant-retained prosthesis is one second premolar teeth and incisors are all
retained by osseo-integrated implants (see Figure present in the upper and lower jaws and are in
7.4a). A single implant may support a single tooth occlusion. This has become known as the short-
prosthesis (Figure 7.4b, c and d) or a series of ened dental arch. Some patients cope very well
implants may support a prosthesis replacing a with this but others feel that they cannot eat
number of teeth. This is usually known as an properly or are concerned about the appearance
implant-supported bridge. The patient cannot of the space behind the premolar teeth. With a
remove it, but in some cases the dentist can, by shortened dental arch it is important that all the
undoing the screws holding the prosthesis to the remaining teeth have good occlusal contact, or
implants (Figure 7.4e, f and g). Implant-supported over-eruption and tilting will occur.
bridges may be small, replacing only one or two Despite this evidence, many patients would
teeth, or may be larger, including replacing all the prefer to have at least some of their missing teeth
teeth in one arch. Implants may also be used to replaced. It is the dentists role, as a professional
support a bar (or other attachments) on to adviser, to advise the patient whether or not it is
which a removable complete overdenture can be really in their best interest to have a tooth or teeth
clipped. Overdentures are beyond the scope of replaced. In some cases it is wise for a dentist to
this book. refuse to replace missing teeth, particularly by
means that are likely to give rise to problems
The term fixture is sometimes used to describe elsewhere in the mouth, or if the prosthesis has a
the osseointegrated part of the implant, but is poor prognosis, even if the patient attempts to
also sometimes used to describe the whole insist that a replacement should be made. This is
implant assembly. It is helpful to use the follow- primarily for the patients benefit but also for the
ing terms: dentists. There have been a number of dento-legal
cases in which dentists have been successfully sued
Implant to describe the part that osseointe- for making prostheses, particularly bridges and
grates and that is buried beneath the gingival implant-retained prostheses, when it was against
tissues (in most systems) for a period of the dentists better judgement and the prosthesis
months before exposing it and inserting the has subsequently failed.
Transmucosal abutment (TMA), which is The first big decision that therefore must be
the part of the implant that attaches to the made jointly by the dentist and patient is should
fixture and passes through the gingival tissues the missing tooth/teeth be replaced or not?
to the mouth. To this, is attached the It is necessary for both the dentist and the
Restoration which replaces the missing tooth patient and in some cases a third party finan-
or teeth. cially involved with the transaction to be
convinced that the replacement will produce how essential it was before a decision is made
significantly more benefit than harm. The follow- regarding its replacement.
ing questions must be asked:
How will the patients general or dental well-

Occlusal stability
being be improved by the replacement?
What disadvantages will the replacement This was discussed in Chapter 4, where it was
bring with it? also made clear that in many cases although
What is the ratio of these advantages and occlusal stability is lost initially when teeth are
disadvantages? extracted tilting and over-eruption usually
If the balance is strongly in favour of replace- eventually lead to an occlusal relationship that,
ment, should the replacement be by means of: although it may not be ideal and may contain
A bridge occlusal interferences, is nevertheless stable. If
A partial denture the missing teeth can be replaced before the
A removable bridge tooth movements occur and when tooth
An implant-retained prosthesis. movements are likely, this may well be sufficient
(Of these, a bridge or a partial denture are by justification for the replacement. In many cases,
far the most common.) however, the patient is first seen some years after
the extraction and has a new stable relationship.
Replacement of the missing teeth would therefore
not improve the stability and so is not justified
Advantages of replacing missing teeth (see Figure 7.14). Special occlusal considerations
are discussed under orthodontic retention and
Appearance alterations to the OVD (see later).
For many patients with teeth missing in the

anterior part of the mouth, appearance is an
overriding consideration. For them a replacement Other advantages
is certainly necessary. Just as with crowns, it is
also necessary to judge the appearance of gaps The three advantages listed above are by far the
further back in the mouth, taking account of the most common indications for replacing missing
anatomy and movement of the patients mouth. teeth. The following, though less common, can be
extremely important for individual patients:
Ability to eat Speech Patients concerned about the quality of

their speech are usually also concerned about
Many patients manage to eat quite successfully their appearance. The upper incisor teeth are the
with large numbers of teeth missing. Patients with most important in modifying speech, and so when
no lower molar teeth who are fitted with well- they are missing they will usually be replaced to
designed and well-constructed partial lower improve both speech and appearance.
dentures frequently leave them out because they
claim that it is easier to eat without them. Some Periodontal splinting Following the successful
patients, though, have a genuine and persistent treatment of advanced periodontal disease, it may
feeling of awkwardness if they are deprived of be necessary to splint uncomfortably mobile
even one posterior tooth. As with appearance, teeth. In order to produce a cross-arch splinting
the patients concept of the problem is as impor- effect it is necessary to bridge any gaps to provide
tant in deciding on a replacement as the problem a continuous splint whether or not there are
itself. Generally though, the more teeth that are any other indications for replacing the missing
missing, the more important is a replacement. If teeth (Figure 7.5).
a posterior tooth is to be lost it is generally sens-
ible for the patient to live with the space for A feeling of completeness Some patients
several months following extraction to determine believe, or have been told, that there is a major
Figure 7.5
a A 12-unit bridge supported by 6 teeth with consid-

erably reduced periodontal support. Several teeth were
uncomfortably mobile before the provisional bridge
was fitted. The patient was able to maintain good oral
hygiene following periodontal therapy, and the provi-
sional bridge was replaced after a year by this perma-
nent bridge. The patient understood the reasons for
the visible supragingival margins and accepted them.
The bridge lasted just over 20 years before it had to
be removed and the abutment teeth extracted.
b Radiographs of the three abutment teeth on the left-

hand side for the patient shown in a at the time the
bridge was fitted.
disadvantage to having teeth missing, even when Orthodontic retention is a special example of
they have no problems with appearance, eating or an indication for tooth replacement for reasons
occlusal stability. These patients appear to receive of occlusal stability. In almost all patients who
considerable comfort from a bridge less from a have taken the trouble to have orthodontic treat-
removable appliance. This feeling should not be ment, appearance will also be important.
discounted if it is held with conviction, even
though the dentist may not be equally convinced Restoring occlusal vertical dimension
of the benefits of a bridge. However, such (OVD) Occlusal collapse with excessive wear or
attitudes should not be encouraged. drifting of the incisor teeth sometimes follows the
loss of a number of posterior teeth. This is a diffi-
Orthodontic retention Most orthodontic cult problem to treat, but in some cases the
treatment is stable, but it is occasionally neces- posterior teeth are replaced by bridges, remov-
sary to provide a bridge partly to maintain an able dentures or implants that not only replace
orthodontic result. A common example is in the missing teeth but restore the lost OVD,
cases where the lateral incisors are congenitally creating space for the upper incisors to be
missing and the upper canines have been retracted or crowned as necessary.
retracted to recreate space for them. The main
reason for replacing the missing lateral incisors is, Wind-instrument players Players of brass or
of course, appearance, but a second reason is to reed instruments contract the oral musculature
prevent the canine teeth relapsing forwards again, to form what is known as the embouchure. This
and so the bridges must be designed to serve this allows for the proper supply of air to the instru-
purpose. The resulting appearance is usually ment. Even minor variations in the shape of the
better than attempts at converting the appear- teeth can affect the embouchure, and missing
ance of the canines to lateral incisors. teeth can have a disastrous effect on the music
Another example is in patients with cleft produced by some players.
palates who have been treated orthodontically as With brass instruments the mouthpiece is
well as surgically (Figure 7.6). supported indirectly by the teeth, via pressure on
Figure 7.6
A surgically repaired cleft lip and palate with missing

lateral incisor to be replaced by a bridge. The palatal
gingival inflammation is exacerbated by the temporary
denture an additional indication for a bridge.
the lip. Clearly with these patients not only is the the preparations parallel may involve more reduc-
replacement of any missing teeth essential but a tion in one part of the tooth than if it were for
bridge or an implant-supported restoration will a crown and so endanger the pulp.
usually be necessary. This must be designed very With the falling incidence of caries in many
carefully to reproduce as much of the original countries, and a more conservative approach to
contours of the missing teeth as possible. restorative dentistry, situations arise more and
With reed instruments the mouthpiece is more commonly in which the logical abutment
inside the musicians mouth and any pressure teeth for a bridge are sound and unrestored or
from it is to the palatal side of the upper incisors. have minimal restorations. To prepare these
teeth would be very destructive, and this is one
reason why the minimum-preparation bridge and
implant-retained prostheses are becoming so
Disadvantages of replacing missing popular.
teeth
Damage to tooth and pulp Secondary caries

In preparing teeth for conventional bridges or As with all restorations, bridges carry the risk of
precision-attachment partial dentures, it may be microleakage and caries. This risk is more signif-
necessary to remove substantial amounts of icant (particularly dento-legally) if the restoration
healthy tooth tissue. This damage, although it may is an elective one rather than the result of caries.
be justified if the indications are powerful enough,
should not be undertaken lightly. The problem is
less serious if the teeth to be used to support the Failures
bridge are already heavily restored or crowned.
Whenever a tooth is prepared, there is a Chapter 14 contains a black museum of failures
danger to the pulp, even if proper precautions among crowns, bridges and implant-retained
such as cooling the bur are followed. There is prostheses. Provided that the bridge is well
sometimes an additional threat to the pulp when planned and executed and the patient is taught
teeth are prepared for bridges. With some proper maintenance and is conscientious, the
designs, preparations for two or more teeth have chances of failure are small. However, there is
to be made parallel to each other, and if the teeth always an element of risk, and this must be
are slightly out of alignment, the attempt to make explained to the patient.
How long do bridges last? conventional bridges and increasing use of

implants. The reason for this ratio is more to do
This is an impossible question to answer for the
with the perception by both patient and dentist
individual patient and bridge. Some start with a
of the skill and training required of the dentist
better chance of survival than others. Chapter 14
and technician for each of the procedures,
gives a more extensive discussion of restoration
together with a concept that the more sophisti-
failure.
cated procedures must cost more. This approach
is based on historical and traditional views and is
not particularly logical. There is nothing intrinsi-
Effects on the periodontium cally more difficult or demanding about any of the
techniques as compared with the others. If
There is ample evidence that subgingival crown anything, bridges are more demanding because,
margins, whether or not as part of a bridge, once they are permanently cemented, it is diffi-
increase the likelihood of gingival inflammation. cult to make any significant modifications.
Although there is less evidence that this However, removable dentures and implant-
progresses to destructive periodontal disease, it retained prostheses that can be unscrewed and
is an unwelcome factor. Even poorly maintained removed by the dentist give more potential for
supragingival crown margins can produce modifications after they are fitted.
periodontal effects, as can restrictions of embra- Comparing typical fees and calculating approx-
sure spaces and reducing access by the presence imate fees per hour for the three treatment
of a bridge. The average partial denture is capable methods of partial dentures, bridges and implant-
of causing even more significant periodontal retained prostheses, and taking the cost for
damage. replacing one tooth with a partial denture as the
Some patients, given extensive courses of baseline, replacing it with a bridge would cost two
treatment, even if without special oral hygiene to three times as much and with an implant-
instruction, still improve their plaque control. retained prosthesis three to four times as much,
Presumably their increased dental awareness even allowing for the additional items that must
improves their motivation. Although this change be purchased for the implants.
seems to have long-lasting effects, it is obviously Dental treatment is much less painful than
not a justification on its own for making bridges. some patients imagine, but there is nearly always
some discomfort, such as holding the mouth open
for long periods and difficulty in controlling fluids
in the mouth. If the treatment is carried out
Cost and discomfort under sedation, there are the disadvantages of the
patient needing to be accompanied, being unable
Many patients regard these as the most impor- to drive after the appointment, and so on.
tant disadvantages in any tooth replacement.
Bridges, dentures and implant-retained prostheses
cannot be made other than by the individual
attention of the dentist and the technician. The choice between fixed and
Personal service of this type will always be expen- removable prostheses
sive. The cost of partial dentures does not signif-
icantly rise in proportion to the number of General considerations
missing teeth, whereas the cost of a bridge tends
to do so.
Patient attitude
Implant treatment is usually charged per
fixture, irrespective of the number of artificial Patients show different degrees of enthusiasm for
teeth supported by each implant. Traditionally, fixed and removable prostheses. Unless the patient
the charges were significantly higher than those is particularly anxious to have a bridge or implant-
for bridges, which are in turn higher than those retained prosthesis and fully understands the impli-
for partial dentures. However, this has changed cations, it is often better, particularly when a
over the years, partly due to increasing costs for number of teeth are missing, to make a partial
Figure 7.7
a Original study cast and diagnostic wax-ups for a

patient who lost the upper right central incisor in an
accident in his early teens. Rather than maintain the
space, the lateral incisor was moved into the position
of the central incisor and the canine tooth into the
position of the lateral incisor. On the patients left the
first premolar was extracted since the teeth were
crowded, and so the midline was maintained. This study
cast was made when the patient was 16 and was
becoming very concerned about his appearance. The
shape of the lateral incisor had been modified with
composite, but this and the canine tooth were still
unattractive. The appearance of simply crowning the
lateral incisor to make it resemble a central incisor is
shown in the first diagnostic wax-up. This is also not
satisfactory, and so the second diagnostic wax-up
shows the effects of extracting the upper right first
premolar, retracting the canine tooth and the lateral
incisor orthodontically and making a bridge to replace
the central incisor tooth. However, the patient was not
prepared to have further orthodontic treatment to
achieve this ideal result, and so the bottom diagnostic
wax-up shows the appearance that would be achieved
by extracting the lateral incisor and making a conven-
tional three-unit fixedfixed bridge. This is a very
destructive approach, but was justified in this case in
view of the patients considerable anxiety over his
appearance.
b The bridge in place. The patient is happy with this

appearance and considers the treatment to be success-
ful.
denture first to see how the patient responds. It Alternatively, if the patient is unhappy with the
may be that the denture is satisfactory, both partial denture, he or she will enter into the
aesthetically and functionally. If so, the destructive arrangements for making a bridge or implant-
and irreversible tooth preparations that may be retained prostheses with greater enthusiasm and
necessary for a bridge or surgical procedures for commitment. They will have had experience of
implants can be avoided, or at least deferred. the alternative to a bridge or implant-retained
prosthesis and therefore have better information However retentive a partial denture, some
upon which to base their consent to a more patients never lose the anxiety that it will become
interventive and expensive procedure. dislodged during speaking or eating. Others are
Patients should never be persuaded to have not prepared to remove partial dentures at night.
bridges or implants against their wishes, and they Many patients do tolerate partial dentures very
must give fully informed consent, including well, however, and it is often difficult to tell
enough time to reflect. Some patients take longer beforehand what the response will be to either
to make their minds up, or to plan the financial form of treatment. The majority of patients who
implications. It is prudent to put the summary of have had both partial dentures and bridges prefer
treatment proposed with the alternatives along the latter.
with the full costs in simple, short but not patron-
izing written form to allow the patient time to
Occupation
consider the plan before starting treatment.
Sports players and wind-instrument players have
been referred to earlier (see Chapter 3). Although
Age and sex
sports players should be provided with crowns
Similar arguments apply to bridges as to crowns when necessary, it may be better to defer making
(see Chapter 3). However, whereas there may be an anterior bridge or implant-retained prostheses
no satisfactory alternative to a crown for an old until the patient gives up the more violent sports,
or young patient, a partial denture may make a and meanwhile to provide a partial denture.
very satisfactory alternative to a bridge or implant- Although wind-instrument players usually need
retained prostheses. This is particularly true for a bridge replacement for their missing anterior
very young patients, who may not fully appreciate teeth, there are some who find that air escapes
the lifelong implications of bridges or implants. It beneath and between the teeth of a bridge. They
is better to make a minimum-preparation bridge are better able to maintain a seal with a partial
or partial denture until the patient is mature denture carrying a buccal flange.
enough to assess the relative merits of the alter- Public speakers and singers who make more
natives. But a teenager with a missing incisor who extreme movements of the mouth often need the
cannot be fitted with a minimum-preparation confidence that comes from wearing a bridge.
bridge may be desperately unhappy about wearing
a partial denture. In this case, the provision of a
General health
conventional bridge or single tooth implant as early
as possible may make a remarkable psychological Both bridges and partial dentures are elective
difference (Figures 7.4b, c and d and Figure 7.7). forms of treatment, and need not be provided for
At the other end of the age scale, no patient, people who are ill. When tooth replacement is
however old, should be written off as being past necessary for someone who will have difficulty
having a bridge. Figure 9.4c shows an immediate tolerating it because of poor physical or mental
insertion provisional bridge made for a spritely 76- health, or when there are medical complications
year-old who would have been appalled at the idea such as with patients who require antibiotic cover
of wearing a partial denture. Many patients 10 or for every appointment, it is better to consider the
more years older than this would have the same simpler, less time-consuming form of treatment
attitude. Figure 9.4c was published in the first edition first. Having missing anterior teeth replaced,
of this textbook and the patient is still well and though, can boost the morale of patients recov-
happily wearing the permanent bridge made when ering from long illnesses or facial trauma.
the two lower incisor sockets had fully healed. The
bridge has so far lasted for more than 17 years and,
Appearance
like the patient (now 93), is still going strong.
When a tooth is lost, alveolar bone and gingival
contour are also lost, and it is never possible to
Confidence
disguise this fact entirely (Figures 7.1a and 9.9a).
Many patients feel more confident with a bridge Thus no artificial replacements ever look exactly
than with any form of removable appliance. like the natural teeth, although some may be
Figure 7.8
a An unsightly appearance following gingival recession

and surgery. The teeth are splinted together.
b A removable acrylic gingival prosthesis in place.
sufficiently realistic to deceive all except the provided that the periodontal disease is under
dentist with their bright light and mouth mirror. control it is preferable to provide a bridge
In some cases dentures with flanges achieve this whenever possible rather than a partial denture.
object better than bridges; in others bridges have This is because a number of abutment teeth
the better appearance. When a substantial splinted together as part of a bridge have a better
amount of alveolar bone is lost, the combination prognosis than individual teeth with reduced
of a bridge with a separate removable buccal alveolar support, which may be mobile, used as
flange sometimes gives the best appearance denture abutments.
(Figure 7.8). When only one or two teeth are missing in the
When the loss of alveolar bone is significant arch, a bridge or implant restoration is usually
and the lipline is such that it shows and is diffi- considered the better solution. When large
cult to disguise easily, the ridge may be numbers of teeth are missing, particularly when
augmented surgically and the tooth or teeth there are free-end saddles, partial dentures or
replaced by a bridge or implant. The preferred implant-retained prostheses are a more logical
material is autogenous bone usually taken from choice. In some cases the preferred treatment is
somewhere within the patients mouth, often the to replace one or two missing anterior teeth with
chin, or the maxillary tuberosity or the ramus a bridge and the posterior teeth with a partial
but freeze-dried bone or other artificial materials denture. This has the advantage that the patient
are available (Figure 7.9). is not embarrassed to leave the denture out at
night and is more confident when wearing it
during the day
Occlusal problems may indicate a bridge rather
General dental considerations than a partial denture. For example, a missing
upper incisor in an Angles Class II Division I
Questions of oral hygiene and periodontal health malocclusion with the lower incisors occluding
were dealt with in relation to crowns in Chapter against the palate would be difficult to replace by
3 and similar considerations apply to bridges. means of a partial denture without increasing the
However, when there are strong indications for occlusal vertical dimension (OVD) or providing
replacing missing teeth in a case where there has orthodontic treatment; a bridge would be more
been periodontal disease and alveolar bone loss, straightforward (Figure 7.10).
Figure 7.9
Surgical ridge augmentation.
a A minimum preparation bridge with a very unsightly

and unsatisfactory flange in pink porcelain which does
not match the patients gingival pigmentation. It is also
unhygienic.
b After removing the bridge the thin receded ridge can

be seen.
c The alveolar ridge is exposed.
d After augmentation and suturing.

e The ridge healed.
f A new minimum-preparation bridge with an

improved appearance of the pontics and the augmented
ridge. It is also more cleansable.
Figure 7.10
Sectioned study casts of a patient with a complete

overbite, with the lower incisors occluding against the
palate. A denture would not be possible without alter-
ing the occlusion, shortening the lower teeth or
providing orthodontic treatment.
Local dental considerations term until the prognosis is clearer. The doubtful
tooth could then either be used as a support for
The condition of the teeth adjacent to and oppos- a bridge or extracted and a larger bridge or
ing the missing teeth may help to determine denture constructed. If the angulation or size of
whether a fixed or removable prosthesis is the teeth adjacent to the space make them
indicated. When the prognosis of teeth adjacent unsuitable to support a bridge, it may be better
to the space is doubtful it may be better to to provide a partial denture rather than design an
provide a partial denture at least in the short unnecessarily elaborate and complex bridge.
Figure 7.11
Cases illustrating indications for bridges.
a A small but visible space in an otherwise healthy and

unrestored arch. The indication here is to improve the
patients appearance and prevent any further mesial
movement of the posterior teeth, which have already
reduced this two-unit space to less than a single tooth
width. Orthodontic treatment to complete the closure
was not possible. A minimum-preparation bridge was
made.
b The patient, a professional singer, had tried a succes-

sion of partial dentures of various designs. She did not
like the appearance of any of them and did not feel
secure about their retention when singing. The bridge,
which is shown in Figure 9.4d (page 217), has now been
present for more than 30 years and has solved her
problems.
c Substantial alveolar bone loss together with the loss

of several teeth following a motorcycle accident in an
18-year-old girl. The soft tissue support is not ideally
suited to dentures. The patient was very depressed
about her other facial injuries and felt unable to cope
with dentures. The preparations for the lower bridge
are shown in Figure 3.17h (page 72) and the finished
bridge, together with the preparations for the upper
bridge, in Figure 8.1a (page 198).
d A patient with developmentally missing upper lateral

incisor teeth replaced with minimum-preparation
bridges.
e Originally both of fixed/fixed design they have

repeatedly debonded and one has been converted to a
cantilever design. The patient requests alternative
treatment.
f Long cone periapical radiographs show root conver-

gence that does not allow space for implants.
Orthodontic treatment to open the spaces was
declined by the patient.
g The central incisor teeth are prepared for conven-

tional metalceramic cantilever bridges.
h Completed bridges.
Figure 7.12
Indications for partial dentures.
a A heavily worn dentition with short clinical crowns

and no posterior teeth on one side. A partial denture
is the obvious choice here.
b Several teeth missing as a result of hypodontia in a

19-year-old patient. In view of the recent extraction of
the deciduous teeth together with the apparently high
caries incidence judged from the number and size of
amalgam restorations, and the small size of the anterior
abutment teeth, a partial denture was provided. An
additional problem in providing a bridge would have
been the lingual inclination of the first lower molar
teeth, making parallel preparation difficult. Implants
would have been a possibility, probably with ridge
augmentation, if funding was available.
In both a and b the indications for replacing the missing

teeth are both aesthetic and functional.
Figure 7.13
Indications for implants.
a and b The upper left lateral incisor and canine teeth

have been lost through trauma. The mouth is very
clean and well cared for with no caries or restorations.
The ridge is substantial (confirmed by appropriate
imaging).
c The occlusion of the patient shown in a and b. It is

unfavourable for a minimum-preparation bridge.
Therefore all the indications in this case are for an
implant-retained prosthesis.
d In this case only one central incisor tooth is missing

but the gap is much greater than the other central
incisor. The patient had previously had a midline
diastema with which he was content. The mouth is well
cared for with few restorations and a single tooth
implant is indicated.
Figure 7.14
This patient had had these spaces for many years and,
despite some mesial drift of the lower molar tooth and
considerable mesial movement of the upper molar
teeth so that space for both premolar teeth was now
less than half a unit she was not concerned about
the appearance, had no difficulty eating, and even these
extensive tooth movements had not produced occlusal
interferences. There is therefore insufficient justifica-
tion to replace any of the missing teeth.
Examples of specific indications for Scope of this book

bridges, dentures and implant
bridges This chapter has dealt with the decisions to be
made about whether the tooth or teeth should
Figure 7.11 shows four cases in which bridges be replaced and, if so, whether the replacement
were preferable, and Figure 7.12 one where a should be by a partial denture, bridge or implant-
partial denture was the chosen treatment and one retained prosthesis. All these alternatives need to
where it might have been. Figure 7.13 shows be considered equally at the planning stage and
patients for whom implant-retained bridges are so are included here in some detail.
indicated. Figure 7.14 shows a case where it
would be better to leave the patient with no
prosthesis.
10 Designing and
planning bridges
Criteria for selecting a bridge Support

design
One of the best known rules for bridge design
No firm rules can be given for selecting any was devised by Ante and described by him in
particular design. Bridge design is complex, poorly 1926. He suggested that each pontic should be
researched and dominated by personal opinion supported by the equivalent of an abutment tooth
derived from clinical experience, or lack of it. with at least the same root surface area covered
Many of the ground rules of bridge design were by bone as would have supported the missing
laid down in the early part of the last century by tooth; that is, a given area of periodontal
teachers who were trying to rescue the subject membrane could support up to twice its normal
from the purely empirical approach used until that occlusal load. The root surface area of an
time. Although they were a major advance on abutment tooth covered by bone is of course
what had gone before, these ground rules were reduced following destructive periodontal disease.
not scientifically investigated. Yet they became This was a guiding principle for many years but is
accepted as irrefutable and remained relatively now regarded as little more than a guiding prin-
unaltered for over 50 years, despite a growing ciple if that.
understanding in that time of related subjects This arbitrary, mechanical rule is similar to the
such as the supporting structures of teeth in engineering principles used for designing bridges
health and disease, and of occlusion and jaw across rivers. There are many reports in the liter-
function. In the last two decades, great develop- ature of experiments (usually carried out in the
ments have been made in restorative materials laboratory on models or in computer simulations)
and techniques, so that bridges now fit better, relating occlusal forces to reactions in the
look better and are stronger. This increased supporting structures of teeth. The results of
understanding and technical development should these experiments have tended to reinforce these
affect traditional ideas of design to a considerable mechanical ideas of how bridges should be
degree. designed.
Clinical (and some research) evidence suggests The evidence now suggests that these prin-
that many of the early rules of bridge design ciples are wrong, or at least do not tell the whole
should no longer be applied. However, this story. Provided that any periodontal disease is
evidence is not yet sufficiently clear-cut for new, treated and periodontal health is maintained, and
firm rules to be established, leaving todays provided that the occlusal forces are evenly
dentists, including the authors, still having to make distributed, bridges can be successful with as little
clinical decisions about bridge designs based on as one-quarter of the support advocated by Ante.
an incomplete evidence base. Such bridges have been successful for many years.
A number of criteria may nevertheless be used The assumptions made by the engineering
in choosing a design, although the weight given to school of thought ignore the fact that the occlusal
each will vary with the circumstances and the load on a bridge is determined not by extrane-
opinions held by the operator. It is to be hoped ous influences, such as lorries driving across road
that with further clinical research (which is bridges, but by the muscles of mastication. These
urgently needed) the relative importance of these are under the control of the neuromuscular
criteria will become clearer. mechanism, itself influenced by proprioception
225
226 Designing and planning bridges
Figure 10.1 only capable of generating a resisting force of X, and if

they retain a full periodontal sensory mechanism, once
Occlusal loading of abutment teeth.
force X is exceeded, the proprioceptive mechanism will
a In an intact dentition an occlusal force, X, is resisted suppress the contractions of the muscles of mastica-
by an equal and opposite force generated within the tion so that the force delivered to the three occlusal
supporting structures of the tooth. surfaces totals 2X.
This is an oversimplified version of what happens in
b When a tooth is extracted and replaced by means
real life. Sometimes the sensory mechanism is not
of a bridge, engineering principles suggest that the same
intact owing to periodontal disease and alveolar bone
force, X, delivered to each of the three occlusal
loss. The proprioceptive mechanism may be overrid-
surfaces would require the generation of 1.5X in the
den by stimulae from higher centres, producing
supporting structures of the two remaining teeth. This
bruxism or other parafunctional activity. The descrip-
principle is no doubt true for inanimate objects but
tion also ignores the effects of lateral forces, which are
assumes that the occlusal force is constant.
more complex. However, the illustration serves to
c The occlusal force is of course generated by muscles show that bridges should not be designed simply by
of mastication, which are under physiological control using engineering principles: the biological implications
and do not function independently. Therefore, if the must be taken into account.
supporting structures of the two remaining teeth are
from receptors in the periodontal membrane of occlusal area of a tooth by adding a pontic to it
the teeth supporting the bridge. Comparisons will inevitably increase the occlusal loading on that
with road bridges are therefore meaningless. tooth. However, forces in an unnatural direc-
There is plenty of evidence that occlusal tion, for example rotational or leverage forces,
loading is modified by the presence or absence of may not be resisted so well. There is not the
natural teeth and by their condition. For example, same inbuilt mechanism to perceive and control
patients can generate 10 times as much force these forces (Figure 10.1).
between upper and lower natural teeth as they Teeth will also adapt to increasing load physio-
can between upper and lower complete dentures, logically with changes to the periodontal ligament,
where the force is resisted by mucous membrane. which thickens to cope with the extra load. The
It is false logic to assume that increasing the bone support for a tooth will be stable with
Designing and planning bridges 227
Figure 10.2
Abutment support and length of span.
a A tiny pontic is needed here, and any of the avail-

able abutment teeth, which have no alveolar bone loss,
would provide more than enough support.
b Radiographs of the six abutment teeth supporting the

10-unit bridge in c. All the abutment teeth have less
than half their original bone support. For the remain-
ing lower teeth this is also much reduced, but the
periodontal treatment has been successful and there
has been no increase in bone loss or further mobility.
c The bridge has been satisfactory, with no further

bone loss, but the terminal abutment on the left of the
picture has had to be root-treated through the
retainer. The bridge, which was 9 years old when this
photograph was taken, is rather bulbous.
increasing function and loading as long as the same patient. It has been successful for many
patient maintains oral hygiene and no inflamma- years.
tion is present. An example of a bridge design that is
These considerations are often less important sometimes unnecessarily destructive because it
in designing small bridges than they are with large relies in part on Antes law for its justification is
bridges. Figure 10.2a shows a case where the span the replacement of four upper incisor teeth when
is so small that any of the available abutment the canines and first premolar teeth on both sides
teeth would meet all the traditional criteria for are used as abutments. Not only is this destruc-
support; while in the case of Figure 10.2b a bridge tive, it also creates embrasure spaces between
could not be provided if Antes law were to be the splinted abutment teeth, which are difficult to
observed. Figure 10.2c shows the bridge for the clean. The premolars are less satisfactory
abutments than the canines, and add little to this All conventional bridges are potentially
design. It has been said that occlusal pressure on destructive, and some are immediately so. For
the pontics, which are in front of a straight line example Figure 10.3 shows a case in which a
between canine abutments, would produce a bridge was made before the introduction of
tilting force on the canines. However, in a canine- minimum-preparation bridges. The bridge has
guided occlusion these same teeth will withstand remained stable and satisfactory. A conventional
the entire force of lateral excursions and yet bridge necessitated extensive preparation of
often remain the firmest teeth in the arch. Figures sound tooth tissue of the lower left canine. A
8.1a and 11.6a show two cases where the canines cantilever design with only one abutment tooth
alone have been used very satisfactorily as was a conservative approach at the time rather
abutments. This design, using the two canine than fixedfixed or fixedmovable designs that
teeth as the only abutments, can now be regarded would have involved more abutment teeth. Today
as the normal design for a bridge to replace the the design would only be used if the canine
four incisor teeth in either the upper or lower needed a crown in any case or was unsuitable for
jaw. It is not necessary and is indeed counter- a minimum-preparation retainer.
productive to include the first premolar teeth.
The best guidance that can be given for the
present is that abutment teeth with healthy
periodontal tissues are well able to support a Cleansability
(theoretical) increase in loading in an axial direc-
tion, because the load is limited by the natural This is a critical consideration. Some bridges fail
body defence mechanism. in the short term because of poor retention or
However, they are not so well able to the appearance is unsatisfactory; however, more
withstand twisting or levering forces. This means bridges fail in the medium term because the design
that large bridges of fixedfixed design can be does not take sufficient account of accessibility for
made with very limited numbers of abutment oral hygiene procedures. Not only should access
teeth. The curvature of the bridge around the be possible, it should be easy to help the
arch reduces the leverage and twisting forces so average, rather than the highly committed patient.
that all forces are in the long axis of the abutment Abutment teeth towards the front of the
teeth (Figure 10.2c). This is the principle of cross- mouth are easier for patients to clean than those
arch splinting, and it may be extended so that in further back, partly because of access and partly
ideal circumstances long cantilever extensions of because the bucco-lingual width of the contact
several units may be carried by such bridges areas is greater with posterior teeth. Chapter 14
(Figure 8.5). However, these long cantilevers includes advice on cleaning bridges.
cannot be supported by individual abutment teeth. Figure 9.7 shows well designed, accessible
They would produce a leverage or twisting force embrasure spaces which are easy to clean.
on the abutment tooth causing movement of the
tooth in the same way as an orthodontic appli-
ance, or they would loosen the tooth.
The application of these principles of support Appearance
is illustrated in a series of examples at the end of
this chapter, and more practical advice on select- This is the criterion which is often the one of
ing abutment teeth is also given later in the greatest concern to the patient. Some patients
chapter. have unrealistic expectations and it is sometimes
necessary to persuade the patient that a compro-
mise in favour of cleansability over appearance is
important for the survival of the bridge. Figure 9.7
Conservation of tooth tissue illustrates this.
Figure 9.1b illustrates the way in which the
The most conservative design is a minimum- appearance of the bridge is often one of the
preparation bridge. This is therefore the design of factors in determining its design. If a conventional
choice whenever possible. fixedfixed or distal cantilever design had been
Figure 10.3
a and b A cantilever bridge with a single lower canine

abutment tooth and two incisor pontics (only one
tooth is missing). One reason for this design was to
avoid preparing the lower incisors. This bridge was
made before the days of minimum-preparation bridges
or implants, which might now solve this problem. It
has, however, been successful for many years, with no
rotation, mobility or bone loss.
used it would have been necessary to make a should be taken with a patient for a bridge. There
complete crown for the upper canine. This would are, however, a number of additional considera-
probably not have been as attractive as the tions relating to bridges. These are listed below
natural tooth. A fixedmovable design with a and should be read in conjunction with the
distal-palatal inlay in the canine carrying a slot for relevant paragraphs in Chapter 5.
the movable connector as the minor retainer
would mean that the appearance of the buccal
surface of the canine would be left undisturbed.
The ideal would be a minimum-preparation Consideration of the whole patient
retainer on the canine supporting a distal
cantilever pontic, but the occlusion was With crowns, the choice may be between crown-
unfavourable for this. Another possibility would ing a tooth or extracting it, and the decision may
be a single tooth implant which would not involve well be to make a crown even though many
the canine at all. factors, for example, the patients age, attitude to
Thus consideration of support, a conservative treatment or oral hygiene are less than ideal.
approach to tooth preparation, cleansability and With bridges, there is often the alternative of a
appearance led to a decision in the case illustrated partial denture, a minimum-preparation bridge or
in Figure 9.1b to make the bridge fixedmovable a conventional bridge or an implant, and so it may
rather than fixedfixed or cantilever. not be necessary to make so many compromises.
If there is any doubt, it is better to make a partial
denture first.
Planning bridges
Collecting information about the Clinical examination
patient
Assessing abutment teeth
Chapter 5 includes a detailed review of the
history and examination of a patient for whom Abutment teeth for minimum-preparation bridges
crowns are being considered. The same approach should have sufficient enamel for the retainer,
Figure 10.4
Minimum-preparation retainer incorporating an intra-

coronal element replacing an MO amalgam. This is a
very strong and retentive retainer.
although small composite restorations can be tion bridges because the metal shines through
included in the area covered by the retainer. spoiling the appearance (see Figure 9.1c).
Composite restorations should not be partly Preferably none of the metal of the minimum-
covered. preparation retainer should show but this should
For posterior teeth the retainer may be be assessed and if metal will show, for example
designed to replace small restorations (Figure an occlusal rest on a lower premolar tooth, then
10.4). This increases the enamel bonding surface the patient should be warned about this in
area intracoronally as well as extracoronally. advance. Short incisor spans are almost always
For anterior abutment teeth there must either treated by cantilever bridges, preferably of the
be sufficient clearance for the minimum prepara- minimum-preparation design. This is the
tion retainer between upper and lower teeth or preferred option and should be considered first
it must be possible to create space, preferably by and only if there are problems with it should
a type of Dahl approach or, more destructively, alternative designs be considered.
by adjusting the opposing tooth or preparing the With short posterior spans an option is to
abutment tooth within enamel. consider a cantilever design with a single abutment,
Using the Dahl principle it can be acceptable to again preferably of a minimum-preparation design.
cement a conventional or minimum-preparation However, the occlusion must be carefully assessed.
bridge high and allow for it to create tooth Occlusal forces on a cantilever pontic will produce
movement. With a minimum-preparation bridge leverage forces on the abutment tooth and tend
the contact should be onto the retainer not the to tilt it. This is not the case with anterior
pontic so that the bridge is not dislodged before abutments where the forces are not axial or
the occlusion stabilizes. This is not the same as a substantial. The limit is normally a premolar width
high filling, as the retainer is cemented onto an pontic supported by a molar tooth with a
intact external surface and the patient will not favourable occlusion or perhaps a pontic
experience pulpitic symptoms. cantilevered distally from a premolar abutment for
Very thin, translucent incisors are not always reasons of appearance when the pontic will be
suitable as abutment teeth for minimum-prepara- unopposed or opposed by a denture.
When an anterior span is longer it is prefer- abutments. Given the choice between a tooth
able to use separate cantilever bridges rather than with a post crown as an abutment and a perfectly
a fixedfixed design for reasons described earlier sound tooth, it is more conservative of tooth
(Figures 7.1d and e). tissue to use the former. Although some surveys
It is not uncommon for all four incisor teeth (mostly out of date and relating to obsolete post
to be missing either in the upper or lower jaws. systems) have shown a higher incidence of failure
This may be due to trauma or multiple failed with post crowns than other forms of retainer,
restoration in a caries-prone patient or periodon- these figures are similar to the failure rate for
tal disease. The canine teeth are often in reason- individual post-retained crowns.
able condition in these cases and so the preferred There may be no suitable alternative abutment
option is frequently a fixedfixed design with the to a root-filled tooth, and the choice is then
canine teeth as the only abutments. between using the tooth or not making a bridge.
With larger posterior spans the preferred Many successful bridges have been made using
option is a fixedmovable design, either minimum root-filled abutment and post and core supported
preparation or conventional and with properly retainers. Success will depend upon the amount
designed movable joints (see Chapter 9) long of residual dentine present and the occlusal loads
span fixedmovable bridges are very successful. on the bridge as well as the stability of the posts.
There is little reliable survey evidence of the
relative success rates of long span fixedmovable
and fixedfixed posterior bridges. But what there
Length of span
is, together with clinical evidence suggests that,
with appropriate abutment teeth, the fixed Any design of bridge may be used for short spans
movable design is preferred unless there is a of one premolar or incisor width. Simple
need to splint the teeth (see later). With longer minimum-preparation cantilever bridges might still
spans the potential advantages of implant- be possible for longer upper anterior spans using
supported restorations increase as the complex- either the canine or central incisor as the
ity and risks of bridges increase. However, many abutment tooth, but the palatal surface of the
patients cannot pay for multiple implant restora- pontic should be designed so that it shares the
tions and if this is the case and a bridge would guidance with the other teeth and does not carry
have a poor prognosis the only alternatives are it exclusively.
to leave the space unrestored or provide a
partial denture.
Any tooth that can be crowned can also be
Occlusion
considered as an abutment tooth for a conven-
tional bridge, but the abutment tooth may have Not only should the occlusion of the remaining
to withstand forces from different directions than teeth be assessed, as described in Chapter 4, but
one crowned as an individual tooth (Figure 3.7). the potential occlusion of the pontic with the
Teeth with active periodontal disease should opposing teeth should also be assessed. In some
not be used as abutment teeth until the disease cases the occlusal relationships of the potential
has been successfully treated. However, many abutment teeth will help determine which should
teeth with reduced alveolar support following be used and which design of bridge is suitable.
successful treatment of periodontal disease can Figure 10.5 shows two cases: one suitable and
be used. They are commonly splinted to other one unsuitable for a simple cantilever bridge
abutment teeth to give mutual support. replacing the upper lateral incisor, with the canine
Some dentists prefer to avoid root-filled teeth as the only abutment tooth. The difference
or teeth needing post crowns because of the between them is the way the lower incisors relate
chances of fracture of the roots. However, this to the space when the mandible is moved in the
risk exists whether or not the tooth is used as protrusive lateral direction. In the second case
an abutment tooth. It may even be reduced if the two abutment teeth will be necessary: either the
tooth is used as one of a number of abutment canine and the first premolar with a cantilever
teeth in a larger bridge, so that the force of a design, or the canine and central incisor with a
blow to the tooth is shared by the other fixedfixed or fixedmovable design.
Figure 10.5
Occlusal assessment.
a A missing lateral incisor with deep overbite. The
lower canine tooth touches the palate and the palatal
surface of the upper canine. There would be insufficient
space for a minimum-preparation bridge without minor
orthodontic treatment or some reduction of upper or
lower canine teeth.
b The same patient in a right lateral excursion. The

occlusion is canine-guided and the lower teeth are clear
of the upper lateral incisor space, so that a simple
cantilever bridge with the canine as the sole abutment
would not apply unfavourable forces to the pontic.
Even with some tooth reduction, this would still be the
least destructive design. Alternatively the bridge could
be made without any tooth reduction or tooth
movement, leaving the retainer high in the occlusion
acting as a Dahl appliance. The occlusion of the patient
shown in Figure 8.1c is similar.
c In this case the lower incisor passes through the

upper lateral incisor space in right lateral excursion,
such that group anterior guidance will be inevitable.
Shape of ridge very concerned about their appearance, then one

of the procedures described below should be
The contour of the saddle area will be taken into followed to ensure an acceptable final result.
account in determining whether a bridge with a
movable buccal veneer or a partial denture should
be made (see Chapters 7 and 8), or whether
surgical ridge augmentation should be considered Predicting the final result
(Figure 7.9).
When a bridge is to be made, the shape of the The final appearance of the bridge can be
ridge will affect the appearance of the pontic, and predicted using the study casts, by various intra-
if this is likely to be a critical factor, in other words oral trials or by means of a provisional bridge.
if the neck of the pontic shows and the patient is Sometimes combinations of these methods are
necessary. In straightforward cases the dentist The work should not be started until the patient
and technician will have a good idea of what the understands and accepts this.
final bridge will look like, but the patient will be If the patient is to be shown the study cast, it
less clear. The prediction is therefore for the is best to produce the wax-up in ivory-coloured
patients benefit. In other cases where there are wax, or to duplicate the waxed-up cast. The
unusual features, the dentist and technician may patient can thus look at a cast without the
not realize the full aesthetic implications of distraction of the contrast between the artificial
attempting to make a bridge, or their under- stone and coloured wax. Most find it easier to
standing may be different. In these cases the compare the second, modified study cast with the
patient is likely to be even more confused. first, rather than with themselves, partly because
Many patients who complain about bridges study casts look so artificial to them that they are
after they are fitted are unhappy with their better comparing two similarly artificial objects,
appearance. Not only is it good planning to but also of course because they have difficulty in
predict the final appearance of the bridge and relating a study cast, which is how others see
seek the patients acceptance before starting, but them, to a reversed, mirror image of themselves.
a record of the predicted appearance may also be Other precautions are detailed in Chapter 5. It is
useful from a dento-legal point of view should the however, difficult for the patient to interpret the
patient eventually complain. potential clinical result from a diagnostic wax-up
As well as the appearance of the final bridge, and ideally an intra-oral trial should be provided
potential difficulties in preparing the teeth should for patients where extensive changes to their
be predicted when possible. These include teeth are planned.
problems with retention and path of insertion,
and the possibility of endangering the pulps of the
abutment teeth.
Intra-oral trials
Study casts Partial dentures

A second study cast should be poured of the arch Many patients who are to have anterior bridges
in which the bridge is to be made. It is sufficient already have a partial denture. If the appearance
simply to cast the alginate impression a second of the artificial tooth on the denture is satisfac-
time, if it can be removed from the initial cast tory and can be duplicated in a bridge, no further
intact. Alternatively, two impressions should be trial is necessary. An impression of the denture
taken or the study cast duplicated in the labora- in the mouth should be taken to guide the techni-
tory. cian on the appearance required. However, if the
The second study cast may be used for trial denture carries a buccal flange, it is wise to try a
preparations to predict the problems outlined denture tooth or teeth in the mouth without a
above as well as problems of the individual buccal flange, usually attached to a simple wax or
abutment preparation (Figure 5.3b, c and d). The shellac base, to show the patient the effect (Figure
prepared study cast may be used to make a trial 10.6). The change can be dramatic. This form of
or diagnostic wax-up of the bridge to show to intra-oral trial is suitable only when the shape of
the patient. This is particularly useful when the abutment teeth is not to be changed.
shape of the abutment teeth will be altered by
the retainer crowns or where orthodontic treat-
ment is planned prior to bridge construction.
Other reversible intra-oral modifications
There are usually alternative means of replac-
ing missing teeth and these change the appear- The size and shape of potential abutment teeth
ance in different ways. Figure 5.3 shows modified can be increased by the temporary addition of
study casts illustrating two ways of changing the wax or composite. In some cases a denture tooth
appearance that would be difficult to describe to representing a pontic can also be temporarily
the patient. Neither is ideal, and so the patient attached to adjacent teeth by means of com-
must be warned that compromise is necessary. posite. This is particularly useful when there is an
Figure 10.6
An intra-oral trial.
a A partial denture replacing four incisor teeth, which

is to be replaced by a bridge. There is a buccal flange
and a midline diastema.
b Denture teeth set on a wax baseplate being tried in

to ensure that the patient is happy about the appear-
ance of pontics without a buccal flange or the midline
diastema. Periodontal treatment will be provided
before a bridge is made. The bridge will be six units,
with the upper canines as the two abutment teeth.
incisor space which is larger than the missing are satisfied with the result. These modifications
tooth. The design will usually be a cantilever from are then incorporated into the permanent bridge.
one or other of the adjacent teeth leaving a resid- The provisional bridge can also be removed and
ual space. If the patient is not willing to have adjusted to allow periodontal or endodontic
orthodontic treatment to reduce the space to the treatment as necessary.
appropriate size, then showing them the appear- A provisional bridge can also be used to
ance of the diastema will give them the informa- confirm that the selected abutment teeth are
tion to consent to having one. Again an adequate to support the bridge. For example, if
impression should be taken of the temporary the abutment teeth demonstrate increasing
pontic to guide the technician. With extensive mobility or the provisional bridge continually
restorations a matrix can be taken from a debonds it may indicate that the abutment teeth
diagnostic wax-up and a labial slip made in the are not suitable for long-term use and alternative
mouth over the teeth using temporary crown and approaches should be considered.
bridge materials to give the patient a better idea An example of the use of a provisional bridge
in the mouth of the anticipated appearance. is as an immediate insertion replacement of a
tooth or teeth to be extracted. If the permanent
bridge is to be a conventional design, the
Temporary and provisional bridges abutment teeth are prepared and the provisional
bridge made before the extraction the prep-
Once the preparations for a conventional bridge arations being protected by separate temporary
have been made in the mouth, it is possible to crowns.
make a provisional bridge in the laboratory with If the permanent bridge is to be a minimum-
acrylic or other materials. These provisional preparation design, a Rochette design may be
bridges are rather more permanent than tem- used to facilitate removal and modification as the
porary bridges (usually made at the chair side), extraction socket heals.
which are only intended to last for 2 or 3 weeks
while the permanent bridge is being made. This is
comparable to temporary and provisional crowns
(see Chapter 6). Practical steps in choosing a bridge
One of the purposes of a provisional bridge is design
to allow further modifications to the shape of the
bridge for aesthetic reasons or as modifications So far, all the discussion of bridge design has been
to the occlusion until both the dentist and patient rather theoretical and somewhat inconclusive.
Figure 10.7
The upper first molar has over-erupted. It should

either be intruded to the original occlusal plane
orthodontically or ground level to the occlusal plane
prior to a lower bridge being made. This is in order to
avoid occlusal interferences in lateral excursions.
This is inevitable, since designing bridges is still should be examined and a note made of the
rather more of an art than a science. It is based presence of caries or restorations and the extent
partly on the clinical experience of the dentist, and quality of any restoration present.
which will vary from person to person, and on The periodontal state should be examined,
the clinical condition of the patient, which again including the presence of plaque and other
will vary. However, the design process has to deposits, gingival bleeding and periodontal
start somewhere. Examples at the end of this pockets.
chapter illustrate the logical steps in this process. The vitality and mobility of the tooth should be
tested and a periapical radiograph obtained.
Usually any major problems with the individual
tooth should be dealt with first by appropriate
General approach treatment, but sometimes the more sensible
solution is to extract the tooth and replace it as
A list should be made of all the likely designs for an additional pontic on the bridge rather than
a bridge in the case being considered. This should retain a dubious tooth as an abutment when its
include the potential abutment teeth and their presence may well jeopardize the future of the
retainers, together with the basic design of bridge whole bridge. An example of this is where three
(conventional, minimum-preparation, cantilever, lower incisor teeth are already missing and the
fixedmovable, fixedfixed and so on). In a simple fourth has very little bone support. The lower
case when the dentist is experienced, the list can canines are sound and will make good abutment
be made mentally. For the less experienced and for teeth. They will have to be used in any case to
more complex cases, it is helpful to write it down. support the bridge. Including the remaining
Every design should be considered in turn and incisor will not add significantly to the support of
advantages and disadvantages listed. In some the bridge and may well detract from its long-
cases, the optimum design will be obvious from term prognosis.
this procedure. In others, further investigations A judgement must be made as to the progno-
with modified study casts, intra-oral trials or sis of all the teeth in the vicinity of the bridge and
provisional bridges may be required. in the rest of the mouth to reduce the risk of
another tooth having to be extracted shortly after
the bridge is made.
Details of stages in the design
process Selecting the retainers
Selecting abutment teeth The list of potential alternative retainers will

include minimum-preparation, complete and
After the general examination of the patient and partial crowns retainers. The choice of a crown
whole mouth, individual potential abutment teeth is inevitable when the tooth is already heavily
Figure 10.8
Bridge designs for single missing incisors.
a A missing upper lateral incisor with rotated canine and first
premolar teeth. There is a Class II Division II incisor relation-
ship with a deep overbite and minimum overjet. This means that
no space is available for a minimum-preparation bridge attached
to the central incisor without orthodontic (or Dahl) treatment
or some tooth reduction. The occlusion is satisfactory for a
simple cantilever bridge using just the canine tooth as the
abutment, and its rotation could be corrected with a complete
crown and a conventional bridge. The first premolar has a failed
a amalgam restoration, which will be replaced separately with a
composite restoration to improve the appearance.
b Another missing lateral incisor, this time with one
discoloured, non-vital, root-filled central incisor and a large
mesial carious lesion in the other. The central incisors are also
misaligned. The canine is sound. The choice here is between
(in order of preference):
Making a cantilever minimum-preparation bridge retained by
the canine and restoring the two central incisors indepen-
dently, possible by bleaching the root-filled central incisor.
To restore the carious incisor and crown the root-filled
b incisor, bringing it into line with the other tooth and using
the crown as a conventional retainer for a cantilever pontic.
If it is considered that the root-filled central incisor would
not be an adequate abutment alone for a cantilever bridge,
both central incisors could be crowned and splinted
together to support the cantilever pontic.
c A missing upper canine tooth. These are difficult to replace by
bridges when the occlusion will be guided by the pontic in lateral
excursions, and in these cases several abutment teeth may be
necessary. By grinding the lower canine slightly and leaving the
pontic slightly short, it was possible to maintain group function
in this patient rather than produce canine guidance by the pontic.
The two premolar teeth were connected as abutments for a
three-unit cantilever bridge. This design was chosen in prefer-
ence to a fixedfixed bridge so that preparing the sound, match-
ing and well-aligned incisor teeth could be avoided.
c A fixedmovable design with an inlay in the distal surface of
the lateral incisor would not have been practicable, because the
angulation of the lateral incisor would prevent a common path
of insertion between the first premolar and a groove in an inlay
in the incisor. This design would have been possible (although
not desirable) if the lateral incisor had been more proclined.
A fixedfixed minimum-preparation bridge could be consid-
ered, but not a cantilever design as both adjacent teeth would
be poor abutments.
d A complicated case. If the only tooth missing was the upper
lateral incisor then the ideal design would probably be a
cantilever minimum-preparation bridge from the canine tooth.
However, this tooth is needed to help retain a bridge replac-
ing the two premolar teeth. Therefore the design to replace
the lateral incisor consisted of a minimum-preparation bridge
cantilevered from the central incisor. The two premolar spaces
were both restored by minimum-preparation, fixedfixed
bridges with the canine and first molar teeth as abutments.
These were made in the days when fixedfixed minimum-
d preparation designs were generally used. Now the design
would be fixedmovable on both sides with the canines
supporting the major retainers with fixed connectors and
movable joints distally. On the right-hand side of the picture
the molar tooth would have a minimum-preparation retainer
with a rest seat supporting a finger from the pontic, resisting
axial forces on the pontic. On the left the minor retainer
would be a gold inlay replacing the MO amalgam restoration
in other words a hybrid bridge.
Figure 10.9
Replacing more than one tooth.
a With an anterior open bite and normal lateral
incisors, a four-unit fixedfixed minimum-preparation
bridge with the lateral incisors as the abutment teeth
would be satisfactory. There is no need to include the
canine teeth. This design is also acceptable in some
cases where there is normal occlusion between the
anterior teeth, but the left and right lateral excursions
are canine-guided. In such cases the design may be
minimum-preparation or conventional.
b Even with three incisors missing, with the occlusion

being protected in right lateral excursion by a sound
canine (shown here), the lateral incisor may be used as
the only abutment on the right side for a five-unit
fixedfixed conventional bridge. The bridge could be
extended to include the right canine, giving additional
support and a more symmetrical appearance, but this
would make the embrasure space between the lateral
incisor and canine difficult to clean and would be
unnecessarily destructive.
c and d The central incisor space is now reduced to

approximately one-quarter of its proper width,
although this is somewhat difficult to judge since the
left central incisor has an acrylic crown. The right
canine also has an unsatisfactory acrylic crown. Trial
wax-ups showed that a satisfactory appearance could
be obtained by extracting the non-vital lateral incisor
and making a four-unit fixedfixed bridge. Both central
incisors and the lateral incisor pontic would be small,
but would give a better appearance than two large
central incisors with the midline offset even further.
The alternative of orthodontic treatment prior to
bridgework was offered to the patient and declined.
This is a similar problem to that of another patient,
shown in Figure 7.7.
d The upper lateral incisor has been extracted and the

two abutment teeth prepared. It is now clear that
there will be sufficient space for the planned treatment.
A provisional bridge will be fitted and periodontal
treatment provided before impressions are taken for
the permanent bridge.
e Existing crowns and a bridge following extensive,

successful periodontal treatment and the extraction of
the lateral incisors. None of the remaining teeth are
satisfactory abutments for simple small bridges, and a
partial denture replacing the lateral incisors and the
totally unsatisfactory premolar pontic would be damag-
ing to the periodontal tissues. A splint/bridge incorpo-
rating the principle of cross-arch splinting is indicated
here.
f Sound restored abutment teeth and a span that will

accommodate one premolar and one molar pontic. The
buccal surface of the premolar is sound and of good
appearance, and so one design could be a fixed
movable conventional bridge with a complete crown on
the molar tooth and an MOD inlay (without cuspal
coverage to avoid showing gold) in the premolar. The
movable joint will be accommodated in the distal box
of the inlay. A hybrid bridge would not be suitable,
since the restoration in the molar tooth is too large
for this tooth to have a minimum-preparation retainer.
restored. The choice between a minimum-prep- should indicate where the porcelain should be
aration retainer and a crown will depend upon finished. In some cases an all-porcelain occlusal
whether the abutment teeth have restorations in surface is required; in others the porcelain covers
them, the occlusal clearance and the appearance only the buccal surface and buccal cusp, leaving
of the abutment teeth. If the only difficulty with the remainder of the occlusal surface in metal.
minimum-preparation retainers is the lack of Again, this should be specified.
occlusal clearance, it may be possible to create
sufficient clearance by the means described in the
caption to Figure 10.5.
Planning the occlusion
Details of this stage were given in Chapter 4. The
Selecting the pontics and connectors first decision to be made is whether to articulate
study casts and, if so, whether it is necessary to
The design of pontics and connectors is the use a simple hinge or semi-adjustable articulator.
responsibility of the dentist and not the techni- With small bridges it is helpful to mount casts on
cian. Detailed instructions should be given to the at least a simple hinge articulator. With most
technician, particularly on the contour of the large bridges a semi-adjustable or fully adjustable
ridge surface of the pontic (see Chapter 9). When articulator should be used.
the technician is unfamiliar with the dentists usual The second decision is whether any occlusal
requirements, the details of the design should adjustment is necessary prior to tooth prepara-
be drawn and sent to the technician as part of tions for the bridge. With posterior bridgework
the prescription for the bridge. Where a it is often necessary to adjust an over-erupted
metalceramic pontic is to be made, the dentist opposing tooth (Figure 10.7). The anticipated
Alternative designs for a bridge to replace an upper lateral incisor
Design Abutment(s) Retainer(s)
1 Cantilever Canine Minimum-preparation

2 Cantilever Canine Crown
3 Cantilever Central incisor Minimum-preparation
4 Cantilever Central incisor Crown
5 Cantilever Both central incisors Minimum-preparation
6 Cantilever Both central incisors Crowns
7 Fixedfixed Canine + central incisor Minimum-preparation
8 Fixedfixed Canine + central incisor Crowns
9 Fixedmovable Canine + central incisor Minimum-preparation
10 Fixedmovable Canine + central incisor Crowns
11 Fixedmovable Canine + central incisor Minimum-preparation + crown
The most common designs are at the top of the list but all the designs, and others, are used in appropriate
circumstances.
occlusal relationship of the pontic with the oppos- in Figures 10.8 and 10.9. Care should be taken to
ing teeth may influence the basic design of the prevent this bias overriding more substantial clini-
bridge as well as the details of the occlusal surface cal criteria.
of the pontic; although this step is listed as the As another example, the above list sets out
final one in the sequence, and it is usually consid- alternative designs for the replacement of one
ered last. If the bridge design is influenced by it, upper lateral incisor. Some of the suggestions on
it will be necessary to introduce feedback loops this list are uncommon and would not be used
to earlier stages. other than in exceptional circumstances. In some
cases, however, the upper lateral incisor would
be replaced as part of a much larger bridge/splint.
In that case all the remaining upper incisors and
Examples of the bridge design probably teeth further back in the arch would
process also be included. So the list could be extended
further to show an even greater variety of poten-
Figures 10.8 and 10.9 give practical examples and tial abutment teeth, and extended further still to
the reasons for the choice. Some alternative show the choice of materials.
designs, and the reasons for rejecting them, are The important point is to show the large range
also given. of designs possible and the dangers inherent in
Dentists will inevitably become biased in their falling into the habit of only using a limited range
selection of bridge designs by their own experi- of designs. Each case has a unique combination of
ence of clinical success and failure. Indeed, the features and a specific design should be chosen to
bias of the authors may be detected, for example, address these.
11 Clinical techniques
for bridge
construction
This chapter should be read in conjunction with teeth. When the patient has a satisfactory tem-
Chapter 6. Many of the techniques are identical, porary denture and especially if the design is a
and so this chapter will deal only with those that cantilever or fixedmovable conventional bridge
are peculiar to bridges or where a different or any design of minimum-preparation bridge, it
emphasis is necessary. is often better to make separate temporary
restorations rather than a temporary bridge.
When the design is fixedmovable and the paths
of insertion of the retainers will not be parallel
Preoperative procedures to each other, it may be impractical to make a
temporary bridge. Besides, when a minor retainer
All the planning stages described in Chapters 5, 6 such as a distal-occlusal inlay is to be made for a
and 10 should be undertaken. In particular, the fixedmovable bridge, the temporary bridge
shade should be taken and an impression for the (which will be fixedfixed) may loosen at the
opposing cast made. The following additional minor retainer.
preoperative procedures may also be required. However, in many cases, particularly for larger
fixedfixed conventional bridges, a temporary
bridge is essential to protect the abutment teeth
and to retain their relationship with each other
Occlusal adjustment and the opposing teeth. Temporary bridges may
be made in one of two ways: either by one of the
It is more often necessary to carry out an occlusal chair-side techniques described in Chapter 6, or
adjustment in preparation for a bridge than for by making an acrylic temporary bridge on the
crowns. Indications for this are identified in study cast, using the trial preparations, and then
Chapter 4. A new impression must be taken for relining and adjusting this at the chair side as
the opposing jaw if this has been adjusted, since necessary.
the study cast will obviously no longer be If a chair-side technique is to be used, a trial
accurate. wax-up on the study cast should be made and
Additional space for anterior retainers can be duplicated (by means of an alginate or elastomeric
produced by using a Dahl appliance (see Chapter 6). impression) to make a stone cast. A vacuum-
formed PVC slip or a silicone putty matrix can
then be produced (Figure 6.17). Alternatively, a
silicone impression of the waxed-up study cast
Preparations for a temporary bridge may be used directly in the mouth to make the
temporary bridge.
For a conventional bridge it must be decided Figure 11.1 shows a laboratory-made tem-
whether a temporary bridge will be made or porary bridge, constructed before the teeth are
whether the patient will be left with individual prepared so that it can be adapted and cemented
temporary restorations to protect the abutment at the tooth preparation visit. Techniques for
241
242 Clinical techniques for bridge construction
Figure 11.1
A laboratory-made temporary acrylic bridge (see also

Figure 9.4c).
constructing chair-side temporary bridges are discrepancy between the retainer surface and the
described later. enamel which might be plaque-retentive. Usually
the enamel cannot be prepared to a sufficient
depth to allow a straight-line junction between
the retainer and the tooth surface without
Preparing the abutment teeth encroaching on dentine. It is better to make the
margin of the retainer a millimetre or two away
Preparations for minimum- from the gingival margin so that access for clean-
preparation bridges ing is easy.
One danger of overpreparing teeth for these
Since the introduction of minimum-preparation types of retainer is that if the retainer becomes
bridges there have been fluctuations in fashion as debonded but the bridge is held in place by other
to the degree of tooth preparation that should be retainers, features such as grooves tend to
carried out. Initially very little preparation was become carious more rapidly than unprepared
undertaken, and then over the next few years enamel surfaces and, because the dentine is closer
various authors recommended more and more to the base of the groove, it too becomes carious
extensive preparation with finishing lines, seating with the result that a further minimum-prepara-
grooves at right angles to the path of insertion tion retainer is not possible. There is also less
and location grooves in the line of the path of enamel to bond to and all resin cements bond
insertion all being advocated. Some dentists even better to enamel than to dentine. Therefore the
went as far as using operating microscopes and preparation should be within enamel and the use
complicated paralleling devices. of a local anaesthetic is discouraged to allow the
There is very little evidence that any of these patient to warn the dentist when the dentine is
produce significant benefit. With this lack of being approached.
evidence the only sensible approach is to limit However, some tooth preparation is usually
tooth preparation to those aspects where there necessary and the principles that should guide the
is a logical reason to prepare the tooth (see operator in deciding what this should be are:
later).
There is no justification for producing a finish- The maximum surface area of enamel should
ing line near to the gingival margin of either be used for retention of major retainers, avoid-
anterior or posterior teeth. Some dentists have ing the incisal edges and potential shine
advocated this in order to identify where the through of the metal framework (Figure 9.2c).
technician should complete the wax-up. It is not The bridge should seat positively so that it can
justified to prepare enamel for this purpose which be held firmly in place without movement
can be achieved equally well by drawing a line on against the resistance of rubber dam while the
the study model with a pencil. Gingival margin cement is setting. For anterior teeth this should
preparation is also advocated to reduce the thick- be a small horizontal notch with the base at
ness of metal at the surface and therefore the right angles to the path of insertion of the
Clinical techniques for bridge construction 243
Figure 11.2
Preparations for minimum-preparation bridges.
a A shallow rest in the cingulum and minor prepara-

tion to the mesial surface with a shallow slot. This
defines the extent of metal wrap-around possible
without metal showing labially.
b A mesial rest seat on a molar tooth with minor

preparation to the palatal surface to allow the metal
framework to extend over the maximum surface area.
c Incorporating an MO preparation into a minimum-

preparation retainer.
Figure 11.3
a The lingual view of an incompletely erupted upper

canine tooth to be used as an abutment for a minimum-
preparation bridge.
b Crown lengthening has been carried out to give a

greater surface area and a horizontal seating ledge has
been prepared at the cingulum to stabilize the retainer
firmly while the bridge is being bonded. This size of
ledge is all that is necessary for the purpose.
bridge. The notch should be entirely in enamel retainer is to finish. This is a completely unjusti-
and need only be 2 or 3 mm wide (Figure fiable reason, because the same indication could
11.2a). With posterior retainers this purpose is be given by the dentist drawing the retainer
usually served by preparing a shallow rest seat outline on the study cast.
in enamel (Figure 11.2b) or alternatively by
replacing a small restoration (Figure 11.2c).
Preparation may be necessary to allow an
adequate thickness of retainer when the occlu- Preparations for conventional bridges
sion is unfavourable. It is sometimes possible
Paralleling techniques for conventional
for the framework of a minimum-preparation
preparations
bridge to be cemented high to achieve space
in the same way as a Dahl appliance works. A fixedfixed conventional bridge requires two or
more teeth to be prepared in a common path of
The maximum enamel surface area can often be insertion. Special techniques are used to ensure
achieved with anterior bridges without any tooth that there are no undercuts and yet each individ-
preparation other than a seating ledge (Figure ual preparation is as retentive as possible. These
11.3). are listed in increasing order of complexity.
Figure 11.4 shows a section of an unprepared
molar tooth (Figure 11.4a), together with a
pattern for a minimum preparation retainer
Paralleling by eye
without preparing the tooth (Figure 11.4b) and
after preparing the tooth (Figure 11.4c). In both Two or three teeth close together can be made
Figure 11.4b and c there is inevitably a change of parallel by eye. The clinician will become more
contour at the margin of the retainer, which must adept at doing this with experience, and should
be kept clean by the patient. In this, and many concentrate on developing the skill, in the first
cases, there would be no advantage in preparing place on study models. The inexperienced opera-
this axial surface. It has been suggested that a tor should always practice on study models before
finishing line indicates to the technician where the preparing the teeth.
Figure 11.4
Posterior minimum-preparation retainer design.
a A section through an extracted molar tooth.
b The tooth has not been prepared and the retainer

will be bonded directly to the enamel surface. The
junction at the gingival margin should be well clear of
the gingival tissue
c There has been some preparation, entirely within

enamel, and so the retainer is partly within and partly
outside the original tooth contour.
Figure 11.5
Clinical methods of assessing parallelism of bridge

abutment preparations.
a Using direct vision, from a distance with one eye

closed when, for example, upper canine teeth are being
prepared for a fixedfixed bridge.
b Using a full arch mirror for the same purpose in the

lower jaw. Full arch mirrors are used in clinical photog-
raphy and many of the photographs in this book were
taken with one of these large mirrors.
c Using a straight probe as an intra-oral surveyor. The

operator must stay very still other than moving the
probe round the abutment teeth in a controlled
fashion. This, on its own, may not be enough but gives
a guide to the presence of undercuts. Operators who
make a significant number of bridges develop consid-
erable skill in this technique.
In the anterior part of the mouth it is poss- incisor teeth. It helps to look from as far away
ible to see along the long axis of the teeth by as possible. It may also be useful to make a small
direct vision. Only one eye should be used, since pencil mark on the two surfaces that may still
binocular vision can see around undercuts. be undercut. An assessment of parallelism or
Figure 11.5a shows a dentist assessing the path undercut can then be made by closing one eye
of insertion of the upper canine teeth, which are and moving the head so that one of the pencil
being prepared for a bridge replacing the four marks just disappears and then continuing to
Figure 11.6
Surveying preparations.
a Initial preparations have been carried out on the

upper canine teeth in the mouth and this cast has been
made from an alginate impression. The two prepara-
tions have been varnished. The bridge will be a six-unit
immediate-insertion provisional bridge, and the two
remaining incisors with extensive alveolar bone loss will
be extracted.
b The preparations are surveyed with a fine rod, and the cast is
trimmed until they are parallel. Trimmed areas show up in contrast
to the untouched varnished areas. Similar reduction is carried out in
the mouth. The process may need to be repeated.
move the head until the other pencil mark reliable guide of course, and will detect only fairly
appears. gross undercuts or over-taper, but many clinicians
In the lower jaw and in posterior parts of the do find it useful (Figure 11.5c).
mouth large mirrors are useful to show all the The risk of not striving for near parallelism is
preparations in the same field. Parallelism cannot that excessive taper between abutment teeth is
be assessed satisfactorily when two or more more likely to result in de-cementation
preparations can be seen only by moving the somewhere on the bridge.
small mouth mirror. Many of the photographs in
this book have been taken in larger, front-surface-
reflecting mirrors (Figure 11.5b). Extra-oral survey
It is also helpful to use a straight probe like a
laboratory surveyor, but in the mouth. The probe With larger bridges and when teeth are prepared
is placed against one of the prepared tooth on both sides of the arch, the simplest and most
surfaces, and then, held rigidly, it is moved over reliable method of assessing parallelism is to take
to the other abutment tooth without its angula- a simple impression (usually in alginate) once the
tion being changed. This is not a completely basic reduction has been carried out on all the
abutment teeth. The impression is cast at the Laboratory-made temporary bridges are made
chair side in a fast-setting plaster, usually with an with similar techniques to those described for
accelerator such as alum added. The cast is then crowns in Chapter 3. However, long-term provi-
surveyed at the chair side and further preparation sional bridges often need reinforcement to
carried out as required (Figure 11.6). The proce- strengthen the span and this can be achieved by
dure may be repeated several times with more the technique described in Chapter 6 using light-
difficult cases or with large numbers of abutment cured composite and quartz-fibre reinforcement.
teeth. When the abutments are satisfactory for Alternatively a simple metal casting may be made
the path of insertion, the final smoothing and using an impression of the prepared teeth and this
finishing of the preparations is carried out. can be faced with composite or acrylic. However,
the occlusal surface and margins should be acrylic
or composite so that adjustments can be made
Paralleling devices for crown preparations
either by removing or adding material if neces-
Many of the devices available are cumbersome, sary. Modern temporary crown and bridge
unreliable or extremely expensive. One of the materials are sufficiently resistant to wear for this
simpler ones consists of a stainless-steel mirror to be possible.
with vertical lines scribed on it. This is placed
buccally or lingually and used to assess the mesio-
distal parallelism of abutment preparations. It
cannot be used for the buccal-lingual surfaces. Choice of technique
Another device consists of a clear plastic disc
with a pin passing through it. This is held against
Chair-side construction
the occlusal surfaces and can be moved around,
acting as a surveyor. These two devices may be The majority of temporary bridges can readily be
useful, but the inexperienced dentist is better made at the chair side, often in less time than it
advised to master the basic techniques of survey- takes to modify a laboratory-made temporary
ing by eye and extra-oral surveying bridge, and of course avoiding the additional
laboratory cost.
The chair-side technique illustrated in Figure
11.7 is similar to the temporary crown techniques
Making temporary and provisional shown in Figures 6.17 and 6.18. The mould may
bridges be an impression of a study cast with the pontic
made from a denture tooth, or it may be a
Temporary bridges are made at the chair side or vacuum-formed PVC slip. In many anterior
more rarely in the laboratory and are expected bridges, though, the patient is already wearing a
to be used clinically for a few weeks while the temporary denture, and it is sufficient to take an
permanent restorations are made. Provisional alginate or silicone impression of the arch with
bridges are used when longer-term temporary the denture in place and use this to make the
restorations are required, usually while occlusal temporary bridge. This is the technique illustrated
or appearance issues are resolved and time is in Figure 11.7. The excess material flowing into
needed before the permanent restoration is the areas of the impression previously occupied
provided. They may also be used where endodon- by the denture can be removed with an acrylic
tic or periodontal treatment needs time to be bur in a straight handpiece, once the plastic has
assessed or while implants are integrating. They set and the temporary bridge has been removed
are normally laboratory-made. from the mouth.
For posterior bridges, where there is often no
temporary denture, but where the appearance
of the pontic is not important, an impression
Choice of material may be taken (with nothing in the saddle area)
before the teeth are prepared, and used to make
Chair-side temporary bridges are made with one individual temporary crowns for the abutment
of the materials designed for the purpose. teeth.
Figure 11.7
Chair-side temporary bridge construction.
a An alginate impression is taken before the prepara-

tions are started, with the temporary denture in place.
The alginate is removed from the buccal sulcus area to
facilitate reseating in the mouth before the temporary
crown and bridge material is put into the impression.
b The plastic temporary bridge removed from the

mouth. The material has flowed palatially into the space
left by the plate of the denture. This can now be
removed together with the thin flash over the adjacent
unprepared teeth. The almost-transparent buccal
incisal surface of the upper right central incisor retainer
shows that more preparation of the abutment tooth is
needed here or the retainer will be too thick. To a
lesser extent the same is true at the tip of the upper
left lateral incisor. These modifications should be made
to the preparations before the impression is taken.
Laboratory-made provisional bridges is waxed up and processed in the laboratory using

conventional acrylic techniques (Figure 11.1).
If the provisional bridge is to last for more than Once the abutment teeth have been prepared
a week or two, if it is large or if its appearance in the mouth, the provisional bridge is tried in and
is particularly important, then a laboratory-made will usually need to be relined with a higher
provisional bridge is preferable to a bridge made acrylic.
at the chair side. The technique using an accurate working
One technique is to make preparations of the impression of the prepared teeth to make a
abutment teeth on a study cast so that when the provisional bridge is more reliable, and often
full-scale preparation is done in the mouth the produces a better marginal fit but takes an extra
temporary bridge will be a loose fit. If the prep- appointment. This is necessary, however, if a
arations on the study cast are completed to full metal casting is to be incorporated for extra
depth, it will be impossible to duplicate them strength (Figure 11.8).
exactly in the mouth, and the provisional bridge Cast metal and composite provisional bridges
will not seat. (and crowns) have become popular with some
If full-scale trial preparations have been made dentists. They are strong, fit well and have a good
to assess parallelism, this cast may still be used appearance. However, the laboratory costs are
to make a provisional bridge, the prepared teeth high, sometimes nearly as much as permanent
on the study cast are covered with a spacer of restorations. When they are used, all the surfaces
tin foil, or the fit surfaces of the bridge are which may need to be adjusted must be in
enlarged with a bur in the laboratory before the composite which can be ground and added to
bridge is returned to the chair side. The bridge with more composite. This is sometimes difficult,
Figure 11.8
A long-term, immediate-insertion, metal/composite

provisional bridge in heat-cured acrylic incorporating a
metal casting.
for example, when the palatal surface of an upper with sudden loading such as with a bridge
incisor abutment has been prepared with a remover (see Chapter 14). The cement remain-
chamfer for a metalceramic retainer there will ing on the preparation can easily be removed as
not be enough room for metalcomposite. This it is not adhesive.
means that the laboratory will make a metal
palatal surface which will be difficult to adjust and
which negates the purpose of a provisional
restoration. An all-acrylic or composite provi- The working impression
sional restoration would be better. Before making
a metalcomposite provisional restoration there Any of the impression materials or techniques
should be a costbenefit analysis compared with described in Chapter 6 are suitable for bridges.
less expensive alternatives. With fixedfixed bridges it is often an advantage
to have two working casts, one with removable
dies for making the individual retainers and one
that is not sectioned and therefore preserves the
Cementing temporary and provisional full contour of the saddle area together with the
bridges relationship of the abutment teeth and adjacent
teeth. With good die location and a small bridge,
Temporary bridges should be sufficiently retentive an unsectioned model is not necessary, but with
not to cause trouble between appointments, but larger reconstructions where the dies have to be
it should be possible to remove them without removed and replaced often, some die location
excessive force or damage. The temporary crown systems tend to wear, allowing movement of the
and bridge cementing materials are supplied with dies. Then a solid model may be necessary. By
a modifying paste that may be combined in varying ensuring the correct relationships between
proportions with the base and catalyst pastes to abutment teeth the solid model is used to
weaken the final mix. Modified cement is recom- confirm the bridge will seat easily in the mouth,
mended with large or very retentive bridges. the correct contacts to the soft tissues and the
Experience will guide the operator as to the contact points with the adjacent teeth.
correct proportions for the particular bridge and All bridges should be made with full arch
the particular cement; 50% or more of the total working impressions for maximum stability of the
mix may consist of the modifying paste. occlusion.
Provisional bridges may also be cemented with For short span bridges a stock tray is normally
temporary crown and bridge cement, but usually adequate but for extensive or complex bridges a
without modifying paste because they need to last special tray is better. Figure 6.4 shows the
longer. Temporary cements are easily fractured construction of special trays.
Figure 11.9
Localization
a The metal framework for a three-unit metalceramic
bridge. This has been tried in the mouth and found not
to fit. When sectioned diagonally through the pontic, the
separate retainers fitted, and so it was relocalized in the
mouth and soldered before the porcelain was added.
b A large bridge, cast in four sections, being localized

in the mouth with fast-setting acrylic. To stabilize it, a
bar (a long bur shank is the right stiffness) will be
attached across the back with more acrylic.
Occlusal records returned to the laboratory for the porcelain to

be added.
For the choice of appropriate occlusal records, If the framework does not seat, and once
see Chapter 4. The larger the bridge, the more obvious causes have been eliminated, such as tight
time-consuming is any occlusal adjustment at the contact points or air blows on the fit surface of
chair side, so a semi-adjustable (or fully adjustable the casting, it must be assumed that the relation-
articulator) should be used, together with the ship between the abutment teeth is the problem.
appropriate occlusal records. This may be wrong either because the abutment
teeth have moved since the impression was taken
(perhaps because a temporary bridge was not
provided) or because the die location is at fault. If
Trying in the metal framework or this is suspected, the bridge should be divided and
separate units the separate components tried in. It is better to
saw through the bridge with a fine fretsaw cutting
Metalceramic conventional bridges should be diagonally through one of the pontics rather than
tried in at the metal stage. Experienced operators through a connector (Figure 11.9a). This gives a
making small bridges, who are familiar with their larger surface area for the bridge to be re-
technicians work, sometimes omit this stage, but soldered, and the solder joint will be covered by
this is inadvisable under other conditions. porcelain, which will further strengthen it. If the
Metalceramic bridges of up to six units are separate units fit, the bridge is relocated (see
often cast in one piece. When they are tried in, below) and soldered with a high temperature
all the checks listed in Chapter 6 should be made, solder or laser welded before the porcelain is
and if the framework is acceptable, it may be added. It is advisable to retry the bridge again.
If, once the bridge is sectioned, some of the Try-in and trial cementation of
retainers fit and others do not, a further impres- finished bridges
sion is needed. This will be of the unsatisfactory
abutments, with the satisfactory retainers and the The checking procedure is as described in
attached parts of the pontic left in situ. They will Chapter 6. In some cases the bridge does not fully
be a guide to the technician in waxing-up the seat and the operator may suspect that the teeth
repeated sections. A further retry and localization have moved, particularly if a metal stage try-in
in the mouth is necessary before soldering. was satisfactory. Rather than sectioning the bridge
With larger bridges not cast in one piece, the again, it may be left in the mouth for a few hours,
separate sections should be tried in before local- preferably with no cement, or with petroleum
ization and soldering. jelly and zinc oxide powder (which does not set)
Bridges made in other materials are usually to prevent oral fluids from irritating the exposed
completed and not tried in as separate units. dentine. If after a few hours the bridge has not
Posterior all-metal bridges are necessarily seated, the next stage is to use a silicone seating
relatively small, as are anterior all-porcelain cement which does not set fully and flows under
bridges. Where metal units are to be soldered to pressure. These cements will retain the bridge for
metalceramic units, it is possible to try in the 24 hours while full seating occurs. Once full
separate retainers before the connectors are seating has occurred it can be cemented with a
soldered. very weak temporary crown and bridge cement
with a large proportion of modifier. Bridges
cemented in this way may be left for days or even
weeks to settle before being finally cemented.
Localization techniques This should be done routinely with larger bridges.
The advantages of trial cementation are that, as
Full arch impressions should be taken almost well as possible improvements in marginal fit, the
universally for bridges and so there is little need patient has a chance to become accustomed to
for localization of individual retainers. However, the appearance and feel of the bridge, which can
problems still arise, as outlined in the previous still be modified out of the mouth if necessary.
section, with the fit of one-piece castings. It may Any problems with the occlusion are likely to
also be difficult to get a single impression of all show themselves and can be dealt with before the
the teeth at once, especially when large bridges bridge is permanently cemented.
are made in the lower arch. The tongue makes it Trial cementation should not be attempted
difficult to obtain a dry field on both sides of the with all-porcelain bridges or the minor retainers
arch at the same time. In these cases separate of fixedmovable bridges. Trial cementation is not
impressions of groups of abutment teeth are possible with minimum-preparation bridges.
taken and related to each other with a localiza-
tion technique.
An overall impression of the castings in place
may be used for localization. A rigid elastomeric Permanent cementation
material such as polyether must be used, since
softer materials distort when the casting and dies Minimum-preparation bridges
are seated in the impression. Sometimes, it is
necessary to cement the retainers with a very This depends on the technique used to make the
weak cement or petroleum jelly to keep them in bridge and the luting cement. The commonest
position while the localizing impression is taken. types are now those with grit-blasted fit surfaces
An alternative is to use acrylic with a paint-on luted with an adhesive resin, or Rochette (macro-
technique. When adjacent retainers are to be mechanically retentive) bridges or splints cemented
located or a cut pontic re-soldered, it is sufficient with a conventional, chemically cured composite
simply to clean the surfaces, paint a fast-setting material. These are used when it is likely that they
cold-cure acrylic over the surface and allow it to will have to be removed atraumatically.
harden before withdrawing the bridge (Figure Figure 11.10 shows the luting process for a
11.9b). grit-blasted bridge.
Figure 11.10
Clinical technique for a minimum-preparation bridge.
A fixedfixed design was used as the canine pontic was

in occlusion in lateral excursion. It was decided that a
cantilever bridge supported by either abutment would
not be sufficiently robust to withstand the occlusal
forces.
a The working impression.
b The metal framework and pontic on the model. This

is tried in the mouth and adjusted before etching or
sandblasting. It should not be retried after etching, or
the delicate etched surface will be damaged. The design
is fixedfixed because the tooth being replaced is an
upper canine that will be in occlusion in lateral excur-
sions. A cantilever bridge from the premolar would not
have been adequate with this occlusion, and there was
insufficient space to make a movable connector in the
lateral incisor without excessive tooth preparation.
c Polishing the abutment teeth with pumice and water

after applying rubber dam.
Summary of clinical techniques for Take an accurate working impression in an

minimum-preparation bridges elastomeric material and other records, for
example the shade and an impression of the
The stages in the construction are usually as opposing teeth although these should have
follows (Figure 11.10): already been done at the planning stage.
First appointment Laboratory stage

Thoroughly scale and polish the abutment teeth Make the metal framework and pontic the
(and the remainder of the mouth of course) pontic is usually metalceramic. Grit-blast the
Carry out any necessary tooth preparation fit surface of the retainer(s).
d Phosphoric acid gel applied carefully with a paint-

brush or with a syringe to the areas to be covered by
the retainers.
e Luting the etched bridge with a chemically cured

composite specially made for the purpose. It would
have been a good idea to place some floss between the
abutment and the adjacent teeth before cementing the
bridge. Pulling this through the contact points before
the cement set would have helped to remove excess
cement. If the bridge had been sandblasted and luted
with an adhesive resin, the margins would be coated
with gel to exclude air while the cement set.
f Immediately after removing the rubber dam.
Second appointment Cement the bridge with a bonding resin made

Try in and if necessary adjust the bridge specially for the purpose, and remove excess
Re-grit-blast the fit surface with a chair-side cement from the margins
grit-blaster, or if one is not available, it is worth The set of some bonding resins is inhibited by
returning the bridge to the laboratory if the fit air and so a water-soluble gel is applied to the
surface has been contaminated with saliva or margins until the bonding resin is fully cured
rubbed too hard against the tooth surface. Not The manufacturers setting time must be
taking care over this stage is one of the common- strictly adhered to and very firm, very still
est causes of failure of the bond pressure applied for the whole period. If your
Re-polish the enamel surfaces to which the fingers do not go white and hurt a bit you have
bridge is to be cemented, apply rubber dam not done it properly. Slight movement of the
and acid-etch the enamel surfaces (if the luting bridge while the cement is curing is another
cement used requires this) common cause of failure.
Success with minimum preparation combined abutment preparations is larger than an

bridges individual crown and so the hydrostatic pressure
of the unset cement is greater. Greater force
In the early days minimum-preparation bridges therefore has to be applied to seat the bridge
failed commonly and developed a poor reputation fully.
with some dentists. This attitude has lingered on Because of the difficulty of cementing large
to some extent and some dentists still do not bridges and the need for a long working time
make minimum-preparation bridges. However, all before the cement starts to set, zinc phosphate
the surveys of properly made bridges with cement is still the most popular for large bridges.
modern designs and materials now show good Its working time can be extended considerably:
success rates and it is likely that these success the mixing slab is cooled, very small increments
rates will improve. of powder are added at a time, and mixed for a
If you or one of your family needed a tooth long period (approximately 90 seconds). Ready
replaced, would your first choice be a minimum- proportioned cement in a plastic syringe is also
preparation bridge, a conventional bridge or an available and is mixed in a mechanical vibrator. If
implant? the syringe is used straight from the refrigerator,
Minimum-preparation bridges only work if they a consistent, slow-setting, air bubble-free mix is
are done properly but then they work well. Both obtained.
authors of this book have made minimum-prep- For preparations with nearly parallel walls the
aration bridges which have been successful for technician may use an additional layer of die-relief
more than 20 years. varnish on the axial walls. This increases the
The golden rules for success are: cement film thickness in this area without increas-
ing it at the margins, and so reduces hydrostatic
Proper control of moisture from saliva or the pressure during cementation. With multiple
humidity of the patients breath using rubber preparations it is also important that a dry field
dam. is maintained across all teeth. The dentist should
A dry supply of air for the three-in-one syringe. always be in control of the seating of the bridge
Some air supplies are contaminated by with finger pressure, getting the patient to bite
moisture. This can be checked by blowing air into a cotton wool roll is not acceptable.
at a clean sheet of paper. If the air supply is
contaminated it should be repaired or an alter-
native air supply used.
The bridge should be tried in before the rubber
Oral hygiene instructions and
dam is applied and then re-grit-blasted immedi- maintenance
ately before bonding. If there is a laboratory on
hand this is straightforward. If there is not then This is particularly important with bridges, and in
it is worth investing in a chair-side grit-blaster. some cases the techniques will be entirely differ-
Framework of adequate rigidity so that no ent from those the patient has been taught to
flexing occurs. date or for crowns. The areas where different
Well planned design cantilevers and cleaning techniques may be needed are between
fixedmovable designs work better than the pontic and the ridge and the gingival margins
fixedfixed designs. of the abutment teeth beneath the connectors.
Adequate bonding areas. The technique will depend upon the design of the
Proper adjustment of the occlusion. ridge surface of the pontic, the part of the mouth
where the bridge is situated and the patients
manual dexterity. With ridge-lap and saddle
pontics, superfloss, dental floss or tape should be
The cementation of conventional threaded through an embrasure space and then
bridges passed under the pontic to clean it and the ridge.
The furry section of superfloss makes cleaning
This differs from crowns only in that with under pontics much easier (Figures 9.5 and
fixedfixed bridges the surface area of the 11.11).
Figure 11.11
a Cleaning aids for use with bridges. This is only a

small selection of products which are available. New
cleaning aids are being developed and introduced all the
time.
From the top:
a soft toothbrush with two rows of bristles that can

be used around dome and ridge-lap pontics;
two single tuft interspace brushes these are often
too stiff except in very large open embrasure spaces;
two bottle brushes with multiple small lateral tufts
that are useful for medium-sized embrasure spaces;
a bottle brush with a simple wire handle;
superfloss, the most useful of the bridge cleaning aids
this has a stiffened end, right, and a furry section
that is very useful for cleaning under pontics, and
especially under smooth saddle pontics;
regular floss, which can sometimes be passed through
embrasure spaces to clean under pontics; but when
this is difficult it is used in conjunction with;
a floss threader, a flexible nylon loop with a stiff end
that passes easily between tight embrasure spaces.
b Superfloss being used to clean beneath the upper

pontic.
Wash-through and dome-shaped pontics are appointment the occlusion and the retainers
usually cleansable entirely with the toothbrush, should be checked.
although in some cases a bottle brush is better. It is advisable to see the patient at regular
Oral hygiene instruction should be given at the intervals when the full range of checks of margins,
same appointment as the bridge is cemented. The gingival health, cleaning, occlusion and the
patient should be seen again in 1 or 2 weeks to mechanical integrity of the bridge are made.
ensure that the new cleaning techniques are Chapter 14 deals with repairs and modifications
successful. At this stage it may be helpful to use to bridges where these checks reveal any
disclosing tablets or solutions. At the same problems.
c Superfloss being used in an embrasure space together

with a different design of interspace brush (the TeePee
brush).
d The clinical use of some of the cleaning aids shown

in a and b they would not normally all be used at
once!
15
INTERIM FIXED
RESTORATIONS
Anthony G. Gegauff and Julie A. Holloway
rected). Whatever the intended length of time of

KEY TERMS treatment, an interim restoration must be adequate
acrylic resin interim luting agent to maintain patient health. Thus, it should not be
autopolymerizing resin poly(methylmethacrylate) casually fabricated on the basis of an expected short
exotherm poly(R methacrylate) term of use.
external surface form tissue surface form (TSF) Interim procedures also must be efciently per-
(ESF) formed, because they are done while the patient is
in the operatory and during the same appointment
that the teeth are prepared. Costly chairside time
nterim crowns or partial xed dental prostheses must not be wasted, but the dentist must produce an
I (FDPs) are essential in prosthodontic therapy. The

word interim means established for the time being,
pending a permanent arrangement. Even though a
acceptable restoration. Failure to do so results in the
eventual loss of more time than was initially thought
saved. For example, an inadequate restoration may
denitive restoration may be placed as quickly as 2 lead to unnecessary repairs or to the need to treat
weeks after tooth preparation, the interim xed gingival inammation and remake the impression.
restoration must satisfy important needs of the Such problems can be avoided if the dentist thor-
patient and dentist. Unfortunately, temporary usually oughly understands what is required of the interim
connotes laxity, and this may imply that require- restoration and makes the effort to meet these
ments pertaining to the more permanent condition requirements.
are ignored. If this connotation becomes a philoso-
phy governing the interim phase of treatment, the
clinical efciency and treatment quality will be REQUIREMENTS
needlessly reduced. Experience has repeatedly An optimum interim xed restoration must satisfy
shown that time and efforts expended in fullling the many interrelated factors, which can be classied as
requisites of interim xed restorations are well spent. biologic, mechanical, and esthetic (Fig. 15-1).
Because of unforeseen events (e.g., laboratory
delays or patient unavailability), an interim xed
restoration may have to function for an extended Biologic Requirements
period. On the other hand, a delay in placing the
denitive restoration may be deliberate (e.g., Pulpal protection
because the etiologic factors of a temporomandibu- An interim xed restoration must seal and insulate
lar disorder or periodontal disease must be cor- the prepared tooth surface from the oral environ-
466
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Chapter 15 INTERIM FIXED RESTORATIONS 467
BIOLOGIC MECHANICAL
Protect pulp Resist functional loads
Maintain periodontal Resist removal forces
health Maintain interabutment
Provide occlusal alignment
compatibility
Maintain tooth position
Protect against fracture
ESTHETIC
Easily contourable
Color compatibility
Translucency
Color stability
Optimal
interim
restoration
Fig. 15-1
Factors to be considered in making an interim restoration. The
central area represents the optimum, in which biologic,
mechanical, and esthetic requirements are adequately met.
Fig. 15-2
ment to prevent sensitivity and further irritation to Pulp trauma and exposure of the dentinal tubules from tooth
the pulp. A certain degree of pulp trauma is preparation.
inevitable during tooth preparation because of the
sectioning of dentinal tubules (Fig. 15-2). In health,
each tubule contains the cytoplasmic process of a Table 15-1 FACTORS CONTRIBUTING TO
cell body (the odontoblast), whose nucleus is in the
PULP DEATH
pulp cavity. Unless the environment around the Present (during
exposed dentin is carefully controlled, adverse pulp xed prosthodontic
effects can be expected.1 In addition, the pulp health Past therapy)
of a tooth requiring a cast restoration is likely to
Caries Preparation trauma
be compromised before and after preparation
Operative dentistry Microbial exposure
(Table 15-1). In severe situations, leakage can cause
Bruxism Desiccation
irreversible pulpitis, with the consequent need for
Periodontal surgery Chemical exposure
root canal treatment.2
Prosthodontic therapy Thermal exposure
Periodontal health
To facilitate plaque removal, an interim xed restora-
tion must have good marginal t, proper contour, When gingival tissue is impinged upon, ischemia is
and a smooth surface. This is particularly important likely to develop. This can be detected initially as
when the crown margin is placed apical to the free tissue blanching. If it is not corrected, a localized
gingival margin.3 If the interim xed restoration is inammation or necrosis develops.
inadequate and plaque control is impaired, gingival
health deteriorates.4 Occlusal compatibility and tooth position
The maintenance of good gingival health is always The interim xed restoration should establish or
desirable, but it has special practical signicance maintain proper contacts with adjacent and oppos-
when xed prosthodontics is undertaken. Inamed ing teeth (Fig. 15-4). Inadequate contacts allow
or hemorrhagic gingival tissues make subsequent supraeruption and horizontal movement. Supra-
procedures (e.g., impression making and cementa- eruption is detected at the evaluation appointment,
tion) very difcult. The longer the interim xed when the denitive restoration makes premature
restoration must serve, the more signicant any de- contact. It is possible to correct this in the operatory,
ciencies in its t and contour become (Fig. 15-3). but the effort is time consuming and often leads to
468 PART II CLINICAL PROCEDURES: SECTION 1
Rough margins around interim

restorations will jeopardize
subsequent procedures.
Fig. 15-5
A missing proximal contact allows tooth migration. The result-
ing root proximity may necessitate surgical or orthodontic cor-
rection to allow impression making.
Fig. 15-3
An interim restoration should have good marginal t, proper
contour, and a smooth surface nish. A, The properly contoured
interim restoration. Smoothly continuous with the external
surface of the tooth. B, Overcontouring. Irregular transition
from the restoration to the root surface and inadequate mar-
ginal adaptation. These contribute to plaque accumulation and
an unhealthy periodontium.
Fig. 15-6
The interim restoration must protect the tooth. Fracture of a
If an interim restoration does not tooth after the impression phase delays treatment and jeop-
ensure positional stability, ardizes restorability.
tooth movement can occur,
and additional treatment
will be necessary.
particularly true with partial coverage designs in
which the margin of the preparation is close to the
occlusal surface of the tooth and could be damaged
during chewing. Even a small chip of enamel makes
the denitive restoration unsatisfactory and necessi-
tates a time-consuming remake.
Mechanical Requirements
Function
Fig. 15-4 The greatest stresses in an interim xed restoration
Proper occlusal and proximal contacts promote patient comfort are likely to occur during chewing. Unless the
and maintain tooth position. patient avoids contacting the prosthesis when eating,
internal stresses are similar to those occurring in the
denitive restoration. The strength of polymethyl
a restoration with poor occlusal form and function. methacrylate resin is about one-twentieth that of
Horizontal movement results in excessive or de- metal-ceramic alloys,5 which makes fracture of the
cient proximal contacts. The former require tedious interim xed restoration much more likely. Fracture
chairside adjustment; the latter involve a laboratory is not usually a problem with a complete crown as
procedure to add metal or ceramic to the decient long as the tooth has been adequately reduced. More
site. In spite of these efforts, proximal crown con- frequently, breakage occurs with partial-coverage
tours are distorted. This, along with a resulting restorations and partial FDPs. Partial-coverage
root proximity (Fig. 15-5), impairs oral hygiene restorations are inherently weaker because they do
measures. not completely encircle the tooth.
A partial FDP must function as a beam in which
Prevention of enamel fracture substantial occlusal forces are transmitted to the
The interim xed restoration should protect teeth abutments. This creates high stresses in the connec-
weakened by crown preparation (Fig. 15-6). This is tors,6 which are often the site of failure. To reduce
A
Fig. 15-8
In this mesiodistal section, an overcontoured connector
impinges on the gingiva. Pressure ischemia and poor access for
plaque removal promote gingivitis.
Areas of
overcontouring BOX 15-1 Indications for Cast Metal Interim
to improve
strength Restorations
A long-span posterior partial xed dental
prosthesis
Prolonged treatment time
B Patients inability to avoid excessive forces on the
prosthesis
Above-average masticatory muscle strength
History of frequent breakage
Areas of
overcontouring
usually required, which results in considerable
Fig. 15-7 inconvenience for both patient and dentist. Dis-
The connectors of an interim xed dental prosthesis are often
placement is best prevented through proper tooth
purposely overcontoured. A, In the anterior region, the degree
of overcontouring is substantially limited by esthetic require- preparation and an interim restoration with a closely
ments. B, In the posterior region, esthetics is less restrictive, but adapted internal surface. Excessive space between
overcontouring still must not jeopardize the maintenance of the restoration and the tooth places greater demands
periodontal health. on the luting agent, which has lower strength than
regular cement and thus cannot tolerate the added
force. For this and for biologic reasons, unlined pre-
the risk of failure, connector size must be increased formed crowns should be avoided.
in the interim restoration in comparison with the
denitive restoration (Fig. 15-7). Greater strength is Removal for reuse
achieved by reducing the depth and sharpness of the Interim restorations often need to be reused and so
embrasures. This increases the cross-sectional area should not be damaged when removed from the
of the connector while reducing the stress concen- teeth. In most instances, if the cement is sufciently
tration associated with sharp internal line angles. weak and the interim restoration has been well fab-
The biologic and sometimes the esthetic require- ricated, it does not break upon removal.
ments place limits on just how much larger connec-
tors can be made. To avoid jeopardizing periodontal
Esthetic Requirements
health, they should not be overcontoured near the
gingiva (Fig. 15-8). Good access for plaque control The appearance of an interim xed restoration is
must have high priority. particularly important for incisors, canines, and
In some instances, cast metal or heat-processed sometimes premolars. Although it may not be possi-
resin interim restorations can spare the practitioner ble to duplicate exactly the appearance of an un-
and the patient inconvenience, lost time, and the restored natural tooth, the tooth contour, color,
expense of remaking a restoration (Box 15-1). translucency, and texture are essential attributes.
When necessary, esthetic enhancement procedures
Displacement are available to create personalized details; however,
If irritation to the pulp and tooth movement are to because these are not routinely called for, they are
be avoided, a displaced interim restoration must be addressed on page 500, after the discussion of
recemented promptly. An additional ofce visit is cementation and repair.
How well a material matches the color of adjacent

teeth initially is easily recognized as an essential
requirement of prosthodontics. However, some
resins discolor with time intraorally,7 and thus color
stability (along with the propensity for stain accu-
mulation) governs the selection of materials when a A
long period of service is anticipated.
The interim restoration is often used as a guide to
achieve optimum esthetics in the denitive restora-
tion. In complete denture prosthodontics, it is cus-
tomary to have a wax evaluation so that the patient
can respond to the dentists esthetic interpretation
before the denture is processed. Many dentists con-
sider this essential because of the frequency of
patients requests for changes and the ease with
which such changes can be made. When xed B
prosthodontics is performed in the anterior oral
cavity, it greatly inuences appearance, and the
patient should be given an opportunity to voice an
opinion. Beauty and personal appearance are highly
subjective and difcult to communicate verbally, Fig. 15-9
and a facsimile prosthesis can play a vital role in the A, This interim xed dental prosthesis established anterior
patients consideration of esthetics and the effect guidance and pontic form before work on the denitive restora-
that the prosthesis has on his or her self-image. tion was begun. (Note the facial cavosurface margin of the
Obtaining the opinions of others whose judgment is mandibular second premolar covered by the interim restora-
valued is also important. An accurate interim tion to protect it from damage.) B, The denitive restoration
restoration is a practical way of obtaining specic closely matches its predecessor in form and function.
feedback for the design of a denitive restoration.
Word descriptions alone are often too vague and fre-
quently cause overcorrections, which are difcult to edentulous ridge contact area. The terms external
reverse in the denitive restoration. The interim surface form (ESF) and tissue surface form (TSF) are
restoration is shaped and modied until its appear- suggested for these mold parts. This terminology is
ance is mutually acceptable to dentist and patient. used in the ensuing discussions.
When this is achieved, an impression is made of the
interim restoration (Fig. 15-9) and a cast is poured.
External Surface Form
This cast accompanies the xed prosthodontic de-
nitive cast to the laboratory, where the contours are There are two general categories of ESFs: custom
duplicated. This process is more efcient when it and preformed.
begins with diagnostic waxing procedures. Involving
the patient in decision making results in greater Custom
patient satisfaction. A custom ESF is a negative reproduction of either
the patients teeth before preparation or a modied
diagnostic cast. It may be obtained directly with any
MATERIALS AND PROCEDURES impression material. Impressions made in a quad-
Many procedures involving a wide variety of materi- rant tray with irreversible hydrocolloid or silicone
als are available to make satisfactory interim restora- are convenient. The higher cost of addition silicone
tions (Fig. 15-10). As new materials are introduced, may be offset by its ability to be retained for possible
associated techniques are reported, and thus there is reuse at any future appointment. Accurate reseating
even more variety. It is a helpful principle that all the of the ESF is easier and the mold cavity produces
procedures have in common the formation of a mold better results if thin areas of impression material (as
cavity into which a plastic material is poured or may be found interproximally or around the gingival
packed. Furthermore, the mold cavity is created by margin) are trimmed away (Fig. 15-11). The mold-
two correlated parts: one forming the external able putty materials are popular because they can be
contour of the crown or FDP, the other forming the used without a tray and are easily trimmed to
prepared tooth surfaces and (when present) the minimum size with a sharp knife. Also, their exi-
A B
C D
E F
Fig. 15-10
Although there are many variations, molds used in making interim restorations consist of an external surface form (ESF) and a tissue
surface form (TSF). Direct techniques entail use of the patients mouth directly as the TSF. A, Indirect technique: ESF, an alginate impres-
sion; TSF, a quick-set plaster cast. B, Direct technique: ESF, a baseplate wax impression; TSF, the patient. C, Direct technique: ESF, a
vacuum-formed acetate sheet; TSF, the patient. D, Direct technique: ESF, a polycarbonate preformed shell; TSF, the patient. E, Indirect-
direct technique: ESF, a custom preformed three-unit xed dental prosthesis shell (maxillary right central incisor to canine) made indi-
rectly; TSF, the patient. F, Indirect technique: ESF, a silicone putty impression; TSF, a quick-set plaster cast of the preparations.
Fig. 15-11
Shortening proximal projections of the impression material facilitates complete reseating of the ESF. Note that excess impression mate-
rial palatally and facially has been trimmed away with a sharp knife for this reason. The anterior sextant tray shown was selected because
it adequately captures the teeth adjacent to the proposed interim restoration.
bility facilitates subsequent removal of the polymer- is still pliable (Fig. 15-13). This produces a transpar-
ized resin (Fig. 15-12). ent form with thin walls, which makes it advan-
A custom ESF can be produced from thermoplas- tageous in the direct technique because of its
tic sheets, which are heated and adapted to a stone minimum interference with the occlusion. It is lled
cast with vacuum or air pressure while the material with resin, placed in the mouth, and fully seated as
A B
Fig. 15-12
A, One of the exible silicone putties suitable for making external surface forms. B, The putty form has been spread apart. Note the
completed resin interim restoration in place, to demonstrate the degree of putty exibility.
A B
C D
Fig. 15-13
A, Inexpensive system for producing external surface forms from thermoplastic sheets. B, After heating, the sheet is formed with
reusable putty and nger pressure applied over a stone cast. C, More expensive system incorporating an electric heating element
and a vacuum source. D, Trimmed polypropylene external surface form. Note the detail that can be captured with this material.
A B
Fig. 15-14
A, The thinness and transparency of these external surface forms (ESFs) allow their use directly as tooth-reduction guides both in
and out of the mouth. B, Tooth reduction may be assessed by using the ESF to mold alginate over the prepared tooth. When the
alginate is set, the ESF is removed, and a periodontal probe is pushed through the alginate for measurements at desired locations.
(B, Courtesy Dr. T. Roongruangphol.)
the patient closes into maximum intercuspation.

Little additional effort is required to adjust the
occlusal contacts. The thinness of the material may
also be a disadvantage in the direct technique,
however. The material is a poor dissipater of the heat
released during resin polymerization, and so care A
must be taken to remove it from the mouth before
injury can occur. A thermoplastic ESF has other uses
in xed prosthodontic treatment, in both the clinical
and the laboratory phase; for example, it can be
helpful in evaluating the adequacy of tooth
reduction8,9 (Fig. 15-14).
Transparent sheets are available in cellulose
acetate or polypropylene of various sizes and thick-
nesses; a 125 125 mm sheet of 0.5-mm (0.020- B
inch) thickness is recommended for making interim
restorations. Polypropylene is preferred because it
produces better surface detail and is more tear resist-
ant. Better tear resistance makes initial removal from
the forming cast less tedious and enables the ESF to Fig. 15-15
be used more than once. A, The time necessary to modify this particular preformed
Although thermoplastic sheets have a number of crown outweighs the advantages it might provide. Were a
advantages, a wide variety of other materials and custom external surface form available, it would be more ef-
methods can be used successfully. For example, cient and more economical. B, The excessively tapered inter-
some practitioners favor baseplate wax because it is nal lingual wall of this preformed crown requires grinding in
convenient and economical (see Fig. 15-10B). order to accommodate a properly prepared tooth. The stone
cast in the lower portion of the illustration duplicates the inter-
Preformed nal surface of the preformed crown.
Various preformed crowns are available commer-
cially. On their own, they rarely satisfy the require-
ments of a interim restoration, but they can be consuming. Preformed crowns are generally limited
thought of as ESFs rather than as nished restora- to use as single restorations, because it is not feasible
tions and thus must be lined with autopolymerizing to use them as pontics for partial FDPs.
resin. Most crown forms need some modication Materials from which preformed ESFs are made
(internal relief, axial recontouring, occlusal adjust- (Fig. 15-16) include polycarbonate, cellulose acetate,
ment) in addition to the lining procedure (Fig. 15- aluminum, tin-silver, and nickel-chromium. These
15). When extensive modication is required, a are available in a variety of tooth types and sizes
custom ESF is superior because it is less time (Table 15-2).
Polycarbonate Polycarbonate ESFs are supplied in incisor, canine,

Polycarbonate (Fig. 15-17) has the most natural and premolar tooth types.
appearance of all the preformed materials. When Cellulose acetate
properly selected and modied, it rivals in appear- Cellulose acetate is a thin (0.2- to 0.3-mm) trans-
ance a well-executed porcelain restoration. Although parent material available in all tooth types and a
available in only a single shade, this can be modied range of sizes (see Fig. 15-16A). Shades are entirely
to a limited extent by the shade of the lining resin. dependent on the autopolymerizing resin. The resin
does not chemically or mechanically bond to the
inside surface of the shell; therefore, after polymer-
ization, the shell is peeled off and discarded to
prevent staining at the interface. Removing the shell
has the disadvantage of necessitating the addition of
resin to reestablish proximal contacts.
Fig. 15-16
A, Preformed anterior crown forms: polycarbonate (left) and
cellulose acetate (right). B, Preformed posterior crown forms: Fig. 15-17
aluminum shell (left), aluminum anatomic (center), and tin- Polycarbonate crowns. Available in maxillary and mandibular
silver anatomic (right). incisor, canine, and premolar shapes.
Table 15-2 PREFORMED CROWNS

AREA OF USE
Sizes in Approximate
Incisor Canine Premolar Molar each mold cost ($/unit)
RESIN
Cellulose acetate X X X X 6 1.00
Polycarbonate X X X 7 0.64
METAL
Aluminum X X 20 0.16
Aluminum (anatomic) X X 6 2.90
Tin-silver (anatomic) X X 7 5.00
Nickel-chromium X* X* X X 5 4.83
(anatomic)
*Primary teeth.
Fig. 15-18 Fig. 15-19

Aluminum anatomic crowns. Available in a variety of sizes and Nickel-chromium anatomic crowns. These are available in an
shapes. The manufacturer has produced two maxillary and four array of sizes and shapes, including ones for the primary teeth,
mandibular shapes for the left and right side of the mouth, each with straight and contoured axial surfaces.
in six sizes.
Aluminum and tin-silver very hard and thus can be used for longer-term
Aluminum (Fig. 15-18) and tin-silver are suitable for interim restorations.
posterior teeth. The most elaborate crown forms
have anatomically shaped occlusal and axial sur-
Tissue Surface Form
faces. The most basic and least expensive forms are
merely cylindrical shells resembling a tin can (see There are two primary categories of TSFs: indirect
Fig. 15-16B). and direct. A third category, indirect-direct, is the
The nonanatomic cylindrical shells are inexpen- sequential application of these.
sive but require modication to achieve acceptable
occlusal and axial surfaces. It is more efcient to use Indirect procedure
crowns that have been preformed as individual max- An impression is made of the prepared teeth and
illary and mandibular posterior teeth. Care must ridge tissue and is poured in quick-setting gypsum
also be taken to avoid fracturing the delicate cavo- or polyvinyl siloxane.10 The interim restorations are
surface margin of the tooth preparation when a fabricated outside the mouth. This technique has
metal crown form is tted. This is a greater risk if several advantages over the direct procedures:
adaptation is carried out directly by having the 1. There is no contact of free monomer with the pre-
patient forcefully occlude on the crown shell. The pared tooth or gingiva, which might cause tissue
edge of the shell can engage the margin and fracture damage11 and an allergic reaction or sensitiza-
it under biting pressure. An even greater risk occurs tion.1215 One group of investigators16 reported a
when the crown has a constricted cervical contour. 20% incidence of allergic sensitivity in subjects
Tin-silver crowns are deliberately so designed (see previously exposed to a monomer patch test. The
Fig. 15-16B). This highly ductile alloy allows the risk of sensitization in patients who are not aller-
crown cervix to be stretched to t the tooth closely. gic to monomer increases with the frequency of
Direct stretching on the tooth is practical only where exposure. In allergic patients, an exposure to even
feather edge margins are used. For other margin small amounts of monomer usually causes
designs, cervical enlargement should be performed painful ulceration and stomatitis (Fig. 15-20).
indirectly on a swaging block, which should be sup- 2. The procedure avoids subjecting a prepared tooth
plied with the crown kit. to the heat evolved from polymerizing resin. The
Nickel-chromium exotherm charted in Figure 15-21 gives an indi-
Nickel-chromium shells (Fig. 15-19) are used pri- cation of temperature increases with time for
marily for children with extensively damaged several materials under similar experimental
primary teeth. In that application, they are not conditions. Clinical simulation experiments17,18
lined with resin but are trimmed, adapted with have shown peak temperature increases of
contouring pliers, and luted with a high-strength approximately 10 Celsius in the pulp chambers
cement. They may be applied to secondary teeth of prepared teeth upon which direct interim
but are more suitable for primary teeth, where restorations had been made. That amount of
longevity is less critical. Nickel-chromium alloy is temperature elevation is capable of causing
A B
Fig. 15-20
Labial (A) and gingival (B) ulcerations after brief polymethyl methacrylate monomer exposure.
70 Sevriton
60
Temperature (C)
50 TCB
Scutan
Trim
40
30
20
0 1 2 3 4 5 6 7 8 9 10 11
Time (min)
Fig. 15-21
Heat generated during resin polymerization. Under nonclinical experimental conditions, the temperature rises are severe. Sevriton
(a polymethyl methacrylate resin) produced signicantly higher temperatures than did the others represented. This is useful infor-
mation for selecting resins to be used intraorally, although under clinical conditions the differences may be insignicant. (Redrawn
from Braden M, et al: A new temporary crown and bridge resin. Br Dent J 141:269, 1976.)
irreversible damage to the pulp.19 The simulation and the practical reason that it must be drawn
experiments also indicate that temperature rise through the undercuts of adjacent proximal tooth
depends directly on the type and volume of resin surfaces, the resin should be removed at the
present. Therefore, a directly made restoration rubbery stage of polymerization, which typically
with a large pontic is more likely to cause injury occurs 2 to 3 minutes after insertion in the
than one for a single crown (especially if the tooth mouth. In Figure 15-22, the temperature rise is
is prepared conservatively). These studies also negligible at 3 minutes, which suggests that
demonstrate that the heat-conducting properties thermal injury is easily avoidable.
of the ESFs signicantly inuence the maximum 3. The marginal t of interim restorations that have
temperature reached. However, of importance is been polymerized undisturbed on stone casts is
that peak temperatures were not reached until 7 signicantly better than that of interim restora-
to 9 minutes had elapsed18 (Fig. 15-22). For this tions that have been removed from the mouth
40 Methylmethacrylate (Jet) restoration. However, the direct technique has sig-

Vinylethylmethacrylate (Trim)
nicant disadvantages: potential tissue trauma from
Bis-GMA Composite (Protemp)
the polymerizing resin and inherently poorer mar-
C 35 ginal t. Therefore, the routine use of directly
formed interim restorations is not recommended
30
when indirect techniques are feasible.
Indirect-direct procedure
1 2 3 4 5 6 7 8 9 10 11 12
Time In this technique the indirect component produces
Fig. 15-22 a custom-made preformed ESF similar to a pre-
These exotherms (time in minutes) are derived from a simu- formed polycarbonate crown. In most cases, the
lated clinical procedure for making a single crown with silicone practitioner uses a custom ESF with an underpre-
putty as the ESF. A thermocouple probe in the pulp chamber pared diagnostic cast as the TSF. The resulting mold
of an extracted tooth was used to measure temperature forms a shell that, after tooth preparation, is lined
changes. Initial readings reect the cooling effect of room- with additional resin (the patient serving as the TSF).
temperature resin mixtures. For all three classes of resins This last step is the direct component of the proce-
tested, the temperatures did not exceed 35C until more than dure. Another method of creating the shell elimi-
6 minutes had elapsed. (Redrawn from Tjan AHL, et al: Temper-
nates the need for an indirect TSF. It is accomplished
ature rise in the pulp chamber during fabrication of provisional
crowns. J Prosthet Dent 62:622, 1989.)
by painting monomer liquid into the ESF and care-
fully sprinkling or blowing resin powder on it. The
thickness of the resin shell is difcult to control with
this technique, however, and may result in the need
before becoming rigid.20,21 The reasons for this for time-consuming corrective grinding.
are that (1) the stone restricts resin shrinkage The indirect-direct approach has these ad-
during polymerization and (2) separating the vantages:
resin from the tooth causes distortion. Directly 1. Chairside time is reduced. Most of the procedures
made long-span or multi-abutment partial FDPs have been completed before the patients visit.
are likely to have unacceptable marginal discrep- 2. Less heat is generated in the mouth. The volume
ancies caused by shrinkage and distortion. of resin used during lining is comparatively small.
4. When a dimensionally stable elastomer impres- 3. Contact between the resin monomer and soft
sion is made to form the TSF,10 it can be retained tissues is minimized in comparison with the
for possible reuse with the ESF. This allows direct procedure. Because pontic ridge areas do
replacement restorations to be made without not normally require lining, there is reduced risk
having the patient present. For example, if a of allergic reaction.
patient calls to report a lost interim partial FDP, However, even with the diagnostic cast method,
a replacement can be made at the dentists con- adjustments are frequently needed to seat the shell
venience before the patient arrives. This mini- completely on the prepared tooth. This is the chief
mizes disruption of the ofce schedule and earns disadvantage of the indirect-direct procedure.
the appreciation of the patient. Whether using an
elastomer TSF results in margins that t as well
Materials for Interim Fixed Restorations
as those obtained with a gypsum TSF is not
known. The elastomer may not resist polymer- While in a uid state, the interim restorative mate-
ization shrinkage as effectively as the gypsum. rials ll the cavity formed by the external and TSFs;
5. The technique gives the patient a chance to rest, they then solidify, producing a rigid restoration.
and it frees the dentist to perform other tasks, pro-
vided that an auxiliary is trained to carry out the Ideal properties
laboratory procedures. The characteristics of an ideal interim material are
as follows:
Direct procedure Convenient handling: adequate working time, easy
The patients prepared teeth and gingival tissues (in molding, rapid setting time
the case of a partial FDP) directly provide the TSF, Biocompatibility: nontoxic, nonallergenic, nonexo-
and so the intermediate steps of the indirect tech- thermic
nique are eliminated. This is convenient when assis- Dimensional stability during solidication
tant training and ofce laboratory facilities are Ease of contouring and polishing
inadequate for efciently producing an indirect Adequate strength and abrasion resistance
A B
C D
Fig. 15-23
Currently available interim materials. A, A poly(methyl methacrylate) resin. B, A poly(R methacrylate) resin. C, Microlled com-
posite resins with AutoMix delivery system. D, Light-cured resins: a microlled urethane-dimethacrylate (left) and a light-cured poly-
ethyl methacrylate.
Good appearance: translucent, color controllable, categories. Choosing a material should be based on
color stable optimally satisfying the requirements or conditions
Good acceptability to patient: nonirritating, crucial for the success of the treatment. For example,
odorless materials with the least toxicity and least polymer-
Ease of adding to or repairing ization shrinkage should be chosen for a direct tech-
Chemical compatibility with interim luting agents nique. Alternatively, when a long-span prosthesis is
being fabricated, high strength is an important selec-
Currently available materials tion criterion.
As yet, an ideal interim material has not been devel-
oped. A major problem still to be solved is dimen-
sional change during solidication. These materials
MATERIALS SCIENCE
(Fig. 15-23) shrink and cause marginal discrep- William M. Johnston
ancy,2022 especially when the direct technique is
used (Fig. 15-24). Also, the resins currently employed The material used for fabrication of an interim
are exothermic and not entirely biocompatible. restoration consists of pigments, monomers, ller,
The materials can be divided into four resin and an initiator, all combining to form an esthetic
groups: restorative substance. The pigments are incorporated
Poly(methyl methacrylate) by the manufacturer so that the set material appears
Poly(R methacrylate)* as much like natural tooth structure as possible, with
Microlled composite a variety of shades available. Although each of the
Light-cured other ingredients plays a role in the handling, setting,
The properties of these resins are compared in and nal properties of the interim restoration, many
Table 15-3. The overall performances of the groups important characteristics of the material are deter-
are similar, with no material being superior in all mined by the primary monomer. The ability of this
monomer to convert to a polymer allows the mate-
*The R represents an alkyl group larger than methyl (e.g., ethyl or isobutyl). rial, after it has been formed as desired, to set into a
A small amount of
resin shrinkage will
result in a significant-
ly open margin.
Fig. 15-24 With ideal axial wall convergence, a 2% reduction in crown diameter results in a comparatively high marginal
discrepancy.
solid that is durable enough to withstand the oral a monomer. Free radicals are formed by the decom-
environment for the necessary interim period. position of a chemical (the initiator), with the
Depending on the brand, the most commonly method of decomposition dependent on the nature
used monomers are methyl methacrylate, ethyl of the initiator. Possible initiators include benzoyl
methacrylate, isobutyl methacrylate, bisphenol A peroxide and camphoroquinone.
diglycidylether methacrylate (bis-GMA), and ure- Benzoyl peroxide decomposes to free radicals at
thane dimethacrylate. Each of these, or combina- approximately 50C or higher in a process called
tions thereof, may be converted to a polymer by free thermal activation. Because the heating of some
radical polymerization, although the conversion monomers to temperatures near 100C can cause
process is never perfectly complete. them to vaporize, with subsequent formation of
porosity in the resultant polymer, excessive temper-
atures should be avoided during the early stages of
Free Radical Polymerization
thermal activation. Thermal activation results in
The polymerization process invokes chemical, greater contraction on cooling than is obtained with
mechanical, dimensional, and thermal changes that other activation methods and therefore is usually
affect the successful use of these materials in den- avoided for interim restorations.
tistry. Because monomers may be unpleasant or Benzoyl peroxide also decomposes to free radicals
even harmful biologically, the chemical conversion when catalyzed by a tertiary amine, and this process
of monomer to a biologically inert polymer is desir- is called chemical activation. Chemical activation
able. Also, if the polymerization process is not prop- occurs when the activator, initiator, and monomer
erly initiated or if it is prematurely terminated, the are mixed together, and so these materials are
resultant restoration may not have adequate usually supplied separately, the monomer and acti-
mechanical properties and may fail easily or quickly. vator in one container and the initiator and ller in
However, because the density of the polymer is another. Proper mixing is necessary to prevent voids.
inherently and often substantially greater than that Because chemical activation requires intimate
of the monomer, a dimensional contraction occurs contact of the chemical activator with the initiator,
during polymerization. The polymerization reaction this activation method is not as efcient as thermal
is exothermic, which causes the material to become activation. Inefcient activation of the initiator
hot before it loses its uidity, and so an additional results in more residual monomer and less color sta-
contraction occurs on cooling of the restoration. If a bility of the restoration, inasmuch as unreacted
direct technique is being used, the heat of reaction benzoyl peroxide can cause color changes. However,
can cause irreversible damage to nearby pulpal because benzoyl peroxide is decomposed by both
tissues, which may already have been thermally thermal and chemical activation, increased temper-
insulted during cavity preparation. ature can enhance its decomposition in a chemically
cured system and does not increase contraction if
Initiation the restoration initially undergoes chemical setting.
Free radical polymerization begins with the forma- Heating a recently set restoration in 100C water
tion of a free radical, a process called activation, and promotes greater polymerization efciency and
the subsequent combination of this free radical with removes any unconverted monomer, which might
480
PART II
Table 15-3 RANKED CHARACTERISTICS OF REPRESENTATIVE PROVISIONAL

RESTORATION RESINS
Material/characteristic A B C D E F G H I J K L M N
Jet (PMMA) 2* 2 3 1 1 3 1 2 1 1 2 1 3 1

Duralay (PMMA) 1 3 1 2 1 1 1 3 1

Trim (PRMA) 2 1 2 3 3 2 3 1 1 3 1 2 1
Snap (PRMA) 2 2 2 2 2 3 1 1 1 2 1

Protemp Garant (bis-GMA 1* 1 1 2 2 1 2 3 2 2 1 2 1 2
composition)
CLINICAL PROCEDURES: SECTION 1
Unifast LC (light-cured, PRMA) 2* 2** 3 2 2 1 3 1 2 3 2

Triad (light-cured, urethane 2 3 1 1 1 1 3 1 3 3 3 1 3
DMA composition)
Column heads: A, marginal adaptation (indirect); B, temperature release during reaction; C, toxicity/allergenicity; D, strength (fracture toughness); E, repair strength (% original);
F, color stability (ultraviolet light); G, ease of trimming and contouring; H, working time; I, setting time; J, owability for mold lling; K, contaminated by free eugenol; L, special
equipment needed; M, odor; N, unit volume cost.
Numbers in table: 1, Most desirable; 2, Less desirable; 3, Least desirable.
*Tjan AHL, et al: Marginal delity of crowns fabricated from six proprietary provisional materials. J Prosthet Dent 77:482, 1997.
Wang RL, et al: A comparison of resins for fabricating provisional xed restorations. Int J Prosthodont 2:173, 1989.
Gegauff AG, Pryor HG: Fracture toughness of provisional resins for xed prosthodontics. J Prosthet Dent 58:23, 1987.
Koumjian JH, Holmes JB: Marginal accuracy of provisional restorative materials. J Prosthet Dent 63:639, 1990.
Gegauff AG, Rosenstiel SF: Effect of provisional luting agents on provisional resin additions. Quintessence Int 18:841, 1987.
**Castelnuovo J, Tjan AH: Temperature rise in pulpal chamber during fabrication of provisional resinous crowns. J Prosthet Dent 78:441, 1997.
Doray PG, et al: Accelerated aging affects color stability of provisional restorative materials. J Prosthodont 6:183, 1997.
Bis-GMA, bisphenol A diglycidylether methacrylate; DMA, dimethacrylate; PMMA, poly(methyl-methacrylate); PRMA, poly(R methacrylate).
cause a sensitivity reaction in a patient susceptible to Filler

monomer irritation. Although the primary properties of an interim
Camphoroquinone decomposes to free radicals in restorative material are determined by the monomer
the presence of both an aliphatic amine and blue or monomers involved, a decrease in the less desir-
light energy, and this process is called visible-light acti- able setting and mechanical properties is accom-
vation. Light-activated materials have two advan- plished mainly through the ller. An increase in
tages: (1) the ingredients can be mixed by the ller content reduces the relative amounts of
manufacturer with little porosity, and (2) working exothermic heat and contraction while increasing
time is innitely long because no setting occurs if the the strength of the set material. However, too much
material is kept in a dark environment. The limita- ller can lead to insufcient handling characteristics
tion of this method is the depth to which visible light before setting, and this impedes mixing and shaping,
can penetrate (less for darker materials). Whenever as well as introduces porosity in the set restoration.
possible, the activation illumination should be For light-activated systems, the amount of ller is
directed toward the center of the restoration from all determined by the manufacturer; for the other
surfaces. Also, for darker materials, the exposure systems, it is desirable to incorporate as much ller
time should be longer. as possible without interfering in the handling or
manipulation characteristics of the material.
Propagation

After its onset, the polymerization process continues
by including more monomer molecules in the
growing molecular chain. It is important that the PROCEDURES
material be allowed to set undisturbed because, To minimize duplication, a basic clinical and a basic
during this phase, defects can easily result if the laboratory armamentarium are listed just once; they
material is jostled. During propagation, (1) the may be referred to as needed. As each procedure is
setting material undergoes an increase in density, discussed, only items necessary to augment the basic
causing contraction, (2) the exothermic heat of reac- armamentarium are listed.
tion may cause a substantial increase in temperature,
with subsequent increased contraction, and (3)
other physical properties (e.g., rigidity, strength, and
Clinical Armamentarium (Fig. 15-25)
resistance to dissolution) increase. Gloves
Face mask
Termination Protective eyewear
Because of the randomness of position of the Mouth mirror
growing chains, it is possible that some of them Explorer
might combine and thereby terminate the growth Periodontal probe
process. This type of termination cannot be avoided, Saliva evacuator
although it is desirable to have termination only after Cotton rolls
polymerization of all the monomer has occurred. Gauze squares
Termination may also result from the reaction with Gingival displacement cord
eugenol, hydroquinone, or oxygen; therefore, contact Astringent solution
with these substances must be avoided or at least Cotton-roll pliers
minimized when possible. Plastic lling instrument
Cotton pellets
Petrolatum
Properties Associated with the Monomer
Autopolymerizing resin
The various monomers exhibit different initial and Dropper
setting characteristics and result in polymers with Three dappen dishes
signicantly different properties (i.e., viscosity before Cement spatula
setting, exothermic heat of reaction, dimensional Backhaus towel clamp forceps
change on setting, and strength). In general, the Soft lead pencil
greater the size of the monomer molecule, the less Straight slow-speed handpiece
is the exothermic heat of reaction on setting and the Carborundum disks with mandrels, straight
lower the physical strength of the set mass. handpiece
Properties of available materials are presented in Fine garnet paper disks (7/8-inch diameter) with
Table 15-3. mandrels, straight handpiece
Straight slow-speed handpiece

Carborundum disks with mandrels, straight
handpiece
Fine garnet paper disks (7/8-inch diameter) with
mandrels, straight handpiece
Tungsten carbide burs, straight handpiece
Dental lathe
A Muslin wheels
Robinson bristle brushes
Felt wheels (1-inch diameter) with mandrels
Fine pumice
Resin-polishing compound
Ultrasonic cleaner with detergent solution
Custom Indirect Interim Partial Fixed

Dental Prostheses
The custom indirect procedure is probably the best
overall technique for partial FDPs and should
provide the most predictable results with the least
B risk to patient health.
Additions to clinical armamentarium
Shade guide
Irreversible hydrocolloid impression material
Fig. 15-25 Rubber bowl
A and B, Basic clinical armamentarium. Impression tray
Mixing spatula
Step-by-step procedure
1. After shade selection and tooth preparation,
Tungsten carbide burs, straight handpiece obtain an impression tray for an irreversible
High-speed handpiece with air-water supply hydrocolloid impression. A sextant impression is
Round bur (No. 4), friction-grip adequate only if it extends one tooth beyond the
Tungsten carbide 12-uted nishing bur, friction- abutments, and so the ESF will index accurately
grip (e.g., 7803) with the cast (TSF).
High-volume evacuation 2. Displace the gingiva if necessary to expose the
Articulating ribbon and holder cavosurface margins (Fig. 15-27).
Disposable brush 3. Make an irreversible hydrocolloid impression.
Cup of warm water Other clinical procedures (e.g., making the den-
itive impression) can take place while the assis-
Laboratory armamentarium (Fig. 15-26) tant is pouring the cast.
Protective eyewear
Face mask (for respiratory protection) Additions to laboratory armamentarium
Soft lead pencil Accelerated-setting plaster
Disposable brush Rubber bowl
Gypsum-resin separating medium Spatula
Autopolymerizing resin Vibrator
Dropper ESF
Two dappen dishes
Cement spatula Step-by-step procedure
Polypropylene syringe The setting of plaster can be accelerated by shaking
Rubber bands dry powder with the water before mixing (1 tsp of
Pressure vessel powder in 30 mL water23). Alternatively, a commer-
Cast trimmer cially available quick-setting plaster may be used.
A B
C D
Fig. 15-26
Basic laboratory armamentarium. A, Assorted small items appearing on the accompanying list. B, Pressure-curing vessel. C, Cast
trimmer. D, Dental lathe and dust collector. E, Ultrasonic cleaner and liquid detergent.
1. Pour the quick-setting stone or plaster into the the cavosurface margins of the preparations
irreversible hydrocolloid impression and allow with a soft lead pencil to serve as a guide for
it to set for 8 minutes. trimming later. This should not be done where
2. Remove the cast and trim it to provide proper the margins are highly visible.
indexing with the ESF. The ESF is normally 4. Mix autopolymerizing resin (methyl methacry-
made from a diagnostic waxing of the proposed late is a good choice) and load it into a
restoration. Check that the two forms t polypropylene syringe. The orice of the syringe
together passively and completely. tip should be about 2 or 3 mm in diameter.
3. Paint the cast uniformly with separating 5. Fill the ESF methodically with the syringe, start-
medium (Fig. 15-28). Avoid leaving unpainted ing at one end of the restoration space and
islands on the cast, especially at the cavosur- working to the other. To avoid trapping air, keep
face margin areas. Drying can be accelerated by the syringe tip in constant contact with the resin.
a gentle stream of air. Do not forcefully blow the The mold should not be overlled; the resin
medium from the surface of the cast. When should just reach the level of the gingiva
the cast is thoroughly dry, it is optional to mark (Fig. 15-29).
Fig. 15-29
A polymer syringe with a widened orice (2 mm diameter) is
Fig. 15-27 useful for lling the external surface form (ESF). To avoid entrap-
Subgingival margins often require tissue displacement before ping air, it is best to begin at one end and progress slowly to
an adequate impression can be made. Alginate in a disposable the other, keeping the syringe tip in contact with the expressed
tray produces an economical and satisfactory impression. After resin.
treatment for infection control, the impression is poured in
quick-set plaster to create the tissue surface form (TSF).
6. Seat the TSF into the lled ESF (Fig. 15-30).

They can be lightly held together by rubber
bands. The assembly is then placed in warm
water (40C [100F]) in a pressure vessel, after
which air is applied at about 0.15 MPa (20 psi).
Pressure curing reduces resin porosity.
A
7. Remove the assembly after 5 minutes.
8. Separate the ESF from the cured resin restora-
tion, which usually remains in contact with the
TSF (Fig. 15-31). The bulk of the stone can be
removed on a cast trimmer and with a car-
borundum disk (Fig. 15-32). If the margins were
marked with lead, dielike remnants of the TSF
should be retained for use as a guide to correct
trimming. However, the TSF often separates
completely from the resin during handling. This
is an advantage because it eliminates any
B further effort needed to remove the stone. Even
if the margins were marked, it would probably
be better to discard the stone and carefully mark
the resin margins with a ne-pointed graphite
pencil. This should not be postponed, because
the margins are more difcult to identify accu-
rately after trimming is begun.
Fig. 15-28
A, After trimming, the indirect tissue surface form (TSF) is 9. Eliminate resin ash with an acrylic-trimming
mated with the external surface form (ESF) to verify accurate bur and a ne-grit garnet paper disk.
passive indexing. B, With this accomplished, the forms are sep- 10. Contour the pontic areas according to proper
arated, and the TSF is completely coated with a resin-gypsum pontic design (Fig. 15-33) (see Chapter 20.)
separating medium (brushed on). 11. Finish the restoration with wet pumice. Do not
neglect the gingival surface of the pontic. If this
area is not otherwise accessible, a Robinson
brush on a straight handpiece should be used.
12. Check for and remove any resin blebs or rem-
nants of stone on the internal surfaces of the
restoration.
A B
C D
Fig. 15-30
A, The resin-lled external surface form placed on the tissue surface form. B, Rubber bands around the mold assembly and located
over adjacent unprepared teeth. This avoids distorting the external surface form. C, The assembly being placed into a pressure vessel
lled with warm water. D, The resin cures for 5 minutes under 0.15 MPa (20 psi) pressure.
to 9), provided that the patient has no history of

allergy to monomer. If occlusal correction is needed,
the restoration is marked with articulating ribbon
and adjusted with a 12-uted tungsten carbide n-
ishing bur rotating at high speed with copious air-
water spray to prevent the resin from melting (Fig.
15-35). Adequate intraoral evacuation and eye pro-
tection are essential.
14. After practicing appropriate infection control
procedures, return to the laboratory for nal wet
pumice nishing and dry polishing with resin-
polishing compound. If access to the gingival
Fig. 15-31 surfaces of the pontics is restricted, a 3/4-inch
External surface form removed. diameter felt wheel can be used for polishing.
Custom Indirect-Direct Interim Partial

13. Clean the restoration, using appropriate
Fixed Dental Prostheses
infection control procedures in preparation for
clinical try-in. The custom indirect-direct procedure may be a good
compromise when laboratory support is not imme-
Evaluation diately available and chair time must be minimized.
The interim partial FDP should be evaluated in the
patients mouth for proximal contacts, contour, Additions to laboratory armamentarium
surface defects, marginal t, and occlusion. De- (Fig. 15-36)
cient proximal contacts, imperfections in contour, or Diagnostic TSF (duplicate of conservatively pre-
surface defects can be corrected by adding resin pared diagnostic cast)
through the bead-brush technique (Fig. 15-34; see ESF (vacuum-formed polypropylene sheet)
Fig. 15-70). Original diagnostically prepared cast mounted on
Unacceptable marginal t can be corrected as for an articulator
custom indirect-direct partial FDPs (p. 487, steps 3 Articulating ribbon
A B,C
D E
Fig. 15-32
Tissue surface form reduced to attain the nal shape of the restoration. A, Bulk reduction on a cast trimmer. B, Sectioning and
removal of pontic-contact areas with a carborundum disk. C, Linguogingival surface of the pontic shaped with a tapered bur. D, An
abrasive disk (7/8-inch diameter, garnet) is excellent for creating proper embrasure form. It must be carefully oriented parallel to
the desired contour so that overtrimming at the margins is avoided. E, The contoured restoration.
Fig. 15-33
The restoration before try-in. Fig. 15-35
Intraoral adjustment of occlusal contacts.
Fig. 15-34
Proximal contact added by the bead-brush technique. When
the resin reaches the doughy stage, the restoration is set on the Fig. 15-36
prepared tooth to form the contact. Additions to the basic laboratory armamentarium for the
indirect-direct procedure: the diagnostic tissue surface form
(TSF) and the polypropylene external surface form (ESF).
Step-by-step procedure 3. Coat the stone TSF with separating medium.

1. Prepare the abutment teeth on articulator- 4. Perform a diagnostic waxing procedure on the
mounted diagnostic casts (Fig. 15-37). The diag- articulated casts. This step also is often recom-
nostic preparation should be more conservative mended in the treatment planning phase. The
than the eventual tooth preparation and should ESF is made from the diagnostically waxed cast.
have supragingival margins. These preparations If a thermoplastic sheet is used, it should be
are often helpful for treatment planning (see molded over a stone duplicate of the cast rather
Chapter 2). than directly on the wax (which melts if contacted
2. Make an irreversible hydrocolloid impression of by the heated sheet) (Fig. 15-39).
the diagnostic preparations to duplicate them in 5. Check that the external and TSFs t together
stone (Fig. 15-38). accurately (Fig. 15-40).
6. Using a syringe, apply the resin into the ESF and
complete the interim restoration as described in
the preceding section (see Figs. 15-29 to 15-33).
7. If the wax has been removed from the
diagnostic cast (after duplication), seat the
B
B
Fig. 15-39
Fig. 15-37 Creating a custom external surface form (ESF) from a diagnos-
Preparations involved in making the articulator-mounted diag- tic waxing. A, The diagnostically waxed articulated casts.
nostic cast. A, Conservative depth-orientation grooves. B, Patterns should satisfy biologic, mechanical, and esthetic
Placement of supragingival cavosurface margins. requirements. B, If a thermoplastic ESF is desired, the com-
pleted waxing must be duplicated in stone.
Fig. 15-40
Fig. 15-38 Proper relationship between the external surface form (ESF)
The prepared cast is duplicated by means of an alginate impres- and the tissue surface form (TSF). If it is necessary to remove
sion. This creates the indirect tissue surface form. Quick-set any cast artifacts to correct the relationship, this should be
plaster is used. done before the separating medium is applied.
completed interim restoration (custom-pre- teeth require more reduction, this should be done
formed ESF) on it and rene the occlusion by and the ESF then reevaluated and adjusted. The
using the articulator. If this cannot be done, more adjustment process can be tedious, particularly if
clinic time is required for adjustment. the preliminary steps were not performed care-
8. Finish and clean the preformed ESF for try-in, fully enough. This is the chief disadvantage of the
which follows tooth preparation (Fig. 15-41). indirect-direct procedure. The remaining steps
outline the (direct) procedure for lining, which is
Addition to clinical armamentarium necessary to produce internal and marginal adap-
Custom-preformed ESF tation (Fig. 15-43). Because of their relatively low
potential for tissue trauma, resins in the poly(R
1. Prepare the patients teeth in the usual manner.
2. Try in the preformed ESF (Fig. 15-42). If it is not
compatible with the occlusion (does not seat
completely) and the teeth have been reduced
adequately, the internal surface of the ESF should
be relieved until the occlusion is acceptable. If the
Fig. 15-42
Fig. 15-41 The custom-preformed external surface form (ESF) fully seated
The completed custom-preformed external surface form (ESF). over the prepared teeth. Note the marginal discrepancy on
This is the end product of the indirect component of the indi- each abutment. The tip of the periodontal probe easily ts into
rect-direct technique. the space, which will be lled by a direct lining procedure.
A B
C D
Fig. 15-43
Lining the custom-preformed external surface form (ESF). This is the direct component of the indirect-direct technique. A, Oral tissues
are protected with petrolatum. B, Vent holes help to eliminate trapped air. C, Abutment retainers lled with lining resin. D, The
restoration completely seated. (The amount of resin at the margins is controlled by covering or uncovering the vent holes.)
methacrylate) group are recommended for direct

procedures.
3. Apply a uniform coat of petrolatum on the pre-
pared abutment teeth, gingival tissues, and exter-
nal surfaces of the ESF.
4. Make a vent hole with a round bur through the
occlusal (or lingual) surface of each abutment A
retainer.
5. Fill the retainers with resin, and after it loses its
surface sheen, seat the restoration. Placing n-
gertips over the vent holes in a manner similar to
playing a ute can control the quantity of excess
resin expressed around the margin. When a small
amount of excess resin appears around the entire
periphery of the margin, the ngertip is lifted,
which allows trapped air and remaining excess
resin to escape. Resin on the occlusal surface can
be wiped away immediately, which eliminates the
need to grind it off after it sets.
6. When the rubbery stage of polymerization is
reached (about 2 minutes in the mouth), engage B
the facial and lingual surfaces of an abutment
retainer with the Backhaus forceps, and rock the
interim restoration buccolingually to loosen it.
Move to the other retainer and rock it in a similar
manner. When the partial FDP is loosened at
both ends, remove it from the patients mouth.
The forceps tines make small indentations in the
resin, but this is not usually a concern for poste-
rior units. The defects can be smoothed later
during the nishing procedures.
7. Place the interim restoration in warm water
(37C) to hasten polymerization.
8. After 3 to 5 minutes, mark the margins with a
C
sharp pencil and eliminate the excess resin. The
bulk of it can be removed with an acrylic resin-
trimming bur or carborundum disk (Fig. 15-44).
A ne-grit garnet paper disk completes axial
shaping.
Accurate trimming to the margins can be simpli-
ed by holding the disk parallel to the desired nal
contour. A paper-thin extension remaining beyond Fig. 15-44
the marked margin is an indication that the contour Removal of excess after the lining resin hardens. A, Margins
is correct and the cavosurface margin fully covered. marked with a sharp soft lead pencil. B, Gross resin excess is
Often this ash can be easily peeled away from the quickly removed. (Margins must be avoided.) C, The nal axial
margin with the ngers (Fig. 15-45). contours, connectors, and marginal t are perfected with an
abrasive disk rotating toward the margin to prevent debris from
9. Conrm the marginal t and occlusion, renish
obscuring the pencil line. Note the orientation of the disk, par-
and polish where necessary, and cement the allel to the desired nal contour.
restoration (Fig. 15-46).
Custom Single-Unit Interim Restorations basic procedures described for partial FPDs.
Because pontics are not involved, creating an ESF is
Complete crowns simpler. Diagnostic procedures are not required
Single-unit complete crowns or splinted crowns may unless extensive coronal changes are planned. For
be made directly or indirectly in accordance with the example, extensive changes are usually required
prevent fracture of enamel, which is likely to result

from the lesser strength of resin in comparison with
metal. Second, if lining is needed, an occlusal vent
hole is not necessary because the shape of these
restorations provides an adequate escape way for
trapped air and excess resin.
Inlays
Inlays present the problem of being small and dif-
cult to handle, especially during trimming.
Fig. 15-45 Making interim restorations requires a number of
Flash at the margin of a restoration whose axial surface was modications.
contoured with proper disk orientation. (Courtesy Dr. R.E. Kerby.) Additions to clinical armamentarium
Tofemire retainer/matrix band
Wedges
Amalgam condenser
Spoon excavator
Scalpel handle and blade (No. 15)
1. For a two- or three-surface inlay, apply the
matrix band and wedges as in preparation
for condensing a Class II amalgam restoration.
The wedges should be placed with rm
pressure so that when the band is removed,
proximal contact is reestablished. The band
must seal all aspects of the proximal cavosurface
margins.
Fig. 15-46 2. Using petrolatum on a small cotton pellet,
Occlusal contacts of the completed restoration are checked
lightly coat all sides of the cavity preparation
and adjusted before polishing. Note that the units are splinted
together for increased resistance to dislodgment during an
and the matrix band.
anticipated lengthy treatment period. (Courtesy Dr. R. Liu.) 3. Make a handle to remove the resin by placing
one end of a 2- to 3-cm length of unwaxed
dental oss in the preparation cavity.
4. Mix a small amount of poly-R methacrylate,
when the occlusal vertical dimension is increased. If and when it can be kneaded like bread dough,
diagnostic procedures are not needed, an alginate mold a small cone of it on the end of an
impression of the crown or crowns before tooth amalgam condenser.
preparation should be adequate to serve directly as 5. Lightly condense the resin into the cavity, being
the ESF or indirectly when a cast has been poured careful not to force it past the matrix into an
in another impression material. undercut. Immediately remove as much
occlusal excess as possible with a sharp spoon
Onlays and partial veneer crowns excavator.
The technique for making onlay and partial veneer 6. Monitor the polymerization by light probing
interim restorations is similar to that for making with a hand instrument. When the resin
custom single crowns. However, the interim restora- reaches the late rubbery stage, remove it by
tions are more easily distorted during handling tugging the oss handle with cotton roll forceps
because of the conservative tooth preparations that along the path of withdrawal (Fig. 15-47).
interrupt the continuity of the axial walls. Thus, the 7. Place the resin in a cup of warm water (37C)
direct method mandates extra care in separating the for 5 minutes.
resin from the tooth. Signicantly better results can 8. Mark the margins with a sharp pencil and trim
be expected with the indirect procedure. away whatever ash may be present.
Two other points merit mention. When the poly- 9. Return the cured resin to the cavity preparation
merized resin is trimmed to the margin, it is advis- and adjust the occlusion, using marking lm
able to leave an excess of resin at the occlusal and a slow-speed handpiece. (Take extreme care
cavosurface margin (see Fig. 15-9). This helps to avoid removing tooth structure.) Leave the
4. Light-cure the resin and remove it from the tooth

surface.
5. Thoroughly clean the petrolatum from the pre-
pared tooth enamel, and apply the etchant gel to
three 1-mm diameter areas to form an equilateral
triangle, with two of the corners at the mesioin-
cisal and distoincisal line angles and the third
centered more cervically. Allow the etchant to
remain for 20 seconds, rinse completely with
water, and dry.
6. Mix the autopolymerizing unlled resin and
place a small amount on the three etched areas.
Fig. 15-47 Immediately place the veneer on the tooth and
A oss handle facilitates removal of an inlay resin interim hold it in place until the resin is set.
restoration during late rubbery stage. 7. At the patients return visit, remove the veneers
with a spoon excavator.
oss handle in place as long as it does not inter-

Mass-Produced ESF Interim Crowns
fere with adjustments of the occlusion.
10. Remove the adjusted interim restoration with Under most circumstances, a custom ESF yields the
the oss handle and put it aside where it may best results in the shortest time. However, there are
be found easily after impression making for the instances when a custom ESF is not readily available:
denitive inlay. for example, a rst-visit emergency in which a crown
11. Clean and dry the cavity preparation and place is missing and must be replaced. If by coincidence a
a thin coat of interim cement on the cavity walls. crown form closely matches the size and shape of
Immediately insert the interim restoration. the desired interim restoration, the mass-produced
12. When the cement is set, remove the excess form is more convenient than initiating custom pro-
with an explorer and a spoon excavator. cedures (generating a diagnostic cast and waxing
Carefully cut off the oss handle with the the missing crown contours). Such coincidences,
scalpel blade. however, are not routine and should not be relied
upon. Whatever the situation, the dentist should
think of mass-produced interim crowns as ESFs; they
Laminate Veneers need to be lined with resin to meet the basic require-
ments of a interim restoration.
Composite resin shade guide
Polycarbonate Crown Forms
Light-cured composite resin
Hand-held curing light Polycarbonate crown forms are useful for making
Phosphoric acid etchant gel interim restorations on single anterior teeth and
Autopolymerizing unlled resin premolars.
Step-by-step procedure Additions to clinical armamentarium
1. Select the most appropriate resin shade or com- Assorted polycarbonate crowns
bination of shades before preparing the tooth. Boley gauge or dividers
2. When tooth preparation is complete, apply a thin Green stone, straight handpiece
coat of petrolatum to the prepared tooth surface.
3. Using a plastic instrument wetted with alcohol, Step-by-step procedure
form the preselected light-cured resin. 1. Measure the mesiodistal width of the crown
If the material is difcult to control, placement space with dividers (some crown kits provide a
and curing may be accomplished in stages. selection guide), and select a shell that is of the
It is also possible to form the veneers indirectly by same or slightly larger width (Fig. 15-48).
creating a TSF and an ESF, as was recommended for 2. Mark the crown height (from the incisal edge)
the partial FDP interim restoration. The indirect with a pencil (Fig. 15-49), and use this meas-
method may be more efcient if multiple veneers urement as a guide to trimming the shell so that
are being made. it matches the approximate curvature of the
B Fig. 15-49
Crown length adjustment. A, Incisocervical height required for
the completed restoration. B, Measurement transferred to the
crown. C, Cervical portion of the crown adjusted to duplicate
the curvature of the cavosurface margin.
Fig. 15-48
Crown selection. A, Measuring the mesiodistal width of the space
with dividers. B, Appropriate crown size for the measured space.
prepared cavosurface margin. For this trimming,

it is recommended that a green stone or small-
diameter carbide be used. A
3. Try the shell on the prepared tooth (Fig. 15-50),
being especially careful that the incisal edge
and labial surface of the shell align properly
with those of the adjacent teeth. The internal
surface of the shell often needs reduction to
achieve this match. For now, the occlusion
should be ignored, inasmuch as it is usually
better to adjust it after lining. When the shell
can be properly positioned without forceful gin-
gival contact, it is ready to be lined with resin. B
4. Apply a uniformly thin coat of petrolatum to
the prepared teeth and adjacent gingivae (Fig. 15-
51). This prevents direct contact of the monomer
with these tissues and the possibility of injury.
5. Mix the autopolymerizing resin and ll the shell Fig. 15-50
(poly[R methacrylate] is recommended). When A, Cervical portion of the crown trimmed until the length and
the surface just loses its gloss or the resin forms axial inclination are correct. B, If necessary, internal surfaces are
a peak without slumping, place the shell over adjusted for proper orientation of the crown.
the tooth and align the incisal and labial sur- 7. When the rubbery stage of polymerization is
faces with those of the adjacent teeth. reached (after about 2 minutes), rock the crown
6. Immediately eliminate any marginal excess. If faciolingually to loosen and remove it. The Back-
polymerization is too far advanced, the doughy haus forceps should be kept within easy reach
resin will pull away from the margin and neces- in case there is difculty separating the crown
sitate a repair later. from the tooth. However, because it makes small
indentations in the crown surface, the forceps
should be used only when needed on anterior
units.
8. Place the crown in warm water (37C)
(Fig. 15-52).
A 9. When the resin has fully set (after about 5
minutes), mark the margins with a sharp pencil.
The axial surfaces can be shaped, and ash
eliminated, with straight-handpiece carbide
burs or abrasive disks.
10. Try on the newly lined crown, and adjust the
lingual surface to the desired occlusion and
contour (Fig. 15-53).
11. Polish and cement the restoration (Fig. 15-54).
B C
Aluminum Crown Forms
Aluminum shells are useful for restoring single pos-
terior teeth, where their unnatural appearance is not
a disadvantage.
(Fig. 15-55)
D Assorted aluminum crowns
Dividers
Crown-and-collar scissors
Contouring pliers
Cylindrical green stone, straight handpiece
Fig. 15-51 Coarse garnet paper disk (7/8-inch diameter)
Lining the adjusted shell. A, Protection with petrolatum. The
shell is lled with resin (B) and is seated (C) when the resin Step-by-step procedure
does not slump after a peak is formed with the tip of an 1. Measure the mesiodistal width of the crown
explorer. D, Excess resin is immediately removed after the space, using dividers, and select an appropriate
crown has been positioned.
A B,C
Fig. 15-52
A, When the resin has reached the rubbery stage, the crown is removed and placed in warm water (37C). Hot water must not be
used, because it increases resin shrinkage. However, warm water is not recommended for polymethyl methacrylate resin, because
excessive shrinkage makes the marginal t unacceptable. B, After about 5 minutes in warm water, the resin should be rigid enough
for marking the margins. C, Initial removal of the excess lining resin is accomplished with a coarse garnet disk.
A B,C
Fig. 15-53
A, A considerable amount of lingual reduction may be called for. If it is only minor, it can be accomplished intraorally. B, To increase
efciency and ensure patient comfort, any bulk reduction should be accomplished extraorally. C, Finalized lingual contour that pro-
motes gingival health and allows access for oral hygiene. Note the more natural contour of the left central incisor than that of the
interim crown on the right central incisor.
A B,C
Fig. 15-54
A, A rag wheel and pumice are used before polishing with compound. Note the parallel orientation of the wheel to the crowns axial
surface at the point of contact (arrow). The crown should be positioned so that the wheel rotates from the surface toward the margin.
B, An explorer and dental oss are used to carefully remove all excess luting agent. C, Overpolishing results in a decient mesial
contact (arrow). The bead-brush technique is recommended for correcting a small inadequacy.
margin (Fig. 15-57). Sharp burrs left by the scis-

sors can be smoothed or rounded with the green
stone.
3. Place the trimmed shell over the prepared tooth,
and apply seating pressure gradually while
observing the gingiva. Trim the margins further
at any location where the gingiva blanches. The
shell margin should not engage the prepared
tooth margin.
4. Repeat the evaluation, and trim as necessary.
5. Instruct the patient to close with moderate force.
The soft aluminum should deform until normal
Fig. 15-55 intercuspation is reached (Fig. 15-58).
Additions to the basic clinical armamentarium for aluminum 6. Apply petrolatum to the prepared tooth and
crown forms. adjacent gingival tissues; mix poly(R methacry-
late) resin, and ll the shell.
shell type with a width as close as possible to 7. When the resin surface becomes matte, place
that measured. A slightly larger or smaller shell the shell over the tooth and guide it to a slightly
can be deformed with contouring pliers to supraclusal position (Fig. 15-59). Have the
attain the proper t (Fig. 15-56). patient close.
2. Measure the occlusocervical height, and trim 8. To avoid pulling the resin away from the cavo-
the shell with crown-and-collar scissors so that surface margin, immediately remove the mar-
it extends about 1 mm apical to the cavosurface ginal excess.
A B
Fig. 15-58
The patient is instructed to bite on the shell after the length
has been adjusted. Note the occlusal indentation and gingival
blanching (arrows). Additional shortening should be done
C
where the blanching occurs.
Fig. 15-56
Aluminum crown selection and modication. A, Mesiodistal
dimension of the space. B, Appropriate crown size, nearest this
measurement. C, Contouring pliers to make small size modi-
cations. This is frequently unnecessary. A
B
A
B
Fig. 15-59
A, Protection with petrolatum. B, The adjusted shell is lled
with lining resin and seated to just short of its nal position
after the resin has lost its sheen. C, The nal position is deter-
mined by the patients closing into maximum intercuspation.
Fig. 15-57 Excess resin is immediately removed.
A, Cervical portion of the crown trimmed to proper length.
B, Smoothing the cut edge to prevent gingival injury.
9. When the rubbery stage of polymerization is aluminum are not usually a problem and can be
reached (after about 2 minutes in the mouth), ignored until the patient returns, whereupon
engage the crown with the Backhaus forceps to they may be used to remove the crown again.
just penetrate the aluminum shell (Fig. 15-60). 10. Place the shell in a cup of warm water (37C).
Loosen and remove the crown by rocking it buc- 11. After about 5 minutes, mark the margins and
colingually or by using the thumb and index trim away any excess. To establish periodontally
nger of the other hand to apply occlusally healthy axial contours, the aluminum shell
directed force under the tines. The small buccal frequently is ground away in certain areas
and lingual holes created in the surface of the (Fig. 15-61).
12. Replace the crown and adjust the occlusion as
deemed necessary. If either proximal surface
lacks contact, resin can be added to correct the
deciency. Metal must be ground away in the
contact area to provide a resin-to-resin bond
(Fig. 15-62).
13. Polish, clean, and cement the restoration.
A
Post and Core Interim Restorations
Intraradicular retention and support are often
obtained from a cast metal post and core (see
Chapter 12). A interim restoration is needed while
the casting is being made.
B C Wire
Wire cutting pliers
Cylindrical green stone, straight handpiece
Wire-bending pliers
Paper points
Fig. 15-60
A, Backhaus forceps provides denite purchase of the shell for Step-by-step procedure
controlled removal. B, After 5 minutes in warm water, the 1. Place a piece of wire (e.g., a straightened paper
margin is marked with a pencil. C, A coarse garnet disk is re- clip) in the post space. To avoid root fracture, it
commended for initial contouring of the axial surfaces. This
must extend passively to the end of the post space.
usually necessitates partially removing the aluminum. After the
A mounted stone can be used to taper the wire if
overcontoured aluminum has been ground away, a ne garnet
disk is used to nalize the axial contours (including the mar- binding occurs.
ginal areas). Again, disk orientation is important to establishing 2. Mark the wire with a pencil at the mouth of the
a straight emergence prole and well-adapted margins. post space. Then, at a point slightly occlusal to this
A B
Fig. 15-61
A, Proper contouring of the axial walls exposes lining resin in the cervical area. Note the indentations in the shell from the Back-
haus forceps. B, Final occlusal adjustment removes the anodized gold nish, but this is of no concern.
A B
Fig. 15-62
Adding proximal contacts to aluminum crowns. A, Contacts absent in this lined crown (arrows). B, The metal in the contact area is
ground away to expose the underlying resin. The bead-brush technique is then used for correcting the deciency. C, Crown after
resin addition to the mesial surface. Further contouring with a disk is recommended to improve the gingival embrasure form.
A B
Fig. 15-63
Interim post preparation. A, Wire marked so that the bend is made at the correct level. When in position, the wire must not inter-
fere with the external surface form. B, A 180-degree or greater bend in the wire to resist displacement in the lining resin.
A B
Fig. 15-64
A, Wire in the post space just before placement of the lled external surface form (ESF). A gauze throat pack is recommended to
protect the patient from aspirating or swallowing the wire. B, Filled ESF seated.
mark, use the pliers to make a 180-degree bend Precautions must be taken to protect the patient
in the wire (Fig. 15-63). from swallowing or aspirating the wire.
3. Lubricate the tooth and surrounding soft tissues 6. Remove the ESF while the resin is still rubbery
with petrolatum. Paper points are convenient for (after about 2 to 21/2 minutes). The stage of poly-
lubricating the post space. merization should be monitored. If the resin is
4. Fill the ESF with interim resin (poly[R methacry- allowed to become rigid and lock into the under-
late] is recommended). cut surfaces within the post preparation, remov-
5. When the resin loses its surface gloss, place the ing it and the wire will be time consuming and
wire in the post space and seat the ESF over it risk the restorability of the tooth. The interim
(Fig. 15-64). usually remains in the ESF, which can be placed
Fig. 15-65
The completed interim post and crown restoration. Note the
unusual mesial contour (which is the result of a mesiobuccal
root amputation). Fig. 15-66
A noneugenol and a eugenol interim luting agent.
in warm water to hasten polymerization. The wire

must not be disturbed while the resin is soft. If the
interim remains on the tooth, it should be loos- most satisfactory. Zinc phosphate, zinc polycarboxy-
ened and reseated several times and then late, and glass ionomer cements are not recom-
removed before the resin has fully polymerized. mended because their comparatively high strength
7. Mark the margins with a pencil, and trim and makes intentional removal difcult. Using high-
contour the restoration with disks or straight- strength cements frequently damages the restoration
handpiece carbide burs. or even the tooth when removal is attempted and can
8. Evaluate the restoration in the mouth, and adjust make seating of the denitive restoration difcult.
as necessary. Weaker ZOE cements provide for easy removal,
9. Polish, clean, and cement the restoration allowing the restoration to be reused when addi-
(Fig. 15-65). tional service is needed. ZOE also has an obtundent
effect on the pulp in addition to its acceptable
sealing properties.24 Unfortunately, however, free
Cementation
eugenol acts as a plasticizer of methacrylate resins.
The primary function of the interim luting agent is It has been shown to reduce surface hardness25 and
to provide a seal, preventing marginal leakage and presumably strength. New resin applied over poly-
hence pulp irritation. The luting agent should not be merized resin previously in contact with free
relied upon to resist occlusal forces, inasmuch as it eugenol results in softening26 of the added resin,
is purposely formulated to have low strength. Unin- making linings or repairs unsuccessful. The R
tentional displacement of an interim restoration is methacrylates are severely affected by free eugenol.
frequently caused by a nonretentive tooth prepara- Methyl methacrylates are affected moderately, and
tion or excessive cement space rather than the the composites are only slightly softened. These
choice of luting agent. adverse effects have stimulated the marketing of
interim luting agents without eugenol, but in the
Ideal properties studies cited, the mere presence of eugenol in a
Desirable characteristics of an interim luting agent cement was not enough to cause adverse effects. It
are as follows: appears that unreacted or free eugenol must be
Seal against leakage of oral uid present to cause problems. Therefore, when using
Strength consistent with intentional removal products that contain eugenol, the dentist must be
Low solubility sure that the correct proportions are blended.
Blandness or obtundent quality Whether free eugenol is necessary to provide an
Chemical compatibility with the interim polymer obtundent effect on the pulp remains a question.
Convenience of dispensing and mixing In situations in which the tooth preparation lacks
Ease of eliminating excess retention, a span is great or long-term use is antici-
Adequate working time and short setting time pated, or parafunction exists, it may be desirable to
use a higher strength cement. A good compromise
Available materials would be reinforced ZOE; another might be eugenol-
Of the currently available materials (Fig. 15-66), free zinc oxide, which has slightly greater strength
zinc oxideeugenol (ZOE) cements appear to be the than cements containing eugenol.27 Conversely,
sometimes minimum strength is desired, as with Cement spatula (C)

temporary placement of the denitive restoration. Plastic lling instrument (D)
(Its removal may be needed to rere the porcelain.) Petrolatum (E)
Petrolatum can be mixed with equal parts of Mirror and explorer (F)
the interim cement base and catalyst to reduce the Dental oss (G)
cements strength by more than half. When Gauge (H)
the denitive cement planned is a resin luting agent,
non-eugenol cements are recommended for the Step-by-step procedure
interim restoration because of the adverse effect of Most interim luting agents are supplied as a two-part
eugenol on bond strength. system (Fig. 15-68).
1. To facilitate removal of excess cement, lubricate
Armamentarium (Fig. 15-67) the polished external surfaces of the restoration
Interim luting agent (A) with petrolatum (see Fig. 15-68A).
Mixing pad (B) 2. Mix the two pastes together rapidly, and apply
a small quantity just occlusal to the cavosurface
margin (see Fig. 15-68B). A marginal bead of
cement forms the required seal against oral
uids. Filling the crown or abutment retainers
B
H should be avoided, because it prolongs cleanup
G
and increases the risk of leaving debris in the
A C sulcus.
3. Seat the restoration and allow the cement to set
(see Fig. 15-68C).
D E 4. Carefully remove excess with an explorer and
F dental oss (see Fig. 15-68D to F).
Cement remnants left in the sulcus have an irri-
tating effect on the gingiva and may cause severe
periodontal inammation with possible bone loss.
Fig. 15-67 Therefore, the sulcus must be carefully checked and
Interim restoration luting armamentarium. irrigated with the air-water syringe.
A B,C
D E,F
Fig. 15-68
Luting procedure. A, The external surface is lightly coated with petrolatum to aid removal of the set luting agent. B, Careful place-
ment of the luting agent seals the margins and reduces the clean-up effort. C, The restoration is seated with rm nger pressure, or
(for posterior restorations) the patient may bite on a cotton roll. D and E, An explorer is used to remove excess and to probe the
sulcus gently for remnants. F, The proximal contact areas and sulcus are cleaned with dental oss (a knot will help remove excess
cement), followed by copious irrigation with the air-water syringe.
Removal, Recementation, and Repair Step-by-step procedure

1. If the interim restoration is going to be rece-
Armamentarium
mented, clean out the bulk of cement with a
Backhaus towel clamp or hemostatic forceps spoon excavator.
Spoon excavator 2. Place the restoration in a cement-dissolving solu-
Ultrasonic cleaner with cement-remover solution tion, and set this in the ultrasonic cleaner.
The interim restoration is removed when the 3. Line the restoration with a fresh mix of resin if
patient returns for placement of the denitive necessary (e.g., if the tooth preparation has been
restoration or for continued preparation. Fracture of modied). The internal surface is relieved slightly
the prepared tooth or foundation must be avoided. and painted with monomer to ensure good
Risk of this can be minimized if removal forces are bonding of the new material.
directed parallel to the long axis of the preparation. A fractured or damaged interim restoration can
The Backhaus or a hemostatic forceps is effective for be easily repaired with resin, added directly by using
obtaining sound purchase on a single unit (Fig. the bead-brush technique (Fig. 15-70).
15-69). A slight buccolingual rocking motion helps
break the cement seal.
Damage can occur when an FDP is being Esthetic Enhancement
removed. If one abutment retainer suddenly breaks Contour, color, translucency, and texture are the key
loose, the other can be subjected to severe exure elements of coronal appearance. Contour and color
stresses when the FDP acts as a lever arm. Care are fundamental and more important than the other
must be exercised to remove the prosthesis along the two elements. The indirect partial FDP procedure
path of placement. Sometimes it is helpful to loop just described includes methods for controlling
dental oss under the connector at each end of the contour and color.
FDP.
Contour
Diagnostic waxing provides the ultimate control of
contour, and using a shade guide before tooth prepa-
ration gives the operator some control of color. If
contour and color are well controlled, most interim
restorations are very acceptable to excellent in
appearance. Routinely achieving this requires atten-
tion to detail and skill. Although listed third, translu-
cency can be a signicant appearance element for
patients with unabraded teeth.
Fig. 15-69 Color

Backhaus towel clamp forceps provide positive purchase on Whereas some resin manufacturers use only general
interim restorations. For maximum control, occlusal nger pres- color descriptors (light, medium, dark) for their
sure is applied directly to the tines. products, most cross-reference their colors to
A B,C
Fig. 15-70
Bead-brush technique for repairs. A, Monomer liquid is painted on the surface of the thoroughly cleaned restoration to which resin
will be added. B, The brush is dipped in monomer and briey touched to the powder, forming a small bead on the tip. C, The bead
is touched to the repair site, and the brush handle is rolled to deposit it. Bead placement continues in this manner until the desired
contour is achieved. To prevent excessive porosity, the unset resin should be painted lightly with monomer until hard.
popular shade guides for porcelain or denture teeth. cavity. This effect is most pronounced with enamel
However, even when cross-referenced, manufacturer that scatters very little light as a result of the absence
and material differences make shade matching inac- of pigments or opacifying mineralization (e.g.,
curate. Better control of color is obtained by using a uorosis). Although less obvious, the translucent
custom shade guide. This can be easily made by appearance of enamel is observable over the entire
casting the resins into an elastomeric putty mold of incisal or occlusal third of the crown. Thus, when it
an extracted incisor crown. Combining two or more is readily visible in adjacent teeth or when a
existing hues in known proportions can create a more realistic appearance is desired, translucency
wider selection of shades, or resin-coloring tints are can be simulated in the interim. The procedure
an option. requires two resins, one colored to match the body
Custom color effects that simulate intrinsic and and one to match the enamel of the tooth.
extrinsic stains, cracks, or hypocalcication of adja- Some manufacturers produce enamel or incisal
cent teeth may be added to interim restorations with shades that may be used without modication.
the help of paint-on stain kits (Fig. 15-71). These are When these are not available or when variation is
best applied quickly, and overmanipulation should needed, clear resin powder may be mixed with a
be avoided because it causes streaking and surface smaller fraction of the body powder to produce the
roughness. Under optimum conditions, the surface desired translucency.
should have a glazed appearance similar to that of Two procedures can be followed to create a
porcelain. Thickening of stains as a result of the evap- translucent effect. In the rst, which is more difcult
oration of solvent is a common problem hampering to control, the enamel color resin is carefully bead-
manipulation. Another problem with the paint-on brushed onto the occlusal or incisal surface of the
colorants is their poor resistance to abrasion. Loss of ESF and tapered to end at the middle or cervical
the pigments in high-abrasion areas produces an third. The tendency to ow where it is not wanted is
unattractive mottled effect. controlled in part by the orientation of the ESF with
regard to gravity and in part by manipulation with
Translucency the brush tip. When the desired distribution of
Coronal translucency is determined by the type and enamel color resin is achieved, a disposable syringe
amount of enamel present. At the incisal edge of an is loaded with body color resin and the ESF is imme-
unworn anterior tooth where there is no dentin in diately lled, to avoid disruption of the enamel color
the light path, that region often takes on a blue or resin. The TSF is then positioned in the ESF, and
gray hue, which comes about from the dark oral normal procedures are followed (Fig. 15-72).
In the second procedure, the enamel color resin
is allowed to polymerize on the ESF without adding
body color resin or the TSF. The rigid enamel veneer
is removed from the ESF and trimmed to occupy
Fig. 15-71
This interim stain kit contains violet, blue, yellow, orange, Fig. 15-72
brown, white, and gray paint-on colorants to create custom The layering of translucent resin and dentin-shaded resin
effects and a clear material used to form a glazed translucent allows a more realistic appearance of the premolar and
surface. The liquids are formulated to dry quickly, which canine interim restorations. They serve as removable dental
requires that they be kept covered until immediately before prosthesis (RDP) abutments and are splinted together to help
use. A thinner and brush cleaner are provided. resist dislodgment.
only the space intended for enamel. It is important wheel nishing. Depending on their size and de-
to check that the ESF and TSF can be mated without nition, these features may be made with a sharp-
interference from the in-place veneer. With the edged inverted-cone green stone rotating parallel to
veneer in place, monomer liquid is painted on it and the occlusal plane and touched briey to the resin.
the body color resin is added. The TSF is then Often the defects are most noticeable in the cervical
inserted, and standard procedures are followed for third of the tooth, but an adjacent tooth is the best
the remainder of the restoration. The timing for this guide for determining their distribution.
procedure is less crucial than for the rst one Imbrication lines may be simulated with a coarse
described and may be better suited to practitioners diamond rotary instrument rotating slowly and
with less experience. A disadvantage is that some- moved across the facial surface from proximal to
times there is a more obvious demarcation between proximal. This reduces the surface reectance of the
the enamel and the body resins. resin after it is nished and polished. However, as
with all texture effects, overnishing obliterates
Texture these lines. Care must be taken to monitor the n-
With practice, texture effects require only a small ishing by rinsing pumice from the surface and
amount of time, but in some cases they contribute drying it. A completely smooth and highly polished
signicantly to the overall appearance of the interim interim restoration may be excellent for plaque
restoration. These effects are most important for control but not esthetically compatible with the adja-
maxillary anterior teeth adjacent to teeth with well- cent teeth. The debate as to which is more important
dened lobes, imbrication lines, or developmental can probably best be settled by consulting with the
defects. patient to determine his or her needs.
Developmental lobes are best simulated in wax
during the nal stage of the diagnostic waxing. To
SUMMARY
produce a natural effect, it is crucial to avoid making
grooves that are straight or sharp edged or have Although interim restorations are usually intended
uniform cross-sections. Rather, the simulation for short-term use and then discarded, they can be
should have a gentle crescent shape, with softening made to provide pleasing esthetics, adequate
of the edges and slight varying of the cross-section support, and good protection for teeth while main-
by burnishing with the largest diameter waxing taining periodontal health. They may be fabricated
wire. If a polypropylene sheet is used to form the in the dental ofce from any of several commercially
ESF, these subtle details can be reproduced in the available materials and by a number of practical
resin. methods. The success of xed prosthodontics often
Placement of developmental defects is best depends on the care with which the interim restora-
accomplished in the resin just before pumice and rag tion is designed and fabricated.
?
STUDY QUESTIONS
1. What are the ideal properties of an interim restorative material? What are the ideal properties of the optimal
interim luting agent?
2. List at least ve requirements of a successful interim restoration.
3. Explain why these factors are crucial to clinical success. What would occur if they were not appropriately per-
formed or obtained?
4. Select three techniques for fabricating an interim restoration for a single tooth. Identify the factors involved
when a certain technique is selected for an indication or tooth.
5. What are the currently available materials for fabrication of interim restorations? What are their respective
material properties, advantages, and disadvantages?
6. Explain the basic chemistry involved in resin polymerization.
7. What factors should be considered when deciding between a direct, indirect, or indirect-direct fabrication
technique for interim xed dental prostheses?
1
pumice \pums\ n (15th cent.): 1: a type of volcanic glass
GLOSSARY* used as an abrasive. It is prepared in various grits and
accelerator \ak-sela-rater\ n (1611): 1: a substance used for nishing and polishing 2: a polishing agent, in
that speeds a chemical reaction 2: in physiology, a nerve, powdered form, used for natural teeth and xed and
muscle, or substance that quickens movement or removable restorations
response resin \rezn\ n (14c): 1: any of various solid or semisolid
acrylic resin \a-krlk rezn\: 1: pertaining to polymers amorphous natural organic substances that usually are
of acrylic acid, methacrylic acid, or acrylonitrile; for transparent or translucent and brown to yellow; usually
example, acrylic bers or acrylic resins 2: any of a group formed in plant secretions; are soluble in organic sol-
of thermoplastic resins made by polymerizing esters of vents but not water; are used chiey in varnishes, inks,
acrylic or methylmethacrylate acids plastics, and medicine; and are found in many dental
impression materials 2: a broad term used to describe
activator \akt-va tr\ n: a removable orthodontic
natural or synthetic substances that form plastic materi-
device intended to stimulate perioral muscles
als after polymerization. They are named according to
autopolymer \to-pola-mer\ n: a material that poly- their chemical composition, physical structure, and
merizes by chemical reaction without external heat as a means for activation of polymerizationsee AUTOPOLY-
result of the addition of an activator and a catalyst MERIZING R., COPOLYMER R.
autopolymerization \to
-po
la-me shun\ vb
r-za
resin crown \rezn kroun\: a resin restoration that
autopolymerizing resin \to-pol-a-mer-zing rezn\: a restores a clinical crown without a metal substructure
resin whose polymerization is initiated by a chemical 1
spatulate \spacha-lt\ adj (1760): shaped like a spatula
activator
2
bench set \bench set\: a stage of resin processing that spatulate \spacha-lt\ vt -ed/-ing/-s: to work or treat
with a spatula
allows a chemical reaction to occur under the conditions
present in the ambient environment; also used to thermoplastic \thrma-plastk\ adj (1883): a charac-
describe the continuing polymerization of impression teristic or property of a material that allows it to be
materials beyond the manufactures stated set time softened by the application of heat and return to
1
festoon \fe-stoon\ n (1630): 1: any decorative chain or the hardened state on coolingthermoplasticity n
strip hanging between two points 2: in dentistry, carv- tinfoil \tnfoil\ n (15c): 1: paper thin metal sheeting
ings in the base material of a denture that simulate the usually of a tin-lead alloy or aluminum (a misnomer) 2:
contours of the natural tissues that are being replaced by a base-metal foil used as a separating material between
the denture the cast and denture base material during asking and
2
festoon \fe-stoon\ vt (1800): to shape into festoons polymerizing
hypertrophy \h-prtra-fe\ n (1834): an enlargement or

overgrowth of an organ or tissue beyond that considered REFERENCES
normal as a result of an increase in the size of its con- 1. Seltzer S, Bender IB: The Dental Pulp; Biologic
stituent cells and in the absence of tumor formation Considerations in Dental Procedures, ed 3, p 191.
methyl methacrylate resin \methal meth-akra-lat Philadelphia, Lippincott, 1984.
rezn\: a transparent, thermoplastic acrylic resin that is 2. Seltzer S, Bender IB: The Dental Pulp; Biologic
used in dentistry by mixing liquid methyl methacrylate Considerations in Dental Procedures, ed 3, pp
monomer with the polymer powder. The resultant 267272. Philadelphia, Lippincott, 1984.
mixture forms a pliable plastic termed a dough, which is 3. Larato DC: The effect of crown margin extension
packed into a mold prior to initiation of polymerization on gingival inammation. J South Calif Dent Assoc
37:476, 1969.
obtundent \ob-tundant\ n: an agent or remedy that 4. Waerhaug J: Tissue reactions around articial
lessens or relieves pain or sensibility crowns. J Periodontol 24:172, 1953.
photoactive \foto-aktv\ adj: reacting chemically to 5. Phillips RW: Skinners Science of Dental Materials,
visible light or ultraviolet radiationphotoactivation 8th ed, pp 221, 376. Philadelphia, WB Saunders,
1982.
6. El-Ebrashi MK, et al: Experimental stress analysis
*Reprinted in part from The Journal of Prosthetic Dentistry, Vol. 94, No. 1,
The Glossary of Prosthodontic Terms, 8th Edition, pp. 1081, 2005, of dental restorations. VII. Structural design and
with permission from The Editorial Council of The Journal of Prosthetic stress analysis of xed partial dentures. J Prosthet
Dentistry. Dent 23:177, 1970.
20
PONTIC DESIGN
R. Duane Douglas, Contributing Author
not enough. The pontic must be carefully designed

KEY TERMS and fabricated not only to facilitate plaque control of
conical pontic residual ridge the tissue surface and around the adjacent abutment
crest residual ridge resorption teeth but also to adjust to the existing occlusal con-
emergence prole ridge augmentation ditions. In addition to these biologic considerations,
hygienic pontic ridge lap pontic design must incorporate mechanical princi-
modied ridge lap pontic sanitary pontic ples for strength and longevity, as well as esthetic
ovate pontic principles for satisfactory appearance of the replace-
ment teeth (Fig. 20-2).
The pontic, as it mechanically unies the abut-
ment teeth and covers a portion of the residual ridge,
ontics are the articial teeth of a partial xed assumes a dynamic role as a component of the pros-
P dental prosthesis (FDP) that replace missing

natural teeth, restoring function and appear-
ance (Fig. 20-1). They must be compatible with con-
thesis and cannot be considered a lifeless insert of
gold, porcelain, or acrylic.1
tinued oral health and comfort. The edentulous

areas where a xed prosthesis is to be provided may
PRETREATMENT ASSESSMENT
be overlooked during the treatment planning phase. Certain procedures enhance the success of an
Unfortunately, any deciency or potential problem FDP. In the treatment-planning phase, diagnostic
that may arise during the fabrication of a pontic is casts and waxing procedures may prove especially
often identied only after the teeth have been pre- valuable for determining optimal pontic design (see
pared or even when the denitive cast is ready to be Chapters 2 and 3).
sent to the laboratory. Proper preparation includes a
careful analysis of the denitive dimensions of the
Pontic Space
edentulous areas: mesiodistal width, occlusocervical
distance, buccolingual dimension and location of One function of an FDP is to prevent tilting or drift-
the residual ridge. To design a pontic that meets ing of the adjacent teeth into the edentulous space.
hygienic requirements and prevents irritation of the If such movement has already occurred, the space
residual ridge, particular attention must be given to available for the pontic may be reduced and its
the form and shape of the gingival surface. Merely fabrication complicated. At this point, creating an
replicating the form of the missing tooth or teeth is acceptable appearance without orthodontic reposi-
616
Chapter 20 PONTIC DESIGN 617
A A
B B
Fig. 20-1 Fig. 20-3

A and B, A metal ceramic pontic in this three-unit partial xed Careful planning is always necessary in deciding how to restore
dental prosthesis replaces the maxillary rst molar. an undersized pontic space where orthodontic treatment is not
practical. A, In this patient, individual crowns of increased prox-
imal contours were preferred to a partial xed dental prosthe-
sis with undersized pontics. Excellent plaque control had been
demonstrated, and the design provided the optimum occlusal
relationship. B, Here two small pontics were used to replace
the missing maxillary teeth.
BIOLOGIC MECHANICAL
Cleansable tissue Rigid (to resist tioning of the abutment teeth is often impossible,
surface deformation)
Access to abutment Strong connectors particularly if esthetic appearance is important.
teeth (to prevent fracture) (Modication of abutments with complete-coverage
No pressure on Metal-ceramic framework retainers is sometimes feasible.) Careful diagnostic
ridge (to resist porcelain
fracture) waxing procedures help determine the most appro-
priate treatment (see Chapters 2 and 3). Even with
a lesser esthetic requirement, as for posterior teeth,
overly small pontics are unacceptable because they
ESTHETIC
trap food and are difcult to clean. When ortho-
dontic repositioning is not possible, increasing the
Shaped to look like tooth
it replaces proximal contours of adjacent teeth may be better
Appears to grow out of than making an FDP with undersized pontics (Fig.
edentulous ridge 20-3). If there is no functional or esthetic decit, the
Sufficient space for
porcelain space can be maintained without prosthodontic
intervention.
Optimal
pontic
design
Residual Ridge Contour
Fig. 20-2
Biologic, mechanical, and esthetic considerations for successful The edentulous ridges contour and topography
pontic design. should be carefully evaluated during the treatment
618 PART III LABORATORY PROCEDURES
planning phase. An ideally shaped ridge has a surgery to augment such residual ridges should be
smooth, regular surface of attached gingiva, which carefully considered.
facilitates maintenance of a plaque-free environ-
ment. Its height and width should allow placement
Surgical Modication
of a pontic that appears to emerge from the ridge
and mimics the appearance of the neighboring Although residual ridge width may be augmented
teeth. Facially, it must be free of frenum attachment with hard tissue grafts, this is usually not indicated
and be of adequate facial height to sustain the unless the edentulous site is to receive an implant
appearance of interdental papillae. (see Chapter 13).
Loss of residual ridge contour may lead to unes-
thetic open gingival embrasures (black triangles)
(Fig. 20-4A), food impaction (Fig. 20-4B), and per-
colation of saliva during speech. Siebert2 classied
residual ridge deformities into three categories
(Table 20-1 and Fig. 20-5):
Class I defects: faciolingual loss of tissue width A
with normal ridge height
Class II defects: loss of ridge height with normal
ridge width
Class III defects: a combination of loss in both
dimensions
There is a high incidence (91%) of residual ridge
deformity after anterior tooth loss3; the majority of
these are Class III defects. Because patients with
Class II and III defects are frequently dissatised
with the esthetics of their FDPs,4 preprosthetic B
A
C
B D
Fig. 20-5
Fig. 20-4 Residual ridge deformities as classied by Siebert.2 A, Class
Loss of residual ridge contour, leading to unesthetic open gin- O, no defect. B, Class I defect. C, Class II defect. D, Class III
gival embrasures (A) and food entrapment (arrow) (B). defect.
Table 20-1 INCIDENCE OF MAXILLARY Class I defects

ANTERIOR RESIDUAL Soft tissue procedures have been advocated for
RIDGE DEFECTS improving the width of a Class I defect; however,
INCIDENCE (%) because Class I defects are infrequent and are not
esthetically challenging, surgical augmentation of
Abrams Siebert ridge width is uncommon. Paying careful attention
Class Description et al3 et al2 to interim pontic contour helps the operator identify
patients who would benet from surgery. In the roll5
0 No defect 12 0
technique, soft tissue from the lingual side of the
I Horizontal loss 36 13
edentulous site is used. The epithelium is removed,
II Vertical loss 0 40
and the tissue is thinned and rolled back upon itself,
III Horizontal 52 47
thereby thickening the facial aspect of the residual
and vertical
ridge (Fig. 20-6). Pouches may also be prepared in
loss
the facial aspect of the residual ridge6 into which
Adapted from Edelhoff D et al: A review of esthetic pontic subepithelial7,8 or submucosal9 grafts harvested from
design options. Quintessence Int 33:736, 2002. the palate or tuberosity may be inserted (Fig. 20-7).
A B
C D
Fig. 20-6
The roll technique for soft tissue ridge augmentation. A, Cross-section of Class I residual ridge defect before augmentation. B, Epithe-
lium removed from palatal surface. C, Elevation of ap, creating a pouch on the vestibular surface. D, The ap is rolled into the
pouch, enhancing ridge width.
A B
C D
Fig. 20-7
The pouch technique for soft tissue ridge augmentation. A and B, Split-thickness ap is reected. C, Graft material placed in the
pouch increases ridge width. D, Flaps sutured in place.
Class II and III defects tional graft, its survival is greatly dependent on revas-
Unfortunately, few soft tissue surgical techniques can cularization, which requires meticulous preparation
increase the height of a residual ridge with pre- of the recipient site. Therefore, it is more technique
dictability. The interpositional graft2,10 is a variation sensitive than the interpositional graft. In fact, con-
of the pouch technique, in which a wedge-shaped nective tissue grafts have been demonstrated to
connective tissue graft is inserted into a pouch prepa- achieve approximately 50% more ridge volume gain
ration on the facial aspect of the residual ridge. The 3.5 months after surgery than do free gingival grafts
epithelial portion of the wedge may be positioned in single-tooth residual ridge defects.12
coronally to the surrounding epithelium if an
increase of ridge height is desired (Fig. 20-8A and B).
Gingival Architecture Preservation
The onlay graft is designed to gain ridge height2,11 but
also contributes to ridge width, which makes it useful Although the degree of residual ridge resorption
for treating Class III ridge defects (Fig. 20-9). It is after tooth extraction is unpredictable, resulting
a thick free gingival graft harvested from partial- deformities are not an inevitable occurrence. Pres-
or full-thickness palatal donor sites. Because the ervation of the alveolar process can be achieved
amount of height augmentation can be only as thick through immediate restorative and periodontal
as the graft, the procedure may have to be repeated intervention at the time of tooth removal. By condi-
several times to reestablish normal residual ridge tioning the extraction site and providing a matrix
height. Although the onlay graft has greater potential for healing, the pre-extraction gingival architecture,
for increasing ridge height than does the interposi- or socket, can be preserved.
A B
Fig. 20-8
An interpositional graft for augmentation of ridge width and height. A, Tissue reected. B, Graft positioned and sutured in place.
A B
C D
Fig. 20-9
An onlay graft for augmentation of ridge width and height. A, Presurgical view of Class III residual ridge defect with abutment teeth
prepared. B, Recipient bed prepared by removing epithelium. C, Striation cuts are made in connective tissue to encourage revascu-
larization. D, Onlay graft is sutured in place.
F G
H I
J K
Fig. 20-9, contd

E, An interim partial xed dental prosthesis with open embrasures is placed immediately to allow adaptation of tissue during healing.
F, Cast with Class III residual ridge defect; the lateral incisor was unrestorable. G, Donor site for graft. H, Graft sutured in place.
I, Augmented ridge. J and K, Final restoration with improved contours.
Preparing the abutment teeth before the extrac- before or during extraction, the sockets can be
tion is the preferred technique. An interim FDP grafted with an allograft material (hydroxyapatite,
can be fabricated indirectly, ready for immediate tricalcium phosphate, or freeze-dried bone).1315
insertion. Because socket preservation is dependent Immediately after preparation of the extraction
on underlying bone contour, the extraction of the site, a carefully shaped interim FDP is placed (Fig.
tooth to be replaced should be atraumatic and 20-10A and B). The tissue side of the pontic should
aimed at preserving the facial plate of bone. The scal- be an ovate form, and, according to Spear,16 it should
loped architecture of interproximal bone forming extend approximately 2.5 mm apical to the facial
the extraction site is essential for proper papilla free gingival margin of the extraction socket (Fig. 20-
form, as are facial bone levels in the prevention 10C and D). Because the soft tissues of the socket
of alveolar collapse. If bone levels are compromised begin to collapse immediately after the tooth extrac-
A B
C D
Fig. 20-10
Alveolar architecture preservation technique. A, Atraumatic tooth extraction. B, Cross-section view of the immediate interim partial
xed dental prosthesis, demonstrating ovate pontic form. C, Interim restoration. Note the 2.5-mm apical extension of the ovate
pontic. D, The seated interim restoration should cause slight blanching of interdental papilla. E, Interim restoration 12 months after
extraction. Note the preservation of interdental papilla. (Courtesy of Dr. F.M. Spear and Montage Media, Mahwah, New Jersey.)
tion, the pontic causes tissue blanching as it supports Techniques involving orthodontic extrusions have
the papillae and facial/palatal gingiva. The contour also been employed to preserve ridge form before
of the ovate tissue side of the pontic is critical and extraction. In these proactive methods, light forces
must conform to within 1 mm of the interproximal are used to extrude the teeth destined to be
and facial bone contour to act as a template for extracted. As the teeth are extruded, apposition of
healing. Oral hygiene in this area is difcult during bone occurs at the root apex, thereby lling the
the initial healing period, and so the interim restora- socket with bone as the tooth is slowly extracted
tion should be highly polished to minimize plaque orthodontically. First employed to avoid ridge aug-
retention. After approximately 1 month of healing, mentation and gain vertical ridge height before
oral hygiene access is improved by recontouring the immediate implant placement,17 the orthodontic
pontic to provide 1 to 1.5 mm of relief from the extrusion technique has been used successfully to
tissue. When the gingival levels are stable (approxi- maintain ridge contour before treatment with con-
mately 6 to 12 months), the nal restoration can be ventional FDPs (Fig. 20-11). In addition to the addi-
fabricated (Fig. 20-10E). tional time and expense of orthodontic treatment,
A B
C D
E F
Fig. 20-11
Orthodontic extrusion to preserve alveolar architecture. A, Pretreatment (note gingival crest height discrepancy between the maxil-
lary central incisors). B, Orthodontic extrusion. C, Pre-extrusion and post-extrusion radiographs. Red line denotes reference point; blue
and yellow lines denote change in gingival crest height. D, Post-extraction evaluation of interim restoration with ovate pontics. E, Gin-
gival architecture immediately prior to pression. F, Final restoration.
because the teeth to be extracted must continuously advantages of the various pontic designs are sum-
be adjusted as they are extruded, previous endodon- marized in Table 20-2.
tic treatment is necessary.
Although maintenance of the residual ridge
Sanitary or Hygienic Pontic
after extraction is admirable, socket-preservation
techniques are technically challenging and require As its name implies, the primary design feature
frequent patient monitoring and conscientious of the sanitary pontic allows easy cleaning, because
hygiene on the part of the patient. Even when its tissue surface remains clear of the residual
the procedure is performed meticulously, success ridge (Fig. 20-12A). This hygienic design permits
is unpredictable because of the variability in easier plaque control by allowing gauze strips
patients healing response. Additional surgical and other cleaning devices to be passed under
augmentation of the ridge may still be necessary the pontic and seesawed in a shoeshine manner.
for some patients. Disadvantages include entrapment of food
particles, which may lead to tongue habits that
annoy the patient. The hygienic pontic is the least
PONTIC CLASSIFICATION
Pontic designs are classied into two general groups:
those that contact the oral mucosa and those that do Box 20-1 Pontic Design Classication
not (Box 20-1). There are several classications
within these groups, based on the shape of the gin- MUCOSAL CONTACT
gival side of the pontic. Pontic selection depends pri- Ridge lap
marily on esthetics and oral hygiene. In the anterior Modied ridge lap
region, where esthetic appearance is a concern, the Ovate
pontic should be well adapted to the tissue to make Conical
it appear as if it emerges from the gingiva. Con-
versely, in the posterior regions (mandibular premo- NO MUCOSAL CONTACT
lar and molar areas), contours can be modied in Sanitary (hygienic)
the interest of designs that are less esthetic but Modied sanitary (hygienic)
amenable to oral hygiene. The advantages and dis-
A B
C D
Fig. 20-12
A, Sanitary pontic. B and C, Modied sanitary pontic. D, Placement of the pontic, close to the ridge, has resulted in tissue prolifer-
ation (arrow).
626
Table 20-2 PONTIC DESIGN

Recommended
Pontic design Appearance location Advantages Disadvantages Indications Contraindications Materials
PART III
Sanitary/ Posterior Good access Poor esthetics Nonesthetic zones Where esthetics All metal
hygienic mandible for oral Impaired oral is important
2 mm
hygiene hygiene Minimal vertical
dimension
Saddle- Not Esthetic Not amenable Not Not recommended Not applicable
ridge-lap recommended to oral recommended
hygiene
Conical Molars without Good access Poor esthetics Posterior areas Poor oral hygiene All-metal
LABORATORY PROCEDURES
esthetic for oral where esthetics Metal-ceramic

requirements hygiene is of minimal All-resin
concern
Modied High esthetic Good Moderately Most areas with Where minimal Metal-ceramic
ridge-lap requirement esthetics easy to clean esthetic esthetic concern All-resin
(i.e., anterior concern exists All ceramic
teeth and
premolars,
some
maxillary
molars)
Ovate Very high Superior Requires Desire for optimal Unwillingness for Metal-ceramic
esthetic esthetics surgical esthetics surgery All-resin
requirement Negligible preparation High smile line Residual ridge All ceramic
Maxillary food Not for defects
incisors, entrapment residual
canines, and Ease of ridge
premolars cleaning defects
toothlike design and is therefore reserved for teeth Modied Ridge Lap Pontic
seldom displayed during function (i.e., the mandibu-
lar molars). The modied ridge lap pontic combines the best
A modied version of the sanitary pontic has been features of the hygienic and saddle pontic designs,
developed18 (Fig. 20-12B and C). Its gingival portion combining esthetics with easy cleaning. Figures
is shaped like an archway between the retainers. 20-15 and 20-16 demonstrate how the modied
This geometry allows increased connector size while ridge lap design overlaps the residual ridge on the
decreasing the stress concentrated in the pontic and facial side (to achieve the appearance of a tooth
connectors.19 It is also less susceptible to tissue pro- emerging from the gingiva) but remains clear of the
liferation that can occur when a pontic is too close
to the residual ridge (Fig. 20-12D).
Saddle or Ridge Lap Pontic

The saddle pontic has a concave tting surface that
overlaps the residual ridge buccolingually, simulat-
ing the contours and emergence prole of the A
missing tooth on both sides of the residual ridge. B
However, saddle or ridge lap designs should be
avoided because the concave gingival surface of the
pontic is not accessible to cleaning with dental oss,
which leads to plaque accumulation (Fig. 20-13). Fig. 20-13
This design deciency has been shown to result in A, Cross-section view of ridge lap pontic. B, The tissue surface
tissue inammation1 (Fig. 20-14). is inaccessible to cleaning devices.
A B
C D
Fig. 20-14
A and B, Partial xed dental prosthesis (FDP) with a ridge-lap (concave) gingival surface. C, When it was removed, the tissue was
found to be ulcerated. D, The defective FDP was recontoured and used as an interim restoration while the denitive restoration was
being fabricated. Within 2 weeks the ulceration had resolved.
A B
Fig. 20-15
Modied ridge lap pontic. A, Partial xed dental prosthesis (FDP) partially seated. B, FDP seated.
A B
Fig. 20-16
Three-unit partial xed dental prosthesis replacing the maxillary lateral incisor. A, To facilitate plaque control, the lingual surface is
made convex. B, The facial surface is shaped to simulate the missing tooth.
ridge on the lingual side. To enable optimal plaque

control, the gingival surface must have no depression
or hollow. Rather, it should be as convex as possible
from mesial to distal aspects (the greater the con-
vexity, the easier the oral hygiene). Tissue contact
should resemble a letter T (Fig. 20-17) whose verti-
cal arm ends at the crest of the ridge. Facial ridge
adaptation is essential for a natural appearance.
Although this design was historically referred to as AREA OF CONTACT
ridge-lap,20,21 the term ridge-lap is now used synony- Fig. 20-17
mously with the saddle design. The modied ridge Tissue contact of a maxillary partial xed dental prosthesis
lap design is the most common pontic form used in (FDP) should resemble the letter T. This FDP is viewed from the
areas of the mouth that are visible during function gingival aspect.
(maxillary and mandibular anterior teeth and max-
illary premolars and rst molars).
ridge necessitates atter contours with a narrow
tissue contact area. This type of design may be
Conical Pontic
unsuitable for broad residual ridges, because the
Often called egg-shaped, bullet-shaped, or heart-shaped, emergence prole associated with the small tissue
the conical pontic (Fig. 20-18) is easy for the patient contact point may create areas of food entrapment
to keep clean. It should be made as convex as possi- (Fig. 20-19). The sanitary or hygienic pontic is the
ble, with only one point of contact at the center design of choice in these clinical situations.
of the residual ridge. This design is recommended
for the replacement of mandibular posterior teeth,
Ovate Pontic
where esthetic appearance is a lesser concern. The
facial and lingual contours are dependent on the The ovate pontic is the most esthetically appealing
width of the residual ridge; a knife-edged residual pontic design. Its convex tissue surface resides in a
Buccal Lingual
A B
A
Fig. 20-19
A, Conical pontics may create food entrapment on broad resid-
ual ridges (arrow). B, The sanitary pontic form may be a better
alternative.
Original
tooth A
B
Resorbed
ridge
B
B 12 3
A
C
Fig. 20-20
Ovate pontic. A, Partial xed dental prosthesis (FDP) partially
seated. B, FDP seated.
soft tissue depression or hollow in the residual ridge,

which makes it appear that a tooth is literally emerg-
D ing from the gingiva (Fig. 20-20). Careful treatment
planning is necessary for successful results. Socket-
preservation techniques should be performed at the
time of extraction to create the tissue recess from
which the ovate pontic form will emerge. For a pre-
Fig. 20-18 existing residual ridge, soft tissue surgical augmen-
A and B, A pontic with maximum convexity and a single point tation is typically required. When an adequate
of contact with the tissue surface is the design easiest to keep volume of ridge tissue is established, a socket depres-
clean. C, Evaluating the contour of three possible pontic shapes sion is sculpted into the ridge with surgical dia-
(1, 2, and 3). Contour 3 is the most convex in area B but is too monds or electrosurgery. In either case, meticulous
at in area A. Contour 1 is convex in area A but is too at in attention to the contour of the pontic of the interim
area B. Contour 2 is the best. D, An all-metal partial xed dental restoration is essential when the residual ridge that
prosthesis with a conical pontic, suitable for replacement of a
will receive the denitive prosthesis is conditioned
mandibular molar.
and shaped.
The ovate pontics advantages include its pleasing
appearance and its strength. When used successfully
with ridge augmentation, its emergence from the
Ovate Modified
ridge lap
Fig. 20-21 Fig. 20-22
The ovate pontic design eliminates the potential for unsup- Pressure inevitably leads to ulceration.
ported porcelain in the cervical portion of an anterior pontic.
ridge appears identical to that of a natural tooth. In

addition, its recessed form is not susceptible to food
impaction. The broad convex geometry is stronger
than that of the modied ridge lap pontic, because
the unsupported, thin porcelain that often exists at
the gingivofacial extent of the pontic is eliminated
(Fig. 20-21). Because the tissue surface of the
pontic is convex in all dimensions, it is accessible to
dental oss; however, meticulous oral hygiene is nec-
essary to prevent tissue inammation resulting Fig. 20-23
from the large area of tissue contact. Other disad- Soft tissue blanching at evaluation indicates pressure.
vantages include the need for surgical tissue man-
agement and the associated cost. Furthermore, an
additional evaluation appointment is typically neces-
Ridge Contact
sary to achieve an esthetic result. The socket depres-
sion, with its pseudopapillae, requires the support of Pressure-free contact between the pontic and the
the interim ovate pontic and will collapse when the underlying tissues is indicated to prevent ulceration
interim restoration is removed before an impression and inammation of the soft tissues.1,22 If any blanch-
is made. To compensate for this three-dimensional ing of the soft tissues is observed at evaluation, the
change in the socket that occurs during the impres- pressure area should be identied with a disclosing
sion, it is necessary to scrape the cast in this area medium (e.g., pressure-indicating paste) and the
to ensure positive contact and support of the pontic recontoured until tissue contact is entirely
pseudopapillae with the denitive pontic. Because passive. This passive contact should occur exclusively
these adjustment are made somewhat arbitrarily, it on keratinized attached tissue. When a pontic rests
may also be necessary to make revisions to the tissue on mucosa, some ulcerations may appear as a result
surface of the pontic (reshaping or porcelain addi- of the normal movement of the mucosa in contact
tions) at the evaluation phase. with the pontic (Fig. 20-22). Positive ridge pressure
(hyperpressure) may be caused by excessive scraping
of the ridge area on the denitive cast (Fig. 20-23).
This was once promoted as a way to improve
BIOLOGIC CONSIDERATIONS the appearance of the pontic-ridge relationship.
The biologic principles of pontic design pertain to However, because of the ulceration that inevitably
the maintenance and preservation of the residual results when ossing is not meticulously performed,
ridge, abutment and opposing teeth, and supporting the concept is not recommended1,23,24 unless fol-
tissues. Factors of specic inuence are pontic-ridge lowed as previously described for an ovate pontic.22,25
contact, amenability to oral hygiene, and the direc- Although ovate pontics maintain positive tissue
tion of occlusal forces. contact to support the pseudopapillae, healthy
mucosa can be maintained, provided that the contact
follows. This is usually reversible; when the surface

is subsequently modied to eliminate the concavity,
inammation disappears (see Fig. 20-14). Therefore,
an accurate description of pontic design should be
submitted to the laboratory, and the prosthesis
should be checked and corrected if necessary before
cementation. Prevention is the best solution for con-
trolling tissue irritation.
Pontic Material
Any material chosen to fabricate the pontic should
Fig. 20-24 provide good esthetic results where needed: bio-
The patient must be instructed in how to clean the gingival compatibility, rigidity, and strength to withstand
surface of a pontic with oss. occlusal forces; and longevity. FDPs should be made
as rigid as possible, because any exure during mas-
tication or parafunction may cause pressure on the
gingiva and cause fractures of the veneering mate-
to the mucosa is tight but noncompressive and the rial. Occlusal contacts should not fall on the junction
gingival portion of the pontic is regularly cleaned.26 between metal and porcelain during centric or
eccentric tooth contacts, nor should a metal-ceramic
Oral Hygiene Considerations junction occur in contact with the residual ridge on
the gingival surface of the pontic.
The chief cause of ridge irritation is the toxins Investigations into the biocompatibility of materi-
released from microbial plaque, which accumulate als used to fabricate pontics have centered on two
between the gingival surface of the pontic and the factors: (1) the effect of the materials and (2) the
residual ridge, causing tissue inammation and effects of surface adherence. Glazed porcelain is
calculus formation. generally considered the most biocompatible of the
Unlike removable partial dental prostheses, FDPs available pontic materials,2830 and clinical data23,31
cannot be taken out of the mouth for daily cleaning. tend to support this opinion, although the crucial
Patients must be taught efcient oral hygiene tech- factor seems to be the materials ability to resist
niques, with particular emphasis on cleaning the plaque accumulation32 (rather than the material
gingival surface of the pontic. The shape of the gin- itself). Well-polished gold is smoother, less prone to
gival surface, its relation to the ridge, and the mate- corrosion, and less retentive of plaque than an
rials used in its fabrication inuence ultimate unpolished or porous casting.33 However, even
success. highly polished surfaces accumulate plaque if oral
Normally, where tissue contact occurs, the gingi- hygiene measures are ignored.34,35
val surface of a pontic is inaccessible to the bristles Glazed porcelain looks very smooth, but when
of a toothbrush. Therefore, excellent hygiene habits viewed under a microscope, its surface shows many
must be developed by the patient. Devices such as voids and is rougher than that of either polished gold
proxy brushes, pipe cleaners, Oral-B Super Floss,* or acrylic resin36 (Fig. 20-25). Nevertheless, highly
and dental oss with a threader are highly recom- glazed porcelain is easier to clean than other mate-
mended (Fig. 20-24). Gingival embrasures around rials. For easier plaque removal and biocompatibil-
the pontic should be wide enough to permit oral ity, the tissue surface of the pontic should be made
hygiene aids. However, to prevent food entrapment, in glazed porcelain. However, ceramic tissue contact
they should not be opened excessively. To enable may be contraindicated in edentulous areas where
passage of oss over its entire tissue surface, tissue there is minimal distance between the residual ridge
contact between the residual ridge and pontic must and the occlusal table. In these instances, placing
be passive. ceramic on the tissue side of the pontic may weaken
If the pontic has a depression or concavity in its the design of the metal substructure, particularly
gingival surface, plaque accumulates, because the with porcelain occlusal surface (Fig. 20-26). If gold
oss cannot clean this area, and tissue irritation27 is placed in tissue contact, it should be highly pol-
ished. Regardless of the choice of pontic material,
patients can prevent inammation around the
*Braun Oral-B, South Boston, Massachusetts. pontic with meticulous oral hygiene.37
Occlusal Forces
Reducing the buccolingual width of the pontic by as
much as 30% has been suggested38,39 as a way to
lessen occlusal forces on, and thus the loading of,
abutment teeth. This practice continues today,
A although it has little scientic basis. Critical analy-
sis40 has revealed that forces are lessened only when
food of uniform consistency is chewed and that a
18 m mere 12% increase in chewing efciency can be
expected from a one-third reduction of pontic width.
Potentially harmful forces are more likely to be
encountered if an FDP is loaded by the accidental
biting on a hard object or by parafunctional activi-
ties such as bruxism, rather than by chewing of foods
of uniform consistency. These forces are not reduced
by narrowing the occlusal table.
B In fact, narrowing the occlusal table may actually
impede or even preclude the development of a har-
monious and stable occlusal relationship. Like a mal-
18 m
posed tooth, it may cause difculties in plaque
control and may not provide proper cheek support.
For these reasons, pontics with normal occlusal
widths (at least in the occlusal third) are generally
recommended. One exception is if the residual alve-
olar ridge has collapsed buccolingually. Reducing
pontic width may then be desired and would thereby
lessen the lingual contour and facilitate plaque-
C control measures.
MECHANICAL CONSIDERATIONS
18 m The prognosis of FDP pontics is compromised if
mechanical principles are not followed closely.
Fig. 20-25 Mechanical problems may be caused by improper
Scanning electron micrographs of glazed porcelain (A), choice of materials, poor framework design, poor
polished gold (B), and polished acrylic resin (C). (Microscopy by Dr. tooth preparation, or poor occlusion. These factors
J. L. Sandrik.) can lead to fracture of the prosthesis or displacement
1 2 3 4
Fig. 20-26
Four pontic designs in descending order of strength, based on cross-sectional diameter of the metal substructure. When vertical
space is minimal, design 4 (porcelain tissue and occlusal coverage) may be contraindicated.
Fig. 20-27
Failure of a long span metal-ceramic partial xed dental pros-
thesis subjected to high stress. Fig. 20-28
Failure resulting from improper laboratory technique.
of the retainers. Long-span posterior FDPs are

particularly susceptible to mechanical problems.
Inevitably, there is signicant exing from high
occlusal forces and because the displacement effects
increase with the cube of the span length (see p. 98).
Therefore, evaluating the likely forces on a pontic
and designing accordingly are important. For
example, a strong all-metal pontic may be needed in
high-stress situations, rather than a metal-ceramic
pontic (Fig. 20-27), which would be more suscepti-
ble to fracture. When metal-ceramic pontics are
chosen, extending porcelain onto the occlusal
surfaces to achieve better esthetics should also be
carefully evaluated. In addition to its potential for Fig. 20-29
fracture, porcelain may abrade the opposing denti- Failure of unsupported gingival porcelain.
tion if the occlusal contacts are on enamel or metal.
cussed in Chapter 19, but the following points are

Available Pontic Materials
emphasized in this chapter:
Some FDPs are fabricated entirely of metal, porce- 1. The framework must provide a uniform veneer of
lain, or acrylic resin, but most consist of a combina- porcelain (approximately 1.2 mm). Excessive
tion of metal and porcelain. Acrylic resin-veneered thickness of porcelain contributes to inadequate
pontics have had limited acceptance because of their support and predisposes to eventual fracture
reduced durability (wear and discoloration). The (Fig. 20-29). This is often true in the cervical
newer indirect composites, based on high inorganic- portion of an anterior pontic. A reliable technique
lled resins and the ber-reinforced materials (see for ensuring uniform thickness of porcelain is to
Chapter 27), have revived interest in composite resin wax the xed prosthesis to complete anatomic
and resin-veneered pontics. contour and then accurately cut back the wax to
a predetermined depth (Fig. 20-30).
Metal-ceramic pontics 2. The metal surfaces to be veneered must be
Most pontics are fabricated by the metal-ceramic smooth and free of pits. Surface irregularities
technique. If properly used, this technique is helpful cause incomplete wetting by the porcelain slurry,
for solving commonly encountered clinical prob- which leads to voids at the porcelain-metal inter-
lems. A well-fabricated metal-ceramic pontic is face that reduce bond strength and increase the
strong, is easy to keep clean, and looks natural. possibility of mechanical failure.
However, mechanical failure (Fig. 20-28) can occur 3. Sharp angles on the veneering area should be
and often is attributable to inadequate framework rounded. They produce increased stress concen-
design. The principles of framework design are dis- trations that can cause mechanical failure.
Fig. 20-32
Wear of an acrylic resin-veneered prosthesis.
B
longer term interim restorations. Their resistance to
abrasion was lower than that of enamel or porcelain,
and noticeable wear occurred with normal tooth-
brushing (Fig. 20-32). Furthermore, the relatively
Fig. 20-30 high surface area/volume ratio of a thin resin veneer
A, Waxing to anatomic contour and controlled cut-back are the made dimensional change from water absorption
most reliable approaches to fabricating a satisfactory metal and thermal uctuations (thermocycling) a problem.
substructure (B). Because no chemical bond existed between the resin
and the metal framework, the resin was retained by
mechanical means (i.e., undercuts). Continuous
dimensional change of the veneers often caused
leakage at the metal-resin interface, with subsequent
discoloration of the restoration.
Nevertheless, there are certain advantages to
using polymeric materials instead of ceramics: They
are easy to manipulate and repair and do not require
the highmelting range alloys needed for metal-
ceramic techniques. Indirect composite resin
systems introduced since the 1990s have resolved
some of the problems inherent in previous indirect
Fig. 20-31 resin veneers. These new-generation indirect resins
Failure caused by occlusal contact across the metal-ceramic have a higher density of inorganic ceramic ller than
junction. do traditional direct and indirect composite resins.
Most are subjected to a post-curing process that
results in high exural strength, minimal polymer-
ization shrinkage, and wear rates comparable with
4. The location and design of the external metal- those of tooth enamel.41 In addition, improvements
porcelain junction require particular attention. in the bond between the composite resin and metal42
Any deformation of the metal framework at the may lead to a reappraisal of resin veneers.
junction can lead to chipping of the porcelain
(Fig. 20-31). For this reason, occlusal centric con- Fiber-reinforced composite resin pontics
tacts must be placed at least 1.5 mm away from Composite resins can be used in partial FDPs
the junction. Excursive eccentric contacts that without a metal substructure (see Chapter 27). A
might deform the metal-ceramic interface must substructure matrix of impregnated glass or polymer
be evaluated carefully. ber provides structural strength. The physical prop-
erties of this system, combined with its excellent
Resin-veneered pontics marginal adaptation and esthetics, make it a possi-
Historically, acrylic resin-veneered restorations had ble metal-free alternative for FDPs, although long-
deciencies that made them acceptable only as term clinical performance is not yet known.
ESTHETIC CONSIDERATIONS
No matter how well biologic and mechanical prin-
ciples have been followed during fabrication, the
patient evaluates the result by how it looks, espe-
cially when anterior teeth have been replaced.
Many esthetic considerations that pertain to single A
crowns also apply to the pontic (see Chapter 23).
Several problems unique to the pontic may be
encountered when achieving a natural appearance
is attempted.
The Gingival Interface

An esthetically successful pontic replicates the
form, contours, incisal edge, gingival and incisal
embrasures, and color of adjacent teeth. The pontics
simulation of a natural tooth is most often betrayed B
at the tissue-pontic interface. The greatest challenge
here is to compensate for anatomic changes
that occur after extraction. Special attention should
be paid to the contour of the labial surface as it
approaches the pontic-tissue junction, to achieve a
natural appearance. This cannot be accomplished
by merely duplicating the facial contour of the
missing tooth, because after a tooth is removed,
the alveolar bone undergoes resorption and/or
remodeling. If the original tooth contour were
followed, the pontic would look unnaturally long C
incisogingivally (Fig. 20-33). To achieve the illusion
of a natural tooth, an esthetic pontic must deceive
observers into believing they are seeing a natural
tooth.
The modied ridge-lap pontic is recommended
for most anterior situations; it compensates for
Fig. 20-33
lost buccolingual width in the residual ridge by over- Correct incisogingival height is critical to esthetic pontic design.
lapping what remains. Rather than emerging A, Esthetic failure of a four-unit partial xed dental prosthesis
from the crest of the ridge as a natural tooth would, (FDP) replacing the right central and lateral incisors. The
the cervical aspect of the pontic sits in front of pontics have been shaped to follow the facial contour of the
the ridge, covering any abnormal ridge structure missing teeth, but because of bone loss they look too long.
resulting from tooth loss. Fortunately, because B, The replacement FDP. Note that the gingival half of each
most teeth are viewed from only two dimensions, pontic has been reduced. Esthetic appearance is much
this relationship remains undetected. A properly improved. C, This esthetic failure is the result of excessive
designed, modied ridge-lap provides the required reduction. The central incisor pontics look too short.
convexity on the tissue side, with smooth and open
embrasures on the lingual side for ease of cleaning.
This is difcult to accomplish. Clinically, many
pontics are seen with less-than-optimal contour, unexpectedly placed shadows (Fig. 20-34) can be
which results in an unnatural appearance. This can confusing to the brain. Because of past experience,
be avoided with careful preparation at the diagnos- the brain knows that a tooth grows out of the
tic waxing stage (see Chapter 3). Sometimes the gingiva, and it therefore sees a pontic as a tooth
ridge tissue must be surgically reshaped to enhance unless telltale shadows suggest otherwise. Special
the result. care must be taken in studying where shadows fall
In normal situations, light falls from above, and an around natural teeth, particularly around the gingi-
objects shadow is below it. Unexpected lighting or val margin. If a pontic is poorly adapted to the resid-
resorption makes such a pontic look too long in the

cervical region. The height of a tooth is immediately
obvious when the patient smiles and shows the gin-
gival margin (Fig. 20-36). An abnormal labiolingual
position or cervical contour, however, is not imme-
diately obvious. This fact can be used to produce a
A pontic of good appearance by recontouring the
gingival half of the labial surface (see Fig. 20-36).
The observer sees a normal tooth length but is
unaware of the abnormal labial contour. The illusion
is successful.
Even with moderately severe bone resorption,
obtaining a natural appearance by exaggerated con-
touring of the pontics may still be possible. In areas
where tooth loss is accompanied by excessive loss of
alveolar bone, however, a pontic of normal length
would not touch the ridge at all.
One solution is to shape the pontic to simulate a
B normal crown and root with emphasis on the cemen-
toenamel junction. The root can be stained to simu-
late exposed dentin (Fig. 20-37). Another approach
is to use pink porcelain to simulate the gingival
tissues (Fig. 20-38). However, such pontics then have
considerably increased tissue contact and require
Fig. 20-34 scrupulous plaque control for long-term success.
Optical illusion. A and B are identical except that one image is Ridge augmentation procedures have been success-
upside down. Most people make different three-dimensional ful in correcting areas of limited resorption. When
interpretations of each photograph, interpreting one as a neg- bone loss is severe, the esthetic result obtained with
ative impression and the other as a positive cast. (Verify the a partial removable dental prosthesis is often better
illusion by turning the book.) The interpretation is based on than with an FDP.
how shadows fall; in normal situations, objects are seen illu-
minated from above.
Mesiodistal Width
Frequently, the space available for a pontic is greater
ual ridge, there is an unnatural shadow in the cervi- or smaller than the width of the contralateral tooth.
cal area that looks odd and spoils the illusion of a This is usually because of uncontrolled tooth move-
natural tooth (Fig. 20-35). In addition, recesses at the ment that occurred when a tooth was removed and
gingival interface collect food debris, further betray- not replaced.
ing the illusion of a natural tooth. If possible, such a discrepancy should be cor-
When appearance is of utmost concern, the ovate rected by orthodontic treatment. If this is not possi-
pontic, used in conjunction with alveolar preserva- ble, an acceptable appearance may be obtained by
tion or soft tissue ridge augmentation, can provide incorporating visual perception principles into the
an appearance at the gingival interface that is virtu- pontic design. In the same way that the brain can be
ally indistinguishable from that of a natural tooth. confused into misinterpreting the relative sizes of
Because it emerges from a soft tissue recess, this shapes or lines because of an erroneous interpreta-
pontic is not susceptible to many of the esthetic pit- tion of perspective (Fig. 20-39), a pontic of abnormal
falls applicable to the modied ridge lap pontic. size may be designed to give the illusion of being a
However, in most cases, the patient must be willing more natural size. The width of an anterior tooth is
to undergo the additional surgical procedures that usually identied by the relative positions of the
an ovate pontic requires. mesiofacial and distofacial line angles, and the
overall shape by the detailed pattern of surface
contour and light reection between these line
Incisogingival Length
angles. The features of the contralateral tooth
Obtaining a correctly sized pontic simply by dupli- (Fig. 20-40) should be duplicated as precisely as pos-
cating the original tooth is not possible. Ridge sible in the pontic, and the space discrepancy can be
A
Shadow
CORRECT INCORRECT
Fig. 20-35
A pontic should be interpreted as growing out of the gingival tissue. The second premolar pontic in the four-unit partial xed
dental prosthesis (A) is successful because it is well adapted to the ridge; however, the pontic for the rst premolar is evident because
of its poor adaptation to the ridge, which creates a shadow. B, Shadows around the gingival surface (arrow) spoil the esthetic
illusion.
A B C
H H H
It is often necessary to
recontour a substantial
portion of the facial sur-
face (B) to minimize a
shadow or food trap at the
cervical of the pontic (C).
Fig. 20-36
A, A pontic should have the same incisogingival height (H) as the original tooth. B, Correctly contoured pontic. C, Incorrectly con-
toured pontic. (The dotted lines in B and C show the original tooth contour.) The shelf at the gingival margin may trap food and create
an esthetically unacceptable shadow.
C D
Fig. 20-37
It is difcult without surgical augmentation to fabricate an esthetic xed prosthesis for a patient with extensive alveolar bone loss.
A to D, One approach is to contour the crowns normally and shape and stain the apical extension to simulate exposed root surface.
(A and B, Redrawn from Blancheri RL: Optical illusions and cosmetic grinding. Rev Asoc Dent Mex 8:103, 1950.)
A B
Fig. 20-38
Partial xed dental prosthesis replacing maxillary left central and lateral incisors. This patient had lost signicant bone from the
edentulous ridge. A and B, Appearance of the prosthesis was enhanced with the use of pink porcelain between the pontics to sim-
ulate gingival tissue. The patient has been able to maintain excellent tissue health through the daily use of Oral-B Super Floss.
Fig. 20-39
Optical illusions. A, The authors are the same size. B, The lines are straight. (Tilt the book to verify this.) C, Kitaokas Rotating Snake
Illusion. Look at this one close up. Rotation of the wheels occurs in relation to eye movements. On steady xation the effect
vanishes.44 (A, Modied from Shepard RN: MindSights. New York, WH Freeman, 1990; C, Akiyoshi Kitaoka 2003, reproduced by permission.)
Form is compromised
in the lesser visible half.
a a
A
PONTIC ABUTMENT
B a a A B C
Fig. 20-41
When replacing a posterior tooth (A), duplicate the dimension
of the more visible mesial half of the adjacent tooth. Narrow
(B) and wide (C) pontic spaces. (Redrawn from Blancheri RL: Optical
illusions and cosmetic grinding. Rev Asoc Dent Mex 8:103, 1950.)
by duplicating the visible mesial half of the tooth and

PONTIC ABUTMENT adjusting the size of the distal half.
Fig. 20-40
An abnormally sized anterior pontic space can be restored
esthetically by matching the location of the line angles and PONTIC FABRICATION
adjusting the interproximal areas. Large (A) and small (B) pontic
spaces. Dimension a should be matched in the replacement. Available Materials
(Redrawn from Blancheri RL: Optical illusions and cosmetic grinding. Rev Asoc Over time, several techniques for pontic fabrication
Dent Mex 8:103, 1950.) have evolved. Prefabricated porcelain facings
were very popular for use with conventional gold
alloys. As use of the metal-ceramic technique
compensated by altering the shape of the proximal increased during the 1970s, prefabricated facings
areas. The retainers and the pontics can be propor- lost their popularity and essentially disappeared.
tioned to minimize the discrepancy. (This is another Although an acceptable substitute, custom-made
situation in which a diagnostic waxing procedure metal-ceramic facings never gained widespread
helps solve a challenging restorative problem.) acceptance. Table 20-3 summarizes the various
Space discrepancy presents less of a problem techniques (Fig. 20-42).
when posterior teeth are being replaced (Fig. 20-41) Most pontics are now made with the metal-
because their distal halves are not normally visible ceramic technique, which provides the best solution
from the front. A discrepancy here can be managed to the biologic, mechanical, and esthetic challenges
Table 20-3 AVAILABLE PONTIC SYSTEMS

Advantages Disadvantages Indications Contraindications
Metal-ceramic Esthetics Difcult if an Most situations Long spans with
Biocompatible abutment is high stress
not metal-
ceramic
Weaker than
all-metal
All-metal Strength Nonesthetic Mandibular Where esthetics is
Straightforward molars, important
procedure especially
under high
bite force
Fiber- Conservative when Long-term Areas of high Long-span partial
reinforced used with inlay success esthetic xed dental
all-resin procedures unknown concern prostheses
Esthetics Limited to short
Ease of repair spans
Facings Rarely used; of Rarely used; of Rarely used; of Rarely used; of
historical historical historical historical
interest only interest only interest only interest only
A B
C D
Fig. 20-42
A, Eight-unit partial xed dental prosthesis (FDP) with porcelain facings. B and C, This three-unit posterior FDP has been fabricated
by post-ceramic soldering of a metal-ceramic facing to conventional gold. D, Metal-ceramic FDP with a modied ridge lap pontic
(canine) that appears to emerge from the gingiva.
encountered in pontic design. Their fabrication, Double-ended brushes

however, differs slightly from the fabrication of indi- Cotton balls
vidual crowns. These differences are emphasized in Fine-mesh nylon hose
the ensuing paragraphs. Step-by-step procedure
1. Wax the internal, proximal, and axial surfaces of
the retainers as described in Chapter 18.
Metal-Ceramic Pontics
2. Soften the inlay wax, mold it to the approximate
A well-designed metal-ceramic pontic allows for desired pontic shape, and adapt it to the ridge.
easy plaque removal, strength, wear resistance, and This is the starting point for subsequent modi-
good esthetics (see Fig. 20-42D). Its fabrication is cation. Alternatively (and perhaps preferably), an
relatively simple if at least one retainer is also metal- impression may be made of the diagnostic waxing
ceramic. The metal framework for the pontic and or interim restoration. Molten wax can then be
one or both of its retainers is then cast in one piece. poured into this to form the initial pontic shape.
This facilitates pontic manipulation during the suc- Prefabricated pontic shapes are also available as
cessive laboratory and clinical phases. In the follow- a starting point (Fig. 20-44).
ing discussion, it is assumed that either one or both 3. If a posterior tooth is being replaced, leave the
of the retainers are metal-ceramic complete crowns. occlusal surface at, because the occlusion is best
When this is not the case, an alternative approach is developed with the wax addition technique out-
necessary. lined in Chapter 18.
4. Lute the pontic to the retainers and, for additional
Anatomic contour waxing stability, connect its cervical aspect directly to the
For strength and esthetics, an accurately controlled denitive cast with sticky wax. Then wax the
thickness of porcelain is needed in the nished pontic to proper axial and occlusal (or incisal)
restoration. To ensure this, a wax pattern is made to contour (Fig. 20-45).
the nal anatomic contour. This also enables an 5. Complete the retainers, and contour the proximal
assessment of connector design adequacy and the and tissue surfaces of the pontic for the desired
relationship between the connectors and the pro- tissue contact. The pontic is now ready for evalu-
posed conguration of the ceramic veneer (see ation before cut-back.
Chapter 28). Evaluation
Armamentarium (Fig. 20-43) The form of the wax pattern is evaluated (Fig. 20-
Bunsen burner 46), and any deciencies are corrected. Particular
Inlay wax attention is given to the connectors, which should
Sticky wax have the correct shape and size. The connectors
Waxing instruments provide rm attachment for the pontic so that it does
Cotton cleaning cloth not separate from the retainers during the subse-
Die-wax separating liquid quent cut-back procedure.
Zinc stearate or powdered wax
Fig. 20-43 Fig. 20-44

Waxing armamentarium. Prefabricated wax pontics.
Cut-back 6. Reow and nalize the margins. The pontic is

Armamentarium held in position by the other retainer during this
Bunsen burner procedure.
Waxing instruments 7. Rene the pontic cut-back where access is
Cut-back instrument improved by removal of the rst retainer.
Scalpel 8. Reseat the rst retainer, reattach it to the pontic,
Thin ribbon saw blade or sewing thread section the other connector, and repeat the process.
Explorer 9. Sprue the units, and do any nal reshaping as
Step-by-step procedure needed.
1. Use a sharp explorer to outline the area that will 10. Invest and cast in the manner described in
be veneered with porcelain (Fig. 20-47A). The Chapter 22.
porcelain-metal junction must be placed suf- When one connector of a three-unit FDP is to be cast
ciently lingually to ensure good esthetics. and the other soldered, the cast connector should be
2. Make depth cuts or grooves in the wax pattern sectioned rst when the foregoing procedure is fol-
(see Chapter 19 and Fig. 20-47B). lowed. The gingival surface of the pontic should be
3. Complete the cut-back as far as access allows, with cut back in the metal rather than in the wax, because
the units connected and on the denitive cast. the tissue contact helps stabilize the pontic. Access
4. Section one wax connector with a thin ribbon is difcult, and it is easy to break the fragile wax
saw (sewing thread is a suitable alternative), and connector.
remove the isolated retainer from the denitive
cast (Fig. 20-47C). Metal preparation
5. Finish the cut-back of this retainer, making sure Armamentarium
there is a distinct 90-degree porcelain-metal Separating disk
junction. Ceramic-bound nishing stones
Fig. 20-45 Fig. 20-46

Luting the pontic to the retainers. Anatomic contour wax patterns.
A B,C
Fig. 20-47
Cut-back procedure for a three-unit anterior partial xed dental prosthesis. A, Delineating the porcelain-metal junction. B, Wax pat-
terns cut back for porcelain application. C, A ribbon saw is used to section the connector.
Fig. 20-48 Fig. 20-49

Metal substructure ready for airborne particle abrasion and Armamentarium for porcelain application.
oxidation.
Serrated instrument
Porcelain tweezers or hemostat
Sandpaper disks (nonveneered surfaces only) Ceramists brushes (No. 2, 4, or 6)
Rubber wheel (nonveneered surfaces only) Whipping brush
Round carbide bur (No. 6 or 8) Razor blade
Airborne abrasion unit (with 25 mm aluminum Cyanoacrylate resin
oxide) Colored pencil
Step-by-step procedure Articulating tape
1. Recover the castings from the investment and Ceramic-bound stones
prepare the surfaces to be veneered as described Diamond stones
in Chapter 19 (Fig. 20-48). Diamond disk
2. Finish the gingival surface of the pontic. Do not Step-by-step procedure
overreduce this area. 1. Prepare the metal and apply opaque as described
Evaluation in Chapter 24 (Fig. 20-50).
Less than 1 mm of porcelain thickness is needed on 2. Apply cervical porcelain to the gingival surface of
the gingival surface, because once it is cemented, the the pontic, and seat the castings on the denitive
restoration is seen from the facial rather than from cast. A small piece of tissue paper adapted to the
the gingival side. Excessive gingival porcelain is a residual ridge on the cast by moistening with a
common fault in pontic framework design and may brush prevents porcelain powder from sticking to
lead to fracture and poor appearance (see Fig. 20- the stone. (Cyanoacrylate resin or special sepa-
29). rating agents can be used for the same purpose.)
To facilitate plaque control, the metal-ceramic 3. Build up the porcelain (as described in Chapter
junction should be located lingually. Then tissue 24) with the appropriate distribution of cervical,
contact is on the porcelain and not on metal, which body, and incisal shades. The tissue paper acts as
retains plaque more tenaciously.43 a matrix for the gingival surface of the pontic.
Porcelain application 4. When the porcelain has been condensed, section
between the units with a thin razor blade. This
Many of the steps for porcelain application are prevents the porcelain from pulling away from the
identical to those in individual crown fabrication framework as a result of ring shrinkage. A
(see Chapter 24). There are some features peculiar second application of porcelain is needed to
to pontic fabrication, however, and these are correct any deciencies caused by ring shrink-
emphasized. age. Such additions usually are needed proxi-
Armamentarium (Fig. 20-49) mally and gingivally on the pontic.
Paper napkin 5. Apply a porcelain separating liquid (e.g., VITA
Glass slab Modisol*) to the stone ridge so that the additional
Tissues or gauze squares
Distilled water
Glass spatula *Vident, Brea, California.
A B
C D
Fig. 20-50
Porcelain application. A, Substructure ready for opaquing. B, Opaque application. C, Body porcelain application. D, The porcelain
after the rst ring.
gingival porcelain can be lifted directly from the

cast as in the fabrication of a porcelain labial
margin (see Chapter 24).
6. Mark the desired tissue contact and contour the
gingival surface to provide as convex a surface as
possible. The pontic is now ready for clinical eval-
uation and soldering procedures, character-
ization, glazing, nishing, and polishing (see
Chapters 28 to 30).
Evaluation
The porcelain on the tissue surface of the pontic
should be as smooth as possible (Fig. 20-51). Pits
and defects make plaque control difcult and Fig. 20-51
promote calculus formation. The metal framework Metal-ceramic pontic replacing a lateral incisor.
must be highly polished, with special care directed
to the gingival embrasures (where access for plaque
removal is more difcult). bulk increases. A porous pontic retains plaque and
tarnishes and corrodes rapidly.
All-Metal Pontics
Pontics made from metal (Fig. 20-52) require fewer
SUMMARY
laboratory steps and are therefore sometimes used Designs that allow easy plaque control are especially
for posterior FDPs. However, they have some disad- important to a pontics long-term success. Minimiz-
vantages (e.g., their appearance). In addition, investing tissue contact by maximizing the convexity of the
ing and casting must be done carefully because the pontics gingival surface is essential. Special consid-
mass of metal in the pontic is prone to porosity as the eration is also needed to create a design that com-
?
STUDY QUESTIONS
1. Outline and discuss a logical classication of pontics.
2. How does pontic design change as a function of location in the dental arch?
3. What are the materials available for pontic fabrication? What are their respective advantages, disadvantages,
indications, and contraindications?
4. Discuss the factors that govern the shaping of the facial and lingual surfaces of a modied ridge lap pontic.
5. What common clinical problems might be encountered if a pontic is improperly shaped or fabricated?
6. Discuss the various techniques for soft tissue augmentation and the residual ridge defects they are designed
to resolve.
7. What factors should be considered in selecting the pontic material that will be in contact with the residual
ridge?
GLOSSARY*
augmentation \gmen-tashun\ n (14c): to increase in
size beyond the existing size. In alveolar ridge augmen-
tation, bone grafts or alloplastic materials are used to
A
increase the size of an atrophic alveolar ridge
backing \bakng\ n (1793): a metal support that attaches
a facing to a prosthesis
center of the ridge \senter uv the rj\: the faciolingual or
buccolingual mid-line of the residual ridge
clinical crown \kln-kel kroun\: the portion of a tooth
that extends from the occlusal table or incisal edge to
the free gingival margin
B
connective tissue \ka-nektv tshoo\: a tissue of meso-
dermal origin rich in interlacing processes that supports
or binds together other tissues
crest \krest\ n (14c): a ridge or prominence on a part of a
body; in dentistry, the most coronal portion of the alve-
Fig. 20-52 olar process
All-metal partial xed dental prostheses.
crest of the ridge \krest uv tha rj\: the highest continu-
ous surface of the residual ridgenot necessarily coinci-
bines easy maintenance with natural appearance
dent with the center of the ridge
and adequate mechanical strength. When the
appropriate design has been selected, it must be emergence prole \-mrjens profl\: the contour of a
accurately conveyed to the dental technician. tooth or restoration, such as a crown on a natural tooth
There are subtle differences between metal- or dental implant abutment, as it relates to the adjacent
ceramic pontic fabrication and the fabrication of tissues
other types of pontics. Under most circumstances,
hygienic pontic \hje-enk, h-jen-pontk\: a pontic
the metal-ceramic technique is used because it is
that is easier to clean because it has a domed or bullet
straightforward and practical. However, it requires
shaped cervical form and does not overlap the edentu-
careful execution for maximum strength, appear-
lous ridge
ance, and effective plaque control. Alternative pro-
cedures are sometimes helpful, particularly when
gold alloys are used for the retainers. Resin-veneered
pontics should be restricted to use as longer-term
interim restorations, and all-metal pontics may be The Glossary of Prosthodontic Terms, 8th Edition, pp. 1081, 2005,
the restoration of choice in nonesthetic situations, with permission from The Editorial Council of The Journal of Prosthetic
particularly those in which forces are high. Dentistry.
modied ridge lap \moda-fd rj lap\: a ridge lap surface 3. Abrams H, et al: Incidence of anterior ridge defor-
of a pontic that is adapted to only the facial or buccal mities in partially edentulous patients. J Prosthet
aspect of the residual ridge Dent 57:191, 1987.
4. Hawkins CH, et al: Ridge contour related to
ovate pontic: a pontic that is shaped on its tissue surface
esthetics and function. J Prosthet Dent 66:165,
like an egg in two dimensions, typically partially sub-
1991.
merged in a surgically-prepared soft-tissue depression to
5. Abrams L: Augmentation of the deformed residual
enhance the illusion that a natural tooth is emerging
edentulous ridge for xed prosthesis. Compend
from the gingival tissues
Contin Educ Dent 1:205, 1980.
pontic \pontk\ n: an articial tooth on a xed dental 6. Garber DA, Rosenberg ES: The edentulous ridge
prosthesis that replaces a missing natural tooth, restores in xed prosthodontics. Compend Contin Educ
its function, and usually lls the space previously occu- Dent 2:212, 1981.
pied by the clinical crown 7. Langer B, Calagna L: The subepithelial connective
tissue graft. J Prosthet Dent 44:363, 1980.
residual ridge \r-zjoo-al rj\: the portion of the residual
8. Smidt A, Goldstein M: Augmentation of a
bone and its soft tissue covering that remains after the
deformed residual ridge for the replacement of a
removal of teeth
missing maxillary central incisor. Pract Periodont
residual ridge crest \r-zjoo-al rj krest\: the most Aesthet Dent 11:229, 1999.
coronal portion of the residual ridge 9. Kaldahl WB, et al: Achieving an esthetic appear-
ance with a xed prosthesis by submucosal grafts.
residual ridge resorption \r-zjoo-al rj re-srb
J Am Dent Assoc 104:449, 1982.
shun, -zrb-\: a term used for the diminishing quantity
10. Meltzer JA: Edentulous area tissue graft correction
and quality of the residual ridge after teeth are removed
of an esthetic defect: a case report. J Periodontol
(Ortman HR. Factors of bone resorption of the resid-
50:320, 1979.
ual ridge. J PROSTHET DENT 1962;12:42940.
11. McHenry K, et al: Reconstructing the topography
Atwood DA. Some clinical factors related to
of the mandibular ridge with gingival autografts. J
rate of resorption of residual ridges. J PROSTHET DENT
Am Dent Assoc 104:478, 1982.
1962;12:44150.)
12. Studer SP, et al: Soft tissue correction of a single-
ridge augmentation \rj gmen-tashun\: any procedure tooth pontic space: a comparative quantitative
designed to enlarge or increase the size, extent, or volume assessment. J Prosthet Dent 83:402, 2000.
quality of deformed residual ridge 13. Nemcovsky CE, Vidal S: Alveolar ridge preserva-
tion following extraction of maxillary anterior
ridge crest \rj krest\: the highest continuous surface of
teeth. Report on 23 consecutive cases. J Periodon-
the residual ridge not necessarily coincident with the
tol 67:390, 1996.
center of the ridge
14. Bahat O, et al: Preservation of ridges utilizing
ridge lap \rj lap\: the surface of an articial tooth that has hydroxylapatite. Int J Periodontol Res Dent 6:35,
been shaped to accommodate the residual ridge. The 1987.
tissue surface of a ridge lap design is concave and 15. Lekovic V, et al: A bone regenerative approach to
envelops both the buccal and lingual surfaces of the alveolar ridge maintenance following tooth extrac-
residual ridge tion. Report of 10 cases. J Periodontol 68:563,
1997.
sanitary pontic obs: a trade name originally designed as a
16. Spear FM: Maintenance of the interdental papilla
manufactured convex blank with a slotted back. The
following anterior tooth removal. Pract Periodont
name was used occasionaly as a synonym for a hygienic
Aesthet Dent 11:21, 1999.
pontic, wherein the pontic does not contact the residual
17. Ingber JS: Forced eruption. II. A method of
ridge
treating nonrestorable teethperiodontal and
restorative considerations. J Periodontol 47:203,
1976.
REFERENCES 18. Perel ML: A modied sanitary pontic. J Prosthet
1. Stein RS: Pontic-residual ridge relationship: a Dent 28:589, 1972.
research report. J Prosthet Dent 16:251, 1966. 19. Hood JA, et al: Stress and deection of three dif-
2. Siebert JS: Reconstruction of deformed, partially ferent pontic designs. J Prosthet Dent 33:54, 1975.
edentulous ridges, using full thickness onlay grafts. 20. Shillingburg HT, et al: Fundamentals of Fixed
I. Technique and wound healing. Compend Contin Prosthodontics, 2nd ed, p 387. Chicago, Quintes-
Educ Dent 4:437, 1983. sence Publishing, 1981.
28
CONNECTORS
FOR PARTIAL
FIXED DENTAL
PROSTHESES
KEY TERMS RIGID CONNECTORS

Rigid connections in metal can be made by casting,
antiux nonrigid connectors
soldering, or welding. Cast connectors are shaped
cast connector soldered connectors
in wax as part of a multiunit wax pattern. Cast
neness soldering ux
connectors are convenient and minimize the
index tenon
number of steps involved in the laboratory fabrica-
mortise welding
tion. However, the t of the individual retainers may
be adversely affected because distortion more easily
results when a multiunit wax pattern is removed
from the die system. Soldered connectors involve
the use of an intermediate metal alloy whose melting
temperature is lower than that of the parent metal
(Fig. 28-3). The parts being joined are not melted
onnectors are the components of a partial during soldering but must be thoroughly wettable by
C xed dental prosthesis (FDP) or splint that join

the individual retainers and pontics together.
Usually this is accomplished with rigid connectors
liqueed solder.2 Dirt or surface oxides on the con-
nector surfaces can reduce wetting and impede
successful soldering; for example, the solder may
(Fig. 28-1), although nonrigid connectors are occa- melt but does not ow into the soldering gap.
sionally used. The latter are usually indicated when Welding is another method of rigidly joining metal
it is impossible to prepare a common path of place- parts. In welding, the connection is created by
ment for the abutment preparations for a partial melting adjacent surfaces with heat or pressure. A
FDP (Fig. 28-2A and B). Their use has been reported ller metal whose melting temperature is about the
to be associated with signicantly reduced failure same as that of the parent metal can be used during
rates.1 welding.
843
A B
C D
Fig. 28-1
Rigid connectors: A three-unit partial xed dental prosthesis (FDP) replacing the maxillary second premolar. A, The anterior abut-
ment and the pontic are connected with a rigid cast connector. These two partial FDP components are fabricated separately from
the posterior abutment, which is cast in gold. B, The components are related to one another by a soldering assembly. C, The con-
nected components. D, The xed prosthesis in place.
A B
Fig. 28-2
Partial xed dental prosthesis (FDP) with nonrigid connector. A, Mortise pattern (female) positioned on the distal aspect of the canine
retainer. B, Partial FDP assembled with prefabricated resin tenon (male) on the mesial aspect of the pontic. C, Nonrigid connectors
used to allow the fabrication of an extensive xed prosthesis having abutments prepared with divergent paths of placement. (Cour-
tesy of Dr. M. Chen.)
Chapter 28 CONNECTORS FOR PARTIAL FIXED DENTAL PROSTHESES 845
Investment Boxing
Soldering wax
index
A B
Soldering
index
Torch
Solder
Soldered
connector
Cast
connector C
Soldering
Investment gap
D
Fig. 28-3
The soldering process. A, Occlusal soldering index. B, Fixed dental prosthesis components invested. C, Torch soldering. D, Clinical
evaluation.
In industrial metalworking, a distinction is made dislodgment of complex FDPs. Segmenting complex

between soldering, in which the ller metal has a mandibular FDPs can minimize this risk (Fig. 28-4).
melting point below 450C (842F), and brazing, in Nonrigid connectors are generated through incor-
which the ller has a melting point above 450C.3 poration of prefabricated inserts in the wax pattern
Rigid connections in dentistry are generally fabri- or through custom milling procedures after the rst
cated above 450C, but the process has almost casting has been obtained. The second part is then
always been referred to in the dental literature as custom-tted to the milled retainer and cast. They
soldering. However, in a proposed international are often made with prefabricated plastic patterns.
standard, the term brazing is used. With time, the The retainers are then cast separately and tted to
latter term may become more generally accepted. In each other in metal.
this text, however, the term soldering is used.
NONRIGID CONNECTORS CONNECTOR DESIGN

Nonrigid connectors are indicated when it is not pos- The size, shape, and position of connectors all inu-
sible to prepare two abutments for a partial FDP ence the success of the prosthesis. Connectors must
with a common path of placement. Segmenting the be sufciently large to prevent distortion or frac-
design of large, complex FDPs into shorter compo- ture during function but not too large; otherwise,
nents that are easier to replace or repair individually they interfere with effective plaque control and
is advisable. This can be helpful if there is uncer- contribute to periodontal breakdown over time.
tainty about an abutments prognosis. If the abut- Adequate access (i.e., embrasure space) must be
ment fails, only a portion of the FDP may need to available for oral hygiene aids cervical to the con-
be remade. In the mandibular arch, nonrigid nector. If a connector is too large incisocervically,
connectors are indicated when a complex FDP hygiene is impeded, and over time, periodontal
consists of anterior and posterior segments. During failure will occur (Fig. 28-5A). For esthetic FDPs,
the mandibular opening and closing stroke, the a large connector or inappropriate shaping of the
mandible exes mediolaterally.4 Rigid FDPs have individual retainers may result in display of
been shown to inhibit mandibular exure, and the metal connector, which may compromise the
extensive splints have been shown to ex during appearance of the restoration and lead to patient
forced opening.5 The associated stresses can cause dissatisfaction (Fig. 28-5B).
Optimal connectors are

easy to clean, strong, and
esthetically pleasing.
Fig. 28-4
To accommodate the stresses that potentially result from
mandibular exure, this complex xed dental prosthesis has B C
been segmented through the use of nonrigid connectors on the
distal of the two canines (arrows). (Courtesy of Dr. F. Hsu.)
Fig. 28-6
Cross-sections through xed dental prosthesis connectors. A,
Maxillary anterior. B, Maxillary posterior. C, Mandibular poste-
rior. Note the convexity of the gingival aspect of the connec-
A tors. To prevent excessive display of metal, anterior connectors
should be placed toward the lingual embrasure.
conguration similar to a meniscus formed between

the two parts of the prosthesis.
In a buccolingual cross-section, most connectors
have a somewhat elliptical shape. Such an elliptical
connector is strongest if the major axis of the ellipse
parallels the direction of the applied force. Unfor-
tunately, because of anatomic considerations, this
B
cannot always be achieved. In fact, because of space
constraints, the greatest dimension of most connec-
tors is perpendicular to the direction of applied
force, which tends to result in a weaker connector.
For ease of plaque control, the connectors should
occupy the normal anatomic interproximal contact
areas, because encroaching on the buccal, gingival,
Fig. 28-5 or lingual embrasure restricts access. However, to
Restorative failure. A, Incisocervically an excessively large con- improve appearance without signicantly affecting
nector (arrows) impedes proper plaque control and has led to plaque control, anterior connectors are normally
periodontal breakdown. B, Although it may be acceptable from placed toward the lingual embrasure. Figure 28-6
a biologic and mechanical perspective, a connector (arrow) that depicts typical locations for connectors on selected
displays metal can prove to be esthetically unacceptable. teeth.
Pulp size and clinical crown height can be limit-
ing factors in the design of nonrigid connectors.
In addition to being highly polished, the tissue Most prefabricated patterns require the preparation
surface of connectors is curved faciolingually to facil- of a fairly sizable box. This allows incorporation of
itate cleansing. Mesiodistally, it is shaped to create a the mortise (see p. 843; Fig. 28-9B) in the cast
smooth transition from one partial FDP component restoration without overcontouring of the interprox-
to the next. A properly shaped connector has a imal emergence prole. Short clinical crowns do not
provide adequate occlusocervical space to ensure Soldered connectors

adequate strength. Most manufacturers recommend As with cast connectors, connectors to be soldered
3 to 4 mm of vertical height. are waxed to nal shape but are then sectioned with
a thin ribbon saw (Fig. 28-7A and B); therefore, when
the components are cast, the surfaces to be joined
TYPES OF CONNECTORS are at, parallel, and a controlled distance apart. This
Rigid Connectors allows accurate soldering with a minimum of dis-
tortion.6 Molten solder ows toward the location
Rigid connectors must be shaped and incorporated where the temperature is highest. In metal, the two
into the wax pattern after the individual retainers at surfaces previously created in wax retain heat,
and pontics have been completed to nal contour ensuring that the highest temperature is in the
but before reowing of the margins for investing (see connector area.
Chapter 18). Soldering gap width
As gap width increases, soldering accuracy
Cast connectors decreases.7 Extremely small gap widths can prevent
Connectors to be cast are also waxed on the deni- proper solder ow and lead to an incomplete or
tive cast before reowing and investing of the weak joint.8 An even soldering gap of about 0.25 mm
pattern. The presence of a cast connector makes the is recommended. If a connector area has an uneven
latter somewhat more awkward. Access to the prox- soldering gap width, obtaining a connector of ade-
imal margin is impeded, and the pattern cannot be quate cross-sectional dimension without resulting
held proximally during removal from the die. distortion is more difcult.
Restricting cast connectors to complete coverage
restorations, which can be gripped buccolingually, is Loop connectors
therefore advisable. Partial-coverage wax patterns Although they are rarely used, loop connectors (Fig.
are easily distorted when they are part of a single- 28-8) are sometimes required when an existing
cast partial FDP. One-piece castings often appear to diastema is to be maintained in a planned xed
simplify fabrication but tend to create more prob- prosthesis. The connector consists of a loop on
lems than do soldered connectors, especially as the lingual aspect of the prosthesis that connects
pattern complexity increases. adjacent retainers and/or pontics.
A B
C D
Fig. 28-7
Connector design. A, A ribbon saw is used to section the wax pattern. B, The sectioned surface should be at and located suf-
ciently far incisally and lingually to allow adequate hygiene and esthetics of the completed partial xed dental prosthesis (FDP). C,
A three-unit FDP after sectioning. D, Framework ready for porcelain application. Note the uniform gap width (arrow).
A B
Fig. 28-8
In the presence of a diastema that is to be maintained, a loop connector may be indicated. Incisal (A) and labial (B) views of a four-
unit xed dental prosthesis with a loop connector. Note that the diastema between the lateral and central incisors is maintained.
(Courtesy of Dr. M. T. Barco.)
Tenon
(male)
Mortise
B
A (female)
Nonrigid
connector
Fig. 28-9
Partial xed dental prosthesis with nonrigid connectors. This type of connector may be indicated to overcome problems with inter-
mediate or pier abutments (A) and abutment alignment (B).
The loop may be cast from sprue wax that is cir- (see Fig. 28-2). Paralleling is normally accomplished
cular in cross-section or shaped from a platinum- with a dental surveyor. When the cast is aligned, the
gold-palladium (Pt-Au-Pd) alloy wire. Meticulous path of placement of the retainer that will be con-
design is important for enabling plaque control. tiguous with the tenon is identied. The mortise in
the other retainer is then shaped so that its path of
placement allows concurrent seating of the tenon
Nonrigid Connectors
and its corresponding retainer.
The design of nonrigid connectors that are incorpo- The mortise can be prepared freehand in the
rated in the wax pattern stage consists of a mortise wax pattern or with a precision milling machine.
(also referred to as the female component) prepared Another approach is to use prefabricated plastic
within the contours of the retainer and a tenon (male components for the mortise and tenon of a
component) attached to the pontic (Fig. 28-9). The nonrigid connector (Fig. 28-10). As an alternative, a
mortise is usually placed on the distal aspect of the special mandrel can be embedded in the wax
anterior retainer. Accurate alignment of the dovetail pattern (Fig. 28-11) and the abutment retainer can
or cylindrically shaped mortise is crucial; it must be cast, with renement of the female component
parallel the path of placement of the distal retainer as necessary; the male key is then fabricated
A B
C D
Fig. 28-10
A, Prefabricated plastic patterns are available for incorporation in the wax pattern. B, The metal substructure. C, The anterior com-
ponent of the prosthesis. D, The completed prosthesis incorporates bilateral nonrigid connectors (arrows). (Courtesy of Dr. F. Hsu.)
with autopolymerizing acrylic resin and attached to

the pontic.
MATERIALS SCIENCE
M. H. Reisbick
Solder
Dental gold solders are given a neness designation
to indicate the proportion of pure gold contained in
1000 parts of alloy. For example, a 650-ne solder
contains 65% gold. In an earlier designation,9 the
solder was assigned a carat number, which indicated
Fig. 28-11 the gold content of the castings that were to be joined
Ticon mandrels are prefabricated inserts embedded in the wax with the solder; an 18-carat solder could be used to
pattern. The retainer is cast directly onto the mandrel to form solder castings fabricated of an alloy containing 75%
the female component of the connector. (Courtesy of Dr. F. Hsu.) gold. Because numerous alloys other than type IV
gold are available today, many of which contain
platinum-group metals, the carat designation is of
little value.
Modern casting alloys have become so metal-
lurgically complex that most manufacturers now
recommend specically formulated solders. One match the color of the units that will be joined, and
manufacturer (Heraeus Kulzer) classies traditional to be strong. These factors also depend on the chem-
gold-containing solders as group I and others ical composition of the solder.
(termed special solders) as group II. Most of these have Resistance to tarnish and corrosion is determined
the brand name with a pre or post designation to by a solders noble or precious metal content and its
indicate whether the solder is to be used for joining silver/copper (Ag/Cu) ratio.12 In addition, if the com-
the components before or after porcelain applica- positions of the solder and work piece differ, gal-
tion. The preceramic solders are obviously high- vanic corrosion may occur.
fusing alloys, sometimes fusing only slightly beneath During the soldering procedure, the solder must
the softening point of the parent alloy to be joined. ow freely over clean and smooth surfaces. These
Ideally, they ow well above the fusion range of the surfaces should be smoothed with abrasive disks, not
subsequently applied porcelain. Postceramic solders with rubber wheels or polishing compounds. The
must ow well below the pyroplastic range of the phenomenon of free ow is termed wetting, during
porcelain. For example, one popular silver- which remelting or realloying of the surface of the
palladium (Ag-Pd) casting alloy has a specied units to be joined must not occur.13 Solder ow is
melting range between 1232 and 1304C (2280 to increased by the addition of silver and decreased by
2384 F). The recommended special presolder melts the presence of copper. Figure 28-13 demonstrates
at 1110C to 1127C (2030F to 2061F), whereas a properly made solder joint. Note that the ller
the postsolder melts at 710C to 743C (1310F metal has joined the surfaces of the two castings
to 1369F). The porcelain fuses at about 982C without penetrating either one.
(1800F), depending on time and temperature. Lower-neness gold solders are often more uid
The composition of the solder determines its and are generally chosen for joining castings. If nec-
melting range, among other things. Some typical essary, proximal contacts with a solder of higher ne-
compositions and melting ranges are given in Table ness can also be added, because this tends to ow
28-1. Solders main requirement is to fuse safely less freely. However, the exact minimally acceptable
below the sag or creep temperature of the casting to neness necessary for resisting tarnish and corro-
be soldered. Newer palladium casting alloys, by sion has not been conclusively established; 615 or
virtue of their higher melting ranges, have somewhat
increased the reliability of the preceramic applica-
tion soldering technique.10
However, preceramic soldering is relatively dif-
cult and can be structurally hazardous (Fig. 28-12).
This may be because of the volatilization of base
metal solder constituents that occurs with overheat-
ing.11 Volatilization then results in microporosity or
pitting. The melting range of presolders is quite
narrow, because silver and copper (the usual modi-
ers of temperature range) cannot be used in the
alloy; these elements discolor porcelain on contact.
Another consideration is the oxide necessary for the Fig. 28-12
chemical adherence of porcelain. Porcelain does not Metal substructure for an anterior prosthesis. The preceramic
chemically bond equally well to all solders. soldering procedure has led to partial melting of the frame-
Other requirements of solders are their ability to work (arrow), which can result in distortion and/or premature
resist tarnish and corrosion, to be free owing, to failure.
Table 28-1 COMPOSITION (%) AND FLOW TEMPERATURES OF DENTAL SOLDERS
Fig. 28-13
Photomicrograph of a properly made solder joint connecting Fig. 28-14
two castings. Simulated base metal-to-base metal postceramic soldering pro-
cedure. Excessive oxide formation has prevented wetting by the
solder. (From Sloan RH, et al: Post-ceramic soldering of various alloys. J Pros-
580 neness is probably the lower limit of clinical
thet Dent 48:686, 1982.)
acceptability.
The last requirement, strength, is easily satised
by most solders and is usually greater than that of
the soldered parent metal, provided that the proce- oxides are removed, the solder is free to wet the clean
dure is followed carefully.8 In addition, most solders metal surface.
harden during cooling because of the order- Borax glass (Na2B4O7) is frequently used with gold
disorder transformation and the formation of other alloys because of its afnity for copper oxides. An
intermetallic phases, which occur at grain bound- often-cited soldering ux formula16 is borax glass
aries. Brittleness is frequently encountered with (55 parts), boric acid (35 parts), and silica (10 parts).
gold-based copper-containing solders. As with type These ingredients are fused together and then
III and type IV gold casting alloys, the gold-copper ground into a powder.
order-disorder (or discontinuous phase-hardening) Fluxes are available in powder, liquid, or paste
mechanism causes similar changes in the solders form. The paste is popular because it can be easily
microstructure.14 Simply stated, with these solders, placed and conned. Pastes are made by mixing
cooling to room temperature results in a brittle joint. the ux powder with petrolatum. The petrolatum
The joints are strong but have no ductility. Some excludes oxygen during heating and eventually
solder joints are weakened by notches.15 This means carbonizes and then vaporizes.
that soldered connectors should be well-polished to New uxes are available for use with nongold-
prevent fracture. based alloys. Their formulas are not generally pub-
Partial FDPs fabricated with type III gold alloys lished. At present, none of the new uxes are totally
and joined interproximally with traditional gold- capable of preventing oxide formation during
based solders are usually water quenched 4 to 5 heating of the base metal or nonnoble alloys. An
minutes after soldering is complete. Quenching example of a rapidly forming oxide on a base metal
immediately after soldering causes the partial FDP occurring during a simulated postceramic applica-
to warp; failure to quench leads to creation of a joint tion soldering can be seen in Figure 28-14. Solder-
with little or no ductility. A brittle joint may easily ing of base metal alloys is still unpredictable.17
fracture. Thus, a disadvantage of postceramic sol- All uxes should be kept from contacting
dering is the loss of joint ductility. Because the com- porcelain-veneered surfaces. The contact causes
ponents are partially porcelain, quenching is not pitting and porcelain discoloration.
done, because porcelain fracture will occur.
Soldering antiux
Antiux is used to limit the spreading of solder. It is
Soldering Flux and Antiux placed on a casting before the ux application to
limit the ow of molten solder. When the metal sur-
Soldering ux faces are clean, any excess solder introduced into the
This substance is applied to a metal surface to work gap tends to ow into undesirable areas. The
remove oxides or prevent their formation. When the antiux helps prevent this.
Graphite (from a pencil) is often used as an

antiux. However, the carbon easily evaporates at
higher temperature, leaving the work piece unpro-
tected. A more reliable antiux is iron oxide
(rouge) in a suitable solvent such as turpentine,
which can be painted on the casting with a small
brush.
Soldering Investment
Fig. 28-15
Soldering investments are similar in composition to Stepped weld on left, parent metal on right.
casting investments (see Chapter 22). Casting invest-
ments, both gypsum and phosphate bonded, mixed
with water only, have been used for soldering.
However, the refractory component in casting invest-
ments usually creates unwanted thermal expansion
SELECTION OF SOLDERING TECHNIQUE
and therefore excessively separates the units to be When partial FDPs are assembled by soldering, the
joined. Soldering investments ideally contain fused relative position of the components is recorded with
quartz (the lowest thermally expanding form of a soldering index on the denitive cast or intraorally.
silica) as their refractory component. If pontics are made individually, they can be difcult
Invested units expand during heating, and to position properly in relation to the abutment
they should do so at the same rate as the castings. teeth. Although a positioning index made previously
The units must be correctly gapped so that they do upon completion of the wax pattern can be helpful
not touch. When the work units are allowed to (Fig. 28-16), the pontics should be connected to one
touch, distortion and porous inadequate joints of the retainers with a cast connector because this
result.9 Alternatively, excessive gap spaces cause stabilizes them and makes accurate positioning in
undersized mesiodistal partial FDP widths because relation to the other retainer much easier. To under-
of solder solidication shrinkage. However, Ryge9 stand the selection of soldering technique, a thor-
showed that the gap space closes somewhat ough knowledge of the fusing ranges of all materials
during heating, and so it is doubtful that the alloy involved in the FDP is essential (Fig. 28-17).
and investment truly expand equally or at the Soldering of all-metal FDPs consisting of type III
same rates. Several commercial soldering invest- or IV gold units requires the use of a low-fusing
ments are available; these should be used whenever solder. The procedure is referred to as conventional
possible. A list of reliable investments appears soldering. Through the use of the same low-fusing
in Appendix A. solder, regular gold retainers can also be connected
with metal-ceramic components. A gas-air torch is
used for either of these procedures.
Joining Base Metals For FDPs consisting of metal-ceramic units, the
soldered connectors may be made either before the
Titanium and titanium alloys ceramic application with high-fusing solder (approx-
The advent of titanium and its alloys, as with cobalt- imately 1100C [2012F]) or after the ceramic appli-
chromium-nickel, has brought a new challenge to cation with lower-fusing solder (750C [1382F]).
joining cast units. Titanium also responds to high Soldering before ceramic application is called pre-
heat with an increased oxide formation, which ceramic application soldering or pre-soldering. Soldering
results in a poor union between components to be of metal-ceramic crowns after their completion is
joined. A reasonable solution has proved to be referred to as post-soldering. Many alloys can be com-
welding, by either laser or plasma. Advantages bined by using either pre-ceramic or post-ceramic
include less heat distortion and a compositionally soldering. However, pre-soldering has been found to
uniform joint. Thus, joining with the same chemical be less reliable,8 with a number of apparently sound
element or elements minimizes detrimental gal- connectors exhibiting negligible tensile strength.
vanic degradation. Figure 28-15 shows a stepped Considerable variation in solder joint strength has
laser weld. Much work yet remains to render tita- also been recorded after laboratory testing,18 which
nium a suitable replacement for noble casting alloys. emphasizes the special care needed to avoid defec-
tive connectors.
Does not interfere

with occlusion
A
Index 5-8 mm thick
B C
Fig. 28-16
Once the xed dental prosthesis has been waxed to anatomic contour, a silicone putty buccal index (A) can be made. This can be
helpful when relating the castings. B, Putty is applied to the buccal aspect of the completed waxing. C, Excess is trimmed away with
a scalpel blade. D, The at surface makes verication of accurate reseating of the index much easier.
Base metal alloys can be difcult to solder techniques and materials, reliable base metal
because they oxidize; oxidation must be controlled alloy soldered connectors are possible.21 However,
with special uxes, although excessive uxing can because of the problems of soldering base metal
lead to undesirable inclusions and weak connectors. alloys, various alternative procedures have been
In one study,19 investigators found that 20% of post- advocated. These include making the soldered joint
ceramic soldered joints involving base metal alloys through the center of the pontic to increase the area
had to be resoldered because they were so weak that soldered22 and connecting the parts by a second
they broke with nger pressure. Another study20 casting procedure, with the molten metal owing
showed great variability in solder joint quality with into undercuts in the sectioned pontic.23
these alloys, with no consistent relationship of
strength to gap width. Those authors found that
Soldering All-Metal Partial Fixed
most failures occurred through the solder and were
Dental Prostheses
attributable to voids caused by gas entrapment or
localized shrinkage. With experience and careful Type III and type IV gold retainers of partial FDPs
adherence to the manufacturers recommended are soldered with gold solder ranging from 615 to
1260 C
1175 C
C F
1400
1300
1260 2300
960 C
1200
1175 2150
1100
1000
960 1760
925 1700
900
800
790 1450
925 C
700
600
500
790 C
400
300
200
100
700 C
Fig. 28-17
A, Casting metal-ceramic alloys. B, Presoldering. C, Porcelain ring. D, Casting type III and type IV gold alloy. E, Postceramic
soldering. F, Conventional soldering.
650 neness. An occlusal plaster index or autopoly-

merizing resin index is fabricated intraorally or in
the dental laboratory; after investing, a gas-air torch
can be used to solder the components. A disadvan-
tage of the soldering procedure is that it requires an A
additional step, in comparison with a one-piece
casting. However, soldering simplies the manip-
ulation of wax patterns. For instance, when a three-
abutment FDP with two splinted abutments (e.g.,
two premolars) is fabricated, access to the interprox-
imal margins of the two splinted abutments is
often very difcult during the reowing and
nishing steps. Soldering such retainers enables the
retainers to be shaped and adjusted individually B
with improved access for nishing procedures. Con-
ventional soldering requires a gas-air torch; solder-
ing can also be performed in a furnace.
Soldering Metal-Ceramic Partial Fixed

Dental Prostheses
C
Pre-ceramic soldering
Once a metal-ceramic framework has been assem-
bled by pre-ceramic application soldering, the sub-
sequent procedures are the same as if it had been
cast in one piece. This has the advantage of allowing Fig. 28-18
the connected prosthesis to be tried in the mouth in A, This anterior xed prosthesis was connected by post-ceramic
soldering. B, Note the connector placed sufciently lingually for
the unglazed state. Any necessary adjustments can
good facial embrasure form. C, The assembled xed dental
be made to the porcelain, which fuses at a lower prosthesis.
temperature than does the pre-ceramic soldered
connector. However, with pre-ceramic soldering,
contouring the proximal embrasures so that the units can be added as needed, the restorations can be
resemble natural teeth may be more difcult. A very reglazed, a new index can be made, and the FDP
thin diamond disk is helpful for this. resoldered.
A disadvantage results from having to apply the Because the proximal areas are shaped before sol-
porcelain to a longer structure, which needs support dering, a postsoldered connector can often be made
during ring to prevent high-temperature deforma- to look more natural than a presoldered or cast con-
tion or sag. Sag can be a particular problem with the nector (Fig. 28-18). In addition, customized ring
high-gold content ceramic alloys because they have supports are not needed because sag is not a
a lower melting range. Highpalladium content or problem (the lengths of the individual components
base metal alloys exhibit little sag during ring. Pre- are shorter). Postsoldering is performed either in a
soldering requires a gas-oxygen torch. porcelain furnace or with a gas-air torch.
Post-ceramic soldering
Post-ceramic soldering is necessary when regular HEAT SOURCES
gold and metal-ceramic units are being combined in
Torch Soldering
a partial FDP. The regular gold melts if it is subjected
to the high temperatures needed for porcelain appli- When a gas-air torch is used as the heat source to
cation; therefore, all porcelain adjustment and ring, melt the solder, metal-ceramic restorations are pre-
including that for the nal characterization and heated in an oven to minimize the risk of cracking
glazing, must be completed before the soldering. If of the porcelain veneer. Oxidization of the joint sur-
further corrective adjustment is needed after sol- faces is prevented by using the reducing portion of
dering, the porcelain must be polished, or the joint the ame (Fig. 28-19) and by applying an appro-
must be separated, after which additional porcelain priate ux (some soldering uxes are unsuitable
4 3 2 1 Torch tip
4 3 2 1
Approximate ratios in a properly adjusted flame
Zones:
1. Mixing zone
2. Combustion zone
3. Reducing zone
4. Oxidizing zone
Fig. 28-19
Gas-air torch adjusted for soldering.
because they discolor the porcelain). To prevent

uneven heat distribution, which could result in frac-
ture, the ame is never concentrated in one area but
is kept in constant motion.
Some dentists believe that the ow of solder is
more controllable during torch soldering because a
slight temperature differential can be created and
the solder always ows toward the hotter point. This
makes torch soldering useful when the connector
has not been well designed in wax, and a minor tem-
perature difference can deliberately be created in
the assembly to help direct the ow of the molten
solder to ensure an adequate connector.
Fig. 28-20
Oven Soldering Oven soldering a three-unit xed dental prosthesis. (Courtesy of
Dr. A. G. Gegauff.)
Furnace or oven soldering is performed under
vacuum or in air. A piece of solder is placed at the
joint space, and the casting and solder are heated
simultaneously.
Criticism of this technique has been based on the fusion point of the solder, the mufe door is
earlier observations24 that less porosity resulted opened, and the solder is fed into the joint space
when castings were brought to soldering tempera- (Fig. 28-20).
ture before the solder was applied. The method
does not allow the moment of solder fusion to be
observed.* This may be important, because the Laser Welding
longer the solder remains molten, the more it dis- Laser energy is extensively used for welding (Fig.
solves the parent metal and consequently weakens 28-21) in many industries and has been described
the joint.9 Nevertheless, joints with strength similar in dentistry since the 1970s.25,26 Interest has
or superior to that of the parent metal have been continued in laser assembly of xed prostheses
demonstrated8 when oven soldering was used. with reportedly higher strength27 and reduced
A different technique may be appropriate if the corrosion28 compared with conventional soldering,
porcelain furnace has a horizontal mufe with a although laser-welded connectors seem as suscepti-
xed oor. The soldering assembly is heated above ble to fatigue failure.29 Laser welding may be a prac-
tical way to join cast titanium components (e.g., if
these are to be used for implant-supported prosthe-
*Some porcelain furnaces have an observation window for post-soldering. sis frameworks30,31).
SOLDERING TECHNIQUE
Armamentarium
Autopolymerizing acrylic resin
Zinc oxideeugenol (ZOE) paste
Impression plaster
Mixing bowl
Spatula
Small brush
Waxing instrument
Sticky wax
Baseplate wax
Sprue wax
Soldering investment
Glass slab
Fig. 28-21 Soldering tripod
Laser welding. Individual titanium components are carefully Flux
aligned in the laser welding unit. The joining procedure is mon- Solder
itored with high-magnication video. (Courtesy of Crafford-LaserStar
Tongs
Technologies, Riverside, Rhode Island.)
Pickling solution
Step-by-Step Procedure
SOLDERING ACCURACY Occlusal soldering index
Controversy exists as to the relative accuracy of An intraoral plaster or ZOE impression is made of
partial FDPs that are cast in one piece, preceramic the occlusal surfaces of the partial FDP to capture
soldered, or postceramic soldered. Individual labo- the relative relationship of the individual FDP
ratory technicians often obtain consistently better components and transfer this to the laboratory. This
results with one particular technique, but scientic procedure can also be performed in the laboratory
evidence is conicting.32,33 In evaluating clinical if the technician is satised that the individual
work to determine whether cast or soldered con- components are seated completely on an accurate
nectors provide better results, the determining denitive cast. An advantage of an occlusal index
factor should be the t of the individual retainers. (Fig. 28-22; see Fig. 28-3) is that after the soldering
This should be optimized through the investing and procedure has been completed, the FDP can be
casting process (see Chapter 22) to minimize the reseated in the index and soldering accuracy can be
risks of incomplete seating or excessive luting agent veried (sometimes a small amount of plaster must
space. In some situations, it may be impossible to be removed in the area where the solder has been
cast a long-span FDP with ideal retainer dimensions added, to ensure seating).
and ideal interabutment dimensions; the challenge 1. Grind the connector surfaces of the nished
lies in obtaining enough interabutment expansion castings with a stone or disk to remove surface
without making the retainers too loose. In such oxides. Then fully seat the castings on the
circumstances, a soldered connector may provide denitive cast or in the mouth. Post-ceramic
better accuracy. The situation is reversed for fabri- connectors are best indexed intraorally after the
cating frameworks for implant-supported prostheses contour and appearance have been perfected. If
(see Chapter 13). Here the t of the individual units necessary, the soldering gap can be adjusted at
is determined by the implant manufacturer. Only this time (gap distance, 0.25 mm). The castings
the overall abutment-to-abutment t is under the can be seated intraorally with a small quantity
control of the technician. However, an accurate, pas- of low-viscosity impression material to ensure
sively tting implant-supported framework is crucial they are not disturbed during the indexing.35
for avoiding damaging forces. It is not yet clear 2. Make an impression plaster registration in a
whether accurate implant-supported frameworks small tray or on a sheet of baseplate wax for the
are most effectively made with one-piece castings or occlusal index. As an alternative, an index can
as sectioned and soldered units.34 be made with ZOE paste, a technique that has
6. To create a space that will help the solder

spread, adapt sprue wax gingival to the solder
joint. Burying the units completely in the invest-
ment makes soldering difcult because the
unnecessary bulk of the investment prevents
rapid heating of the castings.
A
7. Protect any glazed porcelain from contacting the
investment by coating it with wax before invest-
ing. To protect regular gold margins from the
soldering ame, they should be embedded in
the investment; otherwise, they may become
overheated and melt. For the same reason, all
margins should be embedded in the investment
before preceramic application soldering.
8. Box the assembly with a suitable sheet wax.
9. Mix the investment carefully, and ow it into the
castings without trapping any air. Only slight
B vibration is used so that the castings are not
displaced from the index.
10. Allow the invested block to bench set before
removing the wax and preheating.
Autopolymerizing resin soldering index
A plaster or ZOE occlusal index is less suitable for
the registration of anterior restorations. The thinness
of the incisal edges of these units makes them
less stable, and accurate repositioning is more dif-
cult. For this reason, autopolymerizing resin (Fig.
28-24) is recommended, although the resin burns
C off during the procedure. Therefore, the accuracy
of the soldering procedure can be veried only
intraorally.
1. Join the completed units together with autopoly-
merizing resin. The resin will later burn out,
leaving no residue that could interfere with the
casting.
Fig. 28-22 2. Apply the resin with a bead technique. This min-
Soldering index (plaster) for posterior xed dental prostheses. imizes the distortion from polymerization shrink-
A, A suitable carrier (e.g., baseplate wax) is trimmed to proper
age. Excessive bulk of resin reduces the accuracy
shape before a registration is made with impression plaster (B).
C, The plaster occlusal registration.
of the technique,37 but sufcient material must be
present to ensure that the components do not
break (because they cannot then be accurately
reseated in the index). The resin should extend
shown36 consistent and accurate recordings. The onto the incisal edges of the retainers.
index should not cover the margins of regular 3. When the resin has fully hardened, carefully
gold retainers because these are to be embed- loosen the prosthesis from the abutments. Then
ded in the investment to prevent their acciden- replace it and check whether distortion has
tal melting during soldering. occurred. This is done in the same way as the
3. Trim the index to fully expose the margins evaluation of a nished FDP. It must be stable
before investing (Fig. 28-23). with no marginal discrepancies (see Fig. 28-24C).
Investing The prosthesis should be invested without delay;
4. Seat each casting into the index, and lute it to otherwise, the resin index will distort.38
place with sticky wax. Investing (Fig. 28-25)
5. Flow wax into the connector area to prevent the 4. Warm a sheet of wax, and push the cervical
investment from entering. aspect of the restorations through it. Then seal it
A B,C
D E,F
G H,I
Fig. 28-23
Investing procedure (occlusal index). A, The index is trimmed to ensure complete seating of the castings. B and C, The connector
area is ground with a noncontaminating stone. D, The restorations are steam cleaned. (Alternatively, an ultrasonic can be used.) E,
The castings are seated rmly and luted to place with sticky wax. F, Glazed porcelain is damaged by contact with the investment;
the porcelain is therefore protected with a layer of wax. G, The wax is owed into the connector areas and is adapted below each
connector to create an airway. H, The soldering assembly is boxed. I and J, When the assembly is lled with soldering investment,
great care is taken to ensure that there are no air bubbles in the investment.
A B,C
Fig. 28-24
Soldering index (autopolymerizing resin). A, Armamentarium. B, A small brush dipped in resin monomer is touched to the polymer
powder. This forms a bead. C, The restorations are thus connected, with resin extending onto the incisal edges of all the retainers.
A B
Fig. 28-25
Investing procedure (autopolymerizing resin). A, The castings pressed rmly into a softened sheet of wax. Note that the internal
walls of the castings are exposed; the wax seals them. B, Castings lled with soldering investment and then inverted onto a patty
of investment.
along the axial wall with a warmed instrument. solder above the gap. Adjust the gas-air torch to give
This protects the porcelain from contact with the a sharp blue cone (as for casting), and then reduce
soldering investment. the air for a softer brush ame. The reducing
5. Fill the castings with soldering investment, and zone of the ame is used to heat the investment
blot excess water from the remaining investment, block. The ame is directed at the lingual aspect of
forming it into a patty on a slab or tile. the block rather than at the casting.
6. Seat the restorations on the patty. When a joint is 2. Heat evenly and slowly, moving the tip of the
to be oven-soldered, the restoration should be ame constantly. This is particularly important
angled forward so that the solder can be placed in post-ceramic application soldering because
above the joint before the block is set inside the the porcelain may easily crack. When the metal
furnace. glows brightly, the solder melts and ows into the
joint space.
Wax removal and preheating (Fig. 28-26). 3. Quickly move the ame to the facial aspect.
1. If a plaster or ZOE index was used, remove it after When the solder spins in the joint, remove the
the investment has fully set. This separation is ame.
most effectively accomplished after the wax is 4. Extinguish the ame, and let the soldered pros-
removed with boiling water. The joint space must thesis cool for 4 or 5 minutes before quenching
be free of investment. Flowing a little ux into the (unless there is porcelain on the restoration, in
joint space while the soldering block is still warm which case it should cool to room temperature).
from wax removal is recommended. This prevents Earlier quenching may lead to distortion,
small particles from inadvertently falling into the whereas prolonged bench cooling increases the
gap. Be aware that many special soldering invest- brittleness of the joint.
ments have low strength, and the assembly is
easily broken at this stage. Torch soldering (high heat) (Fig. 28-28)
2. Preheat the investment in a burnout furnace to 1. Wear dark glasses for eye protection (Fig. 28-29).
650C (1202F) for low-heat soldering or 850C Gas-oxygen torches for high-heat pre-ceramic
(1562F) for preceramic soldering. Acrylic resin soldering have a miniature needle tip so that
indexes are removed by heating slowly to 300C the ame can be pinpointed on the joint space.
(572F), at which time most of the resin will have 2. Place the solder above the gap, and concentrate
burned away. the reducing zone of the ame on the joint space.
3. Heat the block to 650C (1202F) until all traces 3. When the solder melts, draw it into the joint and
of wax and resin have vaporized, and then trans- quickly chase it around with the ame (Fig. 28-
fer it to the soldering stand or porcelain furnace. 30). The pre-ceramic solder may have a melting
point close to that of the parent metal, and there
Torch soldering (low heat) (Fig. 28-27) is danger of melting a thin framework unless the
1. Transfer the assembly to a soldering stand with a ame is concentrated on the joint space (see Fig.
Bunsen ame underneath, and place a piece of 28-12).
A B,C
D E,F
G H
Fig. 28-26
Wax removal and preheating. A and B, Boxing material removed and the wax residue ushed out with boiling water. C, The con-
nector area must be free of contaminants. D, A small amount of soldering ux is applied while the assembly is still warm. E, The
ux is carried into the connector area by capillary action. Then the assembly is placed in the burnout furnace. F and G, Autopoly-
merizing resin indexes. These are burned off directly in the furnace after wax elimination. H, The soldered restorations.
A B,C
D E,F
Fig. 28-27
Low-heat torch soldering. A, The assembly positioned on a wire mesh over a Bunsen burner. B, A exed piece of solder placed into
the connector area. C, A sharply dened ame is preferable for casting procedures. D, A brush ame is more suitable for soldering.
This can be obtained by slightly reducing the amount of air. E, The assembly is heated evenly until the solder melts. The solder must
spin in the connector area to form a complete connection (F).
Fig. 28-29
Eye protection is essential for high-heat soldering and the
casting of high-fusing alloys.
Fig. 28-28
High-heat (pre-ceramic application) torch soldering with a gas-
oxygen torch and a miniature needle tip.
3
1
Torch
Soldering assembly
positioned over flame
on metal mesh
Mesh
Well-defined cone-shaped
flame with tip of reducing
zone at the base of the
soldering assembly
Bunsen
burner
Fig. 28-30
The ame is directed at the connector immediately when the solder melts and is moved around from position 1 to positions 2 and
3. This ensures that a complete meniscus is formed.
Oven soldering (Fig. 28-31) owed properly, the completed joint can be evalu-
1. Prepare a piece of solder by dipping it in liquid ated for size before removal of the investment and,
ux and melting it in a Bunsen ame to form a if necessary, reheated while still hot, with additional
ball. The size of the ball is determined by the solder added. Excessive solder must be ground away
connector size and the joint gap. during the nishing procedure (Fig. 28-32).
2. Leave a short tail attached to the ball to help posi- If the connector has been designed properly and
tion it above the joint space. As an alternative, the the solder has been properly positioned, no solder
solder can be fed into the joint area as shown in should run onto the occlusal surface or cover the
Figure 28-20. margins. To prevent stray ow, a small amount of
3. Put the assembly in the furnace, and increase the antiux (rouge dissolved in turpentine) can be
temperature to melt the solder. A vacuum is not painted on critical areas before the assembly is
needed for oven soldering of noble metal alloys. heated. After bench cooling for about 5 minutes, the
Air ring is preferred by some technicians because assembly is quenched (not porcelain) and the invest-
in a vacuum, there is always the chance of drawing ment broken away (Fig. 28-33). The connector is
entrapped gases to the surface of glazed porcelain, then carefully inspected. If signs of an incomplete
causing localized swelling or bloating. joint are evident (e.g., visible porosity in the solder),
they are removed by grinding with a ne disk; the
units are then reinvested and resoldered.
The joints must be tested for strength (Fig. 28-34).
Evaluation
Any connector that can be broken by force of hand
If the solder fails to ow during torch soldering but will not serve adequately in the mouth. Because
forms a ball above the joint area, heating should be broken connectors cannot be easily repaired intra-
discontinued. The solder has oxidized, and further orally once the prosthesis has been cemented, the
heating will melt the castings. If the solder has entire restoration usually must be remade.
A B
C D
E F
Fig. 28-31
Oven soldering procedure. A, The invested partial xed dental prosthesis (FDP) before soldering. B, A small amount of ux is added
to the clean joint area. C and D, Solder is added, and the assembly placed in the oven. E, The soldered FDP. F, The soldering index
is used to assess soldering accuracy. G, Oven-soldered connector before nishing.
A B,C
D E,F
G H,I
Fig. 28-32
A, A xed splint was indicated for this patient to prevent drifting of teeth with compromised periodontal support. B and C, Plaster
soldering index. D and E, Splint before investing. F, The soldering assembly. G, The assembled prosthesis after soldering. H, Note
that the connectors have been considerably reduced in size during the nishing procedure. Splinted teeth do not require as large
connectors as do xed dental prostheses. I, The completed prosthesis.
A B,C
Fig. 28-33
A, The assembly is quenched after bench cooling for approximately 5 minutes. B, Investment removed from the castings. C, Surface
oxides dissolved in a pickling solution.
REVIEW OF TECHNIQUE
Figure 28-35 summarizes the steps involved in
partial FDP connector fabrication and should be
referred to when the material is reviewed.
1. The design of connectors is determined in the
wax pattern (Fig. 28-35A and B).
2. All soldered connections require clean parallel
surfaces. Gap width should be 0.25 mm.
3. The units are indexed either from the denitive
cast or in the mouth (Fig. 28-35C).
4. Wax is added to the indexed restorations to
shape the soldering assembly. For metal-ceramic
restorations, it is added to protect the porcelain
Fig. 28-34 (Fig. 28-35D).
Solder joints should always be tested for strength.
A B,C
D E,F
G H
Fig. 28-35
Technique review. A, The design of connectors is determined in the wax pattern. B, All soldered connections require clean parallel
surfaces. Gap width should be 0.25 mm. C, The units are indexed either from the denitive cast or in the mouth. D, Wax is added
to the indexed restorations to shape the soldering assembly. For metal-ceramic restorations, it is added to protect the porcelain. E,
The units are invested, and the investment is allowed to bench set. F, If a plaster or zinc oxideeugenol index is used, wax is elimi-
nated with boiling water, the joint is uxed, and the assembly is preheated in a burnout furnace. G, If a resin index has been used,
it is placed directly in the burnout furnace. H, The connectors are soldered with a torch or in a porcelain furnace.
?
STUDY QUESTIONS
1. Contrast soldering, brazing, and welding.
2. Discuss how biologic, mechanical, and esthetic considerations affect connector size and position for each of
the following classes of teeth: incisors, premolars, and molars.
3. When and why would a nonrigid connector be used? A loop connector?
4. Discuss neness and carat. What is their importance in dental soldering?
5. How do soldering investments differ from conventional casting investments? Why?
6. What is ux? Antiux? How do they work? Give several examples of each.
7. What are the fundamental differences among conventional soldering, post-ceramic soldering, and pre-ceramic
soldering? When contrasting the last two techniques, identify the advantages and limitations associated with
their use.
8. Describe the step-by-step procedures for two techniques to make a soldering index for a partial FDP. What
are the respective advantages and limitations?
5. The units are invested, and the investment is

allowed to bench set (see Fig. 28-35E). GLOSSARY*
6. If a plaster or ZOE index is used, wax is elimi- 1
abrasive \uh-bra siv, -ziv\ n (1853): a substance used for
nated with boiling water or chloroform, the joint abrading, smoothing, or polishing
is uxed, and the assembly is preheated in a
burnout furnace (see Fig. 28-35F). airborne-particle abrasion \rbrn prt-kal a-
7. If a resin index has been used, it is placed directly brazhun\: the process of altering the surface of a mate-
in the burnout furnace (see Fig. 28-35G). rial through the use of abrasive particles propelled by
8. The connectors are soldered with a torch or in a compressed air or other gases
porcelain furnace (see Fig. 28-35H). antiux \ante-uks\ n: materials that prevent or connes
solder attachment or ow
SUMMARY bees wax n (1676): a low-melting wax obtained from
honeycomb and used as an ingredient of many dental
Connectors join individual retainers and pontics.
impression waxes
Rigid or nonrigid connectors can be used. Connector
size, shape, and position inuence the success of a brazing investment \brazing n-ve
stment\: an invest-
partial FDP. The use of soldered connectors can sim- ment having a binding system consisting of acidic phos-
plify the fabrication of larger xed prostheses, which phate such as monoammonium phosphate and a basic
may be cast separately in groups of one or two units oxide such as magnesium oxide
and assembled after their individual t has been ver-
brazing material \brazing ma-tre-al\: an alloy
ied. The technical procedures involved in soldering
suitable for use as a ller material in operations
are not difcult. If the joint surfaces have been cor-
with which dental alloy(s) is/are joined to form a dental
rectly designed and soldering gap width has been
restoration
carefully controlled, the procedures are routine. All
debris must be removed from the connector area cast connector: a cast metal union between the retainer(s)
because it interferes with surface wetting. and pontic(s) in a xed dental prosthesis
Conventional soldering involves the assembly of 1
connector \ka-nektor\ n (15c): in removable denture
type II, III, or IV gold castings. Pre-soldering is
prosthodontics, the portion of a removable dental pros-
the assembly of metal ceramic substructures before
thesis that unites its componentsusage: see BAR C.,
porcelain application. Post-soldering is the assembly
CONTINUOUS BAR C., MAJOR C., MINOR C.
of metal ceramic units after porcelain application.
Heat sources used for soldering procedures include
gas-air torches, gas-oxygen torches, furnaces, and
laser units.
If the basic principles are understood and the The Glossary of Prosthodontic Terms, 8th Edition, pp. 1081, 2005,
technique has been mastered, these procedures are with permission from The Editorial Council of The Journal of Prosthetic
entirely reliable. Dentistry.
diastema \da-stema\ n, pl -mata \-ma-ta\ (1854): subocclusal connector \suba-kloozal ka-nektar\: an

a space between two adjacent teeth in the same interproximal nonrigid connector positioned apical to
dental arch and not in communication with the occlusal plane
2
ne \fn\ adj (13c) 1: free from impurities 2: of a metal: weld \weld\ vb: to unite or fuse two pieces by hammer-
having a stated proportion of pure metal in its composi- ing, compression, or by rendering soft by heat with the
tion, expressed in parts per thousand > a gold coin addition of a fusible material
0.9265
neness \fnnes\ n: the proportion of pure gold in a gold
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2003.
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laser welding \lazer weldng\: the joining of metal com- 6. Steinman RR: Warpage produced by soldering
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beam 4:384, 1954.
7. Willis LM, Nicholls JI: Distortion in dental solder-
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1
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2
solder \sodar\ v, soldered \sodard\ soldering 11. Craig RG, Powers J: Restorative Dental Materials,
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solderer \sodar-er\ n: to unite, bring into, or restore to 12. Tucillo JJ: Compositional and functional character-
a rm union; the act of uniting two pieces of metal by istics of precious metal alloys for dental restora-
the proper alloy of metals tions. In Valega TM, ed: Alternatives to Gold
Alloys in Dentistry [U.S. DHEW Publication No.
soldering antiux: a material, such as iron oxide (rouge) (NIH) 771227], p 40. Washington, DC, Deptart-
dissolved in a suitable solvent such as turpentine placed ment of Health, Education, and Welfare, Public
on a metal surface to conne the ow of molten solder Health Service, National Institutes of Health,
1977.
stabilization \staba-l-zashun\ n, obs: the seating of a
13. El-Ebrashi MK, et al: Electron microscopy of gold
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16. Phillips RW: Skinners Science of Dental Materials, 29. Wiskott HW, et al: Mechanical and elemental char-
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26. Preston JD, Reisbick MH: Laser fusion of selected 37. Moon PC, et al: Comparison of accuracy of solder-
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43:569, 1988.
Fate of vital pulps beneath a metal-ceramic crown
or a bridge retainer
G. S. P. Cheung, S. C. N. Lai & R. P. Y. Ng

Discipline of Conservative Dentistry, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China
Abstract Results The numbers of preoperatively vital teeth

in the CMC and BR groups were 122 and 77, and
Cheung GSP, Lai SCN, Ng RPY. Fate of vital pulps beneath a
the mean observation periods were 169 25 (SD)
metal-ceramic crown or a bridge retainer. International Endo-
and 187 23 months, respectively. In the CMC
dontic Journal, 38, 521530, 2005.
group, 19 failed cases (15.6%) were due to an
Aim To investigate the incidence of and factors endodontic reason; total number of failures was 34.
associated with pulpal necrosis in vital teeth restored In the BR group, 25 (32.5%) showed signs of pulpal
with metal-ceramic crowns (CMCs) or crowned as part necrosis; a significant association with maxillary
of a fixedfixed bridge. anterior teeth was noted. The survival rates for pulp
Methodology Patients who had a CMC or bridge vitality were 84.4% (CMC) and 70.8% (BR) after
retainer (BR) placed on a tooth with no previous 10 years, and 81.2% (SC) and 66.2% (BR) after
history of root canal treatment from 1981 to 1989 15 years. The difference between the two groups was
were retrieved from computer records. The collated significant.
patients were randomly selected and their clinical Conclusion The survival of the vital pulp in teeth
records examined. Those who satisfied the inclusion restored with a single-unit CMC was significantly
criteria were contacted and offered a review. After higher than those serving as an abutment of a fixed
clinical examination, long-cone paralleling periapical fixed bridge. Maxillary anterior teeth used as bridge
radiographs were taken of the selected teeth, which abutments had a higher rate of pulpal necrosis than
were then assessed by two precalibrated operators to any other tooth types.
ascertain the pulpal status. Factors that might contrib-
Keywords: bridges, crowns, fixed prosthodontics,
ute to loss of pulp vitality and the tooth type were also
pulpal necrosis, survival analysis.
recorded. The collected data were analysed statistically
using the chi-square test and subject to Bonferroni
adjustment where indicated. Received 16 April 2004; accepted 1 April 2005
have suffered cumulative insults from caries, periodon-

Introduction
tal disease, or trauma, be it physical or due to
Full coverage crowns have long been used to restore restorative procedures, prior to the restoration (Ericson
heavily damaged teeth and/or, in the case of metal- et al. 1966). Any history of dental disease and resto-
ceramic crowns (CMCs), to satisfy the patients aes- rations could have an impact on the health of the
thetic demand. They are also frequently used as dental pulp and further treatment might precipitate
retainers for fixed prostheses to replace missing teeth. pulpal problems in the future (Seltzer & Bender 1984).
In either case, it is likely that the teeth involved might Diseases of endodontic origin affecting the abutment
teeth have been regarded as a biological failure of the
fixed prostheses; other biological reasons for failures
Correspondence: Dr Gary S.P. Cheung, Area of Conservative
Dentistry, 3/F, Prince Philip Dental Hospital, 34 Hospital
include caries and periodontal disease (Selby 1994).
Road, Hong Kong SAR, China (Tel.: +852 2859 0288; fax: Fixed prostheses may also fail mechanically, because of
+852 2559 9013; e-mail: spcheung@hkucc.hku.hk). loss of retention, fracture of porcelain, failure of the
2005 International Endodontic Journal International Endodontic Journal, 38, 521530, 2005 521
Fate of vital pulps Cheung et al.
metal framework or solder joints, wear, and fracture of appears to be a lack of information that highlights any
the abutment tooth. Defective margins, poor contour difference on the pulpal status of teeth supporting
and poor aesthetics may then account for the remain- single crowns or conventional fixedfixed bridge retain-
ing failures. Many of these failures can have a ers. The aim of this study was to investigate the
detrimental effect on the health of the dental pulp. incidence and the factors that might be associated with
Over the years, many reports on the longevity and the development of pulpal necrosis in vital abutment
reasons of failures in fixed prostheses have been teeth that had been crowned either singly or as part of
published. But in many studies the (condition leading a fixedfixed bridge.
to) replacement of the restorations was regarded as the
only criterion for failure (Scurria et al. 1998) whereas
Materials and methods
other types of complications, most notably endodontic,
were not considered (e.g. Morrant 1956, Kantorowicz The study population consisted of patients who had
1968, Roberts 1970, Glantz et al. 1984, Palmqvist & received a CMC or a conventional fixedfixed bridge
Swartz 1993, Smales & Hawthorne 1997). There have on vital tooth/teeth from 1981 to 1989 at the Prince
been a number of studies that gave an indication of Philip Dental Hospital (PPDH), which is a dental
pulpal necrosis after construction of fixed prostheses teaching hospital in Hong Kong. All treatment provi-
(Table 1). Bergenholtz & Nyman (1984) reviewed ded had been recorded on a computer database, from
patients treated for advanced periodontal disease and which a total of 872 CMCs and 241 bridges with no
found pulpal necrosis in 15% of abutment teeth, history of root canal treatment of the abutment teeth
compared with only 3% in nonabutment teeth after a were identified. About half of each type of restoration,
mean observation period of 8.7 years. In a survey i.e. 440 CMCs and 124 bridges, were randomly
where patients with fixed bridges were evaluated, 20 of selected. This was done by choosing every other
169 bridges examined had failed due to endodontic patient who was on the list, arranged in ascending
reasons, that is, some 57% of all failed bridges had one order of the hospital registration number, for that
or both of their abutments so affected (Cheung et al. particular type of restoration. The written clinical
1990). Unfortunately, the number of vital abutment records of selected patients were checked to ensure
teeth that had been affected was not reported. In that all samples fulfilled the following inclusion
contrast, three of 73 previously vital teeth restored with criteria:
single crowns were deemed to have failed because they 1. The tooth (or, in the case of a bridge, at least one of
became periapically involved or had been root canal the abutment teeth) had not received any form of
treated after a mean observation period of 34 months root canal treatment prior to the construction of the
(Cheung 1991). That is, 4% of vital teeth developed restoration; and
pulpal necrosis after placement of single crowns. 2. The tooth either received a CMC or bridge retainer
Jackson et al. (1992) reported that 5.7% of teeth had (BR) for a fixedfixed bridge. In other words, all
received root canal treatment some 16 years after resin-bonded retainers were excluded.
cementation of a single crown or fixed bridge; unfor-
tunately, the response rate of their study was just over
Clinical assessments
10%. Saunders & Saunders (1998) conducted a cross-
sectional, radiographic survey of patients for whom a A total of 284 CMCs and 102 bridges satisfying the
set of full-mouth periapical radiographs was available inclusion criteria were identified. The patients were
and reported that 19% of initially vital teeth developed invited to return for a review. Prior to his/her
periradicular radiolucency after (an unknown period attendance, the patients record was studied for any
of) crown placement. The influence of various factors, possible pre- and intra-operative factors that might
such as preoperative restorative and periodontal status, contribute to the development of pulpal necrosis:
operators, gender and tooth type, has not been preexisting DMFT score, presence of dental pins or
conclusive. pulp capping, status of the preexisting restoration
As most reports in the literature were cross-sectional filling and the alveolar bone level, the reason for
in nature and only a mean observation period was crown/bridge construction, period of temporization
reported, their study methodology thus has assumed a and the luting cement used. Patients who declined to
uniform rate of development of pulpal or periapical attend the recall were interviewed over the phone
complications, which might not be the case. There also whether the tooth in question had received any
522 International Endodontic Journal, 38, 521530, 2005 2005 International Endodontic Journal
Table 1 Summary of some reports that gave an indication of the pulpal status after construction of crowns or bridges
Response Observation Restorations or Assessment Results related to

Reference Subjects rate period teeth examined method pulpal status
Ericson et al. (1966) 272 patients with Yr 1: 97% 4 years 642 teeth (1 year) Radiographs Pulp necrosis 2% in
668 vital teeth in Yr 2: 93% of 573 teeth (2 years) first year review, 2.4%
a student clinic first year 544 teeth (4 years) after 2 years and 2.8%
Yr 4: 95.8% of after 4 years (another
second year 1.6, 1.2 and 0.4% borderline
cases, respectively)
2005 International Endodontic Journal

Bergenholtz & 52 patients with Retrospective Mean 8.7 years 255 bridge abutments Clinical symptoms Pulp necrosis in 15% abutment
Nyman (1984) extensive treatment study (range 413 years) and 417 single crowns and radiographs teeth and 3% beneath single
for periodontal disease (total 627 vital pulps) crowns; half of necrotic pulp
in a teaching hospital was diagnosed 712 years
postoperative
Karlsson (1986) 164 patients in 26% 10 years 238 bridges with Questionnaire, clinical 10% vital abutment had
a private clinic 944 abutments and radiographic radiographically visible
exams periapical lesions
Cheung et al. (1990) 143 patients with 77% Mean 35 months Fixedfixed bridges Clinical and 57.1% of bridges had one or
169 bridges in radiographic both abutments with
a teaching hospital exams endodontic involvement (no. of
initially vital abutment not known)
Cheung (1991) 132 patients with 38% (no. of teeth) Mean 34 months Single crowns; Clinical and Pulp necrosis in
152 crowns in total 73 initially radiographic 4.1% of vital teeth
a teaching hospital vital teeth exams
Jackson et al. (1992) 130 patients in 10.6% 26 years 437 vital teeth: 235 Clinical examination, 25 teeth (5.7%) had had RCT
a teaching hospital bridge retainers cold test and
and 202 single crowns radiographs
Valderhaug et al. (1997) 32 patients with 28% (patients) 25 years Single crowns (n 46) Radiographs 10% of all failures were due to
101 restored teeth in 24% (teeth) Bridges (n 112) pulp necrosis (estimated
a teaching hospital up to 14 units survival of intact pulp was 98%
after 5 years; 92% after 10 years;
87% after 20 years;
83% after 25 years)
Saunders & 202 patients with Cross-sectional study Unknown 802 crowns with Radiographs 87 (19%) showed signs of
Saunders (1998) 802 crowns in two (only on patients 458 on vital teeth radiographic
teaching hospitals requiring full-month peri-radicular disease
periapical radiographs)
Walton (1999) 239 patients in 69% 52% 510 years 688 CMCs, 67% on Clinical 27 (2.7%) units with
a specialist 48% less than vital teeth examination periapical involvement
prosthodontic 5 years but more
practice than 1 year
International Endodontic Journal, 38, 521530, 2005

Cheung et al. Fate of vital pulps
523
further dental treatment and, if so, the time and

Statistics
nature. At the review appointment, the selected
restoration(s) was examined in detail clinically. The Cases already recorded to have failed because of
presence of caries (recurrent or new), and the quality endodontic reason and those diagnosed to be nonvital
and status of the restoration were noted. Percussion at the recall constituted the group that had developed
test, palpation of the corresponding attached mucosa, pulpal necrosis after the restoration. Chi-square test
and cold and electric pulp tests (where possible) were and two-sample t-test were used, where appropriate, at
carried out. A long-cone, paralleling periapical radio- a 0.05. If multiple comparisons were made, then the
graph was then taken. The restoration was deemed to significance level was subject to Bonferroni adjustment
have failed if any one or a combination of the and was set at P 0.005. As the subjects of this study
following complications were noted: (i) technical or were a cohort of patients receiving the treatment, the
mechanical including fracture of any part of the data on pulpal status were examined by survival
restoration or the tooth, and loss of retention of the analysis using the KaplanMeier estimator. For entry
restoration; (ii) aesthetic; (iii) presence of secondary into the KaplanMeier analysis, the time to develop-
caries; (iv) endodontic; and (v) any other reason, such ment of pulpal necrosis was taken as the mid-point
as tooth extraction (Cheung 1991). But, for purpose of between the date of diagnosis of failure and the last
this study, only the endodontic reason was considered; known date of an intact restoration without pulpal
that is, the abutment tooth became pulpally or complications (Cheung 2002). If the date of diagnosis
periapically involved, or had been root filled after could not be found in the record, the patient was asked
the restoration. During the review, the diagnosis of to provide the date when he/she first noticed a problem
the pulpal status of the crowned teeth often had to that led to further treatment, which date would serve
rely on clinical symptomatology and radiographic as the date of diagnosis.
assessment, because pulp testing was not always
possible. Here, the presence of a periapical radiolucent
Results
area was taken as an indicator of nonvitality of the
dental pulp. All teeth that presented with pulpal symptoms at the
review also showed a periapical radiolucent lesion or
had been root-filled; they were classified as failures due
Radiographic assessment
to endodontic reason. The quality of the crown or
Two precalibrated, independent observers examined bridge at the date of examination was acceptable,
the radiographs and categorized the periapical status of except for those that were deemed to have failed due to
the selected teeth according to a written set of criteria various reasons (Tables 3 and 4).
(Table 2). Inter-examiner agreement on the radio-
graphic assessment was determined by computing the
Metal-ceramic crowns
Cohens j value, which was found to be 0.79. If there
was any disagreement, a third observer was recruited Of the 284 CMCs that met the inclusion criteria, 114
as an arbitrator before a final score was reached. CMCs in 79 patients were examined clinically. Another
Table 2 Radiographic categorization of

Category Statusa Description
pulpal status
0 Intact pulp No evidence of radiopaque foreign material
in pulp chamber and/or root canal(s),
and no periradicular radiolucent area
1 Widening of the Widening of the apical part of the periodontal
PDL space ligament space, not exceeding two times the
width of the lateral periodontal ligament space
2 Periapical radiolucency Radiolucency in connection with the apical part
of the root, the diameter exceeding two times
the width of the lateral periodontal ligament space
3 Endodontically treated Tooth with radiopaque material in pulp chamber
tooth (if discernible) and/or root canal(s)
a
Categories 1, 2 or 3 were deemed to be associated with a nonvital pulp.
Table 3 Reasons for failure of CMCs No significant association was found between the
Percentage of total development of pulpal necrosis and gender, presence of
no. examined pins, tooth type, presence and type of preexisting
Reasons of failure Frequency (% of all failed cases) restoration, preoperative alveolar bone level, reasons
Endodontic 19 15.6 (55.9) for crown construction, types of cement used, function
Aesthetic 3 2.5 (8.8) of the crown, operators, the pre- or postoperative DMFT
Prosthetic 3 2.5 (8.8) score, or period of temporization.
Fracture of porcelain 2 1.6 (5.9)
Tooth fracture 3 2.5 (8.8)
Root caries 2 1.6 (5.9) Conventional bridges
Others 2 1.6 (5.9)
All failed CMCs 34 27.9 (100.0) Of the 102 bridges selected, 38 bridges in 33 patients
Total no. of CMCs analysed 122 100.0 () were examined. Including another nine bridges that
had already failed according to the patients records, a
total of 47 bridges and 77 preoperatively vital abut-
Table 4 Reasons for bridge failures
ments were available for analysis. The mean observa-
Percentage of total
tion period was 187 months (SD 23). Of the 30
no. examined
Reasons of failure Frequency (% of all failed bridges)
bridges (64%) that were deemed to have failed, 22 had
at least one of their abutments affected by some form of
Endodontic 14 34.0 (53.3)
Endodontic + debond 6 12.8 (20.0)
pulpal or endodontic complications (Table 4). Twenty-
Pain 2 4.3 (6.7) five of the 77 initially vital abutments had been treated
Loss of retention 6 8.5 (13.3) endodontically or developed pulpal necrosis, an inci-
(include debond of dence of 33% (Table 5). The shortest time to the
one of the retainers)
development of pulpal necrosis was 2 months whilst
Others 2 4.3 (6.7)
All failed bridges 30 63.8 (100.0)
the longest was 176 months after cementation of the
bridge.
Total no. of 47 100.0 ()
Chi-square analysis failed to reveal any association
bridges analysed
between the development of pulpal necrosis in vital
bridge abutments and gender, operators, presence of
eight CMCs were found to have failed according to the preexisting restoration or pin(s), pulp capping, reasons
patients records, which were also included in the for bridge construction, preoperative alveolar bone
analysis. The sample thus comprised (114 + 8 ) 122 level, types of cement used, design of the bridge, or
CMCs, with a mean observation period of 169 months period of temporization. An association was found
(SD 25) up to the date of recall. Of the 34 CMCs between pulpal necrosis and tooth type (v2 15.77,
(28%) that were deemed to have failed, 19 were df 5, P 0.008) with maxillary anterior teeth being
classified as endodontic, giving an overall incidence of most often affected (Table 6).
pulpal necrosis of 16% (Table 3). The shortest interval
to the development of pulpal necrosis was 6 months
Comparison between CMCs and fixed bridges
after cementation whilst the longest was 188 months.
As the cumulative survival had not dropped below Vital abutments in the BR group were distributed in
50%, a medium survival time for maintenance of pulp different regions of the dentition, whereas CMCs were
vitality could not be calculated. placed mostly in the maxillary anterior segment
Table 5 Types of retainers used and

Number of Number of Number showing
the development of pulpal necrosis in Type of abutments initially vital signs of pulpal Percentage of
bridge abutments retainers involved (a) abutments (b) necrosis (c) (c) in (b)
Metal-ceramic crown 60 45 19 42.2

Full gold crown 31 28 6 21.4
Partial veneer crown 3 3 0
Onlay 1 1 0
Total 95 77 25 32.5
Table 6 Frequency of tooth types and the development of pulpal necrosis in the two groups
Presence of necrosis in BR group (% of Presence of necrosis in CMC group (% of

subtotal) subtotal)
Tooth type No Yes (%) Subtotal No Yes (%) Subtotal
Maxillary anteriors 15 18 (54.5) 33 59 14 (19.2) 73

Maxillary premolars 5 2 (28.6) 7 16 2 (11.1) 18
Maxillary molars 7 3 (30.0) 10 1 2 (66.7) 3
Mandibular anteriors 2 0 2 4 0 4
Mandibular premolars 12 2 (14.3) 14 18 1 (5.3) 19
Mandibular molars 11 0 11 5 0 5
Total 52 25 (32.5) 77 103 19 (15.6) 122
(Table 6). Significantly greater amount of bridge abut- placement of a fixed restoration on vital abutment teeth
ments developed pulp necrosis than teeth restored with in a cohort of patients treated some years ago. Some 79
CMC (v2 7.82, df 1, P 0.005). patients (37.4% of the total number of patients in this
The survival of pulpal vitality of teeth restored with group) with 114 CMCs (40.4% of total number of
CMCs was compared with that of bridge abutments; the crowns), and 33 patients (32.4%) with 38 bridges
steeper slope of the survival curve for conventional (34.5%) were examined in this study. These response
bridges indicated a greater probability of finding a rates were comparable to other studies with similar or
necrotic pulp in bridge abutments compared with CMCs longer period of observation (e.g. Karlsson 1986,
at the same period of observation (Fig. 1). Using the Valderhaug et al. 1997) (see Table 1). The character-
KaplanMeier estimator, the survival rates for pulp istics of the nonrespondents (n 24) from the tele-
vitality were 84.4% (CMC) and 70.8% (BR) after phone interview are summarized in Table 7. Ten of
10 years, and 81.2% (CMC) and 66.2% (BR) after them reported that the restoration had dislodged
15 years. The difference was statistically significant (n 2), had been replaced (n 7), or the tooth
between the CMC and BR groups (log rank test, extracted (n 1); it remains unknown if these teeth
P < 0.005). involved were pulpally involved (Table 7). Hence, the
result reported here might be an underestimation of the
actual incidence. For those other patients who did not
Discussion
respond or could not be contacted by phone or in
This is a retrospective study on the incidence of pulpal writing, it is uncertain whether they might have
necrosis, or more accurately, of periapical lesions after influenced the results.
1.0000
0.8000
Cumulative survival
0.6000
0.4000
0.2000
CMC
Bridge Figure 1 Survival curves of pulp vitality
for teeth restored with CMCs or served as
0.0000
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 bridge abutment (BR) with the 95%
Time (years) confidence intervals indicated.
Table 7 Characteristics of the nonrespondents developed and become detectable radiographically in

Reasons for not coming back No. of patients % view of the long observation time in this study.
The study design included only those data that
Not interested (interviewed over the phone)
The crown/bridge was dislodged 2 8.3 indicated the development of a necrotic pulp or the
A new crown/bridge 7 29.2 maintenance of pulp vitality over a reasonable period of
had been made time. Teeth that did not have any review status,
The tooth had been extracted 1 4.2 because the patients had failed to attend any recall
No time 6 25.0
since the cementation visit, would not provide any
Dont want to come back 7 29.2
Disable or ill 1 4.2 censored data in the survival analysis here. Those
Total no. of nonrespondents 24 100.0 restorations and the pulps that were diagnosed or
Total no. of patients 117 recorded as failed and necrotic, respectively, were
examined (respondents) included for analysis. Thus, there might be a possibility
of favouritism for the inclusion of failure cases, which
might explain a higher rate of failure for the restora-
In the present study, the diagnosis of pulpal necrosis tions compared with other studies.
was based on patients presenting history, clinical signs For the survival analysis, the time of failure was
and symptoms, and the radiographic findings. Pulp taken as the mid-point between the date of diagnosis of
testing was not used in most cases because it was not failure and the last known date of an intact restoration.
always practicable on teeth with full coverage restora- Such an estimation is believed to be a better represen-
tions. Moreover, pulp-testing results might not indicate tation of the failure date than using such other time as
the state of the pulp correctly (Seltzer et al. 1963). As the date of recall, because most endodontic complica-
the margins of most crowns were placed equi-gingivally tions would have taken some time to develop (Cheung
(which was the prevailing teaching at PPDH), it made 2002). Also, it would take some time before lesions
strict moisture control and application of the electric became radiographically discernible, and they might
pulp tester difficult. Some methods to expose the tooth remain undiagnosed until another routine examination
substance apical to the margin of the crown were or onset of acute symptoms. The time to the develop-
attempted, such as retracting the free marginal gingi- ment of pulpal necrosis was estimated in a similar
vae with a flat plastic instrument, using a piece of fashion for entry into the KaplanMeier analysis. Such
gingival retraction cord, or placing a surgical suction estimation was believed to be more accurate than
tip next to the electrode probe. However, a false-positive assuming the necrosis to have occurred on the day of
result from the gingival tissue still could not be examination. Only a few long-term studies on the
excluded. The use of a mini-probe did not improve survival or longevity of single-unit extra-coronal res-
the situation either. Cold test with application of ethyl torations were available (Smales & Hawthorne 1997,
chloride-impregnated cotton pellet or solid carbon Walton 1999). These two studies had not used
dioxide (dry ice) on the metallic portion of the crown/ radiographs during their review, which could under-
retainer had been tried, but the response was variable. estimate the incidence of (asymptomatic) endodontic
Dry ice appeared to elicit a response more often than complications. Another study was in the form of
ethyl chloride, but, unfortunately, the apparatus for radiographic evaluation without clinical examination
producing dry ice was not available for the whole (Valderhaug et al. 1997). It has been pointed out that
period of the study. Thus, except for those with many studies have used different survival criteria and
discernible root canal filling materials or periapical analyses, and have presented the survival findings of
radiolucent areas, the determination of pulp vitality crowns as various solitary crown types and/or abut-
was based on a careful study of any presenting ments for fixed bridges, making it impossible to
symptoms and their history and of the radiographs. It compare the study results with any confidence (Leem-
was possible that pulpal necrosis could have developed poel et al. 1989).
but remained undetected in the present study due to a It is noteworthy that the main reason for failure of
lack of radiographic change and an absence of clinical both types of restoration examined in the present study
sign or symptom. As a result, the prevalence of pulpal was endodontic involvement (Tables 3 and 4). The
necrosis could be regarded as the best case scenario pulp could have lost its vitality due to a multitude of
here. On the other hand, any periapical changes as a reasons. Mechanical and chemical insults due to tooth
consequence of pulpal necrosis were likely to have preparation and other clinical procedures, such as the
use of pins and impression taking, and the temporary cations, for entry into the survival analysis was not
or permanent luting cements used during the con- mentioned. If they had taken it as the date of diagnosis
struction of the restoration can lead to pulpal inflam- or recall (which seemed to be the case as a means of
mation. But that usually resolves in time if there is no adjustment was not described), it would have the effect
bacterial contamination (Olgart & Bergenholtz 2003). of shifting the survival curve to the right on the time-
The presence of a preexisting filling may suggest a axis and there would be a steeper drop towards the end
compromised pulp as a result of previous carious attack of the curve when observation was made (Cheung &
and restorative procedures. The period of temporization Chan 2003). The result would be a higher survival rate
and the type of cement would have a bearing on the at any particular point in time on that survival curve,
pulp vitality, if marginal leakage of the temporary or which might explain the difference in the results here.
permanent restoration was not excluded. It has been Whilst many factors could lead to insults to the
the practice at PPDH that all abutment teeth for crowns dental pulp during the construction of a full coverage
or bridges are assessed for their vitality status using restoration (Langeland 1961), tooth type was the only
radiographs and pulp tests prior to the fixed restoration. significant factor associated with the loss of vitality in
These tests, however, might fail to indicate the the bridge abutments. Over 70% of all pulpal necrosis
histologic state of pulp with certainty (Seltzer et al. developed in the maxillary anterior segment in the BR
1963, Chambers 1982). Thus, certain teeth might group. It was true that for anterior teeth, a CMC had
already be suffering from asymptomatic pulpitis preop- been used as the retainer, which required more amount
eratively and further tooth reduction could lead to of tooth reduction than posterior teeth where a full gold
pulpal necrosis. That may explain why some teeth crown might have been used. But the same high rate of
developed pulpal necrosis shortly after cementation of pulpal necrosis was not found in the CMC group
the crown or bridge. (Table 6). This significantly higher incidence of pulpal
Using the KaplanMeier method, the survival rates necrosis in bridge abutments might be related to the
for pulp vitality were estimated to be 84.4% (CMC) and need of additional tooth reduction to align the prepa-
70.8% (BR) after 10 years, and 81.2% (SC) and 66.2% rations for a common path of insertion, hence greater
(BR) after 15 years. In a previous survey carried out in amount of operative trauma (Cheung et al. 1990). The
PPDH, 57% of all failures of fixedfixed bridges were deeper and more extensive tooth preparation would
endodontic in origin, that is, loss of pulp vitality or result in a greater degree of inflammatory pulpal
presence of a periapical radiolucent area at one or both response (Kim & Trowbridge 1998). Although the
abutments (Cheung et al. 1990). But that study also underlying pulps were deemed to have failed (as
included, as failures, those previously root filled abut- evidenced by the development of periapical rarefaction)
ment teeth presenting with periapical lesions and hence in the present study, many of the overlying restorations
a direct comparison with the BR group here could not be were still present and functioning in the patients
made. Another survey in the same hospital reported mouths after endodontic treatment was carried out via
some 4% of crowned, previously vital teeth developed a access through the crown or bridge retainer. So long as
periapical lesion after about 3 years (Cheung 1991). the restoration is present, such endodontic mishaps
The figure seems to agree with the current finding by have not been considered as failures by some investi-
referring to the survival curve for pulp vitality (Fig. 1), gators (Roberts 1970, Glantz et al. 1984, Palmqvist &
but the present study strongly suggested that the Swartz 1993). It has been reported that the reduction
development of pulpal complications was not limited in retention of crowns, through which an endodontic
to the first few years after cementation of the restor- access had been created, can be regained or surpassed
ation, although the rate tended to slow down in time. by simple restoration of the access cavity with
Valderhaug et al. (1997) have also estimated the amalgam (McMullen et al. 1990, Mulvay & Abbott
probability of pulpal complications leading to endodon- 1996). However, little information on the influence of
tic treatment in teeth with an initially vital pulp using marginal leakage, if any, at the restorationcrown
the KaplanMeier method, and reported survival rates interface is available to date (Trautmann et al. 2000).
of 92% after 10 years and 87% after 20 years. These Preparation of teeth to receive crowns or conven-
rates, which were collective of both single crowns and tional bridge retainers could involve a large degree of
bridge abutments, compare favourably to the findings of tooth reduction and inflict considerable trauma to the
this study. However, the method of determining the dental pulp. These teeth might already have a range of
failure date, i.e. the date of the development of compli- restorative procedures before, leaving the dental pulps
with an impaired ability to recover from trauma from Chambers IG (1982) The role and methods of pulp testing in
further dental procedures. In order to prevent endo- oral diagnosis: a review. International Endodontic Journal 15,
dontic complications arising after provision of crowns 115.
or conventional fixedfixed bridges, the operator should Cheung GSP (1991) A preliminary investigation into the
longevity and causes of failure of single-unit extracoronal
undertake the following steps: (1) careful evaluation of
restorations. Journal of Dentistry 19, 1603.
the preoperative status of the tooth/teeth; (2) consider
Cheung GSP (2002) Survival of first-time nonsurgical root
alternative treatment options, such as adhesive bridges canal treatment performed in a dental teaching hospital.
or implants to replace missing teeth, if the potential Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology,
abutments are caries-free, vital and have not received and Endodontics 93, 596604.
any restoration before; (3) avoid over-reduction, over- Cheung GSP, Chan TK (2003) Long-term survival of primary
heating or dehydration of the tooth and carry out the root canal treatment carried out in a dental teaching
tooth preparation with the least amount of trauma to hospital. International Endodontic Journal 36, 11728.
the dental pulps; and (4) provide adequate protection to Cheung GSP, Dimmer A, Mellor R, Gale M (1990) A clinical
the dental pulps whilst the final restoration is being evaluation of conventional bridgework. Journal of Oral
fabricated. It is uncertain whether results in this study Rehabilitation 17, 1316.
Ericson S, Hedegard B, Wennstrom A (1966) Roentgen-
can be extrapolated to general dental practice. On one
ographic study of vital abutment teeth. Journal of Prosthetic
hand, these restorations were placed by operators with
Dentistry 16, 9817.
a wide range of clinical expertise (from dental students Glantz PO, Ryge G, Jendresen MD, Nilner K (1984) Quality of
to professors) that simulates the general practice extensive fixed prosthodontics after five years. Journal of
situation. On the other hand, some restorations placed Prosthetic Dentistry 52, 4759.
by students were likely to have taken more time or Jackson CR, Skidmore AE, Rice RT (1992) Pulpal evaluation of
number of visits to complete. Regardless of the operator teeth restored with fixed prostheses. Journal of Prosthetic
factor, the result on long-term survival of an initially Dentistry 67, 3235.
vital pulp beneath these restorations seems to warrant Kantorowicz G (1968) Bridges, an analysis of failures. Dental
more thoughtful protective measure to maintain the Practitioner 18, 1768.
pulpal vitality of the abutments. Karlsson S (1986) A clinical evaluation of fixed bridges 10 years
following insertion. Journal of Oral Rehabilitation 13, 42332.
Kim S, Trowbridge H (1998) Pulpal reaction to caries and
Conclusion dental procedures. In: Cohen S, Burns RC, eds. Pathways of
the Pulp, 7th edn. St Louis, MO: Mosby, pp. 53251.
The survival probability of the pulp in vital teeth Langeland K (1961) Effects of various procedures on the
restored with a single-unit CMC was significantly human dental pulp. Oral Surgery, Oral Medicine, and Oral
higher than in those teeth serving as an abutment of Pathology 14, 21033.
a fixedfixed bridge. Greater number of maxillary Leempoel PJ, Vant Hof MA, De Haan AF (1989) Survival
anterior teeth serving as bridge abutments developed studies of dental restorations: criteria, methods and analy-
pulpal necrosis than any other tooth types. The ses. Journal of Oral Rehabilitation 16, 38794.
survival rates for pulp vitality were estimated to be McMullen AF, Himel VT, Sarkar NK (1990) An in vitro study
84.4% (CMC) and 70.8% (BR) after 10 years, and of the effect endodontic access preparation and amalgam
restoration have upon incisor crown retention. Journal of
81.2% (CMC) and 66.2% (BR) after 15 years.
Endodontics 16, 26972.
Morrant G (1956) Bridges, with particular relation to the
Acknowledgements periodontal tissues. Dental Practitioner 6, 17886.
Mulvay PG, Abbott PV (1996) The effect of endodontic access
The authors are indebted to Ms. May Wong, Lecturer of cavity preparation and subsequent restorative procedures
Faculty of Dentistry, The University of Hong Kong for on molar crown retention. Australian Dental Journal 41,
statistical advice and assistance. 1349.
Olgart L, Bergenholtz G (2003) The dentine-pulp complex:
responses to adverse influences. In: Bergenholtz G, Hrsted-
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Saunders WP, Saunders EM (1998) Prevalence of periradicu- extensive amalgams and posterior crowns. Journal of Den-
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Scurria MS, Bader JD, Shugars DA (1998) Meta-analysis of Shulman JD (2000) Restoring teeth that are endodontically
fixed partial denture survival: prostheses and abutments. treated through existing crowns. Part II: Survey of restor-
Journal of Prosthetic Dentistry 79, 45064. ative materials commonly used. Quintessence International
Selby A (1994) Fixed prosthodontic failure. A review and 31, 71928.
discussion of important aspects. Australian Dental Journal 39, Valderhaug J, Jokstad A, Ambjrnsen E, Norheim PW (1997)
1506. Assessment of the periapical and clinical status of crowned
Seltzer S, Bender IB (1984) The Dental Pulp Biologic teeth over 25 years. Journal of Dentistry 25, 97105.
Considerations in Dental Procedures, 3rd edn. Philadelphia: Walton TR (1999) A 10-year longitudinal study of fixed
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Seltzer S, Bender IB, Ziontz M (1963) The dynamics of pulp single-unit metal-ceramic crowns. International Journal of
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PII: SO300-5712(96)00008-5 Journal of Dentistry, Vol. 25, No. 2, pp. 97-105, 1997
Copyright 0 1997 Elsevier Science Ltd. All rights reserved
Printed in Great Britain
0300-5712/97 $17.00+0.00
ELSEVIER
Assessment of the periapical and clinical

status of crowned teeth over 25 years
J. Valderhaug, A. Jokstad, E. Ambjcxnsen and P. W. Norheim
Department of Prosthetic Dentistry and Stomatognathic Physiology, Dental Faculty University of Oslo, Oslo, Norway
ABSTRACT
Objectives: The purpose of this study was to examine radiographically changes in the periapical status
and compare the clinical status of teeth with a vital pulp and root-filled teeth restored with crowns and
bridge retainers during 25 years.
Methods: During 1967/68, 114 patients received prosthodontic treatment by senior dental students at the
Oslo Dental Faculty. In all, 291 teeth with a vital pulp and 106 root-filled teeth were restored with 158
prostheses. All root-filled teeth were restored with a cast dowel and core. The casts were made in a type-3
gold alloy, and cemented with zinc phosphate cement. Forty-six teeth were restored with crowns and 351
teeth with bridge retainers. Radiographs were taken preoperatively, immediately after cementation, and
every fifth year. Two independent observers assessedthe periapical status on the radiographs according
to the PAI-index. At the 25 years examination, 32 patients (28%) with 101 restored teeth (24%) remained
in the study. Survival rates of the prostheses and of the restored teeth were estimated using Kaplan-
Meyer non-parametric statistics.
Results: The PAI-score of the periapical status deteriorated in 13 vital and four root-filled teeth. The
survival rates of the fixed prostheseswere not influenced by the pulp vitality of the restored tooth at the
baseline. The survival rates of the restored teeth with a vital pulp and of the root-filled teeth were similar.
Clinical failures were recorded on approximately one-third of the restored teeth. The main reason for
tooth failure was caries (12%), and for the teeth with a vital pulp also pulpal deterioration (10%).
Estimates of the proportions of crowned teeth with a vital pulp that will remain free from signs and
symptoms of pulpal deterioration were 98% after five years, 92% after 10 years, 87% after 20 years and
83% after 25 years.
Conclusions: The incidence of periapical lesions on radiographs of crowned teeth was low during 25 years
observation. Crowned, root-filled teeth with a high quality endodontic treatment and an optimal
morphology of the dowel and core have a similar survival rate as crowned teeth with a vital pulp. A high
proportion of crowned teeth with a vital pulp will remain free from signs and symptoms of pulpal
deterioration over 25 years. 0 1997 Elsevier Science Ltd. All rights reserved.
KEY WORDS: Fixed dental prosthetics, Endodontics, Longevity, Radiographs, Survival
J. Dent 1997; 25: 97-105 (Received 31 May 1995; accepted 7 January 1996)
INTRODUCTION pulp. Furthermore, several studies have shown that

common luting cements dissolve more or less in the oral
The preparation of teeth for fixed prostheses usually
environment depending on the material properties and
involves extensive removal of enamel and dentin. In
fit of the fixed prosthesis*. It is, therefore, probable that
addition, the application of a variety of dental materials
at some time damage to the pulp tissue will occur in a
and operative procedures on the prepared tooth may
proportion of the restored teeth. However, although
have significant biological consequences for the dental
many histological studies have documented pulp and
dentin reactions after prosthodontic therapy3, the inci-
Correspondence should be addressed to: Dr A. Jokstad, Depart-
ment of Prosthetic Dentistry and Stomatognathic Physiology, Den- dence and the risk period of loss of pulp deterioration
tal Faculty, PO Box 1109 Blindern, N-031 6 Oslo, Norway. Telefax: remain uncertain. Different results have been presented
22 85 23 90. E-mail: Jokstad@odont.uio.no. in clinical studiesL23 (Fig. 1). Other data have been
98 J. Dent. 1997; 25: No. 2
and fixed prosthesescemented on teeth with a vital pulp

and on root-filled teeth. The third aim was to compare
the frequency of adverse clinical sequelaeto teeth with a
vital pulp and to root-filled teeth restored with crowns
and bridge retainers.
MATERIALS AND METHODS

0 ;.L-5----5 -..- 7..~--~-H-i-~-.-151j .i9 The patients consisted of individuals receiving prostho-
2 4 6 8 10 12 14 16 18 20 dontic treatment by the senior students at the Depart-
Years ment of Prosthetic Dentistry, University of Oslo, in the
Fig. 7. Repotted frequencies of periapical changes on teeth academic year 1967/68. Patients that could not attend
restored with crowns and bridges assessed in cross-sectional annual re-examinations during a five-year period and
clinical studies. Letters indicate the type of prostheses reported:
A, crowns and bridges; C, full crowns; B, bridges; P, partial patients more than 70 years old were not included in the
crowns. The diagonally traced line indicates approximate study.
mean values. Before the prosthetic treatment the patients received
periodontal treatment including instruction in oral hy-
presented as ratios of pulp deterioration as a reason giene, scaling and surgical elimination of deep pockets.
for failure of prosthodontic therapy6T2b29.The ratios Non-vital teeth and teeth with large amounts of hard
range between 4% in a 13-year-old study sample2 and tissue loss were root-filled. Patients in need of endodon-
3% in an II-year-old study samplez4 to 22% in a tic treatment had this undertaken at the Department of
six-year-old sample28 and 21% in a 14-year-old Conservative Dentistry. For pulp canal obturation a
sample29. technique using a standardized endodontic procedure
These studies do not provide a clear-cut picture of with gutta-percha points coated with chloropercha
the risk involved for pulpal breakdown in teeth sub- (Kloroperka N-0, N-O Therapeutics, Oslo, Norway)
jected to fixed prosthodontic therapy. The reason is as a sealer was used32.A description of the endodontic
differences in study aims and study designs, as well as procedures has been published33.
study populations and types of fixed prostheses. Fur- The indications for prosthodontic treatment were
thermore, the criteria for failure and choice of obser- tooth damage due to caries, wear or trauma, crown
vation unit vary in these studies. The observation unit replacements, or as supporting abutments in bridges.
and criteria for failure can be divided into five cate- All root-filled teeth were restored with an individually
gories: removal of the prosthesis, repair or removal of fitted dowel and core cast in a type-3 gold alloy
the prosthesis, removal of a retainer in the prosthesis, (Gamma Gold, K.A. Rasmussen, Hamar, Norway).
repair of a restored tooth, or removal or repair of a Dowel space was prepared such that if possible the
restored tooth. From a biological view, however, the depth of the dowel was at least equal to or longer than
most interesting question is to what degree prostho- the length of the artificial crown. The intention was also
dontic therapy maintains the integrity of the restored to maintain a minimum of 3 mm of the gutta-percha
tooth in the long run, i.e. the data on restored teeth filling in the apical part of the canal. The gutta-percha
remaining intact would seem the most relevant. The was removed with rotating reamers. The casts were
preparation techniques and procedures, size of pros- controlled for passive fit and rotation resistance and
thesis, cantilever extension, materials used, oral hy- cemented with zinc phosphate cement (De Trey Zinc
giene and patient selection will probably also influence Phosphate Cement, De Trey, Zurich, Switzerland)
the prognosis of prosthodontic therapyz3. Few studies before the final preparation and impression taking for
have focused on the prognosis of prosthodontic the cast.
therapy in patients who have received regular The time between endodontic treatment and the
follow-up and oral hygiene controls3. preparation of the teeth was at least one week. The
There is a controversy whether a root-filling and/or a teeth were prepared using rotary cutting instruments
dowel and core may jeopardize the prognosis of pros- cooled with water spray in a low-speed handpiece.
thodontic therapy3r. The contrary results often pre- One goal of the tooth preparation was to maintain
sented probably reflect differences in study parameters maximum conservation of tooth tissue. The prepar-
and study design as well as definitions of criteria for ations were made with a 1 mm buccal shoulder when
failure. veneered with acrylic resin. The location of the crown
The purpose of the present investigation was to margins was mostly subgingivally (65h)34. The pre-
examine radiographically changes in the periapical sta- pared teeth were temporized during the period
tus of teeth restored with crowns and bridge retainers between the preparation and the cementation. The
during 25 years of observation. A second study aim was temporary crowns were cemented with zinc oxide-
to assessand compare the incidence of failure of crowns eugenol based cements.
Valderhaug et al.: Longitudinal observations of fixed prosthodontic treatment 99
Table 1. Number and dimensions of the fixed prostheses in the present study
No. units No. retainers
1 2 3 4 5 6 7 8 Sum
1 46 46
2 5 2 7
3 58 58
4 36 33 69
5 6 24 30
6 6 12 16 34
7 3 4 5 12
8 4 10 6 20
9 5 14 19
10 10 6 16
11 15 12 8 35
12 5 6 14 25
!3 5 7 12
14 6 8 14
Sum 51 108 72 24 55 36 35 16 397
Per cent 13 27 19 6 13 9 9 4
Table II. The location of the restored teeth, and dimension of the fixed prostheses
Single crowns l-3 Retainer bridges >3 Retainer bridges Sum Per cent
Upper incisors 17 48 62 127 32

Upper cuspids 5 42 37 84 21
Upper premolars 5 32 30 67 17
Upper molars 3 24 21 48 12
Lower incisors 2 4 2 8 1
Lower cuspids 2 15 6 23 6
Lower premolars 10 15 5 30 8
Lower molars 2 7 1 10 3
46 187 164 397
The fixed prostheses were cast in a type-3 gold alloy location of the restored teeth and the size of the
(Gamma Gold, K.A. Rasmussen,Hamar, Norway) and prostheses is shown in Table II. The average ratio of
80% were buccally veneered with heat-cured acrylic retainers to pontics of the bridges was 1.3:1.
resin (Hue-lone, L.D. Chaulk Co., Toronto, Canada). The teeth with a vital pulp (n=291) were restored
All crowns and bridges were made by the same dental with full (~~276) or partial crowns (n= 15) and the
laboratory, ensuring the use of identical materials and root-filled teeth were restored with a full crown with
technical procedures during the fabrication. dowel and core (n=106, 27%).
Zinc phosphate cement was used for the final cemen-
tation (De Trey Zinc Phosphate Cement, De Trey,
Zurich, Switzerland). The cement mixing procedure was Clinical assessments
carried out manually, and according to the manufactur- During the first 10 years the patients received oral
ers instructions. Before cementation, the crowns and hygiene prophylaxis by a dental hygienist every six
the bridge retainers were controlled for passive fit on months, and were examined annually. Later examin-
the tooth, which was cleaned with a slurry of pumice, ations were made after about 15, 20 and 25 years. All
isolated with cotton rolls and air dried. The crowns and the clinical examinations were done by one of the
the bridge retainers were seated with finger pressure at authors (J.V.). The recall examinations included record-
the cementation. ings of the patients dental and periodontal status,
The study group consisted of 114 patients with 158 calculus removal, restorative therapy and oral hygiene
fixed prostheses on 397 teeth. The mean age of the remotivation. The clinical examination for evaluating
patients at the time of cementation was 48 years, quality and failures of the fixed prostheses followed the
varying between 25 and 69 years. The patients had an procedures described in the California Dental Associ-
average of 9.5 teeth in the maxilla and 10.6 in the ation (CDA) quality-evaluation system35.Besides the
mandible. CDA evaluation criteria, all restored teeth were exam-
The fixed prostheseswere either single crowns (n = 46) ined clinically. The criterion for failure of the restored
or bridges (n = 112) with up to 14 units (Table I). The tooth was either a fractured, lost or mobile crown or
100 J. Dent. 1997; 25: No. 2
Table 111.Distance between the end of the root-filling material and the radiographic apex and extent of
remaining root-filling material. Column numbers indicate total number and row percentages
Distance between the end of the root-filling and the radiographic apex (mm)
Excess Excess Root
Remaining root filling material >3 1. i-3 O-l 0.1-l >1 amputation Sum
>3 mm remain 6 25 33 9 12 2 a7
7% 29% 38% 10% 14% 2%
13 mm remain 6 7 4 0 1 1 19
32% 37% 21% 5% 5%
Sum 12 32 37 9 13 3 106
Table IV. Reasons for not attending the clinical examination after 25 years
No. of patients No. of prostheses No. of teeth
Patients examined 32 (28%) 38 (23%) 101 (24%)

Patient dead 35 (31%) 44 (30%) 117 (30%)
Patient lost* 21 (18%) 32 (17%) 52 (13%)
Patient loss due to prosthesis failure 26 (23%) 44 (30%) 127 (33%)
Sum 114 158 397
*Twelve patients due to remote address change, six due to illness, three due to lack of interest.
bridge retainer, tooth fracture, marginal caries, loss of

periodontal support, or a pathological finding on the
radiograph.
0.6
Radiographic assessments 0.4

Intraoral radiographs were taken of all teeth before the
prosthodontic treatment, and immediately after cemen-
tation. Later radiographs were taken every fifth year
using a periodic standardized technique36.Two indepen-
dent observersexamined the radiographs and categorized
.I/ 0 2 4 6 8 10 12
Years
14 16 18 20 22 24 26
the periapical status of all restored teeth according to the

Fig. 2. The estimated probability of survival of the teeth with a vital
PAI-index37. The PAI-index has an ordinal scale of five (V) pulp (n=291) and dowel-and-core-restored root-filled (n=106)
scoresranging from 1 (healthy) to 5 (severeperiapical teeth restored with cast restorations and bridge retainers (R). The
lesion with exacerbating features)37. The PAI-scores shaded areas represent the 95% confidence intervals.
were dichotomized, with PAI-scores 1 and 2 in group A
and PAI-scores 3 to 5 in group B, to reduce the chance of
false positive scoresfor periapical periodontitis. Statistics
At the time of prosthodontic treatment, recordings
were also made of the density of the root-filling material Survival rates were computed using Kaplan-Meyer
non-parametric estimations38. The survival rates were
in the apical region, the distance in millimetres between
estimated using survival rate defined as (i) restored
the root-filling end and the radiographic apex, as well as
tooth remaining intact, (ii) fixed prosthesis remaining
the length of the remaining root-filling apically to the
intact, and (iii) restored tooth remaining free from
dowel. The root-filling density was classified as poor
when an inhomogenous zone was seenin the root-filling radiographic and clinical signs and symptoms of pulp
deterioration.
material.
The average distance between the root-filling end and
the radiographic apex of the root-filled teeth is shown in RESULTS
Table III.
Any differences between the two scorers in their After five years 96 patients attended the clinical exam-
PAI-scores and other measurements of the radiographs ination, 80 were examined after 10 years, 63 after 15
were solved by mutual, acceptable agreement on one years3o, 46 after 20 years and 32 after 25 years. The
value, or in case of disagreement, by use of the lowest reasons for not attending the examinations after 25
score. years are listed in Table IV.
Valderhaug et a/.: Longitudinal obsen/ations of fixed prosthodontic treatment 101
7Me V. Percentage (S.E.) of restored teeth (n=397), which remain intact, and type and size of the
fixed prosthesis. Crowns (n=46), teeth in small bridges with up to four units (n=135), teeth in large
bridges with more than four units and a ratio less than 2:l between pontics and retainers (n=170) and
teeth in large spanbridges, i.e. bridges with more than five units and a 2:i ratio between pontics and
retainers (n=46)
5 Year 10 Year 15 Year 20 Year 25 Year
* *
Crown 96.5(3.4) 82.1(6.1) *
Small bridge 93.4(2.3) 80.8(4.2) 62.7(6.3) 62.7(8.0) 56.0(9.2)
Large bridge 96.6(1.4) 80.6(3.7) 66.4(5.5) 64.1(6.5) 58.3(7.2)
Large spanbridge 97.8(2.2) 81.7(6.9) 62.2(10.5) 62.2(13.3) 57.1(14.6)
* Not computed due to many patient dropouts
Prostheses
Vital teeth
Root-filled teeth
I /
cl 10 20 30 40
Percent
@ Caries IZj Tooth fracture
Loose retainer @ Endodontic complications
b# Periodontitis Other reasons
Fig. 3. The frequencies and reasons for repair or removal of the fixed prostheses (30%) and frequencies of failure of the teeth with a vital pulp
(30%), and dowel-and-core-restored root-filled (37%) teeth restored with cast restorations and bridge retainers.
deterioration and root-filling density, root-filling end

location and length of remaining root-filling material
apically to the dowel.
When survival rate was defined as the restored tooth
0.6 I -~ remaining intact, the survival rates were similar for the
teeth with a vital pulp and the root-filled teeth (Fig. 2).
0.4 i The survival rates of the individual, restored teeth could
not be related to the type and size of the fixed pros-
0.2 ______-____-
theses(Table I). Furthermore, there were no differences
in survival rates depending on the patients age and
01
0 2 4 6 8 10 12 14 16 18 20 22 24 28 gender or on the gingival location of the crown margin
Years at the basis observation. Finally, the survival rate of the
Fig. 4. The estimated probability of endodontic treatment due to root-filled teeth could not be related to the root-filling
pulpal signs and symptoms of teeth with a vital pulp restored with density, location of the root-filling end location and
cast restorations and bridge retainers (n=291). The shaded area
represents the 95% confidence interval. the length of root-filling material remaining apically to
the dowel.
When survival rate was defined as the fixed prosthesis
Deterioration of the periapical status according to the remaining intact, the survival rates were 97% after five
PAI-score was observed in four teeth with a vital pulp years, 80% after 10 years, 70% after 20 years and 65%
and in three root-filled teeth after five years. After 25 after 25 years. Statistically insignificant differences in
years the accumulated sums of teeth with deteriorated survival rates were noted depending on the type and size
PAI-scores were 13 teeth with a vital pulp and four of the fixed prosthesis. Among the bridges, the relative
root-filled teeth. The low number of observations in the proportion of teeth with a vital pulp to root-filled teeth
latter group invalidated further assessmentsbetween used as abutments could not be related to survival rate
102 J, Dent. 1997; 25: No. 2
or to specific failure reasons. Nor did the presence of pulp compared with root-filled teeth, despite whether
partial crown retainers or cantilever solutions influence these have been restored with a dowel and core or
the survival rate of the bridges. not23,40S41.The lack of a corresponding result may be
Thirty per cent of the teeth with a vital pulp (n=86) due to the qualities of the root-fillings and the dowel-
and 37% of the root-filled (n=40) teeth failed during the and-core morphology and adaptation in the present
observation period. The main reason for tooth failure material (Table 110, compared with the average situ-
was caries (12%), and for the teeth with a vital pulp also ation observed in population samples4243.
pulpal deterioration (10%). Other reasons for failure The risk of failure of dowel-and-core restored crowns
varied slightly in frequency for the teeth with a vital is possibly related to the dowel length44. In the present
pulp and the root-filled teeth (Fig. 3). The reasons for study, the length of the dowel was not measured relative
repair or removal of the fixed prostheses (n=44, 30%) to the crown height. However, it was mandatory in the
were different from the reasons for failure of the teeth student clinic to make dowels with lengths exceeding
(Fig. 3). The main reasons for repair or removal of the the crown height before cementation. Other factors
fixed prostheses were inclusion into larger prostheses related to the quality of the dowel that were not
and esthetics, caries and loose bridge retainers. measured was the fit of the dowel in the prepared canal,
During the observation period, 30 (10%) of the teeth and the size of the unfilled space of the root canal
with a vital pulp required endodontic treatment due to visible apically to the dowel end. These factors were
signs and symptoms of pulpal deterioration. Endodon- presumed to be adequate, since the criteria for accept-
tic treatment was indicated mainly in the upper molars ance of the clinical work in the student clinic required
and lower posterior teeth compared with the anterior fulfilment of specific minimum standards.
teeth, upper cuspids and premolars. The survival rate of the restored root-filled teeth
When survival rate was defined as the restored tooth study agree with other clinical data, e.g. 95% after three
remaining free from radiographic and clinical signs and years4, 88% after five years46,47,90% after six years48,
symptoms of pulp deterioration, the survival rates were and 82% and 93% after 10 years49,50.The variation in
98% after five years, 92% after 10 years, 87% after 20 survival rates may be due to differences in the intraoral
years and 83% after 25 years. The decreasein survival location of the crowned teeth41,49.The low number of
rate occurred primarily during the first two to seven failed teeth in the present study invalidated further
years after cementation (Fig. 4). The survival rates assessmentsof this relationship. The reasons for failure
varied slightly with the type and size of the fixed of the restored root-filled teeth differed from other
prosthesis after 10, 15, 20 and 25 years. A lower studies. In the literature, dowel loosening and tooth
frequency of pulp deterioration was estimated among fractures have been reported as the most common
the abutments in the small bridges (85% survival rate at problems46,51 . The small percentage of dowel and core
25 years, ?z=102) compared with the abutments in the loosening and tooth fractures in the present study
large bridges (81% survival rate, n= 125) and in the support the hypothesis that the quality and morphology
large bridges with more than five units and a 2:l ratio of the dowel and core influences markedly the prognosis
between pontics and abutments (76% survival rate, of a restored root-filled tooth.
n=37), However, the differences were not statistically The incidence of pulpal deterioration in the present
significant at the PcO.05 level. study was low compared with several other studies (Fig.
I). One reason may be that the students made compre-
hensive assessment of the pulpal health before the
restorative treatment. The assessmentresulted often in
DISCUSSION endodontic treatment of teeth with dubious pulpal
The patients included in the present study were individ- conditions or in the revision of an existing root-filling.
uals seeking treatment at the dental school. The age, Also the preoperative condition of the tooth, e.g. caries,
gender and dental status of the participants were rep- tooth wear or fracture, probably influences the inci-
resentative of the patients treated at the prosthodontic dence of development of endodontic complications52.
department at the time39. The patient dropout rate for Other factors that influence the risk of pulpal deterio-
reasons besides mortality and prosthesis failure was ration are the cutting temperature and duration3, use of
exceptionally low, and only three out of 114 patients local anaesthetic and retraction tissue cord during the
were unwilling to come for a clinical examination operative proceduresz3,temporization, and the size of
(Table IZ). Thus, the risk of selection bias due to exposed root surface.
absenteescan be considered small. One reason for the different results in the clinical
That the reasons for failure of the restored teeth were studies (Fig. I) may be due to different methods used to
different from the reason for failure of the prostheses evaluate the status of the pulp. Direct measurements of
supports previous findings4. The lack of differences in pulp vitality in the clinic are only possible if irreversible
survival rate of teeth with a vital pulp compared with test methods are used. Therefore, pulp vitality is usually
root-filled teeth contrasts some cross-sectional studies diagnosed based on the patient anamnestic data, as well
that suggest a better survival rate of teeth with a vital as tooth, tissue and radiographic examination and
Valderhaug et a/.: Longitudinal observations of fixed prosthodontic treatment 103
evaluation of the tooth response to thermal or physical others claim that 3 mm are sufficient. The present
stimulation. The diagnosis of pulp necrosis is probably observations show also that root-filled teeth with less
lower when the diagnosis is limited to radiographic than 3 mm remaining root-filling material may have a
examinations compared with when irreversible tests are satisfactory prognosis. It is possible that different sug-
used53.Thus, in the present study there is a possibility gestions of minimum remaining root-filling material
that the frequency of pulp necrosis may have been apically to the dowel may reflect differences in the
underestimated, since deterioration may occur and re- sealing capabilities of the root-fillings, which primarily
main undetected due to lack of radiographic changes is a result of the endodontic technique being used.
and clinical sign and symptoms. However, it was con- Consequently, a discussion and definition of the mini-
sidered that due to the long observation period in the mum remaining length of root-filling material apically
present study, the chance of failing to detect teeth with to the dowel should always be related to the endodontic
pulp deterioration was small. technique that has been used.
During the first 10 years the caries incidence was low,
and the standard of oral hygiene was high34. The
endodontic complications were, therefore, probably not CONCLUSIONS
due to poor oral hygiene and caries, but rather due to
the operative procedures used as a wide term, or to a The estimated survival rates and the reasons for failure
deterioration of the interface between the tooth and the of the teeth with a vital pulp and the root-filled teeth
fixed prosthesis. The reason that most pulp deterior- were similar.
ations were recorded after two to seven years may be The incidence of pulpal deterioration among the
because damaged or non-vital pulp tissue causes peri- restored teeth with a vital pulp was low. One reason
apical tissue destruction only after a certain period. may be that the students made comprehensive assess-
Thus, if necrosis occurs during the preparatory phase, it ments of pulpal health before the restorative treatment.
may take some time before infection develops and pulp The reasons for failure of the restored root-filled teeth
destruction is detected. Few teeth developed endodontic differed from other studies, with a small percentage of
complications later in the study. This situation has also dowel and core loosening and tooth fractures. These
been reported in other studies5,23,but contrasts obser- findings are probably the result of high quality endo-
vations of restored teeth with denuded root surfaces. dontic treatment and an optimal morphology of the
The observations in the present study that the fre- dowel and core.
quency of pulp deterioration in abutment teeth in Given good assessment,tooth selection and careful
bridges seemedto be related to the size of the bridge, technique, the risk for the development of pulp deterior-
support other investigations9s3a23. The correlation may ation and periapical lesions in teeth with a vital pulp
be an effect of biomechanical complexity, i.e. loss of seemsto be low during a 25-year period.
retention precedespulp complications. The higher inci-
dence of pulp complications in large, fixed prostheses
References
may also be due to a more complex alignment of
preparations with possible iatrogenic tissue removal 1. Dahl BL Experimental studies on some materials and
and overtapered abutments31. Large, fixed prostheses clinical procedures used in crown and bridge prosthetics.
are also difficult to cast with an acceptable fit compared Dissertation. University of Oslo, Norway, 1979.
with single crowns. Furthermore, there may be a ten- 2. Pluim LJ, Arends J, Having P and Jongebloed WL
dency to accept small discrepancies in large, fixed Quantitative cement solubility experiments in vivo. J Oval
Rehabil 1984; 11: 171-179.
prostheses compared with single crowns, which other-
3. Mjijr IA Dentin and pulp. In: Mjiir IA, ed. Reaction
wise would result in recasting. Finally, large, fixed Patterns in Human Teeth. Boca Raton: CRC Press, 1983;
prostheses may also indirectly increase the risk of pp 63374.
pulp deterioration due to more complex oral hygiene 4. Glyn Jones JC The successrate of anterior crowns. BY
procedures and the development of secondary caries. Dent J 1972; 132: 399-403.
Deterioration of the periapical status of the root-filled 5. Makila E and Salonen MA Follow-up study of partial
teeth according to the PAI-score could not be related to crowns as bridge retainers. Proc Finn Dent Sot 1975; 71:
the density, the end location or the length of apically 15-28.
remaining root-filling material. However, this obser- 6. Wolf JE, Hakala PE, Kolehmainen L and Jarvinen V A
vation does not validate inadequate endodontic treat- follow-up study of porcelain and acrylic jacket crowns.
ment. Unfortunately, the preoperative status of the Proc Finn Dent Sot 1978; 74: 54-58.
restored teeth before endodontic treatment was not Kerschbaum T and Voss R Zum Risiko durch Uberkro-
nung. Dtsch Zahntivztl Z 1979; 34: 740-743.
recorded in the present study, a decisive factor for the
Lundqvist P and Nilson H A clinical re-examination of
outcome of endodontic treatment33s54. patients treated with pinledge-crowns. J Oral Rehabil
There is disagreement in the literature regarding how 1982; 9: 373-387.
much root-filling material that should remain apically Reuter JE and Brose MO Failures in full crown retained
to the dowe155. Some authors suggest 5 mm, while dental bridges. Br Dent J 1984; 157: 61-63.
Periodontology
Geoffrey J Bateman
Naveen Karir and Shuva Saha
Principles of Crown Lengthening

Surgery
Abstract: Crown lengthening is an invaluable tool for the restorative dentist in the management of short clinical crown heights. This
procedure, as an adjunct to a holistic restorative treatment plan, can produce predictable results, whilst ensuring good aesthetics and
maintaining periodontal health. Crown lengthening procedures are invaluable where toothwear or lack of supragingival tooth substance
would render full coverage restoration difficult. Gaining access to subgingival caries for strategic abutments can also be achieved in
this way. In certain instances, excessive gingival show or inharmonious gingival margin levels can be aesthetically managed with crown
lengthening procedures.
Clinical Relevance: Knowledge of crown lengthening techniques, and where these might be prescribed, may be a useful addition to
practitioners treatment planning options, or to decide when referral may be more appropriate.
Dent Update 2009; 36: 181-185
Restorative dentistry implies a multi-

disciplinary approach to the provision
of dental care and has advanced
tremendously in recent times. Modern
trends see a shift towards implant-retained
restorations and adhesive/resin-bonded
techniques to replace missing tooth tissue.
Recent advances in adhesive dentistry
make the restoration of worn teeth
using these techniques an alternative
predictable treatment option. There are,
however, clinical situations where adoption
of traditional techniques, namely full-
coverage restorations, is necessary. For
many of these techniques, the importance
of retention and resistance form to the
Geoffrey J Bateman, BDS, MFDS

RCS(Ed), MMedEd, MRD RCS(Eng),
FDS(Rest Dent) RCS(Ed), Consultant in
Restorative Dentistry, Naveen Karir,
BDS, MFDS RCS(Eng), Specialist Registrar
in Restorative Dentistry and Shuva
Saha, BDS, MFDS RCS(Eng), MFDS
RCS(Ed), DipConSed, Specialist Registrar
in Restorative Dentistry, Birmingham
Dental Hospital, St Chads Queensway,
Figure 1. Dimensions of the biologic width.
Birmingham B4 6NN, UK.
April 2009 DentalUpdate 181
pg181-185 Principles of Crown Lengthening.indd 1 30/3/09 11:30:56

Periodontology
soft tissue margin occlusally to the incisal/

cusp tip. Crown lengthening is therefore
indicated where insufficient crown length
exists to allow predictable restoration of
the teeth. It may also be indicated to gain
access to subgingival caries or to improve
gingival aesthetics.
Figure 3. Full arch wax-up.
Contra-indications for crown
lengthening
Figure 2. Gold and composite temporary crowns There are few absolute contra-
encroaching on biologic width. indications to crown lengthening and
these include medical issues that might
preclude other oral surgical procedures. A
selection of some of the more important
relative contra-indications include:
success and longevity of restorations, Smoking;
and thus the need to have adequate Thin periodontal tissue biotype;
supragingival tooth tissue, is critical. The Narrow-band of attached gingivae;
need for healthy periodontal tissues to Where a furcation on the tooth or an
support these restorations also cannot be Figure 4. Stent fabricated on waxed-up model and adjacent tooth may be exposed;
overstated. Crown lengthening surgery used during surgery. Surgery in the aesthetic zone;
is underpinned by our understanding of Concurrent endodontic/periodontal
the relationship of restorative margins to disease;
these periodontal tissues. Presence and extent of caries.
of the concepts of the biologic width
Biologic width is of key importance when planning
placement of margins of restorations as
Assessment of treatment
The term biologic width
impingement into this critical space has
options
was originally coined by Gargiulo et Crown lengthening is a
been associated with plaque accumulation,
al1 in 1961. The original research was surgical procedure and a degree of post-
gingival inflammation, attachment loss
based on scientific measurements of operative discomfort and morbidity is to
and crestal bone loss.2 It has therefore
the relationship and dimensions of the be expected. It is therefore incumbent on
been suggested that restoration margins
dentogingival junction in cadaveric a practitioner to consider other potential
should not be placed more than 0.51.0
specimens. Functionally, the supracrestal treatment options as part of the consent
mm subgingivally, and that there should
attachment can be divided into two process.
be at least a 3 mm distance between
parts: the connective tissue attachment Alternative treatment options
the restoration and the alveolar crest to
and the epithelial attachment (Figure
prevent encroachment on to the biologic
1). In this study, connective tissue
width.3,4 The biologic width concept is also
attachment measurements were
relevant to dental implants. Some studies
fairly constant, whereas the epithelial
have suggested a certain width of peri-
attachment (junctional and sulcular)
implant mucosa is necessary to ensure
was highly variable. The mean values
stability of the soft tissue framework and,
of the connective tissue and epithelial
where this is insufficient, then physiological
attachments were 1.07mm and 1.66mm,
bone resorption takes place until this
respectively (junctional epithelium
dimension is secure.5,6
0.97mm and sulcular epithelium 0.69
mm). The biologic width is defined as the
width of the junctional epithelium and Indications for crown
supracrestal connective tissues that lie lengthening
between the base of the gingival sulcus There are many factors to
and the alveolar crest and represents the consider before planning restorative
area of attachment of the periodontal treatment and one of the most
soft tissues to the tooth. The average fundamental is crown length, especially in
dimension of biologic width has been cases involving non-carious tooth tissue
shown to be 2.04mm. loss. Crown length may be defined as the
Figure 5. Split rubber dam.
Understanding and application portion of tooth that extends from the
182 DentalUpdate April 2009

Periodontology
Bone removal around teeth adjacent

to those to be crown lengthened may
compromise their own support. The
risk of exposing a furcation has to
be carefully evaluated. Orthodontic
extrusion of teeth may be valuable in
some instances as the alveolar bone
and gingivae will tend to move with
the tooth. This may help place the
gingival margin in an ideal position and
prevent excessively long clinical crowns.
Exposure of root dentine may also
Figure 6. Simple crown lengthening with gingivectomy.
predispose to dentinal hypersensitivity.
Another, not uncommon,
consequence is relapse of the gingival
width, and where bone removal may margin.7 Bone removal does not come
be a necessary adjunct to crown naturally to restorative dentists and,
lengthening (Figure 2). In addition, well- where this is inadequate, the gingival
fitting margins simplify oral hygiene, margin will tend to return to pre-
reduce plaque accumulation and operative levels. The surgeon should
improve post-surgical healing response. therefore make every effort to ensure
In many cases, crown that, where necessary, bone removal
lengthening is necessary before teeth is carried out to allow at least 3 mm
can be restored, for example in severe between alveolar crest and restorative
tooth surface loss. In such cases, margins. Needless to say, careful clinical
preparation of a pre-operative diagnostic records should be made as part of the
wax-up is an invaluable planning aid planning process and, where aesthetic
(Figure 3). This will provide information change is intended, clinical photographs
such as how much tooth substance are mandatory. It is important to record
needs to be exposed for crown retention, a detailed pocket chart around the
likely post-operative crown-root ratio teeth planned for surgery, to ensure:
Figure 7. Apically-repositioned flap surgery. and planned aesthetic result. In addition, No untreated periodontitis remains
a stent constructed on the diagnostic undetected at the planning stage;
wax-up may also be used as a surgical A detailed record of probing sulcus
guide for bone removal (Figure 4). depth is available at the time of surgery.
may include:
Definitive endodontic
Orthodontic extrusion of teeth +/-
treatment should be carried out prior to Surgical procedures
crown lengthening;
crown lengthening, where appropriate.
Overdenture in cases of extreme There are three main
Failed attempts at root canal treatment
toothwear; approaches to surgical crown
after crown lengthening surgery may
Extraction and tooth replacement. lengthening:
result in tooth loss and therefore the
Gingivectomy;
patient may have been exposed to
Case preparation Apically-positioned flap (APF)
unnecessary surgery. Where isolation
surgery;.
Tooth preparation due to short crown height is difficult, a
APF with osseous reduction.
Where possible, the split dam technique may be used (Figure
As bone removal is often
provisional restoration of teeth that 5).
necessary to avoided encroaching on
are planned for crown lengthening will biologic width, the APF with osseous
simplify further management. Caries Informed consent reduction is probably the most
should be removed, as far as possible, Crown lengthening surgery frequently used approach.
initially. This will allow an assessment has similar risks to other forms of
of the remaining tooth substance and periodontal surgery. In particular, the risk Gingivectomy
restorability. Existing crown restorations of an adverse aesthetic impact should be Gingivectomy represents
should be removed and replaced with discussed carefully. Often, this surgery is the simplest approach to crown
provisional restorations. Provisional in the aesthetic zone. Loss of interdental lengthening. It is generally appropriate
crowns can provide a clear guide to the papillae and subsequent black triangles where there is an element of gingival
surgeon of encroachment on biologic may be a significant consequence. overgrowth or false pocketing. It is
184 DentalUpdate April 2009

Periodontology
also valuable where there has been where an apically repositioned flap was Conclusions
loss of periodontal attachment. In this used to lengthen the clinical crowns of
Crown-lengthening
respect, a detailed pocket chart will be two central incisor teeth.
surgery represents a useful adjunct
invaluable. When the apically-positioned
to restorative treatment planning and
Precise changes in flap is sutured, it is convenient initially
may be very useful, particularly where
gingival margin location are relatively to place sutures in the vertical relieving
toothwear necessitates a conventional
straightforward with a gingivectomy incisions. The needle penetration in the
approach to restoration. As with many
technique. This is in contrast with flap margin should be relatively more
periodontal surgical procedures, case
the apically repositioned flap, where apical in the bound tissue than the
selection and planning is paramount.
location of the gingival margin may be reflected flap as this will generate apical
Crown-lengthening can be technically
less predictable and technically more rather than coronal tension.
demanding and potentially have negative
demanding. On the other hand, the Interdental sutures are
aesthetic consequences. It is important,
gingivectomy approach may be less placed to provide soft tissue coverage
therefore, that practitioners anticipate
conservative of attached gingival tissue. of interdental bone. This is done with
these difficulties and refer for treatment
Where this is only present in a thin minimal tension to avoid coronal
where appropriate.
band, an apically-positioned flap may movement of the flap. It is very difficult
represent a more tissue-conservative to attain perfect closure of an apically
option. Figure 6 demonstrates a case repositioned flap and, in some places, References
where simple gingivectomy was used healing will be by secondary intention. It 1. Gargiulo W, Wentz FM, Orban B.
to effect an increase in crown height. is often prudent to place a periodontal Dimensions and relations of the
dressing after closure to protect any areas dentogingival junction in humans.
of denuded bone. J Periodontol 1961; 32: 261267.
Apically-positioned flap surgery 2. Maynard JG Jr, Wilson RD. Physiologic
Where this flap is dimensions of the periodontium
considered, the width of attached Osseous reduction significant to the restorative dentist.
gingivae should be carefully assessed. Osseous reduction during J Periodontol 1979; 50: 170174.
Where this width is minimal, the crown lengthening is often necessary. A 3. Ingber JS, Rose LF, Coslet JG. The
incision may be intrasulcular to decision can be made on this when the biologic width a concept in
preserve attached gingivae. Where flap is raised and measurement of alveolar periodontics and restorative
there is abundant attached gingivae, crest to restorative margin can be made dentistry. Alpha Omegan 1977; 70:
the incision may be relatively scalloped with a periodontal probe. Initial bone 6265.
and submarginal. Local gingival removal is accomplished with burs and 4. Rosenberg ES, Garber DA, Evian CI.
conditions should be observed and the copious coolant. An osseous contour is Tooth lengthening procedures.
flap may incorporate both intrasulcular created to mirror the parabolic interdental Compend Contin Educ Gen Dent 1980;
and submarginal elements. contour and scalloped cervical margins of 1: 161172.
The flap design for an the original alveolar bone and, ideally, to 5. Berglundh T, Lindhe J. Dimension
apically repositioned flap should support the gingival tissues. of the periimplant mucosa. Biologic
normally involve two vertical relieving It is important to avoid width revisited. J Clin Periodontol
incisions. This increases flap mobility damage to the root surfaces of the teeth 1996; 23: 971973.
and makes apical repositioning more to be lengthened. To this end, a thin 6. Cochran DL, Hermann JS, Schenk RK,
straightforward. The flap will normally layer of bone is left on the root surfaces. Higginbottom FL, Buser D. Biologic
extend to include adjacent teeth and This may then be removed with hand width around titanium implants. A
thus allow interdental bone removal instruments, such as a sharp curette or histometric analysis of the implanto-
and recontouring, as appropriate. chisel. gingival junction around unloaded
Often, the decision to remove bone and loaded nonsubmerged implants
can be made when the flap is raised Post-surgical management in the canine mandible. J Periodontol
and precise measurements may be Healing is by secondary 1997; 68: 186198.
made of the distance between alveolar intention, in many cases, and periodontal 7. Pontoriero R, Carnevale G. Surgical
crest and restoration margins. dressings and sutures are left in place crown lengthening: a 12-month
The relieving incisions for around one week, where possible. clinical wound healing study.
should be made as vertical as Gingival maturation will continue over J Periodontol 2001; 72: 841848.
possible and parallel with each other. time and it is sensible to postpone 8. Wolffe GN, van der Weijden FA,
This means that, when the flap is definitive restoration of teeth until this Spanauf AJ, de Quincey GN.
repositioned apically, there is good time. In particular, definitive restoration Lengthening clinical crowns a
apposition of flap margins at these of teeth in the aesthetic zone should solution for specific periodontal,
relieving incisions. be carried out at least six months after restorative, and esthetic problems.
Figure 7 illustrates a case surgery. Quintessence Int 1994; 25: 8188.
April 2009 DentalUpdate 185

Current ceramic materials and systems
with clinical recommendations: A
systematic review
Heather J. Conrad, DMD, MS,a Wook-Jin Seong, DDS, MS,
PhD,b and Igor J. Pesun, DMD, MSc
School of Dentistry, University of Minnesota, Minneapolis, Minn;
University of Manitoba, Winnipeg, Canada
Statement of problem. Developments in ceramic core materials such as lithium disilicate, aluminum oxide, and
zirconium oxide have allowed more widespread application of all-ceramic restorations over the past 10 years. With
a plethora of ceramic materials and systems currently available for use, an overview of the scientific literature on the
efficacy of this treatment therapy is indicated.
Purpose. This article reviews the current literature covering all-ceramic materials and systems, with respect to survival,
material properties, marginal and internal fit, cementation and bonding, and color and esthetics, and provides clinical
recommendations for their use.
Material and methods. A comprehensive review of the literature was completed seeking evidence for the treatment of
teeth with all-ceramic restorations. A search of English language peer-reviewed literature was undertaken using MED-
LINE and PubMed with a focus on evidence-based research articles published between 1996 and 2006. A hand search
of relevant dental journals was also completed. Randomized controlled trials, nonrandomized controlled studies,
longitudinal experimental clinical studies, longitudinal prospective studies, and longitudinal retrospective studies were
reviewed. The last search was conducted on June 12, 2007. Data supporting the clinical application of all-ceramic
materials and systems was sought.
Results. The literature demonstrates that multiple all-ceramic materials and systems are currently available for clinical
use, and there is not a single universal material or system for all clinical situations. The successful application is depen-
dent upon the clinician to match the materials, manufacturing techniques, and cementation or bonding procedures,
with the individual clinical situation.
Conclusions. Within the scope of this systematic review, there is no evidence to support the universal application of
a single ceramic material and system for all clinical situations. Additional longitudinal clinical studies are required to
advance the development of ceramic materials and systems. (J Prosthet Dent 2007;98:389-404)
Clinical Implications
This investigation supports the view that successful applica-
tion of all-ceramic materials depends on the clinicians ability
to select the appropriate material, manufacturing technique,
and cementation or bonding procedures, to match intraoral
conditions and esthetic requirements.
Following the introduction of ible restorative materials increased to improve mechanical and physical
the first feldspathic porcelain crown for clinicians and patients. In 1965, properties. The clinical shortcomings
by Land,1 the interest and demand McLean2 pioneered the concept of of these materials, however, such as
for nonmetallic and biocompat- adding Al2O3 to feldspathic porcelain brittleness, crack propagation, low
a
Assistant Professor, Division of Prosthodontics, Department of Restorative Sciences, School of Dentistry, University of Minnesota.
b
Assistant Professor, Division of Prosthodontics, Department of Restorative Sciences, School of Dentistry, University of Minnesota.
c
Associate Professor, Department Head, Department of Restorative Dentistry, Faculty of Dentistry, University of Manitoba.
Conrad et al
390 Volume 98 Issue 5
tensile strength, wear resistance, and popular,10 patient demand for im- leucite. Veneering a lithium-disilicate,
marginal accuracy, continued to limit proved esthetics has driven the devel- aluminum-oxide, or zirconium-oxide
their use.3 Although the first biomedi- opment of ceramic for use with inlays, core with glass allows dental techni-
cal application of zirconia occurred in onlays, crowns, FPDPs, and implant- cians to customize these restorations
1969,4 the first paper regarding the supported restorations.11 The use of in terms of form and esthetics.13 The
use of zirconia for the production of conservative ceramic inlay prepara- most commonly reported major clini-
artificial femoral heads was written tions with 5.5 to 27.2% tooth struc- cal complication resulting in failure of
by Christel5 in 1988. Applications ture removal is increasing, along with all-ceramic restorations is the fracture
expanded into dentistry in the early all-ceramic complete crown prepara- of the veneering porcelain and/or the
1990s and have included endodontic tions, which are more invasive and coping (Table II).3,14-30 The success
posts, implants and implant abut- result in 67.5 to 72.3% tooth struc- of these systems is dependent upon
ments, orthodontic brackets, cores ture removal.12 All-ceramic restora- preventing failure by retarding crack
for crowns, and fixed partial denture tions combining esthetic veneering propagation.4,31-33
prosthesis (FPDP) frameworks.6-9 porcelains with strong ceramic cores Expansion of the use of all-ce-
Even though the combination of have become popular (Table I). Ve- ramic systems for FPDPs has limita-
predictable strength and reasonable neering porcelains typically consist tions. Proper diagnosis and patient
esthetics has continued to make tra- of a glass and a crystalline phase of selection are critical for success. A
ditional metal-ceramic restorations fluoroapatite, aluminum oxide, or minimum connector height of 3 to 4
Table I. Ceramic materials and systems and manufacturer-recommended clinical indications

Manufacturing
Core Material System Techniques Clinical Indications
Glass Ceramic
Lithium-disilicate IPS Empress 2 (Ivoclar Vivadent, Heat pressed Crowns, anterior FPDP
Schaan, Liechtenstein) Heat pressed Onlays, 3/4 crowns, crowns, FPDP
(SiO2-Li2O) IPS e.max Press (Ivoclar Vivadent)
Leucite IPS Empress (Ivoclar Vivadent) Heat pressed Onlays, 3/4 crowns, crowns
(SiO2-Al2O3-K2O) Optimal Pressable Ceramic (Jeneric Heat pressed Onlays, 3/4 crowns, crowns
Pentron, Wallingford, Conn) Milled Onlays, 3/4 crowns, crowns
IPS ProCAD (Ivoclar Vivadent)
Feldspathic VITABLOCS Mark II (VITA Zahnfabrik, Milled Onlays, 3/4 crowns, crowns, veneers
(SiO2-Al2O3-Na2O-K2O) Bad Sackingen, Germany) Milled Onlays, 3/4 crowns, crowns, veneers
VITA TriLuxe Bloc (VITA Zahnfabrik) Milled Anterior crowns, veneers
VITABLOCS Esthetic Line (VITA Zahnfabrik)
Alumina
Aluminum-oxide In-Ceram Alumina (VITA Zahnfabrik) Slip-cast, milled Crowns, FPDP
(Al2O3) In-Ceram Spinell (VITA Zahnfabrik) Milled Crowns
Synthoceram (CICERO Dental Systems, Milled Onlays, 3/4 crowns, crowns
Hoorn, The Netherlands) Slip-cast, millled Crowns, posterior FPDP
In-Ceram Zirconia (VITA Zahnfabrik) Densely sintered Veneers, crowns, anterior FPDP
Procera (Nobel Biocare AB,
Goteborg, Sweden)
Zirconia
Yttrium tetragonal Lava (3M ESPE, St. Paul, Minn) Green milled, sintered Crowns, FPDP
zirconia polycrystals Cercon (Dentsply Ceramco, York Pa) Green milled, sintered Crowns, FPDP
(ZrO2 stabilized by Y2O3) DC-Zirkon (DCS Dental AG, Allschwil, Milled Crowns, FPDP
Switzerland) Milled Onlays, 3/4 crowns, crowns
Denzir (Decim AB, Skelleftea, Sweden) Densely sintered, milled Crowns, FPDP, implant abutments
Procera (Nobel Biocare AB)
The Journal of Prosthetic Dentistry Conrad et al

November 2007 391
Table II. Classification of complications and overall survival rates
Major Complications Minor Complications Reported Survival
Study (Restorations Remade) (Restorations Not Remade) Rates (Percent)
Raigrodski37 None Chipped veneer (5) 100
Endodontic therapy (1)
Marginal integrity (1)
Vult von Steyern38 None Chipped veneer (3) 100

Fradeani14 Fracture of veneer and/or coping (2) Chipped veneer (3) 96.7 (100 anterior,
Fracture or delamination of veneer (2) Endodontic therapy (2) 95.15 posterior)
Oden15 Fracture of veneer and coping (3) Endodontic therapy (2) 97

Chipped veneer (2)
Caries (1)
Odman16 Fracture of veneer and coping (4) Decementation (11) 93.5

Caries (1) Chipped/cracked veneer (5)
Caries (2)
Wolfart17 Debonding (3) Endodontic therapy (3) 100 (crown-retained FPDP)

Debonding and fracture (3) Chipped veneer (1) 89 (inlay-retained FPDP)
Frankenberger18 Fracture of veneer and coping (5) Marginal deficiences (94%) 93

Endodontic therapy (2) Removal due to hypersensitivity (2)
Sjogren3 Fracture (7) Slight mismatch in color (13%) 91

Slightly rough surfaces (9%)
Caries (2)
Fradeani19 Fracture (4) (not reported) 95.2 (98.9 anterior,

Post and core fracture (1) 84.4 posterior)
Root fracture (1)
Marquardt20 Fracture (4) (not reported) 100 (posterior crowns)

Endodontic therapy (1) 70 (anterior or premolar
Tooth fracture (1) FPDP)
Esquivel-Upshaw21 Fracture (2) (not reported) 93
Bindl22 Fracture (2) Debonding of composition resin 100 (In-Ceram Spinell)

foundation (1) 92 (In-Ceram Alumina)
McLaren23 Fracture of core (4) (not reported) 96 (98 anterior,

Fracture of veneer (2) 94 posterior)
Removal without failure (3)
Haselton66 Marginal integrity (2) Caries (1) (not reported)

Marginal integrity (1)
Chipped veneer (1)
Fracture (1)
Conrad et al
Table II. continued (2 of 2) Classification of complications and overall survival rates
Major Complications Minor Complications Reported Survival
Study (Restorations Remade) (Restorations Not Remade) Rates (Percent)
Vult von Steyern24 Fracture (2) (not reported) 90
Olsson25 Fracture (3) Fracture (external trauma) (2) 93

Decementation (1)
Sorensen26 Fracture (7) (not reported) 88.5 (100 anterior,

82.5 posterior)
Suarez91 Root fracture (1) (not reported) 94.5
Probster92 None Caries (5) 100

Decementation (1)
Fradeani27 Fracture (1) Chipped veneer (2) 97.5
Pallesen28 Fracture (3) Chipped/cracked veneer (8) 90.6
Otto29 Fracture (5) Chipped veneer (3) 90.4

Tooth fracture (3) Caries (2)
Caries (1) Endodontic therapy (1)
Malament30 Fracture (180) (not reported) 87.5
Scurria93 95 (5 year)
85 (10 year)
67 (15 year)
mm from the interproximal papilla to DPs.7,8,41 The purpose of this article is MEDLINE and PubMed searches were
the marginal ridge is a guideline for to review current literature on all-ce- conducted focusing on evidence-
most systems.7,8,17,21,25,34,35 Placement ramic materials and systems, with re- based research articles published be-
is contraindicated when there is respect to survival, material properties, tween 1996 and 2006. The Journal of
duced interocclusal distance, as with marginal and internal fit, cementation Prosthetic Dentistry and the International
short clinical crowns, deep vertical and bonding, and color and esthetics, Journal of Prosthodontics were addition-
overlap anteriorly without horizontal and suggest clinical recommendations ally hand-searched for this review.
overlap, or an opposing supraerupted for their use. Titles and/or abstracts of articles
tooth, as well as for cantilevers, peri- identified through the electronic
odontally involved abutment teeth, MATERIAL AND METHODS searches were reviewed and evaluated
and patients with severe bruxism or for appropriateness. Suitable articles
parafunctional activity.7,21,36 The pri- A broad systematic search of Eng- were subjected to inclusion and exclu-
mary cause of failure varies from frac- lish peer-reviewed dental literature sion criteria. Randomized controlled
ture of the connector, for aluminum- was designed to identify evidence clinical trials, nonrandomized con-
oxide FPDPs24-26 and lithium-disilicate supporting the restoration of teeth trolled clinical studies, longitudinal
FPDPs,20,21 to cohesive fracture of the with current all-ceramic materials experimental clinical studies, longi-
veneering porcelain, for zirconia FP- and systems. Key words or phrases tudinal prospective clinical studies,
DPs.37,38 Metal-ceramic FPDPs differ included crowns, dental porcelain, and longitudinal retrospective clinical
in that they fail primarily due to tooth ceramics, aluminum oxide, zirconium studies were reviewed. Articles that
fracture39 and caries.39,40 Following oxide, dental cements, composite did not focus exclusively on the resto-
the Law of Beams by maximizing con- resin cements, adhesives, computer- ration of teeth with all-ceramic mate-
nector height and width is the basis aided design, color, dental restoration rials and systems or the material prop-
for proper design of all-ceramic FP- failure, and dental prosthesis design. erties of ceramics were excluded from
November 2007 393
further evaluation. Nonpeer-reviewed in the anterior segment.19 IPS Em- the middle third has a neutral zone
dental literature, abstracts, and clini- press 2 has improved flexural strength comparable to the standard block,
cal reports were excluded from review. by a factor of 3 over IPS Empress, and the outer third is more trans-
Inclusion criteria for survival studies can be used for 3-unit FPDPs in the lucent. CEREC software allows the
included a minimum mean follow-up anterior area, and can extend to the operator to have some visual control
period of 2 years, reporting of com- second premolar.42-45 The framework over the alignment of the restoration
plications, identification of materi- is veneered with fluoroapatite-based within the multilayered block.59,60
als, type of study, setting, and sample veneering porcelain (IPS Eris; Ivoclar Another technique for fabricat-
size. Data supporting the clinical ap- Vivadent), resulting in a semitranslu- ing feldspathic porcelain restorations
plication of all-ceramic materials and cent restoration with enhanced light was through copy-milling (Celay; Mi-
systems was sought. transmission.8,46,47 IPS e.max Press krona Technologie AG, Spreitenbach,
(Ivoclar Vivadent) was introduced in Switzerland).61,62 This system milled
RESULTS 2005 as an improved press-ceramic restorations by duplicating a direct
material compared to IPS Empress 2. acrylic resin pattern replica of an in-
A total of 285 articles were iden- It also consists of a lithium-disilicate lay, onlay, or crown coping. Unable
tified through the MEDLINE and pressed glass ceramic, but its physical to approach the sophistication of the
PubMed searches. Abstracts were properties and translucency are im- digital systems (CEREC 3D; Sirona
reviewed to confirm the articles met proved through a different firing pro- Dental Systems), the Celay system is
the inclusion criteria. A total of 148 cess.48 IPS ProCAD (Ivoclar Vivadent) now obsolete.63 A major contributor
articles published between 1996 and is a leucite-reinforced ceramic similar to the development of glass ceram-
2006 were identified and read in their to IPS Empress, although it has a fin- ics was Dicor (Dentsply Intl, York,
entirety. Nineteen prospective and 4 er particle size.49 Introduced in 1998, Pa). This was a glass-ceramic mate-
retrospective clinical trials related to it is designed to be used with the rial composed of 70% tetrasilicic flu-
survival were reviewed. The literature CEREC inLab system (Sirona Dental ormica crystals precipitated in 30%
demonstrated that multiple all-ce- Systems, Bensheim, Germany) and is glass matrix.64 Originally made using
ramic materials and systems are cur- available in numerous shades, includ- the lost-wax technique,30,65 it was later
rently available for clinical use and ing a bleached shade and an esthetic marketed as a machinable glass ce-
there is not a single universal material block line.49-52 ramic28,64 that is no longer available.
or system for all clinical situations. Vita Mark II (VITA Zahnfabrik,
The successful application of differ- Bad Sackingen, Germany), a machin- Alumina-based ceramics
ent all-ceramic materials is dependent able feldspathic porcelain introduced
upon clinicians ability to match the in 1991 for the CEREC 1 system (Sie- In-Ceram Alumina (VITA Zahn-
ceramic materials to the manufactur- mens AG, Bensheim, Germany), has fabrik), introduced in 1989, was the
ing techniques and cementation or improved strength and finer grain size first all-ceramic system available for
bonding procedures, to adequately (4 m) as compared to the Vita Mark single-unit restorations and 3-unit an-
customize a treatment plan. I.28,49 It is primarily composed of SiO2 terior FPDPs.66 It has a high strength
(60-64%) and Al2O3 (20-23%) and can ceramic core fabricated through the
Discussion be etched with hydrofluoric acid to slip-casting technique.67 A slurry of
create micromechanical retention for densely packed (70-80 wt%) Al2O3
Glass ceramics adhesive cementation with compos- is applied and sintered to a refrac-
ite resin cements.49,53,54 Although this tory die at 1120C for 10 hours.63,68
IPS Empress 2 (Ivoclar Vivadent, product is monochromatic, it is avail- This produces a porous skeleton of
Schaan, Liechtenstein) is a lithium-di- able in multiple shades, including the alumina particles which is infiltrated
silicate glass ceramic (SiO2-Li2O) that Classic Line Vita shades, Vitapan 3D- with lanthanum glass in a second fir-
is fabricated through a combination Master Shades, VITABLOCS Esthetic ing at 1100C for 4 hours to elimi-
of the lost-wax and heat-pressed tech- Line, and a bleached shade, and can nate porosity, increase strength, and
niques. A glass-ceramic ingot of the be additionally characterized.49,55-58 limit potential sites for crack propa-
desired shade is plasticized at 920C To overcome esthetic disadvantages gation.68 Compressive stresses which
and pressed into an investment mold of a monochromatic restoration and further improve the strength are also
under vacuum and pressure. Its pre- to imitate optical effects of natural introduced, due to the differences in
decessor, IPS Empress (Ivoclar Viva- teeth, a multicolored ceramic block the coefficient of thermal expansion
dent), is a leucite-reinforced glass ce- (Vita TriLuxe Bloc; VITA Zahnfabrik) of the alumina and glass.68 The cop-
ramic (SiO2-Al2O3-K2O) which, due to was designed to create a 3-dimension- ing is veneered with feldspathic porce-
its strength, is limited in use to single- al layered structure.59 The inner third lain.22,66 Alumina blanks (VITABLOCS
unit complete-coverage restorations has a dark opaque base layer, while In-Ceram Alumina; VITA Zahnfabrik)
Conrad et al
are also available for milling in com- electronically to a manufacturing fa- parable to metal which enhances
bination with CEREC (Sirona Dental cility where a 20% enlarged model radiographic evaluation of marginal
Systems).22,63 is copy-milled and used for the dry- integrity, excess cement removal, and
In 1994, In-Ceram Spinell (VITA pressing technique.14,45 High purity recurrent decay.8
Zahnfabrik) was introduced as an al- aluminum-oxide powder is mechani- Y-TZP can be manufactured in 2
ternative to the opaque core of In-Ce- cally compacted on the enlarged die methods through computer-aided
ram Alumina. It contains a mixture of and sintered at 1550C, eliminating design/computer-aided manufactur-
magnesia and alumina (MgAl2O4) in porosity and returning the core to the ing (CAD/CAM) technology. First, an
the framework to increase translucen- dimensions of the working die.45,63,76 enlarged coping/framework can be
cy10,69; however, its flexural-strength The crown form is completed by ve- designed and milled from a homog-
is lower than that of In-Ceram Alu- neering it with low-fusing feldspathic enous ceramic soft green body blank
mina, and, thus, the cores are only porcelain matching the coefficient of of zirconia.80 The framework structure
recommended for anterior crowns.70 thermal expansion of aluminum ox- has a linear shrinkage of 20-25% dur-
This material can also be machined ide.14 ing sintering until it reaches the de-
with the CEREC inLab system (Sirona sired final dimensions.6,9 Processing
Dental Systems), followed by veneer- Zirconia-based ceramics with this softer presintered material
ing with feldspathic porcelain.22,57 not only shortens the milling time,
Synthoceram (CICERO Dental Sys- Zirconia is a polymorphic material but also reduces the wear on the mill-
tems, Hoorn, The Netherlands) is a that occurs in 3 forms. At its melting ing tools.6 Although zirconia frame-
high-strength glass-impregnated alu- point of 2680C, the cubic structure works can be milled directly from a
minum-oxide ceramic core fabricated exists and transforms into the te- fully sintered prefabricated blank in
through CICERO technology (Com- tragonal phase below 2370C.4,77,78 the final dimensions,6,80 milling fully
puter Integrated Ceramic Reconstruc- The tetragonal-to-monoclinic phase sintered zirconia may compromise the
tion).71,72 Laser scanning, ceramic transformation occurs below 1170C microstructure and strength of the
sintering, and computer-integrated and is accompanied by a 3-5% volume material.81,82
milling techniques are used to fab- expansion which causes high internal Lava (3M ESPE, St. Paul, Minn)
ricate the cores, which are veneered stresses.32,77,78 Yttrium-oxide (Y2O3 uses a Y-TZP framework with high flex-
with a leucite-free glass ceramic.54,71-73 3% mol) is added to pure zirconia to ural strength, high fracture toughness,
In-Ceram Zirconia (VITA Zahnfab- control the volume expansion and to and low elastic modulus compared to
rik) is also a modification of the origi- stabilize it in the tetragonal phase at alumina, and exhibits transformation
nal In-Ceram Alumina system, with an room temperature.33 This partially toughening when subjected to tensile
addition of 35% partially stabilized zir- stabilized zirconia has high initial stress.4,33 A die is scanned by a con-
conia oxide to the slip composition to flexural strength and fracture tough- tact-free optical process for 5 minutes
strengthen the ceramic.67 Traditional ness.33 Tensile stresses at a crack tip for a crown and 12 minutes for a 3-
slip-casting techniques can be used will cause the tetragonal phase to unit FPDP. The CAD software designs
or the material can be copy-milled transform into the monoclinic phase an enlarged framework that is milled
from prefabricated, partially sintered with an associated 3-5% localized ex- from softer presintered blanks. After
blanks and then veneered with feld- pansion.32 The volume increase cre- 35 minutes of milling for a crown and
spathic porcelain.7,46,74 Since the core ates compressive stresses at the crack 75 minutes for a 3-unit FPDP, the
is opaque and lacks translucency, the tip that counteract the external tensile framework can be colored in 1 of 7
material is recommended for poste- stresses. This phenomenon is known shades, followed by sintering in a spe-
rior crown copings and FPDP frame- as transformation toughening and re- cial automated oven for 8 hours.6
works.7,67 tards crack propagation. In the pres- Other CAD/CAM systems are also
Procera (Nobel Biocare AB, Gote- ence of higher stress, a crack can still available for designing and milling zir-
borg, Sweden) was developed by An- propagate. The toughening mecha- conia restorations. Cercon (Dentsply
dersson and Oden with copings that nism does not prevent the progres- Ceramco, York, Pa) requires conven-
contain 99.9% high purity aluminum sion of a crack, it just makes it harder tional waxing techniques to design the
oxide.75 Combined with a low-fusing for the crack to propagate.4,8,32,33,79 Y-TZP framework, and the wax pattern
veneering porcelain, Procera has the Yttrium-oxide partially stabilized is scanned.7 DCS Precident (DCS Den-
highest strength of the alumina-based zirconia (Y-TZP) has mechanical prop- tal AG, Allschwil, Switzerland) uses
materials and its strength is lower only erties that are attractive for restorative fully sintered DC Zirkon ceramic con-
than zirconia.14,15 A sapphire contact dentistry; namely, its chemical and di- taining 95% ZrO2 partially stabilized
probe is used to scan the working die mensional stability, high mechanical with 5% Y2O3.7,83,84 Denzir (Decim AB,
and to define the 3-dimensional shape strength, and fracture-toughness.13 Skelleftea, Sweden) designs and mills
of the preparation.54 The data is sent The cores have a radiopacity com- ceramic inlays from yttrium-oxide
November 2007 395
partially sintered blocks.67,85,86 any metal display.89,90 tive and the most commonly reported
Although the first all-ceramic im- major complication requiring remak-
plant abutments (CerAdapt; Nobel Survival ing of the restoration.3,14-28,30 Although
Biocare AB) were made of densely 2 groups of investigators considered
sintered, high purity alumina,87,88 When considering the restoration caries a major complication requiring
zirconia implant abutments with or of teeth with all-ceramic materials, refabrication of the restoration in 1
without a metal interface (Procera survival data is important to evaluate instance, they considered it a minor
Zirconia Abutment; Nobel Biocare the effectiveness of different treatment complication that did not require re-
AB; Atlantis Abutment in Zirconia; strategies. Comparing the results from fabrication for 2 other restorations in
Zimmer Dental, Carlsbad, Calif; relevant literature is challenging due the study.16,29 Two groups of investiga-
Straumann Zirconia Custom Abut- to the availability of different ceram- tors reported endodontic therapy as a
ment; Straumann USA, Andover, ic materials and systems, reporting major complication,18,20 while 4 oth-
Mass; Zirconia Abutment; Astra Tech of complications, study conditions, ers reported root or tooth fracture as
Inc, Waltham, Mass; and ZiReal Post; and evaluation times; these varying a major complication.19,20,29,91
Biomet 3i, Palm Beach Gardens, Fla) factors make it difficult to assess the Several of the reported compli-
are now recommended instead of alu- overall effectiveness of therapy. Inclu- cations were considered minor and
mina due to their increased mechani- sion criteria for the reviewed studies did not require remaking of the res-
cal properties.87,88 Abutments are included a minimum mean follow-up toration. The most common minor
either customized through electronic period of 2 years, reporting of com- complication reported was chipping
data or are stock abutments which plications, identification of materials, or cracking limited to the veneering
can be modified via conventional type of study, setting, and sample size porcelain (reported for 33 restora-
preparation. Dental and mucogingival (Tables II and III). tions),14-17,27-29,37,38,66 followed by end-
esthetics can be improved for single Fracture of the veneering porce- odontic therapy (n=14),3,14-17,29,37,38
implant restorations by eliminating lain and/or ceramic coping is objec- decementation (n=13),16,25,92 and
Table III. Study details, including material and restoration type

Type of Type of Sample Mean Range
Study Material Restoration Study Study Size (Years) (Years)
Raigrodski37 Lava FPDPs Prospective University 20 2.6 1.5-3
Vult von Steyern38 DC-Zirkon FPDPs Prospective University 23 2 2
Fradeani14 Procera (alumina) Crowns Prospective Private practice 205 2 0.5-5
Oden15 Procera (alumina) Crowns Prospective Private Practice 100 5 (not reported)
Odman16 Procera (alumina) Crowns Prospective Multicenter 87 (not reported) 5-10.5
Wolfart17 IPS e.max Press Crown-retained Prospective University 36 4 2.5-4.6

FPDP
Inlay-retained 45 3.1 1.7-5
FPDP
Frankenberger18 IPS Empress Inlays, onlays Prospective University 96 (not reported) 1-6
Sjogren3 IPS Empress Crowns, Retrospective Private practice 110 3.6 1.4-5.1
3/4 crowns
Fradeani19 IPS Empress Crowns Retrospective Private practice 125 (not reported) 4-11
Marquardt20 IPS Empress 2 Crowns Prospective University 27 (not reported) 2.75-5.1

FPDPs 31
Esquivel-Upshaw21 IPS Empress 2 FPDPs Prospective University 30 (not reported) 1-2
Conrad et al
Table III. continued (2 of 2) Study details, including material and restoration type
Type of Type of Sample Mean Range
Study Material Restoration Study Study Size (Years) (Years)
Bindl22 In-Ceram Spinell Crowns Prospective University 19 3.25 1.2-4.8

In-Ceram Alumina 24
McLaren23 In-Ceram Alumina Crowns Prospective Private practice 223 3 (not reported)
Haselton66 In-Ceram Alumina Crowns Retrospective University 80 4 (not reported)
Vult von Steyern24 In-Ceram Alumina FPDPs Prospective University 20 5 (not reported)
Olsson25 In-Ceram Alumina FPDPs Retrospective Private practice 42 6.3 0.2-9.2
Sorensen26 In-Ceram Alumina FPDPs Prospective University 61 3 (not reported)
Suarez91 In-Ceram Zirconia FPDPs Prospective University 18 3 (not reported)
Probster92 In-Ceram Alumina Crowns Prospective (not reported) 95 2.42 2-4.5
Fradeani27 In-Ceram Spinell Crowns Prospective Private practice 40 4.17 1.8-5
Pallesen28 Vita Mark II, Inlays Prospective University 16 8 (not reported)

Dicor 16
Otto29 Vita Mark I Inlays, onlays Prospective Private practice 200 10 (not reported)
Malament30 Dicor Crowns, inlays, Prospective Private practice 1444 14.1 (not reported)
onlays
Scurria93 Metal-ceramic FPDPs Meta-analysis Various n/a 5 (not

10 applicable)
15
caries (n=13).3,15,16,29,66,92 Chipping or with direct composite resin restor- of the prosthesis, but also considered
cracking of the veneering porcelain ative material.14,17,29,37 Several authors a broader definition that included
for this review was defined as minor replaced 2 crowns due to cohesive removal and/or a technically failed
cohesive fracture of the veneering por- failures of the veneering porcelain prosthesis requiring replacement.93
celain which did not impair function. and 1 crown due to caries, but did not A more comprehensive definition of
Two studies did not exclude patients classify this as a major complication failure or critical assessment of all-
unavailable for evaluation from the because it only involved the veneering ceramic restorations would thus de-
survival rates (reported for 30 resto- porcelain.15 crease reported survival rates. A more
rations).18,26 Typical survival rates for all-ce- descriptive definition of ceramic res-
In instances where minor cohesive ramic restorations range from 88 to toration outcome might include the
fractures of the veneering porcelain 100% after 2-5 years in service,3,14,17,21- categories of success, survival, and
did not require complete replace- 23,26,27,37,38,91,92
and 84 to 97% after failure.
ment, the restorations were either 5-14 years in service.15,16,18,19,24,25,28-30
polished14,16,27 or repaired with direct Discrepancy in the classification of Material properties
composite resin restorative materi- failures and variability of the materials
al.17,29 Caries identified in the margin- and systems available for all-ceramic The strength of an all-ceramic res-
al areas were excavated and repaired restorations present a challenge to toration is dependent on the ceram-
with direct composite resin restor- combining data from several stud- ic material used, core-veneer bond
ative material,29,66,92 while endodontic ies. A meta-analysis for metal-ceramic strength, crown thickness, and design
access preparations were also filled FPDPs defined failure as the removal of the restoration,13,94 as well as bond-
November 2007 397
ing techniques and the characteristics layer when the crack initiates from shown to significantly decrease the
of the supporting material.95,96 As the veneer surface.107 Although resid- fracture toughness of ceramic mate-
evident from the literature on survival ual compressive stresses in the veneer rials.114 Long-term in vivo studies are
rates, fracture of the ceramic material layer increase the flexural strength of necessary to make conclusions about
is the most frequently reported com- the bilayered restoration, the tensile the clinical indications for ceramic
plication resulting in failure.3,14-28,30 stresses are the primary cause for the materials.
Alumina-based ceramics (In-Ceram observed chipping.107
Alumina; VITA Zahnfabrik) have been Zirconia-based ceramics are rec- Marginal and internal fit
shown to have higher strength and ommended for FPDPs, as they have
fracture toughness than leucite-rein- the highest failure loads when com- When evaluating the clinical suc-
forced glass ceramics (IPS Empress; pared to alumina- and lithium-dis- cess and quality of a restoration,
Ivoclar Vivadent),97 conventional feld- ilicate-based ceramics.46 A lithium- marginal discrepancy is an essential
spathic porcelain (Vita Bloc Mark II; disilicate glass ceramic (IPS Empress criterion.74 Christensen115 reported
VITA Zahnfabrik),98,99 and modified 2; Ivoclar Vivadent) in combination the clinically detectable range for sub-
alumina cores (In-Ceram Spinell; VITA with a fluoroapatite glass-ceramic gingival margins to be 34-119 m and
Zahnfabrik).100 A zirconia-modified (IPS Eris; Ivoclar Vivadent) was found 2-51 m for supragingival margins.
alumina ceramic (In-Ceram Zirconia; to be inappropriate for posterior FP- Subsequently, McLean116 suggested
VITA Zahnfabrik) was found to have DPs due to the high susceptibility of that 120 m should be the limit for
higher fracture toughness than In-Ce- the veneer to subcritical crack growth clinically acceptable marginal discrep-
ram Alumina when tested by indenta- and the absence of crack arresting ancies. Poor marginal adaptation can
tion strength in 1 study,101 and higher at the core-veneer interface.108 Zir- result in cement dissolution, micro-
flexural strength in another.102 Dense- conia frameworks with higher elastic leakage, increased plaque retention,
ly sintered, high purity alumina (Proc- modulus are preferred for all-ceramic and secondary decay.74
era; Nobel Biocare AB) was reported posterior FPDPs compared to lithi- Holmes117 measured various
to have significantly higher flexural um-disilicate based ceramics, as they points between the casting and the
strength than glass-infiltrated presin- reduce the stress on the weaker ve- tooth and clarified the terminology
tered alumina (In-Ceram Alumina).103 neer layer and increase the composite for misfit. Absolute marginal discrep-
The success of many all-ceramic load-bearing capacity, thereby retard- ancy was defined as an angular com-
systems is dependent on the strength ing the fracture of the restoration.106 bination of the horizontal and vertical
of a core-veneer bond. Since the ce- Creating a gingival embrasure with a error and would reflect the total misfit
ramic core is significantly stronger broad radius of curvature, rather than at that point. An internal gap is the
than the veneering materials, this a sharp contour, has been shown to perpendicular measurement from the
bond strength has an important role reduce the stress concentration under axial wall to the internal casting sur-
in their success.13 The thickness ratio loading and increase the fracture re- face.
of the ceramic core to the veneering sistance.109,110 The incidence of gingival inflam-
porcelain is a dominant factor con- Following traditional preparation mation increases around clinically de-
trolling the crack initiation site and guidelines is important not only for ficient restorations, particularly those
potential failure.104 Optimizing the retention of all-ceramic crowns, but with rough surfaces, subgingival fin-
thickness of these layers is necessary to also for stress distribution during dy- ish lines, or poor marginal adapta-
ensure that the veneering porcelain is namic loading of the restoration.111 tion; however, gingival inflammation
under compressive stress and that the Finite element analysis studies have may also develop around properly
ceramic core is under tensile stress.103 shown that FPDP connector heights contoured and highly polished res-
Although it is desirable to increase the of at least 3 to 4 mm considerably torations.118 Although the severity of
thickness of the ceramic coping, it is reduce stress levels in the connector gingival response is patient-specific,
important not to compromise either and provide adequate strength.35,112 current evidence has not shown an
the esthetics of the crown by overcon- In vitro studies on mechanical prop- accelerated rate of bone loss or in-
touring, or the tooth preparation by erties are not always capable of repro- creased attachment loss adjacent to
overreduction.105 ducing intraoral conditions. Artificial crowns.118
Even though the veneering por- oral environments have been devel- Contemporary chairside or labo-
celain is used primarily for esthetic oped to simulate intraoral conditions ratory-based CAD/CAM systems have
reasons, it has an important role in by applying intermittent dynamic cy- additional factors that may affect the
the mechanical behavior of the res- clic forces, artificial saliva, tempera- accuracy of the fit, including software
toration.106 The flexural strength and ture fluctuations, and humidity con- limitations in designing restorations,
fracture toughness of these bilayered trol.66,113 Testing specimens in these and hardware limitations of the cam-
restorations depend on the veneer simulated oral environments has been era, scanning equipment, and mill-
Conrad et al
ing machines. Clinicians and dental tion having a tendency to exacerbate microleakage, marginal discoloration,
technicians experience and expertise surface flaws in ceramic restorations pulpal irritation, secondary caries,
is also key with chairside and labo- due to the increased acidity of the ce- debonding, and decreased fracture
ratory-based CAD/CAM systems.119 ment.130 Glass ionomers are suscepti- load. Adhesive cementation has been
Systems dependent upon an optical ble to early water degradation, result- shown to increase fracture loads
impression experience problems with ing in microcracks which may initiate and improve longevity.50,57,139,141,142 A
rounded edges due to the scanning cracks and facilitate crack propaga- glass-ceramic restoration supported
resolution and positive error, which tion in the cement.131 Resin-modified by a composite resin cement with
simulates peaks at the edges.120 Other glass ionomer cement sets through a good physical properties can with-
systems that use a surface contact- combination of an acid-base reaction stand higher masticatory forces and
ing probe cannot accurately repro- and photo- or chemically initiated demonstrates improved clinical per-
duce proximal retentive features less polymerization. Combining chemical formance.138
than 2.5 mm wide and more than 0.5 adhesion advantages of traditional Light-, dual-, and chemically po-
mm deep.121 Feather-edge finish lines, glass-ionomer cements with advan- lymerized composite resin materials
deep retentive grooves, and complex tages of composite resin results in im- have been advocated for use with
occlusal morphology are not recom- proved strength, fracture toughness, glass ceramics.143 Decreased sur-
mended, not only for scanning and and wear resistance.132 To improve vival rates have been reported with
milling prerequisites, but also to de- success rates with glass- and alumina- dual-polymerizing, composite resin
crease stress that would develop in a based ceramic restorations, nonacid- cement, as compared to chemically
restoration with inadequate prepara- base cements are recommended.130 polymerizing composite resin cement
tion and margin geometry.121 An addi- For conventional glass-ceramic with feldspathic inlays (VITABLOCS
tional problem with computer-milled restorations, the adhesive technique Mark II; VITA Zahnfabrik).144,145 Inad-
ceramic restorations is that the inter- is critical for successful bonding. Sur- equate transmission of light through
nal cutting bur may be larger in di- face treatment of the porcelain by the ceramic restoration to the under-
ameter than some parts of the tooth etching with 5% to 9.5% hydrofluoric lying cement can result in insufficient
preparation, such as the incisal edge. acid133 and etching of the tooth struc- polymerization of dual-polymerizing
This would result in a larger internal ture with 37% phosphoric acid134 and composite resin cement and lack of
gap than with other fabrication tech- application of a silane coupling agent support for the restoration.119 Dual-
niques.120 provided the highest bond strength polymerizing cements contain perox-
Table IV is a summary of current of an adhesive-resin cement to feld- ide and amine components found in
literature evaluating in vivo and in spathic material. A chemical bond chemically polymerized systems, in
vitro marginal discrepancy as well as between feldspathic porcelain and addition to a photosensitizer used in
the in vitro internal discrepancy or tooth structure is achieved through light-polymerized systems.146 The 2
misfit of the coping on the axial sur- silane coupling agents in composite catalytic mechanisms are required to
faces. In general, studies have demon- resins. Bond strength to etched sur- reduce the quantity of remaining dou-
strated that internal gap widths are faces is improved by creating deep ble bonds to maximize strength and
higher than marginal gaps.54,74,76,83,85, involuted spaces where resin can flow adhesion of the cement.147 A slower
86,122-129
This finding has implications and interlock.135,136 Due to the abra- polymerization reaction148 and higher
for glass-ceramic restorations which sion rate with subsequent volume solubility and water absorption occurs
may be dependent upon the mechani- loss and changes in morphology, feld- when dual-polymerizing resins are al-
cal properties of the luting cement to spathic restorations should never be lowed to autopolymerize.149 Depend-
resist functional forces.95 Most of the airborne-particle abraded to improve ing exclusively on the autopolymeriz-
literature reports marginal discrepan- the roughness of the internal surface, ing component of dual-polymerizing
cies in the range of clinical acceptabil- only acid-etched.137 composite resin results in decreased
ity recommended by Christensen115 Considering the brittleness and hardness and premature failure of the
and McLean.116 limited flexural strength of glass ce- cement.119,144,145,150
ramics, definitive adhesive cementa- Nonadhesive cementation is more
Cementation and bonding tion with composite resin should be dependent upon macromechani-
used to increase the fracture resistance cal retention than adhesive cemen-
A variety of cementation and of the restoration.94,130,138,139 The com- tation.138 Finish lines placed below
bonding techniques have been applied pressive strength of composite resin the cemento-enamel junction result
to modern all-ceramic restorations. cements (320 MPa) is superior to that in a significant loss of adhesion, de-
Zinc phosphate, zinc polycarboxylate, of zinc phosphate (121 MPa), which spite following adhesive luting tech-
and conventional glass-ionomer ce- offers limited support.131,140 Fracture niques.151 Since cementum cannot be
ments set through an acid-base reac- or cement breakdown can result in infiltrated by resin to the extent that
November 2007 399
Table IV. Marginal and internal fit studies

In Vivo Mean In Vitro Mean In Vitro Internal
Material and Systems Marginal Gap (m) Marginal Gap (m) Gap (m)
IPS Empress 2/heat pressed 4474 75-10574
IPS Empress/heat pressed 65122 147-16785 20685
Optimal Pressable Ceramic/heat pressed 246-26585 27885
IPS ProCAD/CEREC 3 342123
VITABLOCS Mark II/CEREC 3 53-66124 380123

116-141124
VITABLOCS Mark II/CEREC 2 8554 62-121125 122126
VITABLOCS Mark II/CEREC 1 195122
VITABLOCS Mark II/Celay System 17127
In-Ceram Alumina/Slip-cast 57127
In-Ceram Alumina/Celay System 57127
Synthoceram/CICERO 7454
In-Ceram Zirconia/CEREC in Lab 77128 4374 82-11474
In-Ceram Zirconia/Digident (Digident 92128

GmbH, Pforzheim, Germany)
In-Ceram Zirconia/Slip-cast 2574 71-9474

6083
Procera/densely sintered 6854 1774 119-13674

90-118129 56-6376 36-7476
Lava 80128
DC-Zirkon/Precident System 3374 110-11674

60-7183
Denzir 2374 74-8174

22-4186 110-19286
136-14985 24385
Gold 30122
Ceramic alloy 67128
Conrad et al
acid-etched dentin can, microme- hydrofluoric acid for 2 minutes, dia- the relative translucency of several ce-
chanical retention at the gingival mar- mond abrasion combined with etch- ramic materials and found In-Ceram
gins may contribute little to the bond ing with 37% phosphoric acid for 2 Spinell (VITA Zahnfabrik) to have the
strength.152,153 Restorations that are minutes, and no treatment.155 highest amount of relative translu-
less dependent on predictable adhe- Surface treatments including a cency. This was followed by IPS Em-
sion should be considered when the tribochemical silica coating process press (Ivoclar Vivadent), Procera (No-
finish line is not placed in enamel.154 (Rocatec; 3M ESPE), airborne-par- bel Biocare AB), and IPS Empress 2
Different surface treatments have ticle abrasion with either 250-m or (Ivoclar Vivadent), which had higher
been evaluated to demonstrate the 50-m aluminum oxide, airborne- levels of translucency than In-Ceram
bond strength of composite resin ce- particle abrasion with 50-m alumi- Alumina (VITA Zahnfabrik), followed
ments to alumina-based ceramic res- num oxide combined with 38% hy- by In-Ceram Zirconia (VITA Zahn-
torations. Acid etchants used with drofluoric acid etching, or diamond fabrik), which was comparable to a
glass ceramics do not adequately abrasion with a rotary cutting instru- metal alloy. As a result of this study,
roughen the surface of glass-infil- ment, were reported to have only a In-Ceram Spinell, IPS Empress, and
trated and densely sintered alumi- minor influence on bond strength IPS Empress 2 were recommended
na-based ceramics.155 An effective to zirconia ceramic (Denzir; Decim for high to average translucency situ-
method to roughen glass-infiltrated AB).157 The tribochemical silica coat- ations. Procera was recommended for
alumina-based ceramic (In-Ceram ing process in combination with a average translucency situations, while
Alumina; Vita Zahnfabrik) is through resin cement was shown in 1 study158 In-Ceram Alumina and In-Ceram Zir-
a tribochemical silica coating process to have an initial bond to zirconia that conia are only recommended when
(Rocatec; 3M ESPE).137 This method failed spontaneously after simulated matching to opaque natural teeth or
involves cleaning the surface to be aging, while another study159 found in posterior and nonesthetic zones.69
coated with 110 m of high-purity that it did not improve the retentive The addition of MgAl2O4 to the
aluminum oxide (Rocatec Pre; 3M strength of composite resin cements. In-Ceram system has made In-Ceram
ESPE) at 250 KPa for 14 seconds, cre- Although not apparent immediately, Spinell, with its increased translu-
ating a uniform pattern of roughness. damage from airborne-particle abra- cency, an esthetic competitor. Unfor-
This is followed by a tribochemical sion (50-m aluminum oxide for 5 tunately, mechanical properties have
coating with 110 m (Rocatec Plus; seconds at 276 KPa) has been shown been compromised compared to the
3M ESPE) or a less abrasive 30 m to compromise the fatigue strength of original material, restricting its use
(Rocatec Soft; 3M ESPE) of silica- alumina- and zirconia-based ceramic to the anterior segment, exclusively.70
modified high purity aluminum oxide. materials.160,161 A variety of luting A subjective evaluation reported IPS
The aluminum oxide leaves the sur- agents have been shown to be capable Empress better able to match adja-
face partially coated with SiO2, which of retaining zirconium-oxide crowns cent teeth than In-Ceram Spinell or
is then conditioned with silane (3M (Lava; 3M ESPE) including composite metal-ceramic restorations.47
ESPE Sil; 3M ESPE) to create a bond resin (Panavia F 2.0; Kuraray, Tokyo, Monochromatic restorations ma-
with the composite resin.137 Volume Japan), compomer (Dyract Cem Plus; chined from ceramic blocks have been
loss through this tribochemical pro- Dentsply Intl), resin-modified glass scrutinized for their lack of individual
cess was found to be 36 times less for ionomer (RelyX Luting; 3M ESPE), characterization. Although custom-
a glass-infiltrated alumina (In-Ceram and self-adhesive composite resin ized characterizing of these restora-
Alumina; VITA Zahnfabrik) than for (RelyX Unicem; 3M ESPE).159,162 While tions was shown to compete estheti-
a feldspathic glass ceramic (IPS Em- mechanical properties of cements are cally with layering techniques163 and
press; Ivoclar Vivadent) and did not critical to support glass-ceramic res- multishade block systems,58 no long-
change its surface composition.137 torations,140 zirconia-based crowns term follow-up for color stability has
Pretreatment of a glass-infiltrated can be cemented conventionally due been done.
alumina (In-Ceram Alumina; VITA to their high fracture resistance.159 The ratio and thickness of ceramic
Zahnfabrik) with the tribochemical Zirconia-based restorations do not core and veneering materials influ-
process (Rocatec; 3M ESPE) resulted require an adhesive interface for re- ence the final shade of a layered por-
in a durable resin bond over 5 years.156 tention.8 celain restoration. An aluminum-ox-
Airborne-particle abrasion with 50- ide ceramic core thickness of 0.7 mm
m aluminum oxide for 15 seconds Color and esthetics was found to be sufficient to mask
was found to be the most effective for underlying dentin color.71 With a con-
producing higher bond strengths for Increased translucency correlated servative reduction of 1 mm, a semi-
a densely-sintered aluminum-oxide with improved esthetics is the primary translucent all-ceramic specimen will
coping (Procera; Nobel Biocare AB) advantage in using an all-ceramic res- match a shade tab more closely than a
when compared to etching with 9.6% toration. Heffernan et al10 evaluated metal-ceramic restoration. Increasing
November 2007 401
reduction will improve esthetic results their application when a high degree ability to select the appropriate ma-
for metal-ceramic and semiopaque of translucency is required. terial, manufacturing technique, and
all-ceramic restorations but will not Reported survival rates are vari- cementation or bonding procedures,
further enhance shade-matching for able and dependent upon the mate- to match intraoral conditions and es-
semitranslucent specimens (IPS Em- rial used, manufacturing technique, thetic requirements.
press; Ivoclar Vivadent; In-Ceram clinical application, and the authors
Alumina and In-Ceram Spinell; VITA definition of failure. Optimal thick- References
Zahnfabrik).164 Since IPS Empress res- ness of alumina and zirconia cores
torations were found to require up to and their respective veneering materi- 1. Land CH. Porcelain dental art: No.II. Dent
Cosmos 1903;45:615-20.
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fied alumina is indicated for posterior
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crowns, and anterior FPDPs. Zirconia All-ceramic restorations are de- 2005;36:105-13.
has superior mechanical properties as veloped with cores of glass ceramics, 15.Oden A, Andersson M, Krystek-Ondracek
a core material for posterior crowns aluminum oxide, or zirconium oxide, I, Magnusson D. Five-year clinical evalua-
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stronger ceramic core materials can Successful application of these mate- crowns followed for 5 to 10.5 years: a
prospective clinical study. Int J Prosthodont
be rather opaque and this may limit rials will depend upon the clinicians
Conrad et al
d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) 603623
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.intl.elsevierhealth.com/journals/dema
All-ceramic or metal-ceramic tooth-supported

xed dental prostheses (FDPs)? A systematic
review of the survival and complication rates.
Part I: Single crowns (SCs)
Irena Sailer a, , Nikolay Alexandrovich Makarov a , Daniel Stefan Thoma b ,

Marcel Zwahlen c , Bjarni Elvar Pjetursson d
a Division for Fixed Prosthodontics and Biomaterials, Center of Dental Medicine, University of Geneva, Geneva,
Switzerland
b Department of Fixed and Removable Prosthodontics and Dental Material Science, University of Zurich, Switzerland
c Department of Social and Preventive Medicine, University of Berne, Berne, Switzerland
d Department of Reconstructive Dentistry, Faculty of Odontology, University of Iceland, Reykjavik, Iceland
a r t i c l e i n f o a b s t r a c t
Article history: Objective. To assess the 5-year survival of metal-ceramic and all-ceramic tooth-supported
Received 8 July 2014 single crowns (SCs) and to describe the incidence of biological, technical and esthetic com-
Received in revised form plications.
24 February 2015 Methods. Medline (PubMed), Embase, Cochrane Central Register of Controlled Trials (CEN-
Accepted 25 February 2015 TRAL) searches (20062013) were performed for clinical studies focusing on tooth-supported
xed dental prostheses (FDPs) with a mean follow-up of at least 3 years. This was com-
plimented by an additional hand search and the inclusion of 34 studies from a previous
Keywords: systematic review [1,2]. Survival and complication rates were analyzed using robust Pois-
All-ceramic sons regression models to obtain summary estimates of 5-year proportions.
Single crowns Results. Sixty-seven studies reporting on 4663 metal-ceramic and 9434 all-ceramic SCs ful-
Systematic review lled the inclusion criteria. Seventeen studies reported on metal-ceramic crowns, and 54
Survival studies reported on all-ceramic crowns. Meta-analysis of the included studies indicated an
Success estimated survival rate of metal-ceramic SCs of 94.7% (95% CI: 94.196.9%) after 5 years.
Longitudinal This was similar to the estimated 5-year survival rate of leucit or lithium-disilicate rein-
Failures forced glass ceramic SCs (96.6%; 95% CI: 94.996.7%), of glass inltrated alumina SCs (94.6%;
Complication rates 95% CI: 92.796%) and densely sintered alumina and zirconia SCs (96%; 95% CI: 93.897.5%;
Technical complications 92.1%; 95% CI: 82.895.6%). In contrast, the 5-year survival rates of feldspathic/silica-based
Biological complications ceramic crowns were lower (p < 0.001). When the outcomes in anterior and posterior regions

This paper was originally intended for publication with the set of papers from the Academy of Dental Materials Annual Meeting, 811
October 2014, Bologna, Italy; published in DENTAL 31/1 (2015).

Corresponding author at: Division of Fixed Prosthodontics and Biomaterials, Center of Dental Medicine, University of Geneva, 19, Rue
Barthelemy-Menn, CH 1205 Geneva, Switzerland. Tel.: +41 22 379 4050.
E-mail address: Irena.sailer@unige.ch (I. Sailer).
http://dx.doi.org/10.1016/j.dental.2015.02.011
0109-5641/ 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
604 d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) 603623
were compared feldspathic/silica-based ceramic and zirconia crowns exhibited signicantly

lower survival rates in the posterior region (p < 0.0001), the other crown types performed
similarly. Densely sintered zirconia SCs were more frequently lost due to veneering ceramic
fractures than metal-ceramic SCs (p < 0.001), and had signicantly more loss of retention
(p < 0.001). In total higher 5 year rates of framework fracture were reported for the all-ceramic
SCs than for metal-ceramic SCs.
Conclusions. Survival rates of most types of all-ceramic SCs were similar to those reported for
metal-ceramic SCs, both in anterior and posterior regions. Weaker feldspathic/silica-based
ceramics should be limited to applications in the anterior region. Zirconia-based SCs should
not be considered as primary option due to their high incidence of technical problems.
2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 604
2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605
2.1. Search strategy and study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605
2.1.1. Focused questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605
2.2. Inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606
2.3. Exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606
2.4. Selection of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606
2.5. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606
2.6. Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
3.1. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
3.1.1. Included studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
3.1.2. Excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
3.1.3. Crown survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
3.1.4. Anterior vs. posterior regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
3.2. Technical and biological complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
3.2.1. Technical complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
3.2.2. Biological complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617
5. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
Conict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
Newly included further literature, as given in Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
List of excluded full-text articles and the reason for exclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
reconstructions to anterior regions and to single-unit FDPs

1. Introduction [1]. In the past years, numerous new dental ceramic materials
were developed with the aim to increase the overall stability
All-ceramic xed dental prostheses (FDPs) are considered an of the all-ceramic reconstructions, while still maintaining the
established treatment alternative to metal-ceramic FDPs in esthetic benet. Among those materials, leucite or lithium-
daily clinical practice. The main reason to use of the all- disilicate leucit or lithium-disilicate reinforced glass ceramics
ceramics instead of metal-ceramics is based on more favorable and oxide ceramics such as alumina and zirconia appeared to
esthetics [3]. All-ceramic materials mimic very naturally the be very promising for different indications. Reconstructions
optical properties of teeth. Another more recent factor inu- made of these more recently developed ceramics were placed
encing the choice of materials and leading to an increasing at posterior sites and even included multiple-unit FDPs [5].
use of all-ceramics is treatment costs, mostly due to the pro- Subsequently performed clinical studies conrmed the
nounced raise of the costs for high precious metals like gold assumption that these mechanically more stable ceramic
[4]. materials would perform better than the rstly developed
The main shortcoming of the rstly introduced ceramics ones when used for tooth-borne FDPs. The clinical out-
like, e.g. feldspathic glass ceramic, yet, was low mechan- comes of the more recent ceramics were far better than
ical stability, which limited the indications for all-ceramic the ones of the rst generation of dental ceramics [1,2].
d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) 603623 605
A systematic review of the literature demonstrated signi-

cantly higher survival rates of SCs, e.g. made out of leucit
2. Materials and methods
or lithium-disilicate reinforced glass ceramics compared to
SCs made out of feldspathic ceramics (95.4% vs. 87.5%).
2.1. Search strategy and study selection
Tooth-borne SCs made out of densely sintered alumina exhib-
The present review followed the same search methodology as
ited the highest survival rates (96.4%) compared to all other
the previous one [1].
all-ceramic SCs. Furthermore, all-ceramic crowns exhibited
similar survival rates as metal-ceramic crowns (93.3% vs.
95.6%) [1]. In conclusion, improvements in terms of mate-
rial properties such as mechanical stability of the ceramics 2.1.1. Focused questions
had a positive effect on the clinical outcomes of all-ceramic What are the survival and complication rates of tooth-
reconstructions. supported FDPs after a mean observation period of at least 3
The clinical follow-up of the studies on all-ceramic FDPs, years? Are the survival and complications rates of metal-
however, was rather short. At time of the above-mentioned ceramic and all-ceramic tooth-supported FDPs similar after
systematic review a limited amount of studies was available, a mean observation period of at least 3 years?
most of the published studies did not exceed 5 years of clinical
follow-up. In order to be able to draw clinical conclusions with
respect to the outcomes of all-ceramic reconstructions, more
clinical research with longer observation periods was needed. 2.1.1.1. PICO. The population, intervention, comparison and
In addition, the available clinical research indicated that outcomes, i.e. the PICO for this systematic review was
despite of all material improvements catastrophic fractures dened as follows:
remained to be one major issue of all-ceramic reconstructions. Population: Subjects with anterior and\or posterior tooth-
In addition, this problem was more often found in the poste- supported xed dental prostheses [FDP].
rior region, or for multiple-unit FDPs where high load occurred Intervention: All-ceramic FDPs
[1]. Comparison: Metal-ceramic FDPs
Hence, until recently, it was not possible to recommend all- Outcomes: Clinical survival rates, and technical and\or bio-
ceramic single or multiple-unit FDPs as clinically equivalent logical complication rates.
treatment alternative to metal ceramic FDPs. Metal-ceramics A literature search in databases PubMed, Embase, Cochrane
remained to be the gold standard type of reconstruction. Yet, Central Register of Controlled Trials (CENTRAL) search was
a high number of new manuscripts of all-ceramic and metal- performed. The search was limited to human studies in dental
ceramic single- and multiple-unit FDPs was published since journals written in English language. Articles published from
the previously mentioned systematic review. The more recent 1st of December 2006 up to and including the 31st of December
studies either reported on the all-ceramic or metal-ceramic 2013 were included. The following detailed search terms were
FDPs analyzed before but with longer observation periods, or used and the search strategy was as follows:
on new all-ceramic FDPs made out of improved ceramic mate- P and I: crowns[MeSH] OR crown[MeSH] OR dental
rials. crowns[MeSH] OR crowns, dental[MeSH] OR Denture, Partial,
Therefore, the aim of the present systematic review was to Fixed[Mesh])) OR (crown*[all elds] OR xed partial den-
analyze the outcomes of all-ceramic and metal-ceramic FDPs, ture*[all elds] OR FPD[all elds] OR FPDs[all elds] OR xed
i.e. of single crowns and of multiple-unit FDPs, and to assess dental prosthesis[all elds] OR xed dental prostheses[all
whether or not all-ceramic FDPs achieve similar long-term elds] OR FDP[all elds] OR FDPs[all elds] OR bridge*[all
results as FDPs made out of metal-ceramics. elds].
The objectives of this systematic review, therefore, were: C: Ceramic[MeSH] OR ceramics[MeSH] OR metal
ceramic restorations[MeSH])) OR (ceramic*[All Fields] OR
all-ceramic[all elds] OR Dental Porcelain[All Fields] OR
(1) To update the previous systematic review [1] on tooth- metal-ceramic[All Fields].
supported FDPs with an additional literature search O: Survival[Mesh] OR survival rate[Mesh] OR survival anal-
including retrospective and prospective studies from 2007 ysis[Mesh] OR dental restoration failure[Mesh] OR prosthesis
to 2013. failure[Mesh] OR treatment failure[Mesh].
(2) To obtain overall robust estimates of the long-term sur- The combination in the builder was set as P & I AND C
vival and complication rates of all-ceramic crowns over AND O.
an observation period of at least 3 years. The electronic search was complemented by manual
(3) To compare the survival and complication rates of all- searches of the bibliographies of all full text articles and
ceramic crowns with the ones of metal-ceramic crowns related reviews, selected from the electronic search. The
(gold standard). search was independently performed by two researches (IS
and NAM). Any disagreement was resolved in consensus
between the authors.
The present part 1 of the review presents the outcomes Up to the level of data extraction, the literature was evalu-
of all-ceramic versus metal-ceramic single crowns. Part 2 ated for both single crowns and multiple-unit FDPs at the same
of the review analyzed the outcomes of the multiple-unit time. At full text level the manuscripts were split according to
FDPs. the reconstruction type.
2.2. Inclusion criteria discoloration), reported number of patients free of complica-

tions. Based on the included studies, the FDP survival rate was
Besides the mentioned RCTs, this systematic review was based calculated. In addition, the number of events for all technical,
on prospective or retrospective cohort studies, or case series. biological and esthetic complications was extracted and the
The additional inclusion criteria for study selection were: corresponding total exposure time of the reconstruction was
calculated.
Studies with a minimum mean follow-up period of 3 years. Data was extracted independently by two reviewers (IS &
Included patients had been examined clinically at the NAM) using a data extraction form. Disagreement regarding
follow-up visits, i.e. publications based on patient records data extraction was resolved by consensus of three reviewers
only, on questionnaires or interviews were excluded. (IS, BEP & NAM).
Studies reported details on the characteristics of the recons-
tructions, on materials and methods and on the results.
2.6. Statistical analysis
Studies had to include and follow-up at least 10 patients.
Publications which combined ndings of tooth and implant
For the statistical analysis the new data of the present review,
supported reconstructions where at least 90% was tooth
encompassing the 33 studies was combined with the previous
supported reconstructions.
data of the 34 studies published in Pjetursson et al., 2007.
Hence, the data included in the present analysis was pub-
The nal selection based on inclusion/exclusion criteria
lished from 1990 until the end of 2013.
was made for the full text articles. For this purpose Sections
Survival was dened as the FDP remaining in situ with or
24 of these studies were screened. This step was again car-
without modication for the observation period.
ried out by two readers (IS, NAM) and double-checked. Any
Failure and complication rates were calculated by divid-
questions that came up during the screening were discussed
ing the number of events (failures or complications) in the
to aim for consensus.
numerator by the total FDP exposure time in the denominator.
The numerator could usually be extracted directly from the
2.3. Exclusion criteria
publication. The total exposure time was calculated by taking
the sum of:
The following study types were excluded:
in vitro or animal studies; (1) Exposure time of FDPs that could be followed for the whole
studies with less than 3 years of follow-up; and observation time.
studies based on chart reviews or interviews. (2) Exposure time up to a failure of the FDPs that were lost
due to failure during the observation time.
2.4. Selection of studies (3) Exposure time up to the end of observation time for
FDPs that did not complete the observation period due
Titles and abstracts of the searches were independently to reasons such as death, change of address, refusal
screened by two reviewers (IS & NAM) for possible inclusion in to participate, non-response, chronic illnesses, missed
the review. Furthermore, the full text of all studies of possible appointments and work commitments.
relevance was then obtained and split into literature on single
crowns (part 1 of the review) and literature on multiple-unit
FDPs (part 2 of the review). For each study, event rates for the FDPs were calculated by
The literature on single crowns was independently dividing the total number of events by the total FDP exposure
assessed by three of the reviewers (IS, BEP & NAM). Any dis- time in years. For further analysis, the total number of events
agreement regarding inclusion was resolved by discussion. was considered to be Poisson distributed for a given sum of
FDP exposure years and Poisson regression with a logarithmic
2.5. Data extraction link-function and total exposure time per study as an offset
variable were used [6].
Data on the following parameters were extracted: author(s), Robust standard errors were calculated to obtain 95% con-
year of publication, study design, planned number of patients, dence intervals of the summary estimates of the event
actual number of patients at end of study, drop-out rate, mean rates. To assess heterogeneity of the study specic event
age, age range, operators, material framework, brand name rates, the Spearman goodness-of-t statistics and associated
of framework material, veneering material, brand name of p-value were calculated. If the goodness-of-t p-value was
veneering material, type of manufacturing procedure, num- below 0.05 ve year survival proportions were calculated via
ber of FDPs, number of abutment teeth, number of (non)vital the relationship between event rate and survival function S,
abutment teeth, number of pontics, location of FDP (ante- S(T) = exp(T * event rate), by assuming constant event rates
rior, posterior, maxilla, mandible), reported mean follow-up, [7]. The 95% condence intervals for the survival proportions
follow-up range, published FDP survival rate, number of were calculated by using the 95% condence limits of the event
FDPs lost (anterior, posterior), reported biological complica- rates. Multivariable Poisson regression was used to formally
tions (caries, periodontal, root fracture), reported technical compare construction subtypes and to assess other study
complications (framework fracture, minor chipping, major characteristics. All analyses were performed using Stata , ver-
chipping, loss of retention), esthetic complications (marginal sion 13.1.
Table 1 Study and patient characteristics of the reviewed studies for all-ceramic crowns.
Study Year of Core Study No. of Age range Mean age Setting Drop-out (in
publication material design patients in percent)
study
Gehrt et al. 2013 Lithium disilicate Prospective 41 34 n.r. University 10%
glass ceramic
Monaco et al. 2013 Densely sintered Retrosp. 398 48.6 1884 Private practice 0%
zirconia
Passia et al. 2013 Densely sintered RCT 123 42.7 2473 University 37%
zirconia
Rinke et al. 2013 Densely sintered Prosp. 53 49.6 2970 Private practice 8%
zirconia
Sagitkaya et al. 2012 Densely sintered RCT 42 n.r. n.r. University 0%
zirconia
Sorrentino et al. 2012 Densely sintered Retrosp. 112 n.r. 1869 University 1%
alumina
Ortorp et al. 2012 Densely sintered Retrosp. 169 n.r. n.r. Private practice 32%
zirconia
Vigolo & Mutinelli 2012 Densely sintered Prosp. 20 32 1955 Private practice 3%
zirconia
Wolleb et al. 2012 Leucit reinforced Retrosp. 52 61.3 3484 University 14%
glass ceramic
Cortellini & Canale 2012 Lithium-disilicate Prospective 76 36 2061 Private practice 0%
glass ceramic
Beier et al. 2012 Feldspathic/silica- Retrosp. 302 46.5 n.r. University 0%
based
ceramic
Rinke et al. 2011 Glass-inltrated Retrosp. 80 n.r. n.r. Private practice 0%
alumina
Cehreli et al. 2011 Feldspathic/silica- RCT 33 n.r. n.r. University 0%
based ceramic
Glass-inltrated
alumina
Kokubo et al. 2011 Glass-inltrated Prospective 39 50.9 n.r. Private practice 13%
alumina
Beuer et al. 2010 Densely sintered Prospective 38 50.9 2771 University 0%
zirconia
Schmitt et al. 2010 Densely sintered Prosp. 10 42.1 n.r. University 10%
zirconia
Vanoorbeek et al. 2010 Densely sintered Prosp. 130 N.r. 1870 University 27%
alumina
Kokubo et al. 2009 Densely sintered Prospective 57 46.4 2070 University 19%
alumina
Valenti & Valenti 2009 Lithium disilicate Retrosp. 146 n.r. n.r. Private practice 1%
glass ceramic
Signore et al. 2009 Lithium disilicate Retrosp. 200 37.6 1966 University 4%
glass ceramic
607
608
Table 1 (Continued)
Study Year of Core Study No. of Age range Mean age Setting Drop-out (in
publication material design patients in percent)
study
Toksavul & Toman 2007 Lithium disilicate Prospective 21 38.3 1860 University 0%
glass ceramic
Burke 2007 Feldspathic/silica- Prospective 16 37.5 2251 University 17%
based
ceramic
Malament et al. 2006* Glass-inltrated Prospective n.r. n.r. n.r. Private practice n.r.
2001 alumina
Feldspathic/silica-
based ceramic
Leucit reinforced
glass ceramic
Galindo et al. 2006 Densely sintered Prospective 50 2275 n.r. University 22%
alumina
Naert et al. 2005 Densely sintered Prospective 165 1775 57 University 27%
alumina
Walter el al. 2005 Densely sintered Prospective 70 n.r. 38.8 University 6%
alumina
Marquardt & Strub 2006 Lithium disilicate Prospective 43 2265 39.9 University 0%
reinforced glass
ceramic
Bindl & Mrmann 2004 Glass-inltrated Prospective 29 3077 53 University 17%
alumina
Feldspathic/silica-
based
ceramic
Fradeani & Redemagni 2002 Leucit reinforced Retrospective 59 1868 41 Private practice 8%
glass ceramic
Bindl & Mrmann 2002 Glass-inltrated Prospective 21 n.r. n.r. University n.r.
alumina
Fradeani et al. 2002 Glass-inltrated Retrospective 13 n.r. 48 Private practice n.r.
alumina
van Dijken et al. 2001 Leucit reinforced Prospective 110 2681 53 University 0%
glass ceramic
Scherrer et al. 2001 Feldspathic/silica- Prospective 95 n.r. n.r. University 14%
based ceramic
Glass-inltrated
alumina
Segal 2001 Glass-inltrated Retrospective 253 n.r. n.r. Private practice n.r.
alumina
dmann et al. 2001 Densely sintered Prospective 50 1979 53 Private practice 18%
alumina
McLaren & White 2000 Glass-inltrated Prospective 107 n.r. n.r. Private practice 10%
alumina
Haselton et al. 2000 Glass-inltrated Retrospective 71 1877 47.3 University 42%
alumina
Edelhoff et al. 2000 Leucit reinforced Retrospective 110 n.r. n.r. University n.r.
glass ceramic
Erpenstein et al. 2000 Feldspathic/silica- Retrospective 88 n.r. 40.4 Private practice n.r.
based
ceramic
Sjgren et al. 1999 Feldspathic/silica- Retrospective 48 2469 50.2 Private practice 40%
based
ceramic
Sjgren et al. 1999 Leucit reinforced Retrospective 63 3479 54.7 Private practice 27%
glass ceramic
Oden et al. 1998 Densely sintered Prospective 58 n.r. n.r. University & Private practice 3%
alumina
Sorensen et al. 1998 Leucit reinforced Prospective 33 1769 n.r. University 0%
glass ceramic
Studer et al. 1998 Leucit reinforced Prospective 71 n.r. n.r. University 17%
glass ceramic
Prbster 1997 Glass-inltrated Prospective 22 n.r. 42 University & Private practice 11%
alumina
Scotti et al. 1995 Glass-inltrated Prospective 45 n.r. 44.2 University & Private practice 0%
alumina
Hls 1995 Glass-inltrated Prospective 92 2172 44.2 University 11%
alumina
Kelsey et al. 1995 Feldspathic/silica- Prospective n.r. n.r. >19 University 9%
based
ceramic
Bieniek 1992 Feldspathic/silica- Retrospective 60 2630 n.r. University 8%
based
ceramic
Cheung et al. 1991 Feldspathic/silica- Retrospective n.r. 1773 37.7 University 66%
based
ceramic
n.r. stands for not reported.
Update from 2006 based on personal communication with the senior author.
609
Drop-out (in
3. Results
percent)
19%
15%
5%
8%
14%
3%
5%
3%
8%
14%
51%
23%
7%
21%
30%
0%
35%
From this extensive new search, one randomized controlled
clinical trial (RCT) was available comparing all-ceramic single
crowns with conventional metal-ceramic crowns [8]. This RCT
compared zirconia-based SCs with metal-ceramic SCs [8]. No
further RCT comparing all-ceramic and metal-ceramic crowns
Private practice
Private practice
Private practice
Private practice
Private practice
Private practice
was available. However, one RCT compared crowns made of
University
University
University
University
University
University
University
University
University
University
University
Setting
feldspathic ceramic and glass-inltrated alumina [9]. Finally,
one RCT compared two types of metal-ceramic crowns [10].
Fig. 1 describes the process of identifying the 71 full text
articles selected from an initial yield of 580 titles that were
found published in the period from the 1st of December 2006
to the 31st of December 2013.
From these, 41 full text articles were allocated to the single
Mean age
crown group, whereas 37 were allocated to the group repor-
2164
1565
1481
2970
3484
3783
1955
2667
4391
2856
1882
ting on multiple-unit FDPs.
n.r.
n.r.
n.r.
n.r.
19
51
3.1. Study characteristics
3.1.1. Included studies
Age range
The nal number of the new studies included in the analyses
3369
resulted as 33 studies. Information on the survival proportions
49.6
61.3
60.1
52.5
49.4
59.6
n.r.
n.r.
n.r.
n.r.
n.r.
n.r.
41
32
44
41
of the single crowns was extracted from these included 33
studies. In addition, the data from 34 publications from the
previous systematic review [1] was included in the analyses.
Table 2 Study and patient characteristics of the reviewed studies for metal-ceramic crowns.
The details on the previously included studies as well as

No. of patients
the references are given in Pjetursson et al., 2007, and in

in study
Tables 1 and 2. The newly included 33 studies on all-ceramic

and/or metal-ceramic single crowns were published between
100
95
670
53
52
55
20
39
52
21
102
260
45
456
12
18
61
2006 and 2013 (Tables 1 and 2).
Out of these studies, four were designed as RCTs. How-
ever, only one RCT compared all-ceramic (zirconia-based) and
metal-ceramic crowns. All other RCTs compared either two
Prospective
Prospective
different types of all-ceramics or of metal-ceramics, or all-
design
Retrosp.
Retrosp.
Retrosp.
Retrosp.
Retrosp.
Retrosp.
Retrosp.
Study
Prosp.
Prosp.
Prosp.
Prosp.
Prosp.
Prosp.
ceramic and resin-based single crowns.
RCT
RCT
Furthermore, 14 new studies were reporting on

metal-ceramic crowns, four on crowns made out of
feldspathic/silica-based ceramics (jacket crowns, 3G OPC,
Noritake feldspathic, Dicor), six on reinforced glass-ceramic
crowns (one study on Empress 1 [11], the remaining on
material
Empress 2 or E.max), three on glass-inltrated alumina

Core
PFM
PFM
PFM
PFM
PFM
PFM
PFM
PFM
PFM
PFM
PFM
PFM
PFM
PFM
PFM
PFM
PFM
crowns (InCeram), three on densely sintered alumina crowns

(Procera) and, nally, eight on densely sintered zirconia
crowns (various CAD/CAM manufacturing procedures)
(Table 1).
The studies included patients between the age of 17 and 81.
PFM stands for porcelain fused to metal.
2013, 2005
publication
The proportion of patients who could not be followed for the

Year of
2013
2013
2013
2012
2012
2012
2011
2011
2009
2008
2007
2007
2007
2007
2003
1996
complete study period was available for 27 studies and ranged

from 0% to 66% (Tables 1 and 2).
n.r. stands for not reported.
3.1.2. Excluded studies

During the full-text evaluation of the total of 41 single crown
Napankangas et al.
Vigolo & Mutinelli
studies, eight were excluded. Two articles (Ortorp et al.,

Reitemeier et al.
Abou Tara et al.
De Backer et al.
Marklund et al.
Naumannet al.
Jokstad & Mjr

Boeckler et al.
Eliasson et al.
2009; Walton et al., 2009) were multiple publications on the

Brgger et al.
Gungor et al.
Wolleb et al.
Ortorp et al.
Passia et al.
Rinke et al.
same patient cohorts and were, therefore, excluded. Three

Walton
manuscripts (Mansour et al., 2008; Groten et al., 2010; Rinke

Study
et al., 2011) reported on observation periods of less than 3

years. One study (Cagidiaco et al., 2008) gave no detailed
First electronic search

580 Titles
Independently selected by 2 reviewers

71 titles
Agreed by both
71 titles
Abstracts obtained
Discussion
Agreed on 71 abstracts
Full text obtained
Total full text articles for the

Further hand searching multiple- unit fixed dental
0 studies
prosthesis review
37
Total full text articles for single crown review (number includes also studies reporting
on crowns and bridges at the same time)
41
Exclusion of 8 studies
Total full text articles
For details see reference list of excluded included from previous
literature single crowns review[1]
34
+
Final number of studies included
= Total of included
and included33
studies on single crowns studies in present review
67
Fig. 1 Search strategy and included studies on single crowns.
information on crown material and did not report on the 3.1.4. Anterior vs. posterior regions
details of the outcomes. In one study (Silva et al., 2011) the When the outcomes of anterior and posterior single crowns
reported data was not specied between implant and tooth were compared no statistically signicant differences of the
abutments, single crowns and bridges. The last study (Burke survival rates were found for metal-ceramic crowns, and for
et al., 2009) was based on a chart review and, therefore, was leucit or lithium-disilicate reinforced glass ceramic crowns,
excluded. alumina and zirconia based crowns (p > 0.05).
Crowns made out of feldspathic or silica based ceram-
3.1.3. Crown survival ics, however, exhibited signicantly lower survival rates in
Overall, in the 17 studies reporting on metal-ceramic crowns the posterior region than in the anterior (87.8% vs. 94.6%,
with a mean follow-up of 7.3 years an estimated annual failure p < 0.0001) (Table 5).
rate of 0.88 was reported, translated into an estimated 5-year
survival of metal-ceramic crowns of 95.7%. In comparison, all- 3.2. Technical and biological complications
ceramic crowns had an annual failure rate ranging between
0.69 and 1.96, translating into overall estimated 5-year sur- Tables 6 and 7 display an overview of the incidences, the
vival rates ranging between 90.7% and 96.6%. This was based estimated annual complication rates and the cumulative com-
on 55 studies on all-ceramic crowns included in the analysis plication rates of technical and biological complications for
(Table 3). metal-ceramic SCs and the different types of all-ceramic
The survival rates of all-ceramic crowns differed for the crowns, as well as the statistical differences between the
various types of ceramics. Ten studies reported on the rst crown types.
types of feldspathic/silica based ceramics and rendered an
estimated 5-year survival rate of 90.7%. This survival rate 3.2.1. Technical complications
was signicantly lower than the one reported for the gold- Framework fracture, ceramic fracture, ceramic chipping,
standard, metal-ceramic crowns (Tables 3 and 4). marginal discoloration, loss of retention and poor esthetics
The 12 studies reporting on leucit or lithium-disilicate rein- were technical problems reported for single crowns.
forced glass ceramics showed an estimated 5-year survival Ceramic chipping was a common problem, and overall
rate of 96.6%, which was similar to the survival rate of metal- occurred similarly for metal-ceramics and at the all-
ceramic crowns. The same applied for crowns made out of ceramic crowns. Furthermore, for metal-ceramic crowns,
glass-inltrated alumina (15 studies with an estimated 5- ceramic chipping was the most frequent technical compli-
year survival of 94.6%) and out of densely sintered alumina cation with a cumulative 5-year event rate of 2.6% (95%
(eight studies with an estimated 5-year survival of 96.0%) CI: 1.35.2%). For all-ceramic crowns a tendency to more
(Tables 3 and 4, Figs. 27). chippings of the veneering ceramic was observed for alu-
SCs made out of zirconia had a signicantly lower esti- mina and zirconia-based SCs than for all other ceramic
mated 5-year survival rate compared to metal-ceramic crowns crowns.
(p = 0.05). The zirconia-based crowns reached an estimated 5- Framework fracture rarely occurred for metal-ceramic
year survival rate of 91.2% (Tables 3 and 4, Fig. 7). crowns (cumulative 5-year complication rate 0.03%; 95% CI
612
Table 3 Annual failure rates and survival of single crowns.
Part 1
Study Year of Total no. of Mean No. of Total crown Estimated annual Estimated
publication crowns follow-up failure exposure failure rate (per 100 survival after 5
time time crown years) years (in percent)
Metal ceramic
Passia et al. 2013 100 4.3 9 434 2.07 90.2%
Reitemeier et al. 2013 190 9.6 10 1832 0.55 97.3%
Walton 2013 2211 9.2 83 13,505 0.61 97.0%
Rinke et al. 2013 50 3 1 146 0.68 96.6%
Wolleb et al. 2012 249 5.3 3 1310 0.23 98.9%
Ortorp et al. 2012 90 4.5 8 408 1.96 90.7%
Vigolo & Mutinelli 2012 20 4.8 0 95 0 100%
Abou Tara et al. 2011 60 3.9 1 235 0.43 97.9%
Naumann et al. 2011 52 3.4 6 176 3.41 84.3%
Boeckler et al. 2009 41 2.8 2 114 1.75 91.6%
Npnkangas & Raustia 2008 100 18.2 21 1820 1.15 94.4%
Gungor et al. 2007 260 7 7 1400 0.50 97.5%
Eliasson et al. 2007 12 4.3 0 51 0 100%
De Backer et al. 2007 1037 10 116 10,370 1.12 94.6%
Brgger et al. 2007 106 17 28 1598 1.75 91.6%
Marklund et al. 2003 42 5 3 190 1.58 92.4%
Jokstad & Mjr 1996 43 10 0 281 0 100%
Total 4663 7.3 298 33,965

Summary estimate (95% CI)* 0.88 (0.631.22) 95.7% (94.196.9%)
Feldspathic/silica-based ceramic
Beier et al. 2012 470 8.5 39 3995 0.98 95.2%
Burke 2007 59 3.9 3 187 1.60 92.3%
Malament & Socransky 2006 1061 7.9 177 8407 2.11 90.0%
Bindl & Mrmann 2004 18 3.4 1 67 1.49 92.8%
Scherrer et al. 2001 30 3.4 4 102 3.92 82.2%
Erpenstein et al. 2000 173 7 42 1210 3.47 84.1%
Sjgren et al. 1999 98 6.1 13 599 2.17 89.7%
Kelsey et al. 1995 101 4 16 388 4.12 81.4%
Bieniek 1992 164 3.6 8 641 1.25 94.0%
Cheung 1991 34 3.3 5 114 4.39 80.3%
Total 2208 7.1 308 15,710

Leucit/Lithium disilicate reinforced glass ceramics
Gehrt et al. 2013 104 6.6 4 623 0.64 96.8%
Cortellini & Canale 2012 22 3.5 1 78 1.28 93.8%
Valenti & Valenti 2009 263 4.9 6 1283 0.47 97.7%
Signore et al. 2009 538 5.3 8 2851 0.28 98.6%
Toksavul & Toman 2007 79 3.5 1 273 0.37 98.2%
Marquardt & Strub 2006 27 3.2 0 105 0 100%
Fradeani & Redemagni 2002 125 7.3 6 908 0.66 96.8%
Edelhoff et al. 2000 250 4.2 5 1048 0.48 97.6%
Sjgren et al. 1999 110 3.6 6 396 1.52 92.7%
Sorensen et al. 1998 75 3 1 224 0.45 97.8%
Studer et al. 1998 142 5 14 710 1.97 90.6%
Total 2689 4.5 85 12,231

Glass-inltrated alumina
Cehreli et al. 2011 50 3.3 3 165 1.82 91.3%
Rinke et al. 2011 272 13.5 43 3672 1.17 94.3%
Cehreli et al. B 2011 51 3.4 2 172 1.16 94.4%
Kokubo et al. 2011 101 4.6 7 464 1.51 92.7%
Bindl & Mrmann 2004 18 3.4 1 67 1.49 92.8%
Bindl & Mrmann 2002 43 3.2 3 142 2.11 90.0%
Fradeani et al. 2002 40 4.2 1 167 0.60 97.1%
Segal 2001 546 3 5 1519 0.33 98.4%
Scherrer et al. 2001 120 3 12 344 3.49 84.0%
McLaren & White 2000 223 3.6 9 811 1.11 94.6%
Haselton et al. 2000 80 3 2 240 0.83 95.9%
Prbster 1997 135 3.3 4 446 0.90 95.6%
Scotti et al. 1995 63 3.1 1 195 0.51 97.5%
Hls 1995 335 3 3 1005 0.30 98.5%
Total 2389 4.9 130 11,644

613
614
Table 3 (Continued)
Part 2
Study Year of Total no. of Mean No. of Total crown Estimated annual Estimated
publication crowns follow-up failure exposure failure rate (in survival after 5
time time percent) years (in percent)
Densely sintered alumina
Vanoorbeek et al. 2010 141 2.7 3 377 0.80 96.1%
Sorrentino et al. 2012 128 5.9 3 760 0.39 98.0%
Kokubo et al. 2009 101 4.4 9 441 2.04 90.3%
Galindo et al. 2006 135 4.6 5 619 0.81 96.0%
Naert et al. 2005 300 3 2 886 0.23 98.9%
Walter el al. 2005 107 6 6 597 1.01 95.1%
dmann & Andersson 2001 87 7.6 5 662 0.76 96.3%
Oden et al. 1998 100 5 6 487 1.23 94.0%
Total 1099 4.4 39 4829

Densely sintered zirconia

Monaco et al. 2013 472 3.6 16 1708 0.94 95.4%
Passia et al. 2013 123 3.9 28 483 5.80 74.8%
Rinke et al. 2013 55 3 2 158 1.27 93.9%
Sagitkaya et al. 2012 74 3.9 4 286 1.40 93.2%
rtorp et al. 2012 216 4.1 19 890 2.13 89.9%
Vigolo & Mutinelli 2012 20 4.4 2 89 2.25 89.4%
Vigolo & Mutinelli 2012 20 4.8 1 96 1.04 94.9%
Beuer et al. 2010 50 2.9 0 146 0 100%
Schmitt et al. 2010 19 3.3 0 62 0 100%
Total 1049 3.7 72 3918

Total 14,156 5.8 938 82,462
Based on robust Poisson regression.

Fig. 2 Annual failure rate of metal ceramic SCs.
0.002 0.3%) (Table 7). Overall, this problem occurred signif- fractures occurred at a rate of 2.3% (95% CI 1.05.5%) of the
icantly more often for ceramic crowns, irrespective of the crowns and for zirconia-based single crowns at a rate of 0.4%
type of ceramic used (p < .0001, p = .03) (Table 6). The incidence only (95% CI 0.11.7%).
of framework fracture was associated with the mechani- With the exception of zirconia-based crowns, loss of reten-
cal stability of the ceramic material. Weaker ceramics like tion was not a predominant technical problem. Zirconia based
early feldspathic/silica based ceramics exhibited a high 5-year crowns exhibited signicantly more loss of retention than
framework fracture rate of 6.7% (95% CI 2.417.7%). For leucit metal ceramic crowns (estimated 5-year complication rate
or lithium-disilicate reinforced glass ceramics framework 4.7%; 95% CI 1.713.1%) (p < .0001) (Tables 6 and 7).
Fig. 3 Annual failure rate of glass ceramic SCs.

Fig. 4 Annual failure rate of leucit or lithium-disilicate reinforced glass ceramic SCs.
3.2.2. Biological complications glass ceramic and glass-inltrated alumina crowns (p = .006,
Loss of abutment tooth vitality, abutment tooth fracture and p < .0001).
secondary caries were the predominantly reported as biologic In addition, abutment tooth fracture was also predomi-
complications for SCs. nantly found for metal-ceramic crowns (5-year complication
For metal-ceramic crowns loss of abutment tooth vitality rate 1.2%; 95% CI 0.72.0%). This complication occurred signif-
was the most frequent biologic complication (5-year com- icantly less frequently for all-ceramics like leucit or lithium
plication rate 1.8%; 95% CI 1.61.8%). This problem less disilicate reinforced glass ceramics, glass inltrated alumina
frequently occurred for leucit or lithium-disilicate reinforced or at zirconia-ceramics (p = .009, p = .04, p = .02).
Fig. 5 Annual failure rate of glass inltrated alumina SCs.

Fig. 6 Annual failure rate of densely inltrated alumina ceramic SCs.
Finally, secondary caries was reported for 1% of metal-

ceramic crowns (95% CI 0.81.4%) after 5 years in function.
4. Discussion
Most all-ceramic crowns exhibited similar 5-year caries
The present systematic review showed that the 5-year survival
rates as metal-ceramic SCs. However, zirconia based crowns
rates of all-ceramic crowns made out of leucit or lithium-
had signicantly less secondary caries, and glass-inltrated
disilicate reinforced glass ceramics or the oxide ceramics
ceramic crowns had higher caries rates (p = .04, p < .0001)
alumina and zirconia exhibited similar survival rates as the
(Tables 6 and 7).
gold standard, metal ceramic crowns. This was not the case,
Fig. 7 Annual failure rate of densely sintered zirconia ceramic SCs.

618
Table 4 Summary of annual failure rates, relative failure rates and survival estimates for single crowns.
Type of SCs Total number of Total crown Mean crown Estimated annual 5 year survival Relative failure p-Value**
reconstructions exposure time follow-up time failure rate* summary rate**
estimate* (95% CI)
Metal-ceramic 4663 33,965 7.3 0.88 (0.631.22) 95.7% (94.196.9%) 1.00 (Ref.)
Feldspathic/silica-based 2208 15,710 7.1 1.96 (1.442.67) 90.7% (87.593.1%) 2.23 (1.453.45) p < 0.001
ceramic
Leucit or lithium-disilicate 2689 12,231 4.5 0.69 (0.461.05) 96.6% (94.997.7%) 0.79 (0.471.32) p = 0.373
reinforced glass ceramic
Glass-inltrated ceramic 2389 11,644 4.9 1.12 (0.831.51) 94.6% (92.796.0%) 1.27 (0.821.96) p = 0.276
Densely sintered alumina 1099 4829 4.3 0.81 (0.511.27) 96.0% (93.897.5%) 0.92 (0.541.57) p = 0.761
Densely sintered zirconia 1049 3918 3.7 1.84 (0.893.77) 91.2% (82.895.6%) 2.09 (0.994.45) p = 0.055
Composite crowns 59 165 2.8 3.64 (1.357.75) 83.4% (67.993.5%) 4.14 (3.015.70) p < 0.001

Based on multivariable robust Poisson regression including all types of crowns.
Table 5 Annual failure rates and survival estimates of crowns placed anterior and posterior.
Type of crowns Total Estimated 5 year survival Total Estimated 5 year survival p-Value**
number of annual summary number of annual summary
crowns failure rate* estimate* (95% CI) crowns failure rate* estimate* (95% CI)
Anterior Posterior
Overall results 4517 0.77 (0.620.98) 96.2% (95.297.0%) 4948 1.59 (0.992.57) 92.3% (87.995.2%)
Metal-ceramic 1215 0.69* (0.680.71) 96.6%* (96.596.7%) 1263 0.61 (0.410.93) 97.0% (95.598.0%) p = 0.564
Feldspathic/silica-based ceramic 1432 1.10 (0.741.63) 94.6% (92.296.4%) 1847 2.61 (2.103.24) 87.8% (85.190.0%) p < 0.0001
Reinforced glass ceramic 1019 0.50 (0.241.04) 97.5% (94.998.8%) 430 1.20 (0.552.61) 94.2% (87.897.3%) p = 0.098
Glass-inltrated ceramic 526 0.74 (0.580.94) 96.4% (95.497.2%) 672 1.22 (0.622.39) 94.1% (88.797.0%) p = 0.050
Densely sintered alumina 133 0.67 (0.421.07) 96.7% (94.897.9%) 296 1.05 (0.691.61) 94.9% (92.396.6%) p = 0.135
Densely sintered zirconia 192 0.29 (0.190.47) 98.5% (97.799.1%) 440 1.02 (0.681.54) 95.0% (92.696.7%) p < 0.0001

Based on multivariable robust Poisson regression.

Table 6 Summary of annual complication rates, overall complication estimates and relative complication rates and or single crowns.
Number Estimated Cumulative Relative p-Value** Relative p-Value** Relative p-Value** Relative p-Value** Relative p-Value**
of abut- annual 5 year compl. compl. compl. compl. compl.
ments or complica- complica- rate** rate** rate** rate** rate**
SCs tion rates* tion rates*
(95% CI) (95% CI)
Metal Feldspathic/ Reinforced Glass Densely Densely
ceramic silica-based glass ceramic inltrated sintered sintered
ceramic alumina alumina zirconia
Caries on 7730 0.20* 1.0%* 1.00 0.61 p = 0.094 0.52 p = 0.243 2.05 p < 0.0001 1.33 p = 0.600 0.45 p = 0.045
abut- (0.150.28) (0.71.4%) (Ref.) (0.351.09) (0.181.55) (1.393.04) (0.463.85) (0.200.98)
ments
SCs lost due 11,068 0.08* 0.4%* 1.00 0.62 p = 0.534 0.10 p = 0.049 0.53 p = 0.477 0.38 p = 0.256 0.27 p = 0.217
to caries (0.030.19) (0.20.9%) (Ref.) (0.142.77) (0.010.99) (0.093.08) (0.072.01) (0.032.17)
SCs lost due 11,153 0.18* 0.9%* 1.00 0.33 p = 0.001 0.20 p = 0.009 0.56 p = 0.277 0.43 p = 0.223 0.12 p = 0.024
to (0.110.28) (0.61.4%) (Ref.) (0.180.62) (0.060.67) (0.191.61) (0.111.68) (0.020.75)
abutment
tooth
fracture
Loss of 2494 0.35* 1.8%* 1.00 2.22 p = 0.149 0.41 p = 0.006 0 p < 0.0001 n.a n.a n.a n.a
abutment (0.290.43) (1.42.1%) (Ref.) (0.756.55) (0.210.77)
tooth
vitality
Framework 10,075 0.40* 2.0%* 1.00 274.95 p < 0.0001 92.38 p < 0.0001 82.95 p < 0.0001 93.79 p < 0.0001 17.20 p = 0.033
fracture (0.200.82) (1.04.0%) (Ref.) (23.18 (8.241035.29) (7.96864.29) (9.46929.73) (1.26234.31)
3261.79)
SCs lost due 9144 0.13* 0.7%* 1.00 1.27 p = 0.699 4.06 p < 0.0001 2.71 p = 0.025 4.00 p = 0.003 11.36 p < 0.0001
to (0.070.24) (0.41.2%) (Ref.) (0.374.32) (1.998.28) (1.136.49) (1.5910.07) (6.0921.18)
ceramic
fractures
Ceramic 5499 0.43* 2.1%* 1.00 0.46 p = 0.349 0.56 p = 0.154 0.69 p = 0.316 1.34 p = 0.512 1.19 p = 0.650
chipping (0.290.62) (1.53.1%) (Ref.) (0.092.33) (0.251.24) (0.331.43) (0.563.17) (0.562.54)
Loss of 7594 0.19* 1.0%* 1.00 0.94 p = 0.954 1.64 p = 0.315 1.06 p = 0.861 3.61 p = 0.067 7.85 p < 0.0001
retention (0.110.34) (0.51.7%) (Ref.) (0.127.25) (0.624.33) (0.532.13) (0.9214.27) (2.6723.04)
Esthetic 5671 0.15* 0.7%* 1.00 0.85 p = 0.811 0 p < 0.0001 0.88 p = 0.847 6.73 p < 0.0001 0 p < 0.0001
failures (0.080.30) (0.41.5%) (Ref.) (0.233.18) (0.233.29) (2.4718.35)
Based on multivariable robust Poisson regression including all types of crowns.
619
620
Table 7 Overview of biological and technical complications of different types of SCs.
Complication Number Estimated Cumulative Number Estimated Cumulative Number Estimated Cumulative Number Estimated Cumulative Number Estimated Cumulative Number Estimated Cumulative
of abut- annual 5 year of abut- annual 5 year of abut- annual 5 year of abut- annual 5 year of abut- annual 5 year of abut- annual 5 year
ments or compli- compli- ments or compli- compli- ments or compli- compli- ments or compli- compli- ments or compli- compli- ments or compli- compli-
SCs cation cation SCs cation cation SCs cation cation SCs cation cation SCs cation cation SCs cation cation
rates* rates* rates* rates* rates* rates* rates* rates* rates* rates* rates* rates*
(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)
Metal ceramic SCs Feldspathic/silica-based ceramic SCs Leucit or lithium-disilicate reinforced Glass inltrated ceramic SCs Densely sintered alumina SCs Densely sintered zirconia SCs
glass ceramic SCs
Caries on 2908 0.21 1.0% 890 0.13 0.6% 1685 0.11 0.5% 729 0.43 2.1% 592 0.28 1.4% 876 0.09 0.5%
abutments (0.150.29) (0.81.4%) (0.080.22) (0.41.1%) (0.040.33) (0.21.6%) (0.330.56) (1.62.8%) (0.090.86) (0.54.2%) (0.040.2) (0.21.0%)
SCs lost due to 4303 0.11 0.5% 1261 0.07 0.3% 1797 0.01 0.06% 1623 0.06 0.3% 1099 0.04 0.2% 926 0.03 0.1%
caries (0.030.34) (0.21.7%) (0.020.20) (0.11.0%) (0.0010.09) (0.0070.4%) (0.010.24) (0.071.2%) (0.010.15) (0.0060.08%) (0.0040.19) (0.0021.0%)
SCs lost due to 5276 0.24 1.2% 1088 0.08 0.4% 1628 0.05 0.2% 1077 0.14 0.7% 1099 0.10 0.5% 926 0.03 0.1%
abutment (0.1590.40) (0.72.0%) (0.050.12) (0.30.6%) (0.020.15) (0.10.8%) (0.050.36) (0.31.8%) (0.030.41) (0.12.0%) (0.0040.19) (0.021.0%)
tooth fracture
Loss of 1684 0.34 1.7% 375 0.76 3.7% 395 0.14 0.7% 40 0 0% n.a. n.a. n.a. n.a. n.a. n.a.
abutment (0.320.36) (1.61.8%) (0.212.71) (1.012.7%) (0.070.28) (0.31.4%)
tooth vitality
Marginal 345 0.36 1.8% 160 0.87 4.3% 975 0.46 2.3% 322 1.74 8.3% 370 0 0% 670 0. 0%
discoloration (0.140.90) (0.74.4%) (0.243.11) (1.214.4%) (0.121.75) (0.68.4%) (0.456.65) (2.228.3%)
Framework 3075 0.005 0.03% 1261 1.40 6.7% 1952 0.47 2.3% 1703 0.42 2.1% 1099 0.48 2.4% 926 0.09 0.4%
fracture (0.00050.05) (0.0020.3%) (0.484.06) (2.418.4%) (0.191.14) (1.05.5%) (0.220.80) (1.13.9%) (0.310.73) (1.53.6%) (0.020.35) (0.11.7%)
SCs lost due to 4457 0.06 0.3% 529 0.07 0.4% 1155 0.23 1.1% 1441 0.15 0.8% 577 0.23 1.1% 926 0.64 3.2%
ceramic (0.030.11) (0.10.6%) (0.0023.03) (0.0114.1%) (0.150.36) (0.71.8%) (0.100.24) (0.51.2%) (0.090.55) (0.52.7%) (0.470.88) (2.34.3%)
fractures
Ceramic 1146 0.53 2.6% 953 0.25 1.2% 1408 0.30 1.5% 594 0.37 1.8% 999 0.71 3.5% 340 0.64 3.1%
chipping (0.271.10) (1.35.2%) (0.051.26) (0.26.0%) (0.190.48) (0.92.4%) (0.270.50) (1.32.5%) (0.401.29) (2.06.2%) (0.421.0) (2.14.7%)
Loss of 2971 0.12 0.6% 823 0.12 0.6% 1583 0.20 1.0% 987 0.13 0.7% 757 0.45 2.2% 414 0.97 4.7%
retention (0.070.21) (0.41.0%) (0.011.04) (0.075.1%) (0.080.49) (0.42.4%) (0.080.22) (0.41.1%) (0.111.85) (0.58.8%) (0.342.81) (1.713.1%)
Esthetic failures 2806 0.11 0.5% 563 0.09 0.5% 1006 0 0% 282 0.10 0.5% 757 0.74 3.6% 196 0 0%
(0.080.15) (0.40.8%) (0.020.43) (0.12.1%) (0.020.41) (0.12.0%) (0.262.09) (1.39.9%)
n.a. stands for not available.

however, for feldspathic/silica based ceramic SCs. Crowns that despite all developments and efforts for the improve-
made out of these rather weak ceramics exhibited signicantly ment of the veneering procedures of zirconia frameworks, the
higher failure rates compared to metal-ceramic crowns. problem of chipping of the zirconia veneering ceramic has not
The same observation was made when the outcomes of been eliminated yet [19,20]. Consequently, zirconia-based sin-
the crowns in anterior and posterior regions were compared. gle crowns should not be considered as the primary treatment
Metal-ceramic crowns and all-ceramic crowns out of leucit or option for now, and patients need to be thoroughly informed
lithium-disilicate reinforced glass ceramics or oxide ceram- about current limitations.
ics performed similarly in anterior and posterior regions. Another factor inuencing the choice of the material for
However, weaker feldspathic/silica-based ceramics and glass- single crowns in daily clinical practice is the biologic outcome
inltrated alumina exhibited signicantly lower survival rates of the reconstructions. The present review indicated, that the
in the posterior region than in the anterior. biological outcomes of all-ceramic crowns were signicantly
Technically, catastrophic framework fracture was the main better than the ones of metal-ceramics. Less invasive abut-
complication of the all-ceramics, this problem was most ment tooth preparation for the highly esthetic all-ceramic
specically found when weaker ceramic materials were used FDPs may be assumed as reason for the observed differences
[12]. With respect to the non-catastrophic technical complica- [21,22].
tions, chipping of the veneering ceramic was a main clinical Considering the current trend toward less invasive den-
issue both found at the metal-ceramic as well as at the all- tal rehabilitation, the biological differences between materials
ceramic crowns [13]. Another technical problem observed was may be considered as one of the key decisive factors for the
loss of retention, which was most frequently reported for choice of ceramics as reconstructive material for single crowns
zirconia-based single crowns [14]. today [21,22]. Future research should focus on this topic and
Biologically, all-ceramic single crowns seemed to perform also further elucidate the reasons for the biologic differences
better than the gold standard, metal-ceramic crowns. Signif- between all-ceramic and metal-ceramic reconstructions.
icantly more loss of abutment tooth vitality and abutment
tooth fracture was reported for metal-ceramic crowns. These
biologic complications might impair the prognosis of the 5. Conclusion
abutment tooth or even lead to its loss and a loss of the recon-
struction. In comparison, these complications were rarely All-ceramic single crowns exhibit similar survival rates as
reported for the all-ceramic crowns. metal-ceramic single crowns after a mean observation period
At the time the previous systematic review was published of at least 3 years. However, this is solely true for SCs are
by the same authors in 2007, limited scientic data was avail- made out of leucit or lithium-disilicate reinforced glass ceram-
able in the literature on a number of materials. Still, the ics or oxide ceramics. Those materials perform similarly well
review already indicated favorable outcomes of all-ceramic in anterior and posterior regions. Crowns made out of densely
single crowns made out of more recently developed reinforced sintered zirconia, however, cannot be recommended as pri-
ceramics and oxide ceramics [1]. The review, furthermore, dis- mary treatment option, due to an increased risk of chipping of
played limitations of mechanically weaker all ceramic crowns. the veneering ceramic and loss of retention. These limitations
The gold standard metal-ceramics, interestingly, was not well must rst be overcome by further renements of the produc-
documented [1]. tion technology. Finally, the mechanically weaker ceramics
In the present review, 14 new studies on metal-ceramics like the feldspathic or silica glass-ceramics can only be rec-
were available as well as a high number of new studies eval- ommended in anterior regions with low functional load.
uating all-ceramic crowns. The results of the present review,
hence, may be considered more robust with more impact for
the daily clinical practice. Conict of interest
In the present review it was shown that all-ceramic crowns
made of leucit or lithium-disilicate reinforced glass ceram- The authors do report to have no conict of interest.
ics or alumina based oxide ceramics can be recommended as
an alternative treatment option to the gold standard metal-
ceramics for SCs in anterior and posterior regions. The less Newly included further literature, as given in
stable feldspathic/silica glass ceramics can only be recom- Tables
mended in the anterior region.
The review also indicated that zirconia based single crowns [1] Pjetursson BE, Sailer I, Zwahlen M, Hammerle CH. A
performed less well in the clinics, despite the enhanced systematic review of the survival and complication rates
mechanical stability of this oxide ceramic. Failure due to of all-ceramic and metal-ceramic reconstructions after an
extensive fracture of the veneering ceramic and loss of reten- observation period of at least 3 years. Part I: Single crowns.
tion were frequently found technical problems for this type Clinical oral implants research, 2007;18 Suppl. 3:7385.
of ceramic crowns, occurring more often than at the other [2] Sailer I, Pjetursson BE, Zwahlen M, Hammerle CH. A
types of all-ceramics. Chipping of the veneering ceramic and systematic review of the survival and complication rates
loss of retention were technical complications also reported of all-ceramic and metal-ceramic reconstructions after an
for multiple-unit zirconia based FDPs [1517], occurring sig- observation period of at least 3 years. Part II: Fixed dental
nicantly more often at the zirconia-based FDPs than at prostheses. Clinical oral implants research. 2007;18 Suppl
metal-ceramics [18]. The more recent clinical studies showed 3:8696.
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clinical follow-up study of zirconia single crowns performed the introduction of osseointegrated implant dentistry into a
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[14] Rinke S, Schafer S, Lange K, Gersdorff N, Roediger tics. 22(3):2607.
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[9] Cehreli MC, Kokat AM, Ozpay C, Karasoy D, Akca K. A
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follow-up. Int J Prosthodont 2011;24:7784.
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2014;27:1148. Ferrini F. A 3 years retrospective study of survival for
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Mohamed SE, Billiot S, et al. The efcacy of posterior digital impressions. J Dent 2014;49(9):11515.
three-unit zirconium-oxide-based ceramic xed partial [16] Koenig V, Vanheusden AJ, Le Goff SO, Mainjot AK. Clinical
dental prostheses: a prospective clinical pilot study. J risk factors related to failures with zirconia-based
Prosthet Dent 2006;96:23744. restorations: an up to 9-year retrospective study. J Dent
[6] Kirkwood BR, Sterne JAC. Medical statistics. Chapter 24: 2013;41:116474.
poisson regression. Oxford: Blackwell Science Ltd; 2003. [17] Edelhoff D, Sorensen JA. Tooth structure removal associated
[7] Kirkwood BR, Sterne JAC. Essential medical statistics. with various preparation designs for anterior teeth. J
Chapter 26: survival analysis: displaying and comparing Prosthet Dent 2002;87:5039.
survival patterns. Oxford: Blackwell Science Ltd; 2003. [18] Edelhoff D, Sorensen JA. Tooth structure removal associated
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Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.intl.elsevierhealth.com/journals/dema
Review
All-ceramic or metal-ceramic tooth-supported

xed dental prostheses (FDPs)? A systematic
review of the survival and complication rates.
Part II: Multiple-unit FDPs
Bjarni Elvar Pjetursson a, , Irena Sailer b , Nikolay Alexandrovich Makarov b ,

Marcel Zwahlen c , Daniel Stefan Thoma d
a Division of Reconstructive Dentistry, Faculty of Odontology, University of Iceland, Reykjavk, Iceland
b Division of Fixed Prosthodontics and Biomaterials, Clinic of Dental Medicine, University of Geneva, Switzerland
c Institute of Social and Preventive Medicine, University of Berne, Berne, Switzerland
d Clinic of Fixed and Removable Prosthodontics and Dental Material Science, University of Zurich, Zurich,
Switzerland
a r t i c l e i n f o a b s t r a c t
Article history: Objective. To assess the 5-year survival of metal-ceramic and all-ceramic tooth-supported
Received 7 July 2014 xed dental prostheses (FDPs) and to describe the incidence of biological, technical and
Received in revised form esthetic complications.
24 February 2015 Methods. Medline (PubMed), Embase and Cochrane Central Register of Controlled Trials (CEN-
Accepted 27 February 2015 TRAL) searches (20062013) were performed for clinical studies focusing on tooth-supported
FDPs with a mean follow-up of at least 3 years. This was complemented by an additional
hand search and the inclusion of 10 studies from a previous systematic review [1]. Survival
Keywords: and complication rates were analyzed using robust Poissons regression models to obtain
All-ceramic summary estimates of 5-year proportions.
Metal-ceramic Results. Forty studies reporting on 1796 metal-ceramic and 1110 all-ceramic FDPs fullled the
Fixed partial dentures inclusion criteria. Meta-analysis of the included studies indicated an estimated 5-year sur-
Systematic review vival rate of metal-ceramic FDPs of 94.4% (95% CI: 91.296.5%). The estimated survival rate
Survival of reinforced glass ceramic FDPs was 89.1% (95% CI: 80.494.0%), the survival rate of glass-
Success inltrated alumina FDPs was 86.2% (95% CI: 69.394.2%) and the survival rate of densely
Longitudinal sintered zirconia FDPs was 90.4% (95% CI: 84.894.0%) in 5 years of function. Even though
Failures the survival rate of all-ceramic FDPs was lower than for metal-ceramic FDPs, the differences
Technical complications did not reach statistical signicance except for the glass-inltrated alumina FDPs (p = 0.05). A
Biological complications signicantly higher incidence of caries in abutment teeth was observed for densely sintered
zirconia FDPs compared to metal-ceramic FDPs. Signicantly more framework fractures
were reported for reinforced glass ceramic FDPs (8.0%) and glass-inltrated alumina FDPs

This paper was originally intended for publication with the set of papers from the Academy of Dental Materials Annual Meeting, 811
October 2014, Bologna, Italy; published in DENTAL 31/1 (2015).

Corresponding author at: Department of Reconstructive Dentistry, Faculty of Odontology, University of Iceland, Vatnsmyrarvegi 16, 101
Reykjavik, Iceland. Tel.: +354 525 4871.
E-mail address: bep@hi.is (B.E. Pjetursson).
http://dx.doi.org/10.1016/j.dental.2015.02.013
0109-5641/ 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
(12.9%) compared to metal-ceramic FDPs (0.6%) and densely sintered zirconia FDPs (1.9%)
in 5 years in function. However, the incidence of ceramic fractures and loss of retention
was signicantly (p = 0.018 and 0.028 respectively) higher for densely sintered zirconia FDPs
compared to all other types of FDPs.
Conclusions. Survival rates of all types of all-ceramic FDPs were lower than those reported for
metal-ceramic FDPs. The incidence of framework fractures was signicantly higher for rein-
forced glass ceramic FDPs and inltrated glass ceramic FDPs, and the incidence for ceramic
fractures and loss of retention was signicantly higher for densely sintered zirconia FDPs
compared to metal-ceramic FDPs.
2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625
2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
2.1. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
2.2. Focused questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
2.3. PICO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
2.4. Search terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
2.5. Inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
2.6. Exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
2.7. Selection of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
2.8. Data extraction and method of analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
2.9. Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629
3.1. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629
3.2. FDP survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630
3.3. Biological complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633
3.3.1. Secondary caries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633
3.3.2. Loss of vitality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635
3.3.3. Abutment tooth fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635
3.3.4. Periodontal disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635
3.4. Technical complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635
3.4.1. Material complications: framework fracture, ceramic chipping or ceramic fracture . . . . . . . . . . . . . . . . . . . . . 635
3.4.2. Loss of retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636
3.4.3. Marginal discoloration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636
5. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638
Conict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638
Excluded studies and reasons for exclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638
1. Introduction complication rates for both types of reconstructions. Whereas

for implant-supported reconstructions, systematic reviews
Socio-economic factors, better prophylaxis and oral hygiene provide very recent evidence comparing metal- and all-
regimens with patients included in regular recall programs ceramic reconstructions [3,4], a systematic pooling of newer
have led to an increased number of teeth and to a shift clinical data on tooth-supported reconstructions is limited to
from fully to more partially edentulous patients over the all-ceramic reconstructions [5].
past decades [2]. This resulted in more single and multi- Traditionally, metal-based reconstructions for xed den-
ple tooth gaps that can be restored with xed tooth- or tal prostheses (FDPs) were considered as the gold standard
implant-supported reconstructions. In order to support the [6]. Alloys, mainly gold-based, were fully or partially veneered
decision-making process for either one option, evidence- with feldspathic ceramics. The evolution in material sci-
based clinical data are needed reporting on survival and ence led to the introduction of new framework materials
(ceramics) and partially a change in clinical concepts (e.g. In a systematic review, analyzing the survival and
monolithic rather than veneered framework materials) [710]. complications rates of all-ceramic and metal-ceramic recons-
Ceramics as part of reconstructive materials fulll the tructions, an imbalance in terms of the number of studies
need for esthetics. However, low-strength materials such for all-ceramic and metal-based FDPs was observed [1]. Clin-
as feldspathic-based ceramics and (reinforced) glass-ceramic ical studies on newer materials such as zirconia, lithium
materials appear to be more suitable for single crowns than disilicate reinforced glass ceramics and glass-inltrated
for FDPs [7,11]. In order to overcome the limited mate- alumina (In-Ceram Alumina) or glass-inltrated alumina-
rial properties, high-strength ceramics were introduced in zirconia (Inceram-Zirconia) were available, but only few of
dentistry. Zirconia as the most stable of these materials is them provided longer term data. Since that time, the evidence
available for CAD/CAM technology and offers a higher ex- increased and clinical data are available for a number of all-
ural strength (9001400 MPa) and a higher fracture toughness ceramic materials for FDPs. The aim of the present systematic
(510 MPa m1/2 ) [12,13]. Zirconia is mainly used as a framework review was therefore,
material for single crowns and FDPs [1416]. Zirconia used as
framework material appears to withstand the clinical forces (i) to update the previous systematic review [1] on tooth-
during chewing and regular function and fracture rates are low supported FDPs with an additional literature search
and comparable to metal-based FDPs [17]. However, in contrast including retrospective and prospective studies from 2007
to metal-based FDPs, a higher rate of technical complications to 2013;
(major chippings) was reported [18,19]. The adhesion between (ii) to assess the 3-year survival rate of tooth-supported xed
zirconia and veneering ceramics is reported to be the critical dental prostheses (FDPs) and to describe the rate of bio-
issue for this observation [20]. logical, technical and esthetic complications;
First electronic search

580 Titles
Independently selected by 2 reviewers

71 titles
Agreed by both
71 titles
Abstracts obtained
Discussion
Agreed on 71 abstracts
Full text obtained
Further hand searching

0 studies
Total full text articles for the

fixed dental prosthesis
review:
37
Excluded full text articles: 7 [23-29]

Total full text articles for single crowns
41
(Sailer et al. 2014)
Articles from Sailer et al. 2007: 10
Final number of studies included:

40
Fig. 1 Search strategy.

(iii) to compare the survival and complication rates of metal- An additional hand search was performed identifying rel-
based FDPs and all-ceramic FDPs. evant studies by screening the reference list of all included
publications.
2. Materials and methods

2.5. Inclusion criteria
2.1. Search strategy
Clinical publications were considered if all of the follow-
ing criteria were suitable: (i) human trials with a minimum
This systematic review was designed as an update to a pre-
amount of 10 patients with FDPs, (ii) mean follow-up of at
viously prepared publication with the same objectives [1]. For
least 3 years in function, (iii) randomized controlled trials
that purpose, Medline (PubMed), Embase and Cochrane Cen-
(RCT), controlled clinical trials (CCT), prospective case series,
tral Register of Controlled Trials (CENTRAL) searches were
cohort studies, retrospective studies, (iv) patients needed to
performed for clinical studies, including articles published
be examined clinically, and (v) reported details of materials
from December 1st, 2006 up to December 31, 2013 in the Den-
characteristics, methods and results.
tal literature. The search was limited to the English language
(Fig. 1).
2.6. Exclusion criteria
2.2. Focused questions

Studies not meeting all inclusion criteria were excluded from
the review. Publications dealing with the following topics were
What are the survival and complication rates of tooth-
also excluded: in vitro and preclinical studies, studies with
supported FDPs after a mean observation period of at least
a follow-up of less than 3 years, reports based on question-
3 years? Are the survival and complications rates of metal-
naires, interviews and charts.
ceramic and all-ceramic tooth-supported FDPs similar after a
mean observation period of at least 3 years?
2.7. Selection of studies
2.3. PICO
Two authors (IS, NAM) independently screened the titles
derived from the searches based on the inclusion criteria.
The PICO for the present systematic review was dened as
Disagreements were resolved by discussion. Following this,
follows:
abstracts of all titles agreed on by both authors were obtained,
and screened for meeting the inclusion criteria. If no abstract
P Population: subjects with anterior and/or posterior xed was available in the database, the abstract of the printed arti-
tooth-supported FDPs cle was used. Based on the selection of abstracts, articles
I Intervention: all-ceramic FDP were then obtained in full text. If title and abstract did not
C Comparison: metal-ceramic FDP provide sufcient information regarding the inclusion crite-
O Outcome: clinical survival and technical, biological and ria, the full report was obtained as well. Again, disagreements
esthetic complication rates were resolved by discussion.
The nal selection based on inclusion/exclusion criteria
2.4. Search terms was made for the full text articles. For this purpose Mate-
rials and Methods, Results and Discussion of these studies
The following four searches and search terms were applied: were screened. This step was again carried out by 2 readers
(IS, NAM) and double-checked. Any questions that came up
Population and intervention during the screening were discussed to aim for consensus. In
crowns[MeSH] OR crown[MeSH] OR dental crowns[MeSH] addition, 15 publications from the previous systematic review
OR crowns, dental[MeSH] OR Denture, Partial, Fixed[Mesh])) [1] were included in the analyses.
OR (crown*[all elds] OR xed partial denture*[all elds] OR
FPD[all elds] OR FPDs[all elds] OR xed dental prosthe- 2.8. Data extraction and method of analysis
sis[all elds] OR xed dental prostheses[all elds] OR FDP[all
elds] OR FDPs[all elds] OR bridge*[all elds] All included articles were independently screened and data
comparison extracted using data extraction tables by two reviewers (DTH,
ceramic[MeSH] OR ceramics[MeSH] OR metal ceramic BPJ). Any disagreements were resolved by discussion to aim
restorations[MeSH])) OR (ceramic*[All Fields] OR all- for consensus. In addition, data of the included publications
ceramic[all elds] OR Dental Porcelain[All Fields] OR of the previously published review [1] were extracted as well.
metal-ceramic[All Fields] Data on the following parameters were extracted: author(s),
outcome year of publication, study design, planned number of patients,
Survival[Mesh] OR survival rate[Mesh] OR survival analy- actual number of patients at end of study, drop-out rate,
sis[Mesh] OR dental restoration failure[Mesh] OR prosthesis mean age, age range, operators, material framework, brand
failure[Mesh] OR treatment failure[Mesh]. name of framework material, veneering material, brand name
of veneering material, type of manufacturing procedure,
The search combination in the builder was population number of FDPs, number of abutment teeth, number of
AND intervention AND comparison AND outcome. (non)vital abutment teeth, number of pontics, location of FDP
628
Table 1 Study and patient characteristics of the reviewed studies for all-ceramic FPDs.
Study Year of Framework material Study No. of patients Age Mean Setting Drop-out
publication design in study range age (in percent)
Sola-Ruiz et al. 2013 Lithium disilicate reinforced glass ceramic Prosp. 19 n.r. 49 University 0%
Rinke et al. 2013 Zirconia Prosp. 75 2676 49.4 University 19%
Raigrodski et al. 2012 Zirconia Prosp. 16 3660 48 University 6%
Peleaz et al. 2012 Zirconia RCT 37 2365 n.r. University 0%
Sagitkaya et al. 2012 Zirconia Prosp. 28 n.r. 38 University 0%
Kern et al. 2012 Lithium disilicate reinforced glass ceramic Prosp. 28 n.r. 47.5 University 7%
Lops et al. 2012 Zirconia Prosp. 28 n.r. 46.2 University 14%
Sax et al. 2011 Zirconia Prosp. 45 n.r. 48.3 University 53%
Sorrentino et al. 2011 Zirconia Prosp. 37 2168 45.3 University 0%
Makarouna et al. 2011 Lithium disilicate reinforced glass ceramic RCT 19 n.r. 47 University 26%
Schmitt et al. 2011 Zirconia Prosp. 15 2973 50.1 University 0%
Christensen and Ploeger 2010 Zirconia and glass-inltrated alumina RCT 259 1689 50 Private practice multi-center 4%
Beuer et al. 2010 Zirconia Prosp. 38 2771 50.9 University 0%
Roediger et al. 2010 Zirconia Prosp. 75 2676 49.4 University 11%
Wolfart et al. 2009 Lithium disilicate reinforced glass ceramic Prosp. 29 2568 47.9 Multi-Center 7%
Eschbach et al. 2009 Glass-inltrated alumina-zirconia Prosp. 58 n.r. 46.8 University 3%
Sailer et al. 2009 Zirconia RCT 59 n.r. 54.4 University 5%
Wolfart et al. 2009 Zirconia Prosp. 48 2375 55 University 4%
Beuer et al. 2009 Zirconia Prosp. 19 2771 50.9 University 0%
Edelhoff et al. 2008 Zirconia Prosp. 18 n.r. n.r. University 6%
Molin and Karlsson 2008 Zirconia Prosp. 18 4084 59 Specialists and private practice 0%
Tinschert et al. 2008 Zirconia Prosp. 46 2058 n.r. University 13%
Esquivel et al. 2008 Lithium disilicate reinforced glass ceramic Prosp. 21 3062 n.r. University 0%
Wolfart et al. 2005 Lithium disilicate reinforced glass ceramic Prosp. 29 2568 47.8 University 17%
Marquart and Strub 2005 Lithium disilicate reinforced glass ceramic Prosp. 43 2265 39.9 University 0%
Surez et al. 2004 Glass-inltrated alumina-zirconia Prosp. 16 2350 n.r. University 0%
Olsson et al. 2003 Glass-inltrated alumina Retrosp. 37 2884 54 Private practice 16%
Vult von Steyern et al. 2001 Glass-inltrated alumina Prosp. 18 2570 n.r. University and private practice 0%
Sorensen et al. 1998 Glass-inltrated alumina Prosp. 47 1966 n.r. University 2%
n.r., not reported; RCT, randomized controlled clinical trial.
(anterior, posterior, maxilla, mandible), reported mean follow-
(in percent)
Drop-out
up, follow-up range, published FDP survival rate, number of
FDPs lost (anterior, posterior), reported biological complica-
16%
14%
71%
56%
17%
18%
19%
17%
n.r.
n.r.
n.r.
n.r.
0%
7%
tions (caries, periodontal, root fracture), reported technical
4
complications (framework fracture, minor chipping, major
chipping, loss of retention), esthetic complications (marginal
Private practice multi-center

discoloration), reported number of patients free of complica-
tions. Based on the included studies, the FDP survival rate was
University Students
University Students
University Students
University Students
University students
calculated. In addition, the number of events for all technical,
Single specialist
biological and esthetic complications was extracted and the
Private practice
Setting
corresponding total exposure time of the reconstruction was
University
University
University
University
University
University
University
calculated.
2.9. Statistical analysis
Failure and complication rates were calculated by dividing the

number of events (failures or complications) in the numerator
Mean age
by the total FDP exposure time in the denominator.
56 .8
66.8
50.3
55.3
54.4
The numerator could usually be extracted directly from the
n.r.
n.r.
n.r.
n.r.
n.r.
n.r.
61
47
62
50
publication. The total exposure time was calculated by taking
the sum of:
Age range
(1) Exposure time of FDPs that could be followed for the whole
3990
2365
3484
2164
3684
1689
2769
1374
3982
2672
observation time.
n.r.
n.r.
n.r.
n.r.
n.r.
(2) Exposure time up to a failure of the FDPs that were lost
due to failure during the observation time.
(3) Exposure time up to the end of observation time for
No. of patients
FDPs that did not complete the observation period due

in study
Table 2 Study and patient characteristics of the reviewed studies for metal-ceramic FPDs.
to reasons such as death, change of address, refusal

149
37
52
96
18
84
259
23
59
270
45
30
357
132
58
to participate, non-response, chronic illnesses, missed
appointments and work commitments.
For each study, event rates for the FDPs were calculated by
dividing the total number of events by the total FDP exposure
n.r., not reported; Co-Cr, cobalt-chromium; RCT, randomized controlled clinical trial.
time in years. For further analysis, the total number of events
Study design
Retrosp.
Retrosp.
Retrosp.
Retrosp.
Retrosp.
Retrosp.
Retrosp.
Retrosp.
Retrosp.
Retrosp.
was considered to be Poisson distributed for a given sum of
Prosp.
FDP exposure years and Poisson regression with a logarithmic

RCT
RCT
RCT
RCT
link-function and total exposure time per study as an offset

variable were used [21].
Robust standard errors were calculated to obtain 95% con-
Framework
material
dence intervals of the summary estimates of the event

Gold metal
Gold metal
Gold metal
Gold metal
Gold metal
Gold metal
Gold metal
Gold metal
Gold metal
Gold metal
Gold metal
Titanium
rates. To assess heterogeneity of the study specic event

Co-Cr
Co-Cr
Co-Cr
rates, the Spearman goodness-of-t statistics and associated

p-value were calculated. If the goodness-of-t p-value was
below 0.05. Five-year survival proportions were calculated via
the relationship between event rate and survival function S,
publication
S(T) = exp(T event rate), by assuming constant event rates

Year of
[22]. The 95% condence intervals for the survival proportions

2013
2012
2012
2013
2011
2011
2010
2010
2009
2008
2007
2003
2002
2002
1989
were calculated by using the 95% condence limits of the event

rates. Multivariable Poisson regression was used to formally
compare construction subtypes and to assess other study
characteristics. All analyses were performed using Stata , ver-
Reichen-Graden and Lang
sion 13.1.
Napankangas et al.
Christensen et al.
Makarouna et al.
3. Results
De Backer et al.
Hochman et al.
Svanborg et al.
Boeckler et al.
Eliasson et al.
Brgger et al.
Wolleb et al.
Heschl et al.
Peleaz et al.
Sailer et al.
3.1. Study characteristics

Walton
Study
A total of 40 studies fullled the inclusion criteria of the

present systematic review. Seven studies were excluded for
various reasons, ranging from multiple publications on the 3.2. FDP survival
same patient cohort to insufciently reported data on FDPs
[2329]. 28 studies, published between 1998 and 2013, on For metal-ceramic FDPs, 15 studies provided data on 1796 FDPs
all-ceramic FDPs and 15 studies, published between 1989 after a mean follow-up time of 7.0 years. Out of these, 145
and 2013, on metal ceramic FDPs, were included in this FDPs were reported to be lost. The annual failure rate was esti-
review (Tables 1 and 2). The median year of publications mated at 1.15% (95% CI: 0.721.84%) (Fig. 2), translating into a
for all-ceramic FDPs was 2009 and for metal-ceramic FDPs 5-year survival rate for metal-ceramic FDPs of 94.4% (95% CI:
2010. For all-ceramic FDPs, the majority or 28 studies had 91.296.5%) (Table 3).
a prospective design and only one had a retrospective The results for all-ceramic FDPs was divided split into
design. In contrast, for metal-ceramic FDPs the majority reconstructions based on reinforced glass ceramic, glass-
of the included studies or 10 were retrospective and the inltrated alumina (InCeram Alumina and InCeram Zirconia)
remaining 5 studies were prospective. Four of the included and densely sintered zirconia. For reinforced glass ceramic
studies (Peleaz et al., 2012, Makarouna, 2011, Christensen, FDPs, 7 studies provided data on 208 FDPs. After a mean follow-
2010 and Sailer et al., 2009) were randomized controlled up time of 6.0 years, 29 FDPs were reported to be lost. The
clinical trails comparing different types of all-ceramic FDPs annual failure rate was estimated at 2.31% (95% CI: 1.234.35%)
with metal-ceramic FDPs. The included studies on all- (Fig. 3) translating into a 5-year survival rate for reinforced
ceramic FDPs reported on reconstructions made out of glass ceramic FDPs of 89.1% (95% CI: 80.494.0%) (Table 3). For
reinforced glass ceramics, glass-inltrated alumina (InCeram glass-inltrated alumina FDPs, 6 studies provided data on 229
Alumina), glass-inltrated alumina-zirconia (InCeram Zirco- FDPs. After a mean follow-up time of 4.1 years, 28 FDPs were
nia), and densely sintered zirconia (Table 1). The studies reported to be lost. The annual failure rate was estimated at
of metal-ceramic FDPs reported on reconstructions having 2.97% (95% CI: 1.207.35%) (Fig. 4) translating into a 5-year sur-
framework out of gold metal, cobalt chromium or titanium vival rate for glass-inltrated alumina FDPs of 86.2% (95% CI:
(Table 2). 69.394.2%) (Table 3). For densely sintered zirconia FDPs, 16
The majority of the included studies, or 35 out of 40 studies provided data on 673 FDPs from which 62 FDPs were
were conducted in university settings. The remaining stud- reported to be lost after a mean follow-up time of 4.5 years. The
ies were executed in specialist clinics or private practices annual failure rate was estimated at 2.02% (95% CI: 1.243.31%)
(Tables 1 and 2). (Fig. 5) translating into a 5-year survival rate for densely sin-
The 29 studies using all-ceramic materials included 1225 tered zirconia FDPs of 90.4% (95% CI: 84.894.0%) (Table 3).
patients, where as the 15 studies on metal-ceramic FDPs At the 5-year follow-up, the annual failure rates of different
included 1669 patients. The age of the patients ranged types of FDPs ranged from 1.15% to 2.97% and the 5-year sur-
between 16 and 90 years at the time of treatment. The propor- vival ranged from 86.2% to 94.4%. Investigating formally the
tion of patients who could not be followed-up for the complete relative failure rates of different types of FDPs, using metal-
study period was available for 90% of the studies and ranged ceramic FDPs as reference, all-ceramic FDPs showed higher
from 0% to 71%. The mean drop-out rate of patients was 8% annual failure rates. Moreover, for glass-inltrated alumina
for studies reporting on all-ceramic FDPs and 19% for studies FDPs this difference reached statistical signicance (p = 0.052)
on metal-ceramic FDPs (Tables 1 and 2). (Table 4).
Fig. 2 Annual failure rate of metal-ceramic FDPs.

Table 3 Annual failure rates and survival of metal-ceramic and all-ceramic FDPs.
Study Year of Total no. Mean No. of Total FDPs Estimated annual failure Estimated survival after
publication of FDPs follow-up time failure exposure time rate* (per 100 FDP years) 5 yearsa (in percent)
Metal ceramic
Svanborg et al. 2013 201 4.6 7 915 0.77 96.2%
Peleaz et al. 2012 20 4.2 0 83 0 100%
Wolleb et al. 2012 76 5.3 1 400 0.25 98.8%
Heschl et al. 2013 28 6.3 1 177 0.56 97.2%
Makarouna 2011 19 2.5 1 48 2.08 90.1%
Brgger et al. 2011 82 12.1 2 992 0.20 99.0%
Christensen and Ploeger 2010 87 3.0 5 261 1.92 90.9%
Boeckler et al. 2010 31 2.7 1 84 1.19 94.2%
Sailer et al. 2009 38 2.7 0 104 0 100%
De Backer et al. 2008 322 11.4 72 3675 1.96 90.7%
Eliasson et al. 2007 51 4.3 3 217 1.38 93.3%
Hochman et al. 2003 49 6.3 6 324 1.85 91.2%
Walton 2002 515 7.4 37 3363 1.10 94.6%
Napankangas et al. 2002 204 7.6 7 1478 0.47 97.7%
Reichen-Grad and Lang 1989 73 6.4 2 465 0.43 97.9%
Total 1796 7.0 145 12,586

Summary estimate (95% CI)a 1.15 (0.721.84) 94.4% (91.296.5%)
Reinforced glass ceramic

Sola-Ruiz et al. 2013 21 10.0 6 210 2.86 86.7%
Kern et al. 2012 36 10.1 4 363 1.10 94.6%
Makarouna 2011 18 4.7 6 84 7.14 70.0%
Wolfart et al. 2009 36 6.9 2 247 0.81 96.0%
Esquivel et al. 2008 30 3.3 5 100 5.00 77.9%
Wolfart et al. 2005 36 4.0 0 120 0 100%
Marquart et al. 2005 31 4.2 6 129 4.65 79.3%
Total 208 6.0 29 1253

Summary estimate (95% CI) a 2.31 (1.234.35) 89.1% (80.494.0%)
Glass inltrated alumina

Eschbach et al. 2009 65 4.5 2 295 0.68 96.7%
Suarez et al. 2004 18 3.0 1 53 1.89 91.0%
Olsson et al. 2003 42 6.3 5 266 1.88 91.0%
van Steyern et al. 2001 20 5.0 2 95 2.11 90.0%
Soerensen et al. 1998 61 3.0 7 165 4.24 80.9%
Total 229 4.1 28 943

Densely sintered zirconia

Rinke et al. 2013 99 6.3 19 627 3.03 85.9%
631
Raigrodski et al. 2012 20 4.7 0 94 0 100%
632
Table 3 (Continued )
Study Year of Total no. Mean No. of Total FDPs Estimated annual failure Estimated survival after
publication of FDPs follow-up time failure exposure time rate* (per 100 FDP years) 5 yearsa (in percent)
Peleaz 2012 20 4.2 1 83 1.20 94.2%
Lops et al. 2012 28 6.5 2 182 1.10 94.7%
Sax et al. 2011 57 7.6 15 433 3.46 84.1%
Sorrentino et al. 2011 48 5.0 0 240 0 100%
Schmitt et al. 2011 15 4.0 0 60 0 100%
Beuer et al. 2010 18 2.9 1 53 1.89 91.0%
Roediger et al. 2010 99 4.2 7 413 1.69 91.9%
Sailer et al. 2009 38 3.2 0 121 0 100%
Wolfart et al. 2009 24 4.0 1 97 1.03 95.0%
Beuer et al. 2009 21 2.5 2 53 3.77 82.8%
Edelhoff et al. 2008 22 3.1 0 69 0 100%
Molin and Karlsson 2008 19 5.0 0 95 0 100%
Tinschert et al. 2008 65 3.1 0 202 0 100%
Total 673 4.5 62 3062
Overall results 2906 6.1 264 17,844

Summary estimate (95% CI)a 1.48 (1.111.97) 92.9% (90.694.6%)
a
Table 4 Summary of annual failure rates, relative failure rates and survival estimates for FDPs with metal-ceramic FDPs as reference.
Type of FDPs Total number Total FDPs Mean FDPs Estimated annual 5-Year survival summary Relative failure p-Value**
of FDPs exposure time follow-up time failure rate* estimate* (95% CI) rate**
Metal-ceramic 1796 12,586 7.0 1.15 (0.721.84) 94.4% (91.296.5%) 1.00 (Ref.)
Reinforced glass ceramic 208 1253 6.0 2.31 (1.234.35) 89.1% (80.494.0%) 2.01 (0.954.25) 0.068
Glass-inltrated alumina 229 943 4.1 2.97 (1.207.35) 86.2% (69.394.2%) 2.58 (0.996.69) 0.052
Densely sintered zirconia 673 3062 4.5 2.02 (1.243.31) 90.4% (84.894.0%) 1.76 (0.903.41) 0.096

Based on multivariable robust Poisson regression including all types of FDPs.

Fig. 3 Annual failure rate of reinforced glass ceramic FDPs.
3.3. Biological complications zirconia FDPs. Investigating the relative complication rates of
different types of FDPs, using metal-ceramic FDPs as refer-
3.3.1. Secondary caries ence, densely sintered zirconia FDPs experienced signicantly
Eighteen studies reported on the incidence of secondary caries higher rate of secondary caries (p = 0.001) (Table 6).
on the abutment level. From 3351 FDP abutments included Information about loss of the entire reconstruction due
in those studies, 52 abutments developed secondary caries. to secondary caries was given in 38 studies. From 2145 FDPs
The overall annual complication rate was 0.29%, translating included in these studies 55 were lost due to secondary caries.
into a 5-year complication rate of 1.4% (Table 5). For different The overall annual failure rate was 0.43%, translating into a
types of FDPs the annual rate of secondary caries ranged from 5-year failure rate of 2.1% (Table 5). For different types of FDPs
0.11% to 0.65%. The lowest annual complication rate 0.11% the annual rate of failures due to caries ranged from 0.09%
was reported for reinforced glass ceramic FDPs and the high- to 0.54%. The lowest annual failure rate 0.09% was reported
est complication rate 0.65% was reported for densely sintered for reinforced glass ceramic FDPs and the highest failure rates
Fig. 4 Annual failure rate of glass-inltrated alumina FDPs.

634
Table 5 Overview of biological and technical complications of different types of FDPs.
Complication Number of Estimated Cumulative Number of Estimated Cumulative Number of Estimated Cumulative
abutments or annual 5-year abutments or annual 5-year abutments or annual 5-year
FDPs complication complication FDPs complication complication FDPs complication complication
rates (95% CI) rates (95% CI) rates (95% CI) rates (95% CI) rates (95% CI) rates (95% CI)
Overall results all FDPs Metal ceramic FDPs Reinforced glass ceramic FDPs
* * * *
Caries on abutments 3351 0.29 (0.142.94) 1.4% (0.72.9%) 2497 0.24 (0.100.57) 1.2% (0.52.8%) 199 0.11* (0.010.94) 0.5%* (0.064.6%)
FDPs lost due to caries 2145 0.43* (0.210.88) 2.1%* (1.14.3%) 1053 0.54* (0.241.22) 2.7%* (1.25.9%) 190 0.09* (0.010.76) 0.4%* (0.053.7%)
FDPs lost due to 2096 0.23* (0.100.54) 1.2%* (0.52.7%) 1004 0.06* (0.030.11) 0.3%* (0.10.6%) 190 0.60* (0.103.52) 2.9%* (0.516.1%)
periodontal disease
FDPs lost due to 2107 0.17* (0.120.25) 0.9%* (0.61.3%) 1053 0.19* (0.110.30) 0.9%* (0.61.5%) 190 0.09* (0.020.44) 0.4%* (0.12.2%)
abutment tooth
fracture
Loss of abutment tooth 243 0.44* (0.111.80) 2.2%* (0.58.6%) n.a. n.a. n.a. n.a. n.a. n.a.
vitality
Marginal discolorations 253 3.91* (1.4610.46) 17.7%* (7.040.7%) 20 4.82* (1.3311.88) 21.4%* (6.444.8%) 118 0.72.* (0.232.19) 3.5%* (1.210.4%)
Framework fracture 2640 0.45* (0.250.82) 2.2%* (1.24.0%) 1530 0.12* (0.040.40) 0.6%* (0.22.0%) 208 1.68* (0.843.33) 8.0%* (4.115.3%)
Ceramic fractures 2129 1.56* (0.852.86) 7.5%* (4.213.3%) 1305 1.03* (0.422.56) 5.0%* (2.112.0%) 187 1.34* (0.991.82) 6.5%* (4.88.7%)
Ceramic chipping 1659 2.71.* (1.524.83) 12.7%* (7.321.4%) 781 1.79* (0.813.96) 8.6%* (4.018.0%) 213 1.07* (0.482.36) 5.2%* (2.411.1%)
Loss of retention 1702 0.64* (0.351.16) 3.1%* (1.75.6%) 955 0.42* (0.161.09) 2.1%* (0.85.3%) 142 0.58* (0.350.97) 2.9%* (1.74.7%)
Complication Number of Estimated Cumulative Number of Estimated Cumulative

abutments or annual 5-year abutments or annual 5-year
FDPs complication complication FDPs complication complication
rates (95% CI) rates (95% CI) rates (95% CI) rates (95% CI)
Glass-inltrated alumina FDPs Densely sintered zirconia FDPs

Caries on abutments 168 0.41* (0.220.74) 2.0%* (1.13.6%) 487 0.65* (0.271.56) 3.2%* (1.37.5%)
FDPs lost due to caries 229 0.11* (0.020.56) 0.5%* (0.12.8%) 673 0.39* (0.200.77) 1.9%* (1.03.8%)
FDPs lost due to 229 1.59* (0.624.08) 7.6%* (3.118.4%) 673 0.10* (0.030.30) 0.5%* (0.21.5%)
periodontal disease
FDPs lost due to 229 0.11* (0.011.02) 0.5%* (0.055.0%) 635 0.21* (0.110.38) 1.0%* (0.61.9%)
abutment tooth
fracture
Loss of abutment tooth n.a. n.a. n.a. 243 0.44* (0.111.80) 2.2%* (0.58.6%)
vitality
Marginal discolorations 18 3.77* (0.4612.98) 17.2%* (2.347.7%) 97 6.72* (3.3013.68) 28.5%* (15.249.5%)
Framework fracture 229 2.76* (1.017.52) 12.9%* (4.931.3%) 673 0.39* (0.240.65) 1.9%* (1.23.2%)
Ceramic fractures 65 1.36* (0.373.44) 6.6%* (1.815.8%) 572 3.14* (2.374.17) 14.5%* (11.218.8%)
Ceramic chipping 90 7.55* (1.0952.24) 31.4%* (5.392.7%) 575 4.33* (1.939.72) 19.5%* (9.238.5%)
Loss of retention 107 0.53* (0.310.93) 2.6%* (1.54.5%) 498 1.28* (0.831.97) 6.2%* (4.19.4%)
n.a., not available.

0.39% and 0.54% for densely sintered zirconia FDPs and metal-
p-Value*
Densely sintered zirconia FDPs
ceramic FDPs, respectively. The difference between different
0.001
0.535
0.384
0.784
0.289
0.069
0.018
0.115
0.028
types of FDPs did not reach statistical signicance (p = 0.064,
0.095 & 0.535) (Table 6).
3.3.2. Loss of vitality

Relative compl. rate*
Loss of abutment vitality was reported in three studies. All of
3.23 (0.9111.42)
2.75 (1.505.07)
0.72 (0.262.01)
1.77 (0.496.44)
1.11 (0.522.38)
1.39 (0.752.58)
3.05 (1.217.69)
2.42 (0.817.25)
3.07 (1.128.37)
them reporting on densely sintered zirconia FDPs. Four out of
243 abutment teeth, reported to be vital at the time of cemen-
tation, presented loss of pulp vitality during the observation
period. The annual complication rate was 0.44%, translating
into a 5-year complication rate of 2.2% (Table 5).
3.3.3. Abutment tooth fracture

The incidence of FDPs lost due to fracture of abutment teeth
p-Value*
<0.0001
<0.0001
<0.0001
0.366
0.064
0.612
0.544
0.113
0.621
Glass-inltrated alumina FDPs
was reported in 36 studies evaluating 2107 FDPs, out of which

22 were lost. The overall annual failure rate was 0.17%, trans-
lating into a 5-year failure rate of 0.9% (Table 5). For different
types of FDPs the annual failure rates due to abutment tooth
fractures ranged from 0.09% to 0.21%. The difference between
22.72 (5.13100.69)
different types of FDPs did not reach statistical signicance

28.80 (9.4587.74)
4.21 (0.7124.92)
1.73 (0.535.63)
0.19 (0.031.10)
0.57 (0.074.92)
0.78 (0.780.78)
1.31 (0.543.18)
1.28 (0.483.47)
(p = 0.341, 0.612 & 0.784) (Table 6).
3.3.4. Periodontal disease

The incidence of FDPs lost due to recurrent periodontal dis-
Based on multivariable robust Poisson regression including all types of FDPs with metal ceramic FDPs as reference.
ease, was reported in 37 studies evaluating 2096 FDPs, out

of which 29 were lost. The overall annual failure rate was
0.23%, translating into a 5-year failure rate of 1.2% (Table 5).
For different types of FDPs, the annual failure rates due to
p-Value*
<0.0001
<0.0001
recurrent periodontal diseases ranged from 0.06% to 1.59%.

Reinforced glass ceramic FDPs
0.432
0.095
0.009
0.341
0.578
0.338
0.523
The highest annual failure rate was reported for reinforced

glass ceramic FDPs 0.60% and glass-inltrated alumina FDPs
1.59%, translating into a 5 years failure rates of 2.9% and 7.6%,
respectively (Table 5). Investigating the relative complication
rates of different types of FDPs, using metal-ceramic FDPs as

13.81 (3.6552.28)
0.45 (0.063.29)
0.16 (0.021.37)
10.8 (1.8264.31)
0.46 (0.092.26)
0.14 (0.050.42)
1.30 (0.523.28)
0.60 (0.211.72)
1.40 (0.503.88)
reference, signicantly more glass-inltrated alumina FDPs

and reinforced glass ceramic FDPs were lost due to recurrent
Table 6 Relative complication rates for different types of FDPs.
periodontal diseases (p < 0.0001 & 0.009).
3.4. Technical complications
3.4.1. Material complications: framework fracture,

ceramic chipping or ceramic fracture
Metal ceramic FDPs
The incidence of framework fracture was reported in 43 out

of the 44 studies included in the present systematic review.
1.00 (Ref.)
1.00 (Ref.)
1.00 (Ref.)
1.00 (Ref.)
1.00 (Ref.)
1.00 (Ref.)
1.00 (Ref.)
1.00 (Ref.)
1.00 (Ref.)
From 2640 FDPs that were evaluated, 72 were known to be

lost due to framework fractures. The overall annual failure
rate was 0.45%, translating into a 5-year failure rate of 2.2%
(Table 5). For different types of FDPs, the annual failure rates of
framework fractures ranged from 0.12% to 2.76%. The highest
annual failure rate was reported for reinforced glass ceramic
FDPs (1.68%) and glass-inltrated alumina FDPs (2.76%), trans-
FDPs lost due to abutment
(Chipping and fractures)

Type of complications
Marginal discolorations
lating into a 5-year failure rates of 8.0% and 12.9%, respectively

FDPs lost due to caries
periodontal disease
Caries on abutments
(Table 5). Investigating the relative complication rates of

Framework fracture
Ceramic fractures
Ceramic chipping
different types of FDPs, using metal-ceramic FDPs as refer-

Loss of retention
FDPs lost due to
tooth fracture
ence, signicantly more glass-inltrated alumina FDPs and

reinforced glass ceramic FDPs were lost due to framework frac-
tures (p < 0.0001). Compared to the other ceramics, densely
sintered zirconia exhibited the highest stability as framework

material with an estimated 5-year failure rate of 1.9% (Table 5).

Fig. 5 Annual failure rate of densely sintered zirconia FDPs.
The incidence, however, of fractures of the ceramic veneering with annual complication rate of 0.72% or a 5-year compli-
that needed repair or replacement was highest for densely sin- cation rate of 3.5%. For the other three types of FDPs, the
tered zirconia FDPs with an annual complication rate of 3.14%, annual rates of marginal discoloration ranged between 3.77%
translating into a 5-year complication rate of 14.5%. This dif- and 6.72% with the highest incidence reported for densely sin-
ference reached statistical signicance (p = 0.018) (Table 6). For tered zirconia FDPs, representing a 5-year complication rate of
other types of FDPs the annual rate of ceramic fractures ranged 28.5% (Table 5).
from 1.03% to 1.36%, translating into a 5-year complication
rate of 5.06.5% (Table 6). The incidence of ceramic chipping
4. Discussion
that could be solved with polishing was reported in 32 stud-
ies including 1659 FDPs. The overall annual complication rate
Systematic reviews have been used extensively in medicine for
was 2.71%, translating into a 5-year complication rate of 12.7%
the last two decades to summarize the cumulative informa-
(Table 5). For different types of FDPs, the annual complication
tion on the optimal treatment for clinically relevant questions
rates ranged from 1.07% to 7.55%. Ceramic chipping was the
and to support the clinicians in the decision-making pro-
most frequent technical complication reported, but the differ-
cess for different treatment options. This research method
ence in ceramic chipping between different types of FDPs did
has slowly found its way into dental research. Systematic
not reach statistical signicance (p = 0.338, 0.113 & 0.115).
reviews have mainly been used to analyze and summarize
results from randomized controlled clinical trials (RCTs) [30].
3.4.2. Loss of retention In the absence of RCTs with adequate statistical power to com-
Loss of retention or fracture of the luting cement was analyzed pare head-to-head metal-ceramic and all-ceramic xed dental
in 25 studies reporting on 1702 FDPs. The overall annual com- prosthesis (FDPs) prospective and retrospective cohort studies
plication rate was 0.64%, translating into a 5-year failure rate and case series with stringent inclusion criteria were included
of 3.1% (Table 5). Densely sintered zirconia FDPs experienced in this systematic review in order to summarize the available
statistically signicantly (p = 0.028) (Table 6) more retention information about survival and complication rates of metal-
loss than the other types of FDPs with an annual compli- ceramic and all-ceramic FDPs after a observation period of at
cation rate of 1.28% and a 5-year complication rate of 6.2%. least 3 years. Even with follow-up periods of at least 3 years,
For other types of FDPs the annual complication rates ranged some clinicians may argue that such a period is still too short
from 0.42% to 0.58%, translating into a 5-year failure rates of to obtain reliable information on survival and complication
2.12.9% (Table 5). rates of xed reconstructions. Due to the fact that the use of
all-ceramic FDPs is relatively recent, a mean follow-up period
3.4.3. Marginal discoloration of 3 years or more was a necessary compromise.
Marginal discoloration or the occurrence of marginal gaps However it was interesting to see that the median year of
was evaluated in 9 studies reporting on 253 FDPs. The overall publication was 2010 for metal-ceramic FDPs compared with
annual complication rate was 3.91%, translating into a 5-year 2009 for all-ceramic FDPs. In a systematic review on the same
complication rate of 17.7% (Table 5). The lowest incidence of topic published in the year 2007 by the same authors, only ve
marginal discoloration was seen for reinforced glass ceramic studies on metal-ceramic FDPs fullled the inclusion criterias
and only one of them was published before the year 2000 [1]. frameworks, which may not provide proper support to the
This must be considered peculiar as metal-ceramic FDPs have veneering ceramic.
been considered the golden standard in reconstructive den- Marginal discoloration was, with the exception of rein-
tistry over decades. A positive shift has to be noticed, as 15 forced glass ceramic FDPs (3.5%), a frequent technical
studies reporting on metal-ceramic could be included in the complication reported for all-ceramic FDPs and metal-ceramic
present systematic review. FDPs, ranging from 17.2% to 28.5%. The drawback of this
Survival was dened as FDP remaining in situ with or analysis was that it is based on very few observations for
without modications and success was dened as the FDPs metal-ceramic and glass-inltrated alumina FDPs represent-
remaining in situ free of all complications over the entire ing in a very wide condence interval. In the two studies using
observation period. From the Forrest plots of study specic a pressed glass-ceramic no discoloration was found [37,38].
failure rates, it is evident that these vary widely among the This can partly be explained by the manufacturing procedures
various studies. This may be attributable to the patient cohort of the frameworks. The high precision of the manufacturing
observed, the design and extent of the FDPs, the maintenance technique of pressable glass-ceramics has been documented
care provided and the experience and clinical set-up of the in several investigations [3941]. Among the studies repor-
clinicians. ting on marginal discoloration of densely sintered zirconia
After an observation period of 3 years, the lowest failure ceramic FDPs, there was a clear outlier using a prototype CAM-
rate were observed for metal-ceramic FDPs (5.6%) compared system reporting the highest rate of gaps or discoloration
with a failure rates of 9.6% for densely sintered zirconia [36]. A possible explanation could be the mist of these pro-
ceramic FDPs, 10.9% for reinforced glass ceramic FDPs and totype frameworks. In a RCT comparing metal-ceramic and
13.8% for glass-inltrated alumina FDPs. Due to the different densely sintered zirconia FDPs [17], the t of the frameworks
composition of different ceramic materials it was decided not was analyzed prior to the insertion of the reconstruction
to pull, different types of all-ceramic FDPs, into one group [42]. It was demonstrated that milled zirconia frameworks
in the meta-analysis as was done in the previous review exhibited larger internal gaps than those constructed using
on the same topic. Four of the included studies randomized conventional metal-ceramic techniques. This larger mist of
the patients according to material utilized. Three of them CAD/CAM reconstruction can explain a rather high rate of
reported more failure of all-ceramic FDPs compared with marginal discoloration.
metal-ceramic FDPs [19,31,32]. The last one reported no fail- With the exception of caries on abutment level by densely
ures in either group [17]. sintered zirconia ceramic FDPs (3.2%) and FDPs lost due to
The most frequent reason for failure of reinforced glass periodontal disease by glass-inltrated alumina FDPs (7.6%)
ceramic FDPs and glass-inltrated alumina FDPs over the was the incidence of biological complications such as caries
3 years observation period was fracture of the recon- on abutment level, FDPs lost due to caries, FDPs lost due to
struction framework, reported for 8.0% and 17.2% of the periodontal disease, FDPs lost due to abutment tooth fracture
reconstructions respectively. This technical failure was fre- and loss of abutment tooth vitality relative rare, ranging from
quently related to using reinforced glass ceramic FDPs 0.3% to 2.9% (Table 5).
and glass-inltrated alumina FDPs in the posterior area When densely sintered zirconia was rst introduced as
and where the diameter of the connectors was reduced framework material, its excellent physical properties led to
below 4 mm 4 mm [33]. It has also been argued that all- the assumption that it may successfully be used to replace
ceramic FDPs suffer more often from parafunctional habits the conventional metal-ceramic FDP. The zirconia has been
and malocclusion leading to framework fractures [34]. The proven to be a strong framework material with low inci-
framework fracture failure rate was rarer for metal-ceramic dence of framework fracture. Specially if not used for long
FDPs (0.6%) and densely sintered zirconia ceramic FDPs edentulous spans (3 teeth or more) and criterias for con-
(1.9%). One aspect to consider for all-ceramic FDPs might nector dimension are respected. One the other hand, there
be the length of the reconstruction. Studies demonstrated a are still issues with t and framework design. The present
higher rate of framework fractures with an increasing FDP systematic review has demonstrated that problems such as
length [35,36]. discolorations, secondary caries and loss of retentions, that
The most frequent technical complication was chipping can be directly related to semi optimal t are more frequent by
of the veneering ceramic with an overall complication rate densely sintered zirconia FDPs compared with metal-ceramic
of 12.7% after 3-year observation period. The incidence of FDPs and other types of all-ceramic FDPs. Moreover, high
this complication ranged from 6.6% to 31.4% depending on incidence of ceramic fractures and chipping is another issue
the material type and was most frequently seen by glass- that has taken into account utilizing densely sintered zirconia
inltrated alumina FDPs and densely sintered zirconia FDPs. FDPs.
Ceramic chippings for metal-ceramic FDPs appear to occur In this review stringent study inclusion criteria were used.
more frequently during the rst year in function. The rate Only studies with a clinical follow-up examination of at least
of chippings may then slightly decrease [23]. The high inci- 3 years were included to avoid the potential inaccuracies
dence of chipping by densely sintered zirconia FDPs, may in event description in studies that based their analysis on
be due to the fact that the rst generation of zirconia FDPs patient self-reports. Clearly, a limitation of the present review
was made before special low-fusing ceramics with a ther- is the assumption of a constant annual event rate throughout
mal expansion coefcient compatible with zirconia had been follow-up time after reconstruction. Interpreting the results
developed. Another reason for this might be the difculty of it must be kept in mind that the mean observation period
getting correct uniform thickness of the virtually designed was on average 7.0 years for metal-ceramic FDPs, and only
4.7 years for all-ceramic FDPs. If the annual failure rates were 2012;107:3739. Reason for exclusion: multiple publication
higher in the years 510 than in the years 05, then average on same patient cohort.
annual failure rates would be automatically higher for those [27] Reitemeier B, Hansel K, Kastner C, Weber A, Walter MH. A
reconstruction types for which studies with longer follow-up prospective 10-year study of metal ceramic single crowns and
were available. To reduce the impact of such a bias, the results xed dental prosthesis retainers in private practice settings. J
of the present analysis were restricted to estimating the 5- Prosthet Dent 2013;109:14955. Reason for exclusion: no data
year survival. Another limitation of this review is that it was for FDPs, only abutments.
mainly based on studies that were conducted in an institu- [28] Sailer I, Feher A, Filser F, Gauckler LJ, Luthy H, Hammerle
tional environment, such as university or specialized implant CH. Five-year clinical results of zirconia frameworks for pos-
clinics. Therefore, the long-term outcomes observed, cannot terior xed partial dentures. Int J Prosthodont 2007;20:3838.
be generalized to dental services provided in private practice. Reason for exclusion: multiple publications on same patient
cohort.
[29] Walton TR. Changes in the outcome of metal-ceramic
5. Conclusion
tooth-supported single crowns and FDPs following the
introduction of osseointegrated implant dentistry into a
Metal-ceramic FDPs had lower failure rates then all-ceramic
prosthodontic practice. Int J Prosthodont 2009;22:2607. Rea-
FDPs after a mean observation period of at least 3 years.
son for exclusion: multiple publications on same patient
Framework fractures were frequently reported for reinforced
cohort.
glass ceramic and glass-inltrated alumina FDPs. Densely sin-
tered zirconia was signicantly more stable as framework
material, but mist lead to complications such as discol- references
orations, secondary caries and loss of retention. Moreover,
ceramic fractures and chipping of ceramics were frequent.
In the future, further renements in the production of all- [1] Sailer I, Pjetursson BE, Zwahlen M, Hammerle CH. A
ceramic reconstructions are indicated. systematic review of the survival and complication rates of
all-ceramic and metal-ceramic reconstructions after an
observation period of at least 3 years. Part II: Fixed dental
Conict of interest prostheses. Clin Oral Implants Res 2007;18(Suppl. 3):8696.
[2] Pihlgren K, Forsberg H, Sjodin L, Lundgren P, Wanman A.
The authors do report to have no conict of interest. Changes in tooth mortality between 1990 and 2002 among
adults in Vasterbotten County, Sweden: inuence of
socioeconomic factors, general health, smoking, and dental
Acknowledgments care habits on tooth mortality. Swed Dent J 2011;35:7788.
[3] Pjetursson BE, Thoma D, Jung R, Zwahlen M, Zembic A. A
systematic review of the survival and complication rates of
The authors are grateful to Kristin Heimisdttir, sta skars- implant-supported xed dental prostheses (FDPs) after a
dttir and Gisela Mller, Study Monitor, Clinic of Fixed and mean observation period of at least 5 years. Clin Oral
Removable Prosthodontics and Dental Material Science, Uni- Implants Res 2012;23(Suppl. 6):2238.
versity of Zurich, for their help in the preparation of the [4] Jung RE, Zembic A, Pjetursson BE, Zwahlen M, Thoma DS.
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crowns on implants reported in longitudinal studies with a
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[5] Raigrodski AJ, Hillstead MB, Meng GK, Chung KH. Survival
[23] Behr M, Winklhofer C, Schreier M, Zeman F, Kobeck C,
and complications of zirconia-based xed dental prostheses:
Brauer I, et al. Risk of chipping or facings failure of metal
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8 Types of bridge

Conventional and minimum-

b Fixedmovable: a DO inlay in the lower second

c Cantilever: these are the two metalceramic bridges

d Occlusal view of the bridges in place.

e Spring cantilever: the first molar tooth is the

An unsatisfactory design for a fixedfixed bridge.

A conventional fixedfixed bridge should have all the

a A conventional bridge with an MOD gold inlay as the

b Acrylic burn out patterns for movable connectors.

c and d A minimum-preparation fixedmovable bridge.

c Shows the minor retainer in place with a depression,

d Shows the finger from the pontic resting on the

a All-ceramic cantilever bridges. The lateral incisor

b and c A minimum-preparation cantilever bridge

d A similar cantilever bridge but this time retained by

A large splint/bridge with cantilevered pontics.

a The working dies.

b The metal framework, showing two cantilevered

c The completed restoration in the mouth

design, which is shown in Figure 8.3c and d, is to Cantilever bridge

A hybrid bridge with a conventional retainer (an inlay in the premo-

Fixedmovable with the minimum-preparation

Typical temperature ranges for the metalceramic

Ceramic only fracturing if the bridge receives a blow. It is not

COMPARISON OF CONVENTIONAL BRIDGE DESIGN

COMPARISON OF MINIMAL-PREPARATION BRIDGE DESIGNS

a This patient presented with periodontal disease and

b it was decided that the prognosis was hopeless and

A Rochette bridge replacing one central incisor. The

An all-metal retainer (a crown or minimum- abutment for a metalceramic crown would be

a A scanning electron micrograph (SEM) of a cast

b An SEM of a cast nickelchromium metal surface

Types of minimum-preparation tooth. This can often be done as a simple and

increase strength, but this is not always neces- Advantages of minimum-preparation

Materials Figure 9.1b shows an example of where a distal-

The appearance of retainers.

a The canine tooth has a partial crown retainer that is

b The upper canine tooth has an extensive incisal wear

c The upper central incisors both have minimum-

Non-parallel abutment teeth. It would not be possible

The strength of metalceramic pontics.

a The central incisor pontics in this case have no metal

b When the palatal reduction of the abutment teeth is

The surfaces of a pontic is required for functional purposes rather than

This surface of the pontic is the most difficult to

The four designs of pontic ridge surface.

a A wash-through pontic with a concave mesio-distal

b and c Dome-shaped pontics. b A molar dome-shaped

d and e Ridge-lap pontics. d This bridge has been satis-

f Typical ridge-lap pontics on another failed bridge.

g Saddle-shaped pontics with well-contoured, cleans-

a Mucous membrane reactions under pontics. This area

b A much more serious case, with ulceration and a

Well-contoured open embrasure spaces.

Sections through both the lateral incisor areas of the

Buccal ponticridge relationships.

a A pontic replacing an upper canine, where the neck

b The same compromise has not been made with this

The occlusal surface connector and the gingival tissue be as open as

An acceptable appearance for a bridge or is there

Creating a fixedfixed design with non-parallel

a The central incisor could not be retracted sufficiently

b and c The bridge is made in two parts with separate