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Issue

April 2004 (Vol. 48, Issue 2)


Fixed Prosthodontics
Guest Editor: J.R. Agar and T.D. Taylor

Table of contents
pages v-ix
PDF (33 KB)
Forthcoming issues
page x
PDF (21 KB)
Preface
Fixed prosthodontics
Agar JR, Taylor TD
pages xi-xii
Full Text | PDF (142 KB)
Review article
Advances in color matching
Brewer JD, Wee A, Seghi R
pages 341-358
Full Text | PDF (462 KB)
Review article
Designing tooth preparations for optimal success
Goodacre CJ
pages 359-385
Full Text | PDF (1072 KB)
Review article
Resistance form in tooth preparation
Parker M H
pages 387-396
Full Text | PDF (214 KB)
Review article
Restoration of endodontically treated teeth
Morgano SM, Rodrigues AHC, Sabrosa CE
pages 397-416
Full Text | PDF (571 KB)
Review article
Cervical margin design with contemporary esthetic restorations
Donovan TE, Chee WWL
pages 417-431
Full Text | PDF (486 KB)
Review article
Current concepts in gingival displacement
Donovan TE, Chee WWL
pages 433-444
Full Text | PDF (347 KB)
Review article
A review of contemporary impression materials and techniques
Donovan TE, Chee WWL
pages 445-470
Full Text | PDF (623 KB)
Review article
Jaw relation records for fixed prosthodontics
Squier RS
pages 471-486
Full Text | PDF (507 KB)
Review article
Interim restorations
Gratton DG, Aquilino SA
pages 487-497
Full Text | PDF (201 KB)
Review article
Casting alloys
Wataha JC, Messer RL
pages 499-512
Full Text | PDF (232 KB)
Review article
Dental ceramics: current thinking and trends
Robert Kelly J
pages 513-530
Full Text | PDF (262 KB)
Review article
Contemporary all-ceramic fixed partial dentures: a review
Raigrodski AJ
pages 531-544
Full Text | PDF (368 KB)
Review article
Fiber-reinforced composite prostheses
Freilich MA, Meiers JC
pages 545-562
Full Text | PDF (873 KB)
Index
pages 563-566
PDF (142 KB)
FIXED PROSTHODONTICS

CONTENTS

Preface xi
John R. Agar and Thomas D. Taylor

Advances in Color Matching 341


Jane D. Brewer, Alvin Wee, and Robert Seghi
Recent advances in color matching have been driven by the market
demand for high-quality esthetic restorations. Improved shade
guides, availability of shade-taking devices, and research in the
area of human color vision have improved the potential of clini-
cians to achieve excellent color-matched restorations. A thorough
understanding of appearance attributes of natural teeth is required
along with these new tools to maximize shade-matching results.

Designing Tooth Preparations for Optimal Success 359


Charles J. Goodacre
The form of prepared teeth and the amount of tooth structure re-
moved are important contributors to the mechanical, biologic,
and esthetic success of the overlying crown or fixed partial denture.
Therefore, it is important to develop clinical guidelines that can be
used to optimize success in fixed prosthodontics.

Resistance Form in Tooth Preparation 387


M. Harry Parker
Theoretical and clinical studies of resistance form are reviewed,
supporting the basic prosthodontic principle that resistance form
is an essential element in preparation design. Concepts of the
"on-off" nature of resistance form, its application in guidelines for
minimally acceptable preparation taper, and the controversy over
whether there is a relationship with clinical success or failure are
discussed. It is more challenging to obtain resistive molar prepara-
tions than resistive anterior preparations, and uneven preparation
margins can make parallel 0( taper preparations lack resistance
form. The usefulness of grooves, especially in molar preparations

VOLUME 48 NUMBER 2 APRIL 2004 v


with uneven margins, is illustrated. The Lewis and Zuckerman
techniques for evaluating resistive areas of a preparation are shown
to be consistent with each other but not with the Weed method.

Restoration of Endodontically Treated Teeth 397


Steven M. Morgano, Antonio H.C. Rodrigues, and Carlos
Eduardo Sabrosa
Endodontically treated teeth have lost substantial tooth structure
as a result of previous restorations, dental caries, and the access
preparation for the endodontic therapy. The topic of restoring these
teeth is complex and controversial, and their long-term prognosis is
directly connected to the quality of the final restoration. This article
describes contemporary knowledge of the biomechanical principles
related to the restoration of pulpless teeth and provides a critical
review of currently available materials and methods.

Cervical Margin Design with Contemporary Esthetic


Restorations 417
Terry E. Donovan and Winston W.L. Chee
The contemporary dentist has a wide variety of options to use in
the restoration of extensively damaged or previously restored
teeth. Metal-ceramic and all-ceramic crowns are frequently used to
restore esthetics and function. One of the essentials for success with
either option is proper tooth preparation, which includes proper
selection and preparation of the cervical margin of the preparation.

Current Concepts in Gingival Displacement 433


Terry E. Donovan and Winston W.L. Chee
Gingival displacement is an important procedure with fabricating
indirect restorations. Gingival displacement is relatively simple
and effective when dealing with healthy gingival tissues and when
margins are properly placed a short distance into the sulcus.
Several techniques have proven to be relatively predictable, safe,
and efficacious. No scientific evidence has established the supe-
riority of one technique over the others, so the choice of tech-
nique depends on the presenting clinical situation and operator
preference.

A Review of Contemporary Impression Materials and


Techniques 445
Terry E. Donovan and Winston W.L. Chee
The contemporary restorative dentist has a host of impression
materials available for making impressions in fixed prosthodontics,
implant dentistry, and operative dentistry. With proper material
selection and manipulation, accurate impressions can be obtained
for fabrication of tooth- and implant-supported restorations. This

vi CONTENTS
article outlines the ideal properties of impression materials and
explains the importance of critical manipulative variables. Avail-
able impression materials are analyzed relative to these variables,
and several "specialized" impression techniques are described. Spe-
cial attention is paid to polyvinyl siloxane impression materials be-
cause they have become the most widely used impression material
in restorative dentistry.

Jaw Relation Records for Fixed Prosthodontics 471


Rachel S. Squier
This article discusses and reviews general principles of jaw relation
records, including the purpose of a jaw relation record and the
concept of a tripod of vertical support with adequate horizontal
stability to allow opposing dental casts to be mounted accurately
on an articulator. The use of the maximum intercuspal position
for the vast majority of patients is favored when the goal of restora-
tive treatment is to maintain a patients pretreatment intercuspa-
tion and vertical dimension of occlusion. In addition, articulator
choice, purpose of a facebow, and materials for jaw relation records
are discussed. Common errors in making impressions, pouring im-
pressions, mounting casts, and making interocclusal records are
elucidated, providing the practitioner important information with
which to avoid inaccuracies that may lead to additional time spent
making intraoral occlusal adjustments at the insertion of fixed
restorations.

Interim Restorations 487


David G. Gratton and Steven A. Aquilino
Interim restorations are a critical component of fixed prosthodontic
treatment, biologically and biomechanically. Interim restoration
serves an important diagnostic role as a functional and esthetic
try-in and as a blueprint for the design of the definitive prosthesis.
When selecting materials for any interim restoration, clinicians
must consider physical properties, handling properties, patient
acceptance, and material cost. Although no single material meets
all the requirements and material classification alone of a given
product is not a predictor of clinical performance, bis-acryl materi-
als are typically best suited to single-unit restorations, and poly
(methylmethacrylate) interim materials are generally ideal for
multi-unit, complex, long-term, interim fixed prostheses. As with
most dental procedures, the technique used for fabrication has a
greater effect on the final result than the specific material chosen.

Casting Alloys 499


John C. Wataha and Regina L. Messer
Although the role of dental casting alloys has changed in recent
years with the development of improved all-ceramic materials
and resin-based composites, alloys will likely continue to be critical

CONTENTS vii
assets in the treatment of missing and severely damaged teeth. Al-
loys have physical, chemical, and biologic properties that exceed
other classes of materials. The selection of the appropriate dental
casting alloy is paramount to the long-term success of dental pros-
theses, and the selection process has become complex with the de-
velopment of many new alloys. However, this selection process is
manageable if the practitioner focuses on the appropriate physical
and biologic properties, such as tensile strength, modulus of elasti-
city, corrosion, and biocompatibility, and avoids dwelling on the
less important properties of alloy color and short-term cost. The
appropriate selection of an alloy helps to ensure a longer-lasting
restoration and better oral health for the patient.

Dental Ceramics: Current Thinking and Trends 513


J. Robert Kelly
Dental ceramics are presented within a simplifying framework al-
lowing for understanding of their composition and development.
The meaning of strength and details of the fracture process are
explored, and recommendations are given regarding making struc-
tural comparisons among ceramics. Assessment of clinical survival
data is dealt with, and literature is reviewed on the clinical behavior
of metal-ceramic and all-ceramic systems. Practical aspects are pre-
sented regarding the choice and use of dental ceramics.

Contemporary All-Ceramic Fixed Partial Dentures: A


Review 531
Ariel J. Raigrodski
High-strength all-ceramic systems for fixed partial dentures (FPDs)
have become available for replacing missing teeth. New core mate-
rials have been developed and have evolved in the last decade,
with yttrium tetragonal zirconia polycrystals (Y-TZP)-based mate-
rials being the most contemporary. With the emphasis on the use
of computer-assisted design/computer assisted-manufacturing
technology, various production techniques have been developed
for enhancing the fabrication of consistent and predictable restora-
tions in terms of strength, marginal fit, and esthetics. Although in-
itial results are limited, results reported in scientific abstracts of
ongoing clinical studies assessing the long-term success of three-
unit all-ceramic FPDs and anecdotal evidence published in peer-
reviewed articles on the use of Y-TZP-based restorative systems
are encouraging. This article reviews the evolution and develop-
ment of materials and technologies for all-ceramic FPDs.

Fiber-Reinforced Composite Prostheses 545


Martin A. Freilich and Jonathan C. Meiers
Metal-free prosthetic dentistry continues to gain interest. Although
the metal alloys contribute great strength and stiffness to restora-
tions and prostheses, they do so at a considerable esthetic liability.

viii CONTENTS
Two somewhat divergent metal-free approaches to fixed tooth
replacement continue to be developed for a variety of clinical ap-
plications. These are all-ceramic and all-polymeric systems. The
polymeric prostheses are the subject of this article.

Index 563

CONTENTS ix
FORTHCOMING ISSUES

July 2004
Removable Prosthodontics
John R. Agar, DDS, MA, and
Thomas D. Taylor, DDS, MSD, Guest Editors

October 2004
Lasers in Practice
Robert A. Convissar, DDS, and
Donald J. Coluzzi, DDS, Guest Editors

January 2005
Soft Tissue Lesions
Thomas P. Sollecito, DMD, Guest Editor

RECENT ISSUES

January 2004
Modern Endodontic Practice
Syngcuk Kim, DDS, MPhil, PhD, MD(hon),
Guest Editor

October 2003
Infections, Infectious Diseases and Dentistry,
Part II
Michael Glick, DMD, Guest Editor

July 2003
Infections, Infectious Diseases and Dentistry,
Part I
Michael Glick, DMD, Guest Editor

THE CLINICS ARE NOW AVAILABLE ONLINE!

Access your subscription at:


http://www.TheClinics.com
Dent Clin N Am 48 (2004) xixii

Preface

Fixed Prosthodontics

John R. Agar, DDS, MA Thomas D. Taylor, DDS, MSD


Guest Editors

Current patient expectations for xed prosthodontic restorations reect a


cultural change in our society that places increased emphasis on youth and
physical appearance. Patients want enhanced esthetics. The progressive
practice oers state-of-the-art dentistry including excellent esthetics but can-
not aord to have a large proportion of premature xed prosthodontic fail-
ures. Short-term cosmetic results are relatively easy to evaluate; however,
clinical durability of new products is dicult to predict. Dentists have the
challenge of satisfying patient desires for maximum esthetics while ensuring
that the function and durability of costly restorations meet patient needs
and professional standards.
Numerous new materials, devices, and techniques are available, and more
are continually being introduced. They are promoted as esthetic, durable,
and functional by eective marketing programs that are often premature.
Companies and their representatives sometimes exaggerate the limitations
of traditional care. Research associated with new materials and devices sup-
ported by industry may not be free of bias. In vitro studies do not simulate
in vivo conditions, and scientically sound clinical studies are extremely dif-
cult to conduct. Evidence-based dentistry has become popular, but den-
tistry struggles to nd ways to conduct valid scientic research.
The goal of this Dental Clinics of North America is to present and discuss
traditional and new xed prosthodontic techniques, materials, and devices.
The articles have been organized to provide suggestions for obtaining supe-
rior results with established procedures and advantages associated with new
products. Each article has been written by experts in the particular subject

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2004.01.002
xii J.R. Agar, T.D. Taylor / Dent Clin N Am 48 (2004) xixii

area. We hope you will learn and that you enjoy reading the articles in this
symposium as much as we did when we reviewed them.

John R. Agar, DDS, MA


Thomas D. Taylor, DDS, MSD
Department of Prosthodontics and Operative Dentistry
University of Connecticut Health Center
School of Dental Medicine
263 Farmington Avenue
Farmington, CT 06030-1615, USA
E-mail addresses: agar@nso2.uchc.edu; ttaylor@nso.uchc.edu
Dent Clin N Am 48 (2004) 341358

Advances in color matching


Jane D. Brewer, DDS, MSa,*, Alvin Wee, BDS, MSb,c,
Robert Seghi, DDS, MSb
a
Department of Restorative Dentistry, School of Dental Medicine, State University
of New York at Bualo, 3435 Main Street, Bualo, NY 17214, USA
b
Department of Restorative and Prosthetic Dentistry, College of Dentistry,
The Ohio State University, 305 West 12th Avenue, Columbus, OH 43218-2357, USA
c
Arthur James Cancer Hospital, 300 West 10th Avenue, Columbus, OH 43210, USA

There have been a number of recent technologic and materials advances


that oer the potential to improve color-matching skills in prosthetic and
restorative dentistry. Although the dental profession has been aware of
shortcomings in shade guides and corresponding materials for decades, it is
probably the current media-driven emphasis on appearance and an esthetic
standard that is primarily responsible for pushing product development
forward. Signicant advances in dental porcelains, resins, bonding chemistry,
and cements have accompanied developments in color measurement optics to
create a marketplace that is exciting and at times overwhelming.
Continued research on the human visual system has given us greater
insight into how color discrimination is aected by our environment and by
disease, drug therapy, and normal aging. Over the last two decades,
a number of laboratory and clinical investigations of instrumental color
measurement have been published [19], and visual thresholds of color
difference perceptibility and acceptability have been established [1012].
The clinical focus of color matching in prosthodontics is the beginning
and the end (ie, shade selection and evaluation of the nal result), but the
overall color replication process is more complicated than these isolated
procedures suggest. The shade duplication phase encompasses many
variables that can have isolated or cumulative negative eects on the nal
outcome. Variables that have been investigated include restoration thickness,
type of crown substrate and veneer material choice, ring temperature and
frequency, and technical skill [1319]. An accurate initial shade selection does
not necessarily lead to an acceptably matched nal restoration.

* Corresponding author. 6435 Webster Road, Orchard Park, NY 14127.


E-mail address: brewer@buffalo.edu (J.D. Brewer).

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2004.01.004
342 J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358

Nature of color
Color is all about light. For color to be seen, light is reected from an
object and stimulates the neural sensors in the eyes retina to send a signal
that is interpreted in the visual cortex of the brain. There are numerous
possibilities along this pathway for altering the nal registration.

Light
Natural white lightdaylightis sunlight reected back from the sky. It
falls between 380 and 770 nm along the electromagnetic spectrum and is
a mixture of component bands containing a continuous contribution from
radiation of each wavelength between these limits. The component bands
produce six dierent sensations (red, orange, yellow, green, blue, violet), but
there are an innite number of gradations, and the boundaries between
component bands are not exact; rather, the colors merge into one another
[20]. Light sources, or illuminants, may be decient in some wavelengths and
therefore be colored themselves.
Object color is dependent on the illuminant in which it is viewed. If
incident light does not contain a particular wavelength segment, the object
cannot reect it. In the achromatic range there are an innite number of
grays that are produced by objects that are nonselective in their
reectance. Colorants, either pigments or dyes, are responsible for
chromatic reection of light. The chemical composition of a colorant makes
it selectively absorb more of one part of the visible spectrum than another.
When a particular wavelength segment of light is reected and enters the
eye, the sensation of color is produced.

Perception
As light enters the eye through the cornea and lens, an image is focused
on the retina. The amount of light entering the eye is controlled by the iris,
which dilates or constricts depending on the level of illumination. Retinal
sensors are positioned to take advantage of this focusing of light. Rods
outnumber cones approximately 19 to 1, are scattered broadly throughout
the retina, and respond to very low light intensity. These sensors are for
registering lightness only. There are three types of cones, sensitive to red,
green, or blue wavelength bands. The distribution of cones is limited
primarily to the fovea centralis, a small area in the center of the retina where
there are no rods. In the area immediately surrounding the fovea, there is
a mixture of both sensors. It is thought that this mixture, unique to each
individual, is responsible for dierences in color discrimination among
observers with normal color vision [20]. The accuracy of color perception
depends on the area of retinal eld stimulated by light. In high illumination,
the pupil narrows, directing light to that small area of the retina where the
cones are located. When light is dim, the pupil widens, and much more of
J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358 343

the retina is exposed, stimulating sensors that are less accurate. As


a regulator of pupil diameter, light intensity is therefore a critical factor
in color perception and shade matching [21,22].
As the eyes scan a scene during normal observation, there is a rapid
and continuous change in chromatic sensitivity that inuences color
perception. The most important of these phenomena that come into play
during color matching are successive contrast, simultaneous contrast, and
color constancy. Successive contrast is the projection of a negative after
image (complementary color) that occurs after staring at a colored object.
Simultaneous contrast is an instantaneous change in chromatic sensitivity
characterized by a change in appearance of hue due to surrounding colors.
Color constancy occurs because we think of objects themselves as being
colored, so that an object seems to be the same color even if the light
received by the eye varies considerably [2325].

Color vision confusion


There are two general categories of color vision confusion (CVC): genetic
and acquired. Genetic CVC is commonly referred to as color blindness
and aects approximately 8% of males and up to 2% of females. The
genetic defect can be an absence of cone type(s), a shift in spectral
sensitivity, or a loss of color-dierence signals [22,24]. These individuals
suffer from a reduction in or absence of discrimination of the reddish-
greenish or bluish-yellowish contents of colors. Absence of all color
discrimination is rare.
Acquired CVC aects everyone and is not necessarily constant. There are
many causes. Emotion aects papillary diameter, and with aging comes
a yellowing of the cornea that aects blue and purple discrimination. En-
vironmental exposure to cigarette smoke, sun, and lasers can have adverse
aects. There are a number of chronic diseases that can have signicant
aects on color perception as well. Diabetes, glaucoma, leukemia, Addison
disease, pernicious anemia, sickle cell anemia, multiple sclerosis, Parkinson
disease, liver disease, and alcoholism have been shown to compromise color
vision [21].
Some of the medications used to treat the above conditions aect some
part of the visual system, leading to CVC. There are many common drugs
that can signicantly aect ones ability to distinguish colors, including
analgesics, antibiotics antihypertensives, sildenal citrate (Viagra), and oral
contraceptives. Because of the number and variety of over-the-counter and
prescription drugs, the risk of medication-related CVC is widespread [21,22].

Color organization and specication


Its three-dimensional nature makes it possible to pinpoint a specic color
in a coordinate system that denes a color solid, and there are many systems
344 J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358

designed for the specication of color. How a person is involved in the use of
color determines which system is preferred. There are two such systems that
are widely used in dentistry. In the Munsell System, the three-color
attributes are Hue, Chroma, and Value. Hue is the attribute of color
perception by means of which an object is judged to be red, yellow, green,
etc. and is tied to a specic spectral wavelength band. Chroma refers to the
depth or purity of the hue and is commonly referred to as saturation. It can
be thought of as a measure of how dierent the color is from gray [25].
Value is the luminous dimension referred to as lightness of an object
appearance and is completely separate from the chromatic attributes of hue
and saturation.
Although these attributes can be designated numerically and the ranges
for tooth color have been well established, they are more often referred to in
descriptive and relative terms. We refer to Hue nominally (ie, red, green,
blue, etc.). When comparing a target color to a standard (tooth to shade
tab), a shift toward another Hue is described. Natural teeth lie in the yellow-
red area of the color solids, so the shifts are generally toward red or
yellow, or the Hue is described as more yellowish or more reddish. Chroma
is either higher or lower, or more or less, because it is descriptive of
intensity. Value can be higher or lower, or lighter or darker, because it is an
achromatic quality and can be thought of as the amount of light that is
reected to the eye.
When color is measured and specic color dierences are identied, the
CIELAB system is frequently used. It is a nearly uniform color space whose
three coordinates dene lightness, red-green chromaticity, and yellow-blue
chromaticity. This is the most popular means of dening the color of solid
objects and is based on the Commission Internationale de lEclairage (CIE)
1976 L*a*b* uniform color space. In 1931 the CIE dened a standard
observer by a set of three functions x(k)y(k),z(k). These were carefully
prescribed spectral sensitivity curves designed to model the blue-, green-,
and red-sensitive cone receptors of the eye, respectively. These functions are
key to the transformation of spectral energy data into meaningful color
data [26].

Visual shade-matching environment


Recommended environmental conditions for color matching have
changed little since the early 1970s, except perhaps with regard to
illuminants. The light source is critically important because of its inuence
on the quality and intensity of light reaching the teeth to be matched.
Although we traditionally have sought natural daylight as the best color-
matching light source, it is not dependable because of its variable color
temperature, which inuences its spectral composition, and its inconsistent
intensity due to varying cloud cover and atmospheric pollutants.
J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358 345

The benets of performing color matching under controlled standard


full-spectrum illumination have been reported [27]. Controlled lighting
sources in the dental operatory and laboratory should be spectrally balanced
in the visible range (380780 nm) and should have a color temperature of
approximately 5500 K and a Color Rendering Index of [90 [28]. A number
of lighting manufacturers supply bulbs that meet these requirements.
The quantity of light is important for optimum comfort and work
eciency. However, the intensity of the dental operatory lighting may not
be critical for color matching [29]. Nonetheless, traditional recommenda-
tions for ambient lighting are a reasonable guide for establishing a comfort-
able environment: 200 to 300 footcandles (fc) in the operatory and 300 fc in
the dental laboratory [30].
It may be helpful to use an auxiliary light source that provides the
appropriate spectral balance and diuse illumination and is bright enough
to overcome the eects of ambient illumination. A 3:1 ratio of task-to-
ambient light has been recommended [28]. The intensity should be
comfortable to the eyes; too much compromises the ability to discriminate
small color differences. A number of hand-held lights are available,
including the Shade Wand (Authentic Products, San Antonio, Texas) and
the Hand Held (Greatlakeslighting, Bay City, Michigan). A prototype, the
Shademat Visual, has recently been evaluated and was found to improve
visual shade matching [31]. The operatory ceiling, walls, counter tops, and
cabinets are reectors that contribute to the intensity and color of the
ambient lighting and therefore should have a high Munsell Value and low
Chroma [28]. Pastels and neutral grays have been suggested for walls, staff
clothing, and patient napkin or drape.
Certain practical guidelines should be followed when selecting shades
visually [32]. The patient should be in an upright position with the mouth at
the dentists eye level. Lipstick should be removed, and a neutral patient
drape should cover colorful clothing. The teeth should be slightly apart and
the tongue retracted. The shade tab should be in the same plane as the tooth.
Shade selection should take place before any intraoral procedure that
dehydrates the teeth, signicantly altering their appearance. The value
dimension should be selected rst, so it is helpful to have a guide whose tabs
are arranged from light to dark for an initial quick scanning. This can be
done with squinted eyes to decrease the amount of light entering the eye so
that the rods are activated for light-dark discrimination. Rapid chromatic
comparisons of less than 5 seconds help avoid cone fatigue. Although it may
help to look away at an achromatic surface (eg, neutral gray) to replenish
the photopigments of the cones, gazing at a blue surface does not heighten
yellow sensitivity as was once thought but distorts it [33].
If having trouble determining Hue, one should reference the natural
canine, which is of higher chroma so the dominant hue is more apparent.
Once a choice has been made, it should be veried under other lighting
conditions, with the patient standing, at dierent viewing angles, and with
346 J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358

the lip retracted and draped naturally. It is helpful to have a second observer
stand about 3 feet behind the primary observer to verify that the value
dimension is appropriate. If the tab stands out, it is most likely too high in
value (ie, too bright).
These procedures can be done at multiple appointments to conrm ones
choice. Provided one has normal color vision, shade selection can be learned
and improved with practice.

Shade guides
Shade guides that are the most widely used today have not changed much
in the last 50 years, except for the addition of a few more tab colors. In the
early 1970s, Sproull [3436] published a series of articles examining color
matching in dentistry and made sound suggestions to the profession and
manufacturers for the direction of research and product development. In the
approximately 25 years that followed, numerous studies identied addi-
tional limitations of available shade guides and porcelain formulations, and
many lecturers and authors called upon dental manufacturers to invest in
reformulation, quality control in porcelain production, and development of
logically ordered shade guides that would allow for proper orientation
within the color space of natural teeth. By identifying the color attributes of
natural tooth and shade guide colors, it was possible to determine that
manufacturers shade guides did not adequately cover the color space
occupied by natural teeth [3739].
Signicant advances in shade guide organization and coverage of natural
tooth color space are coming to the marketplace. An example is the Vitapan
3D-Master Shade System (Vita Zahnfabrik, Bad Sackingen, Germany).
According to the manufacturer, this shade system provides a systematic
arrangement of virtually all existing natural tooth shades, and it has
been determined that the order of color dimensions in this guide is adequate
[40]. Based on spectrophotometric measurements of natural teeth, the shade
guide is organized so that it covers the three-dimensional natural tooth color
space in logical, visually equidistant order. Rather than grouping the shades
by Hue, as in the Vita Classical (Vita Zahnfabrik) and Chromascop (Ivoclar
Vivodent, Amherst, New York) guides, the tabs are arranged in ve clearly
discernible value levels (Figs. 13). Within each level are tabs that represent
different chromas and hues. The ve levels cover that area of the CIELAB
color solid occupied by natural teeth, with approximately 50% of natural
tooth shades occupying the middle value level. The lightest value level has
only two chroma steps of a single hue, and the darkest value level has three
chroma steps of one hue. About 2% of natural teeth occupy these outer
levels. Groups 2, 3, and 4 have three chroma levels of the middle and orange
hue, and two chroma levels in each hue shift toward yellow or red. The
sequence of shade selection is value, then chroma, followed by hue. The way
J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358 347

Fig. 1. Vitapan 3D-Master shade guide.

the shades are formulated allows for one visually perceptible step between
value levels. Unique to this system is the possibility of selecting this in-
between shade; powders can be mixed to achieve it with predictability. There
are no visually perceptible steps between chroma levels of each hue.

Shade-taking devices
These devices have been designed to aid clinicians and technicians in the
specication and control of tooth color. The earliest color-measuring device

Fig. 2. Vita Lumin shade guide.


348 J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358

Fig. 3. Chomascop shade guide.

designed specically for clinical dental use was a lter colorimeter. The
Chromascan (Sterngold, Stamford, Connecticut) was introduced in the early
1980s but enjoyed limited success due to its inadequate design and accuracy
[41,42]. Further development was hindered primarily by lack of resources
and commitment on industrys sidethe market was too small. Now, with
esthetics as a major focus of dental marketing and with the availability of
improved color-measuring optics, companies are willing to make the
investment required to apply advanced technology to the challenge of shade
control.

Basic design
All color-measuring devices consist of a detector, signal conditioner,
and software that process the signal in a manner that makes the data
usable in the dental operatory or laboratory. Because of the complex rela-
tionship between these elements, accurate colorimetric analysis is dicult
at best.

Colorimeters
Filter colorimeters generally use three or four silicon photodiodes that
have spectral correction lters that closely simulate the standard observer
functions. These lters act as analog function generators that limit the
spectral characteristics of the light that strikes the detector surface. The
inability to exactly match the standard observer functions with lters while
retaining adequate sensitivity for low light levels is the reason that the
absolute accuracy of lter colorimeters is considered inferior to scanning
devices such as spectrophotometers and spectroradiometers. However,
because of their consistent and rapid sensing nature, these devices can be
precise with dierential measurements. This is why they often are used for
quality control.
J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358 349

Digital cameras as lter colorimeters


The newest devices used for dental shade matching are based on digital
camera technology. Instead of focusing light upon lm to create a chemical
reaction, digital cameras capture images using CCDs, which contain many
thousands or even millions of microscopically small light-sensitive elements
(photosites). Like the photodiodes, each photosite responds only to the total
light intensity that strikes its surface. To get a full color image, most sensors
use ltering to look at the light in its three primary colors in a manner
analogous to the ltered colorimeter described previously. There are several
ways of recording the three colors in a digital camera. The highest-quality
cameras use three separate sensors, each with a dierent lter over it. Light
is directed to the dierent lter/sensor combinations by placing a beam
splitter in the camera. The beam splitter allows each detector to see the
image simultaneously. The advantage of this method is that the camera
records each of the three colors at each pixel location.

Spectrophotometers and spectroradiometers


Spectrophotometers and spectroradiometers are instruments designed to
produce the most accurate color measurements. Spectrophotometers dier
from spectroradiometers primarily because they include a stable light
source. There are two types of basic designs commonly used for these
instruments. The traditional scanning instrument consists of a single
photodiode detector that records the amount of light at each wavelength.
The light is divided into small wavelength intervals by passing through
a monochromator. A more recent design uses a diode array with a dedicated
element for each wavelength. This design allows for the simultaneous
integration of all wavelengths. Both designs are considerably slower than
lter colorimeters but remain the tools that are required to examine and
develop accurate color-measuring devices.

Currently available devices


There are at least six commercially available systems, ranging from
simple to complicated, with capabilities and prices to match. The devices are
generally one of three typescolorimeters, spectrophotometers, or digital
color analyzersand use various measuring geometries (Table 1).
Shofus Shade NCC (Natural Color Concept) Chroma Meter (Shofu
Dental, Menlo Park, California) has been available since the 1990s (Fig. 4).
It consists of a freestanding, hand-held contact probe that is about 3 mm in
diameter. The probe is placed against the tooth, and an activation button is
pushed. This sends a ash of light to the tooth, from the periphery of the
probe, and the reected light is transported through the center of the probe
to the detector where the collected light is evenly distributed through color
lters that closely match the three standard observer functions. Data are
350 J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358

Table 1
Shade-taking devices
Approximate
System Manufacturer Type cost
ShadeEye Shofu Dental Corp., Colorimeter $7000
San Marcos, CA
EasyShade Vident, Brea, CA Spectrophotometer $5500
ShadeScan Cynovad Inc., Montreal, Digital color $6000
Quebec, Canada imaging/colorimeter
ShadeVision X-Rite Inc., Digital color $6000
Grand Rapids, MI imaging/colorimeter
SpectroShade MHT, Niederhasli, Digital color imaging/ $15,000
Switzerland spectrophotometer
ClearMatch Smart Technology, Software only (to be $3000
Hood River, OR used with digital camera)

transmitted to the docking unit via an infrared signal. There is a database of


porcelain samples stored in memory, and the closest match of the target with
the stored data is presented. A readout is generated that includes the tooth
number; the closest Vita Lumin shade guide designation; and specic
opaque, body, and enamel powders. Although the ShadeEye was developed
for use with the Vintage Halo Porcelain system (Shofu Dental), updated
software versions reference other popular porcelains as well.
The Vita Easyshade (Vident, Brea, California) is a hand-held spectro-
photometer that consists of a handpiece connected to a base unit by

Fig. 4. Shade Eye NCC.


J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358 351

Fig. 5. Vita Easyshade.

a monocoil beroptic cable assembly (Fig. 5). The contact probe tip is
approximately 5 mm in diameter. It contains 19 1-mm-diameter beroptic
bundles. During the measurement process, the tooth is illuminated by the
periphery of the tip, directing the light from a halogen bulb in the base unit
into the tooth surface. There are several spectrometers in the hand piece that
monitor the light source and measure the internally scattered light. A
combination of various lters and photodiode arrays receive the light as it is
directed through the return bers located in the center of the probe tip.
Through this arrangement, spectral reectance of the scattered light is
essentially measured in 25 nm bandwidths. Before measurement, it is
necessary to select a measurement mode (tooth, crown, or shade tab). The
display presents the closest Vita shade in the classical or 3D shade guide
designation.
The rst system to combine digital color imaging with colorimetric
analysis was introduced by Cynovad (Saint-Laurent, Canada). The
ShadeScan is a hand-held device with a color LCD screen to aid in image
location and focus (Fig. 6). Through a beroptic cable, a halogen light
source illuminates the tooth surface at a 45 angle and collects the reected
light at 0 . Light intensity and calibration to gray and color standards are
continuously monitored and adjusted to provide consistent color re-
production. The image is recorded on a ashcard, obviating the need for
a computer in the operatory. The transmitted data can be downloaded to
a computer with the ShadeScan software. Shade and translucency mapping
can therefore be transmitted to the dental laboratory by e-mail or by
including a printout or ashcard with the clinical items required for
restoration fabrication. Surface shade mapping with the standard software
352 J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358

Fig. 6. ShadeScan.

is in basic Vita Lumin shade designations. Higher-resolution shade


mapping, additional shade guide designation conversions, and Hue/Value
Chroma values are possible with additional software for dental laboratories.
Another instrument that combines digital color analysis with colorimetric
analysis is the ShadeRite Dental Vision System (X-Rite Inc., Grand Rapids,
Michigan). It consists of a hand-held device with its own light source, and
an LCD screen facilitates positioning on the tooth (Fig. 7). To focus and
align the camera, a glare spot must be located at the junction of the
gingival and middle thirds of the tooth. Measurements are taken through
a series of rotating lters that simulate the CIE standard observer functions.
The device is freestanding and is placed in its docking station for calibration
and data transmission to the computer. Shade and translucency mapping
are possible, and colorimetric data (CIE L*a*b* values) can be downloaded
from the computer. The laboratory must have the required software.
The SpectroShade (MHT, Niederhasli, Switzerland) is the dental shade-
taking device most complex in design and is the most cumbersome in terms
of hardware. It oers the most exibility in terms of color analysis and
colorimetric data and is by far the most expensive (Fig. 8). It is the only one
that combines digital color imaging with spectrophotometric analysis. The
handpiece is relatively large compared with the contact probe designs, and
positioning can be tricky. Calibration is a two-step process involving
positioning the handpiece against white and green tiles. Light from a halogen
source is delivered through ber optic bundles and lenses to the tooth
surface at 45 . The image of the tooth is displayed on the computer screen so
that positioning can be veried. The incident light is monochromated as it
strikes the tooth, and as it is reected back the spectral scanning process is
completed at 10-nm bandwidths by a black and white and a color-ltered
CCD. Because there is a spectral curve associated with each pixel of the
CCD, a signicant amount of data are generated for analysis. Color
differences can be calculated between compared images, and shade maps of
J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358 353

Fig. 7. ShadeRite Dental Vision System.

increasing complexity and one for translucency are possible. The software
contains shade guide references for most porcelain systems, and more can be
added. The closest shade and the magnitude of the color difference from
that reference are specied. A digital image of the tooth, the shade mapping,
and the colorimetric data can be transmitted to the laboratory electronically
or by printout.
A dierent approach to digital color matching is achieved with the
ClearMatch System (Smart Technology, Hood River, Oregon). This is
a software system that requires a Window platform PC and a digital camera.
To properly calibrate the digital color signal, a black and white standard
and a shade tab must be included in each photograph. Detailed shade
mapping is provided in shade guide designations, and standard and custom
shade tab information can be entered into the system database. Because this
system is software only, it is the most reasonably priced.

Limitations
There are a number of limitations common to all of these systems, and
for the most part they stem from the nature of what is being measured (ie,
translucent structures). Accuracy of color measurement is aected by the
354 J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358

Fig. 8. Spactroshade.

phenomenon of edge loss, which occurs because of light lost primarily


through the translucent tooth and ceramic enamel layers. Although
algorithms are incorporated into the software to accommodate for the
dierent light scattering properties in teeth, crowns, and shade tabs, it is
dicult to compensate totally, and this can be a signicant source of error.
Translucency mapping is inadequate with all of the systems. The
replication of tooth translucency remains the most challenging aspect of
matching the appearance of a natural tooth. The transfer of this three-
dimensional quality to a two-dimensional map provides little benet.
Systems that incorporate digital imaging have the best chance because
a high-quality visual is the best that is currently available.
Positioning of the probe or mouthpiece seems to be critical to the
repeatability of the measurement. In addition, any device that uses a small-
diameter contact probe is limited because it cannot give detailed mapping of
color on the surface; only a general base shade of the limited area measured.
The larger mouthpieces are limited to measurements of anterior teeth
because of access.
J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358 355

The accuracy of the target shade obtained from the measurement is only
as good as the database and its distribution of references shades. The
readout provides the shade closest to the measured surface, and if the tooth
to be matched is not close in color space to a designated shade, then
a mismatched restoration results. None of the above instruments are
sophisticated enough to function in a formulation mode (ie, specifying
powders and layering to achieve the actual color designation of any tooth
color or translucency distribution measured).
For this approach to be ecient, the laboratory must have the system as
well, and indeed many commercial laboratories provide a shade-taking
service. The quality control aspect is a real advantage. The technician can
verify that the color replication process was accurate for the shade
requested, and, with the more sophisticated systems, a virtual try-in can
be accomplished. However, the research examining whether or not this
instrumental approach provides a nal result superior to conventional
shade-matching techniques is lacking. Investigations are ongoing, but there
are only a few published studies available [4347].

Shade communication
Tooth appearance information beyond a basic single-shade designation is
required when the restoration is in an esthetically prominent location. Shade
mapping, which can be accomplished visually and instrumentally, is
becoming a basic component of the work authorization. Characterization
can be located on a drawing but may be more helpful if drawn on a cast that
duplicates the size, shape, and contours of the requested restoration.
Appropriate length and incisal edge position is best communicated in this
way. An image of the selected shade tab(s) near the tooth to be restored or
matched should accompany the written order and casts. Although the color
of the image cannot be relied upon for accurate assessment or matching, the
visual appearance of translucency, characterization, and color blending is
far superior to that of a drawing. Digital images can be sent electronically or
on a CD. Discussing with the technician the preferred methods of
documenting and communicating information enhances the shade duplica-
tion process.

Summary
Media emphasis on an esthetic standard is probably responsible for
driving the most recent advances in dental imaging and shade matching.
Although we tend to focus on color matching, it is an appearance match
that we are after, so the optical properties of translucency, light scattering,
surface texture, and gloss and the basic principles of esthetics, including
356 J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358

tooth size and proportion, symmetry, outline form, and overall harmony are
just as important, if not more so, to a successful restorative match. With
more research and development it should be possible to achieve a higher
percentage of successful matches than the approximately 50% experienced
today [4851], but even with the acceleration of progress in color matching
technology, the success of a restorative effort remains dependent on
adequate tooth preparation, tissue management, and treatment planning.

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Dent Clin N Am 48 (2004) 359385

Designing tooth preparations


for optimal success
Charles J. Goodacre
Department of Restorative Dentistry, School of Dentistry,
Loma Linda University, Loma Linda, CA 92350, USA

The form of prepared teeth and the amount of tooth structure removed
are important contributors to the mechanical, biologic, and esthetic success
of the overlying crown or xed partial denture. Therefore, it is important to
develop clinical guidelines that can be used to optimize success in xed
prosthodontics.

Guidelines for tooth preparation


Total occlusal convergence
Total occlusal convergence (TOC) is the angle formed between two
opposing prepared axial surfaces (Fig. 1). An appropriate clinical goal for
TOC is 10 to 20 . Historically, it has been recommended that the TOC be
minimal, ranging between 2 and 6 [15]. There has been support for these
minimal convergence angles from research focused on pulling a crown o
a prepared tooth in a direction parallel with the long axis of the prepared
tooth [6,7]. However, resistance to lateral forces and not long-axis retention
is likely to be the determining factor in a crowns resistance to dislodgment
[810].
When retention and resistance forms were tested by cementing crowns on
metal dies, resistance testing was found to be more sensitive to changes in
the TOC than retention testing [9]. For this reason, recent testing has
focused on resistance through the use of simulated lateral forces.
The tipping resistance of crowns has been tested for teeth with TOC
angles of 10 , 16 , and 22 [9]. The teeth were similar in size to prepared
molars, and the results indicated that 22 of TOC provided inadequate
resistance. The authors concluded that 10 of TOC was not easy to produce

E-mail address: cgoodacre@sd.llu.edu

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.015
360 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385

Fig. 1. The maxillary central incisor has been prepared with minimal convergence of the mesial
and distal surfaces.

clinically, and they therefore identied 16 as the best convergence angle
among those tested. A TOC between 10 and 22 has been recommended in
a recent textbook [11].
When proposing guidelines for TOC, it is important to determine the
angles formed by students and practitioners. Dental students, general
practice residents, general practitioners, and prosthodontists do not usually
produce minimal TOC angles as have historically been recommended.
Instead, the angles range between 12 and 17 (Fig. 2) [1221]. This

Fig. 2. Posterior teeth such as this mandibular molar are usually prepared with greater TOC
than anterior teeth. This tooth has about 15 of TOC.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 361

information and the resistance testing data previously cited lend credence to
the proposal that 10 to 20 is an appropriate clinical goal.
It is important for practitioners and students to measure the convergence
angles they typically produce on various teeth and determine if the proposed
goal is routinely being achieved. Fig. 3 was developed to aid this evaluation
process. Holding a die of the prepared tooth so the axial walls of the die are
superimposed over the lines present on the drawing permits a close
approximation of the TOC.
There are a number of factors that aect the amount of TOC and
therefore make it more dicult to achieve the goal of 10 to 20 . The
preparation of posterior teeth (see Fig. 2) as opposed to anterior teeth (see
Fig. 1) often leads to greater TOC [16,17,21], as does the preparation of
mandibular teeth compared with maxillary teeth [13,17,21]. Mandibular
molars have been identied as the teeth prepared with the greatest TOC
[18,21]. One study reported greater TOC when the facial-lingual surfaces [16]
were prepared, whereas another study identied greater convergence of the
mesial-distal surfaces [21], possibly indicating that variations occur between
practitioners. Fixed partial denture abutments are generally prepared with
greater convergence than teeth prepared for single crowns [19]. The use of
one eye when viewing teeth (monocular vision) produces greater convergence
than the use of both eyes (binocular vision) [19].

Fig. 3. This diagram can be used to measure the TOC of a die by aligning the axial walls of the
die so they become superimposed over the converging lines on the diagram that mostly closely
match the axial convergence of the die.
362 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385

During clinical tooth preparation, an occlusal view is frequently used to


assess TOC. However, this view is of limited value because small dierences
in the TOC are dicult to ascertain from an occlusal view (Fig. 4). Facial or
lingual views are more valuable when evaluating occlusal convergence.
Therefore, it is recommended that TOC be assessed by evaluating the image
of the preparation(s) in a mirror.
In the presence of the factors that increase TOC beyond the recommended
10 to 20 range, it is recommended that auxiliary tooth preparation features,
such as grooves or boxes, be added to enhance the resistance of restorations
to dislodgment.

Occlusocervical/incisocervical dimension
It is proposed that anterior teeth and premolars have a minimal
occlusocervical (OC) dimension of 3 mm and that molars have a minimal
dimension of 4 mm. Critical convergence angles have been mathematically
calculated and used to identify angles beyond which a crown would
theoretically not possess adequate resistance to dislodgment [22,23].
Although the validity of such angles has been challenged [8,10], an
assessment of the resistance form of dies from clinically failed restorations
supported a relationship between convergence angles and clinical failure [24].
At 1 and 2 mm of OC dimension, the critical convergence angle
calculations indicate a molar crowns resistance to dislodgment was
inadequate unless the tooth was prepared with less than 6 and 12 of
TOC, respectively. Because it is unlikely that molars can be prepared
routinely at such minimal convergence angles, these dimensions are
inadequate for molars. A molar can possess adequate resistance when the
tooth possesses 3 mm of OC dimension and 17 or less of TOC. However,
achieving 17 also is unlikely to routinely occur on molars, making 3 mm an
inadequate OC dimension for molar tooth preparations. As a result, 4 mm
is proposed as the minimal OC dimension for molars. It is important to
measure prepared teeth with a periodontal probe to determine if the minimal
dimensions have been reached (Fig. 5).
The resistance of crowns made for dies the size of prepared incisors and
premolars has been tested, and it was concluded that 3 mm provides
adequate resistance [25], supporting the recommended OC dimension for
premolars and anterior teeth.
The tipping resistance of molar-sized crowns has also been measured [26].
Three millimeters of OC dimension provided adequate resistance but only at
10 TOC. Three millimeters was inadequate at 20 degrees of TOC, an angle
frequently found on molars. These data support the 4 mm minimal
recommended OC dimension for prepared molars. Therefore, 3 mm is
proposed as the minimal OC dimension for premolars and anterior teeth.
Because molars frequently are prepared with greater convergence than
anterior teeth and premolars are larger and are subjected to greater occlusal
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 363

Fig. 4. (A) It is dicult to assess the degree of convergence from an occlusal view. (B) From
a lingual view, it is much easier to make a quantitative assessment of the TOC. The molar has
20 to convergence.
364 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385

Fig. 5. (A) The maxillary premolar has the minimal recommended OC dimension of 3 mm for
anterior teeth and premolars. (B) The OC dimension of the mesial surface is being measured
with a periodontal probe. The wall has only 2 mm of OC dimension.

forces, 4 mm is proposed as the minimal OC dimension for prepared molars.


Teeth lacking these minimal dimensions should be modied to enhance their
resistance form through the formation of proximal grooves/boxes.

Ratio of occlusocervical/incisocervical dimension to faciolingual dimension


The ratio of the OC dimension to the faciolingual (FL) dimension should
be 0.4 or higher for all teeth. Ninety-six percent of incisor crowns, 92% of
canine crowns, and 81% of premolar crowns possess adequate resistance
despite variations in their preparation form and dimensions. However, only
46% of molars possess appropriate resistance [27]. An important factor in
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 365

producing this adequate resistance is the favorable ratio of the OC


dimension compared with the diameter of prepared incisors, canines, and
premolars. The favorable ratio is due to the typical anatomic dimensions of
these teeth when they are prepared (Fig. 6A).
Because chewing and parafunctional habits place FL forces on single
crowns and xed partial dentures, it is recommended that the FL dimension
of the prepared tooth be used in making ratio calculations. Prepared molars
have a larger FL dimension than premolars and anterior teeth, and they
usually have a shorter OC dimension, thereby producing a lower ratio and
poorer resistance (Fig. 6B). Also, the TOC usually is greater on molars
[16,17,21], and this accentuates the unfavorable ratio.
Calculations [23] indicate that adequate resistance can be achieved when
the OC/FL ratio is 0.1, but the convergence angle must be less than 6 . A
ratio of 0.2 requires less than 12 of TOC. A ratio of 0.3 requires less than
18 of TOC. These convergence angles are dicult to produce on molars.
The same calculations indicate that a ratio of 0.4 provides adequate
resistance when the TOC is 24 or less [23], an angle that can be clinically
produced on molars.
The theoretical calculations have been tested by making crowns to t dies
with ve dierent convergence angles, and it was determined that
inadequate resistance is present when a molar-size die (10 mm in diameter)
possessed a 0.35 ratio [28].

Circumferential form of the prepared tooth


Teeth should be prepared so they possess circumferential irregularity
whenever possible. When teeth are anatomically reduced, they possess
characteristic geometric forms. For instance, when prepared maxillary
molars are viewed occlusally, they have a rhomboidal form (Fig. 7).
Mandibular molars have a rectangular form (see Fig. 6B), and most
premolars (see Fig. 7) and anterior teeth have an oval form. These shapes
produce circumferential irregularity. The value of these irregularities has
been evaluated by comparing the resistance areas of conical and pyramidal
tooth preparation. The pyramidal preparations provided increased resistance
[29]. Therefore, it is important to preserve the corners of a tooth
preparation whenever possible.
When prepared teeth have no corners due to their round morphologic
form or existing condition, they should be modied by forming axial
grooves or boxes that provide resistance to dislodging forces. Because
molars are frequently prepared with greater convergence than other teeth
and because they usually have a smaller OC dimension and less favorable
OC/FL dimension ratio, they often benet from axial grooves or boxes that
enhance resistance form. Additionally, mandibular molars are the teeth
prepared with the greatest convergence angles [1821], and it is suggested
366 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385

Fig. 6. (A) When anterior teeth are prepared for complete coverage crowns, they usually
possess a favorable ratio between the incisocervical crown dimension and the mesiodistal/
faciolingual dimension. (B) Molars have less favorable ratios between the OC dimension and
the FL dimension than anterior teeth. When mandibular molars are prepared, they have
a rectangular form with rounded corners that enhance resistance form.

that axial grooves/boxes be routinely used when mandibular molars are


prepared for xed partial dentures (Fig. 8A).
Because chewing and parafunctional habits place dislodging forces on
single crowns and xed partial dentures that are largely FL in direction,
auxiliary resistance form features should be located in the tooth where they
provide optimal resistance to these forces. Proximal grooves provided
complete resistance to FL crown dislodgment, whereas facial or lingual
grooves provide only partial resistance (Fig. 8B) [26]. Therefore, auxiliary
resistance form features such as grooves and boxes should be located on the
proximal surfaces of xed partial denture abutments.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 367

Fig. 7. The prepared maxillary premolar has an oval crown form, and the prepared molar
resembles a rhomboid.

Reduction uniformity
Teeth should be uniformly reduced, thereby enhancing the potential for
normal crown form and an improved esthetic result. Although there is no
scientic evidence to support the benets of uniform reduction of the facial
and proximal surfaces, clinicians and technicians have long recognized the
benets. Uniform reduction makes it easier for a dental laboratory
technician to create esthetic restorations where the color and translucency
can approximate that of a natural tooth. The reduction uniformity also
promotes the development of normal contours in conjunction with the
desired color and translucency. Reduction uniformity is best achieved by
placing depth grooves into the surface to be reduced (Fig. 9) and then
reducing the tooth in accordance with the grooves.

Finish line location


Finish lines should be positioned supragingivally whenever the esthetic
and resistance form requirements permit such a location. The periodontal
benets of supragingival nish lines (Fig. 10) have been well documented
[3038]. However, subgingival nish lines often are used for appropriate
reasons that include the need to achieve adequate OC dimension for
retention and resistance form; to extend beyond caries, fractures, and
erosion/abrasion; or to encompass a variety of tooth structure defects.
Subgingival nish lines are also used to produce a cervical crown ferrule on
endodontically treated teeth and to improve the esthetic result achieved on
discolored teeth and with certain types of restorations. Although
periodontal health can be retained when subgingival margins are used,
368 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385

Fig. 8. (A) The mandibular molar has been modied by placing a groove into the mesial
surface. (B) The prepared maxillary molar has been modied with a facial groove. Facial
grooves are less eective at enhancing resistance to FL dislodging forces than grooves placed
into proximal surfaces.

other factors must be present. The restorations must be properly contoured


and exhibit good marginal t [3941]. Additionally, there must be careful
execution of the hard and soft tissue procedures performed in conjunction
with tooth preparation [3941].
When a subgingival nish line is required, multiple studies indicate that
extension to the level of the epithelial attachment should be avoided. Pocket
deepening does not occur when the margin is at least 0.4 mm occlusal to the
depth of the gingival crevice [42], whereas more severe gingivitis occurs
when subgingival margins approximate the depth of the crevice [37]. When
teeth were prepared so provisional crown margins were located farther
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 369

Fig. 9. (A) Depth grooves have been placed into the facial surfaces of both maxillary central
incisors to aid in the production of uniform facial reduction. (B) Completed metal ceramic tooth
preparations. The facial depth grooves were helpful in the creation of tooth preparations that
possessed adequate and uniform reduction.

apically than recommended, about a millimeter of gingival recession was


noted within 2 weeks and a little over 1 mm of recession was recorded within
8 weeks [43]. Histologic evaluation indicated the recession mechanism was
activated during the rst 7 days [43]. When crown margins were extended to
the bone crest, 1 mm of crestal bone loss was observed [44].

Finish line form


It is recommended that chamfer nish lines be used for all-metal crowns.
For metal ceramic crowns, chamfer, shoulder, or beveled nish lines can be
370 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385

Fig. 10. Supragingival nish lines were placed on the mandibular canines because the cervical
aspects of these teeth were not visible during smiling and because sucient retentive length had
been achieved.

used. With all-ceramic crowns, shoulder nish lines should be used with
nonbonded crowns, whereas a chamfer or shoulder can be used when the
crowns are to be bonded to the prepared tooth.

All-metal crowns
Although no scientic studies are available that support the superiority of
chamfer nish lines for all-metal crowns, they have frequently been used
because they are easy to form and suciently distinct to be visible on the
tooth and die. They also provide space for adequate metal thickness com-
bined with normal axial contours (Fig. 11).

Metal-ceramic crowns
Chamfer (Fig. 12A), beveled chamfer, shoulder with a rounded axiogin-
gival line angle (Fig. 12B), shoulder with a sharp axiogingival line angle
(Fig. 12C), and beveled shoulder (Fig. 12D) nish lines have been used for
metal ceramic tooth preparation. Although initial research identied greater
marginal metal distortion when porcelain was fused to castings made for
chamfer nish lines [45,46], subsequent studies failed to measure signicant
dierences in marginal t [4749]. Additional studies that evaluated the eect
of cementation also failed to identify signicant t dierences as related to
the type of nish line [50,51]. Therefore, the selection of nish line form
should not be based upon expectations of enhanced marginal t but rather
on factors such as formation ease, personal preference, esthetic requirements,
and the type of crown being fabricated.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 371

Fig. 11. A chamfer nish line is being formed on the mandibular rst molar using a tapered
round-end diamond instrument. The rotary instrument was extended into the tooth by
a distance equal to one half its tip diameter, and then the instrument was carefully and
methodically moved around the circumference of the tooth.

All-ceramic crowns
Chamfer nish lines produced lower strengths with nonbonded crowns
in laboratory tests [52,53]. However, the negative eect was not replicated
when the crowns were bonded (internally etched crowns cemented to
etched prepared teeth with resin) to the teeth [54,55]. It therefore seems
appropriate to recommend shoulder nish lines (Fig. 13) for all-ceramic
crowns that are not to be bonded to underlying tooth structure, whereas
chamfer or shoulder nish lines can be used when the crowns are to be
bonded.
372 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385

Fig. 12. (A) Chamfer nish lines have been established on the maxillary anterior teeth for metal
ceramic crowns. (Courtesy of Dr. Wayne Campagni, Loma Linda, CA). (B) A shoulder nish
line (nish line meets the unprepared tooth at about 90 ) has been prepared with a rounded
axiogingival (internal) line angle. (C) A shoulder nish line has been prepared with a sharp
axiogingival line angle. (D) The metal ceramic crown preparations have been prepared with
beveled shoulder nish lines. (Courtesy of Dr. Tony Daher, LaVerne, CA.)

Reduction depths
All-metal crowns should have chamfer depths of at least 0.3 mm, axial
surface reductions of at least 0.5 to 0.8 mm, and occlusal reduction depths of
1 to 1.5 mm. For metal ceramic crowns, depths of 1.0 mm or more have
been proposed and are esthetically desirable for the nish line and facial
surface reductions. However, it does not seem that depths of that magnitude
are regularly achieved clinically, and the presence of younger teeth and
greater TOC angles make it more unlikely that teeth can be reduced to those
depths. Occlusally, reduction depths of 2 mm are achievable even on young
teeth that are being prepared for metal-ceramic crowns. Finish line and
facial reductions depths of 1.0 mm are recommended for all-ceramic crowns.
An incisal/occlusal reduction of 2 mm for all-ceramic crowns permits the
development of appropriate color, translucency, and morphology.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 373

Fig. 12 (continued )
374 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385

Fig. 13. A shoulder nish line has been developed for an all-ceramic crown.

All-metal crowns
For all-metal crowns, nish line depths of 0.3 to 0.5 mm have been
recommended [3,5]. This depth allows restorations to closely approximate
normal tooth dimensions, whereas nish lines \0.3 mm in depth are more
likely to produce overcontoured restorations [56]. Therefore, 0.3-mm-deep
chamfer nish lines are well suited for all-metal crowns (see Fig. 11).
For all-metal crowns and xed partial dentures, there are no data that
identify the ideal axial reduction depths. Therefore, the experience of
clinicians and laboratory technicians forms the basis for recommending 0.5
to 0.8 mm of reduction be developed near the occlusal aspect of the facial and
lingual surfaces. This depth of reduction provides adequate space for the
development of normal axial contours and material thickness for strength.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 375

Because proximal reduction usually exceeds facial/lingual reduction, specic


numeric depth suggestions are not necessary. However, proximal reduction
should include the formation of an adequately distinct nish line and provide
access for impression making.
One millimeter of occlusal reduction provides space for the fabrication of
all-metal crowns, but reduction depths of 1.5 mm provide the space whereby
well-dened occlusal grooves and convex ridges can be developed. Also,
should modest amounts of occlusal adjustment be required clinically, the
crowns can retain adequate ridge and groove form rather than become at
or concave with a lack of occlusal grooves.

Metal-ceramic crowns
Finish lines for metal ceramic crowns should be 1.0 to 1.5 mm deep
[25,11,57], and the facial surface be reduced between 1.0 and 1.7 mm
[25,11,57]. These recommendations are supported by research that de-
termined 1.0 mm or more of translucent porcelain is required to reproduce
shade guide specimens [5860]. However, actual measurements of prepared
teeth [56,61] indicate reduction depths are often [1 mm (Fig. 14). The reason
for failure to achieve the recommended depths may be related to the amount
of tooth structure available for reduction. The combined dentin and enamel
thickness ranged from 1.7 to 3.1 mm in one study [62], from 2.2 to 2.5 mm in
another study [63], and from 2.0 to 3.0 mm in a third study [64]. These
thicknesses indicate that some teeth can safely be reduced in accordance with
the recommended depth range of 1.0 to 1.7 mm (Fig. 15), whereas other teeth
would have thin areas of remaining dentin.
Younger teeth have tooth structure thicknesses of \2 mm and therefore
cannot be reduced to meet the greater depths that have been proposed [26].
Additionally, the eect of TOC must be considered because it can have
a profound eect on the amount of remaining tooth structure for a certain
reduction depth. The thickness of the remaining tooth structure has been
measured on adolescent premolars prepared with two nish line depths (0.8
and 1.2 mm deep) and four TOC angles (5 , 10 , 15 , and 20 ) [65]. The
combination of a 1.2-mm-deep nish line and 20 of TOC produced a 0.3-mm
thickness of remaining dentin. Therefore, the presence of younger teeth or
greater TOC angles make it unlikely that teeth can be reduced to the greater
proposed depths.
When esthetic materials are to be placed over incisal/occlusal surfaces,
reduction depths of 2.0 to 2.5 mm have been recommended for metal ceramic
restorations to provide space for the development of appropriate color,
anatomic form, and occlusion [25,11]. There is [4 mm of combined enamel-
dentin thickness present on young teeth [5,62]. Teeth in older patients have
greater combined enamel and dentin thicknesses that range from 5 to 7 mm
[5,6264]. It seems that reduction depths of 2 mm or more are achievable
recommendations (Fig. 16).
376 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385

Fig. 14. The metal ceramic tooth preparation has a facial cervical reduction depth of \1 mm.

Fig. 15. The two metal ceramic tooth preparations have facial reduction and nish line depths
that exceed 1 mm.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 377

Fig. 16. The incisal edges of the two central incisors have been reduced by a dimension that
exceeds 2 mm.

All-ceramic crowns
All-ceramic nish line depth recommendations range from 0.5 to 1.0 mm
(Fig. 17) [25,11,57]. From a facial reduction standpoint, there is little
improvement in shade matching when the thickness of all-ceramic crowns is
increased beyond 1 mm with semi-translucent, all-ceramic systems (eg,
Empress and InCeram Spinell) and high-value, low-chroma shades (eg, A1)
[60]. However, thicknesses in excess of 1 mm are benecial when using more
opaceous all-ceramic systems or when using lower value, more chromatic
shades such as C2 and A3 [60]. In addition, the inherent color of the prepared
tooth can inuence the color of the overlying all-ceramic crown, requiring
greater ceramic thickness when the dentin is discolored.
Malament and Socransky [66] investigated the eect of ceramic thickness
on the strength of all-ceramic crowns but were not able to correlate
restoration failure with thickness when the crowns were bonded to the
prepared tooth with resin cement. They found no signicant dierences in the
probability of survival after 11.7 years (3430 cumulative monitoring years)
between bonded crowns that were \1 mm thick and those that were >1 mm
thick. The midaxial thickness of crowns in this study averaged approximately
1.5 mm [66]. Therefore, if the crown is to be bonded with resin cement, the
reduction should be based on the ceramic thickness required to achieve
proper color and contour.

Line angle form


Line angles should be rounded on all-ceramic tooth preparations to
increase crown strength. For other types of crowns, rounding is advocated
378 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385

Fig. 17. (A) The facial shoulder nish line on the maxillary lateral incisor is 0.5 mm in depth.
(B) The maxillary central incisor nish line depth is 1.0 mm.

because it facilitates laboratory fabrication and restoration t. Sharp line


angles (Fig. 18A, B), located where prepared tooth surfaces meet each other,
create stress concentration [6769], and rounding these line angles increases
the strength of all-ceramic crowns. With all-metal and metal-ceramic crowns,
line angles are rounded to facilitate laboratory procedures and restoration t
rather than to enhance restoration strength (Fig. 18C). Round line angles
make it easier to pour impressions without trapping air bubbles that produce
voids in the die, and the rounding also facilitates investing wax patterns
without air inclusions. Trapped air bubbles lead to nodules in castings that
can impede complete seating of a restoration if they are not detected and
removed. Also, if casting nodules occur, they are easier to detect and remove
when the lines angles are rounded during tooth preparation.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 379

Fig. 18. (A) The maxillary left central incisor has a sharp mesiofacial line angle that should be
rounded. Although the sharpness of the mesioincisal and distoincisal corners of the maxillary
right lateral incisor has been reduced, there are still sharp angles that could be rounded to
reduce stress concentration. (B) There are multiple proximoincisal line angles that could be
further rounded to decrease the stress concentration in the all-ceramic crowns. (C) There are
sharp distofacial and distal cusp tips on the mandibular molar that has been prepared for an all-
metal crown. Rounding these sharp cusps facilitates laboratory fabrication by making it less
likely that air bubbles will be trapped during pouring and die and investing the wax pattern.
380 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385

Surface texture
Tooth preparations should be reasonably smooth to enhance restoration
t. Some surface roughness improves retention when using zinc phosphate
cement but does not seem to have as substantial of an eect when adhesive
cements are used (polycarboxylate, glass ionomer, and resin).
Tooth preparation smoothness has been found to improve the marginal t
of restorations in two studies [70,71], whereas another study [72] found no
dierence in the marginal seating of complete crowns when the axial surfaces
were prepared with coarse diamond instruments (120 lm grit size) and when
they were prepared with ne diamond (50 lm grit size) instruments.
The eect of smoothness on retention seems to be related to the type of
denitive cement. With zinc phosphate cement, seven of nine studies indicate
that preparations with some roughness (see Fig. 11) provide improved
retention compared with smoother preparations. However, when testing the
eect of adhesive-type cements (polycarboxylate, glass ionomer, and resin),
there is no clear benet to surface roughness. Three studies indicate that
roughness increased retention [7274], whereas three other studies found that
roughness did not improve retention [71,75,76]. Therefore, when using zinc
phosphate cement, one can expect an increase in retention through surface
texture, whereas the benets of surface roughness have not been denitively
established when using polycarboxylate, glass ionomer, and resin cements.

Summary
The following guidelines are proposed when preparing teeth for complete
coverage crowns and xed partial dentures:
1. The TOC (angle of convergence between opposing prepared axial
surfaces) should range between 10 and 20 . However, posterior teeth
are frequently prepared with greater convergence angles as are xed
partial denture abutments. When the TOC angles exceed the recom-
mended levels, the tooth preparation should be modied to include
auxiliary features such as grooves or boxes.
2. Three millimeters should be the minimal occlusocervical/incisocervical
(OC/IC) dimension of incisors and premolars when they are prepared
within the recommended TOC range of 10 to 20 . The minimal OC
dimension of molars should be 4 mm when prepared with 10 to 20
TOC. When the OC dimension is less than the recommended dimension,
the tooth preparation should be modied to include auxiliary features
such as grooves or boxes.
3. The ratio of the OC/IC dimension to the FL dimension should be 0.4 or
higher for all teeth. When this ratio is not present, as on large diameter
molars, the tooth preparation should be modied to include auxiliary
features such as grooves or boxes.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 381

4. Teeth should be prepared in a manner that preserves the facioproximal


and linguoproximal corners whenever possible because circumferential
irregularities enhance resistance form. When prepared teeth lack
corners and are round after tooth preparation, they should be
modied to include auxiliary features such as grooves or boxes.
5. When auxiliary features are placed into teeth, the preferred locations are
the proximal surfaces. The facial and lingual surfaces are secondary
locations to be used when the addition of proximal features leaves the
tooth in a state of questionable resistance form. Proximal grooves/boxes
should routinely be used when mandibular molars are prepared for xed
partial dentures because mandibular molars often are prepared with the
greatest TOC and frequently have limited OC dimension and large FL
dimensions that lead to unfavorable ratios.
6. For the purpose of optimizing periodontal health, nish lines should be
located supragingivally when the condition of the tooth and esthetic
requirements permit such a location. When subgingival nish lines are
required, they should not be extended to the epithelial attachment.
7. For all-metal crowns, 0.3-mm-deep chamfer nish lines should be used.
The axial and occlusal reduction depths for all-metal crowns should be
at least 0.5 mm and 1.0 mm, respectively.
8. For metal ceramic crowns, nish line selection should be based on
formation ease, personal preference, esthetic requirements, and the type
of crown being fabricated rather than on expectations of enhanced
marginal t with one type of nish line compared with the others. Many
teeth, because of available tooth structure thickness external to the pulp,
cannot be reduced facially to depths that exceed 1 mm. Two millimeters
of occlusal/incisal reduction can be achieved even on young teeth because
sucient tooth structure thickness is present incisal/occlusal to the pulp.
9. Shoulder nish lines are recommended for all-ceramic crowns when they
are not bonded to the underlying tooth. However, shoulder and chamfer
nish lines can be used with all-ceramic crowns that are bonded to the
prepared tooth using a resin cement and acid etching. Finish line and
facial reduction depths [1 mm are not required when using a semi-
translucent type of all-ceramic crown but are benecial with more
opaceous porcelain systems are used or when the tooth structure is
discolored. Incisal/occlusal reduction depths of 2 mm are achievable due
to the available thickness of tooth structure.
10. Rounded line angles on tooth preparations for all-ceramic crowns
decrease the stress placed on the crowns and thereby increase crown
longevity. With crowns that contain metal (all-metal and metal-ceramic
crowns), line angles are rounded to facilitate pouring impressions and
investing wax patterns without trapping air bubbles and to facilitate the
removal of casting nodules.
11. Tooth preparation smoothness seems to enhance restoration t, but its
eect on retention appears to be related to the type of cement used.
382 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385

Surface roughness generally increased retention with zinc phosphate


cement, but no denitive relationship has been established when crowns
are cemented with adhesive cements (eg, polycarboxylate, glass ionomer,
resin). It therefore seems appropriate to recommend that teeth be
prepared with a reasonable degree of surface smoothness.

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Dent Clin N Am 48 (2004) 387396

Resistance form in tooth preparation


M. Harry Parker, MS, DDSa,b,*
a
Department of Veterans Aairs Medical Center, Uptown Division (Dental Clinic),
1 Freedom Way, Augusta, GA 30904, USA
b
Department of Oral Rehabilitation, Medical College of Georgia School of Dentistry,
Augusta, GA 30912, USA

Retention and resistance form are the properties of a preparation that


prevent castings from becoming uncemented, which is one of the top three
reasons for the replacement of castings [1,2]. Resistance form is the quality
of a preparation shape that prevents rotational movement of the casting
about a xed point [3]. Before cementation, crowns can be tested. Crowns
for preparations without resistance form can easily be rolled o the die,
whereas preparations with resistance form prevent movement [4,5].
Resistance form is a theoretical concept analyzed in many articles with
a mathematical format [3,69]. From a clinical viewpoint, resistance form of
preparations for which castings were made in a large dental laboratory
revealed that most preparations of incisors (96%), canines (92%), and
premolars (81%) had resistance form, whereas 46%of molar preparations
achieved the desired results [4]. Looking at clinical outcomes, Trier et al [10]
found that over 95% of all castings that failed by becoming uncemented
lacked resistance form. He also found that 63% of the failures were molars,
35% were premolars, and 2% were anterior teeth. In an up to 15-year
outcome assessment of 515 xed partial dentures (FPDs) whose abutments
were tested for resistance form before acceptance for cementation, loss of
retention was found to be less common than in other studies. This was
attributed to the attention given to establishing resistance form, especially
with the use of grooves, before cementation [11]. These clinical results
support the basic prosthodontic principle that resistance form is an essential
element in preparation design and are consistent with the Caputo and
Stanlec [12] statement that resistance form is the most important factor of
a preparation for a crown to be successful.

* Department of Veterans Aairs Medical Center, Uptown Division (Dental Clinic), 1


Freedom Way, Augusta, GA 30904, USA.
E-mail address: Harryparker1@comcast.net

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.009
388 M.H. Parker / Dent Clin N Am 48 (2004) 387396

Guidelines for minimally acceptable preparation taper


Crowns and retainers becoming dislodged is a common problem. A
worthy goal is to master the understanding of what clinicians can do to
prevent the failure of the dislodged restoration. Guidelines for ideal pre-
paration total occlusal convergence are not consistent and range from 3
[13] to 24 [14]. Measurements of the mean taper of actual clinical
preparations have been reported in the range of 25 to 30 [15,16], indicating
that approximately half of the measured preparation tapers exceeded these
mean values. In a 1986 article Owen [17] concluded, Most teeth are
prepared with tapers greater than 12 degrees and still function adequately. It
is not known what retentive gure is the minimum required clinically. The
answer to the question of nding guidelines for minimally acceptable taper
was provided by applying a unique property of resistance form. Retention
and resistance form are dependent on taper. Retention increases as taper
decreases [18,19], but the curved graph gives no clue as to minimal
acceptability; it shows only that less taper is better in that it provides more
retention. Resistance form, on the other hand, exhibits an on or o
nature that is ideally suited for nding minimal acceptability [8,9]. A crown
rolls o the die easily or does not move. Envision a mental experiment
evaluating the resistance form of a molar preparation with a 10-mm base
and a height of 4 mm as the preparation convergence angle is increased from
0 . With parallel sides, the preparation has resistance form and continues to
have it as the taper is increased up to a point. At that specic taper, the
preparation resistance form switches from on to o. All tapers larger
than this dividing point taper do not provide resistance form, and all values
less do provide resistance form. With the premise that an acceptable taper
must provide resistance form, this dividing point taper makes a reasonable
choice for minimal acceptability. Preparations with increasing taper are
illustrated in Fig. 1. The rst ve preparations (A through E) have resistance
form, whereas the second ve preparations (F through J) do not (the
Zuckerman circle and the Lewis perpendicular, which are discussed below,
illustrate that preparation F does not have resistance form). For these
preparations with the given height and base, the minimally acceptable taper
based on principles of resistance form is the taper of preparation E.
Resistance form can be evaluated at one point on a preparation at a time
(unlike retention, which requires area for evaluation). The dividing point
between tapers that do and do not provide resistance form has been dened
as the limiting taper. It has been shown to equal the arctan(h/b), where h is
the projected height of the point and b is the projected base relative to the
center of rotation on the opposite margin. The h and b do not refer to the
height and base of the preparation. It also can be expressed as the arctan(y/
x), where (x,y) is the Cartesian coordinate of the point being evaluated and
the coordinate system origin is the center of rotation on the opposite
margin. It is easier to achieve resistance form on the portion of the tooth
M.H. Parker / Dent Clin N Am 48 (2004) 387396 389

Fig. 1. The on/o nature of resistance form as a function of taper. Preparation tapers
increases from A to J, all of which have the same base width and preparation height.
Preparations A through E have resistance form, whereas preparations F through J do not (the
Zuckerman circle and the Lewis perpendicular illustrate that preparation F does not have
resistance form). Therefore, for these preparations with the given height and base, the minimally
acceptable taper is the taper of preparation E. The minimally acceptable taper is the dividing
point between tapers that do provide resistance form and those that do not.

where y is large (near the occlusal surface) and x is small (near the center of
rotation). Points on a groove nearer the center of rotation and higher on the
preparation provide resistance form more easily (with larger tapers) than
what is required for points lower and farther from the center.
The on/o nature of resistance form can be applied to the average taper
of the entire preparation (not limited to straight preparation walls but valid
for any shape with even or symmetrical margins), and that value is dened
as the limiting average taper [9]. It is mathematically determined to equal
0.5 arcsine (H/B), where the H and B refer to the height and base of
the preparation. The total convergence angle is twice this value. By calculat-
ing the average height-to-base ratio of preparations of incisors, canines,
premolars, and molars, minimally acceptable guidelines for preparation
tapers by tooth group were determined. The values expressed as total
occlusal convergence were found to be 58 for incisors, 66 for canines, 20
for premolars, and 16 for molars. These values are based on resistance form
recommended for minimally acceptable average tapers (ie, the boundary of
unacceptability to avoid). Resistance form is easily obtained on anterior
teeth, although it is more dicult to obtain with posterior teeth because they
are shorter and wider, making the height-to-base ratio less. When a loose
retainer is found for an FPD extending from a molar to a premolar, in this
authors experience it is usually the molar retainer that is loose. The tooth
group order from largest recommended taper to smallest recommended
taper is opposite that given by Shillingburg [14]. His recommended values
for average ideal tapers (total convergence angle) increase from anterior
(10 ) to posterior (19 to 22 ). Clinically, resistance form being more dicult
to achieve for molars is consistent with the nding that over 50% of molar
preparations evaluated from a large laboratory lacked resistance form [4]
and the type of casting that most commonly comes loose is the molar [10].
390 M.H. Parker / Dent Clin N Am 48 (2004) 387396

It is the molar preparation that must be approached with the most caution
to ensure that resistance form is always obtained.

Methods to analyze resistance form


Lewis and Owen [3] showed that for preparations with straight walls, the
dividing point between the resistive and nonresistive sections of a preparation
wall is the point of intersection with the perpendicular line from the center of
rotation on the opposing margin. Consider the side of a preparation to be
evaluated as part of an innitely long line. From the opposing margin,
extend a perpendicular to this line. Depending on the taper and shape of the
preparation, the point of intersection may be gingival or within or occlusal
to the preparation side being evaluated. All points occlusal to the point of
intersection have resistance form, and all points gingival do not. If the point
of intersection is on the extended line above or occlusal to the top of the
preparation, the preparation lacks resistance form. The Lewis and Owen
method of evaluating resistance form of side AC is applied by extending
a perpendicular line to side AC from the center of rotation E at the opposite
margin (Fig. 2). The intersection of the Lewis line and side AC is point B, so
all points occlusal to B (segment BC) are resistive and all points gingival to B
(segment AB) are not resistive.

Fig. 2. Three techniques for evaluating the resistance form of side AC. The Lewis method of
evaluating resistance form of side AC is applied by extending a perpendicular line to side AC
from the center of rotation E at the opposite margin. The intersection of the Lewis line and side
AC is point B, so all points occlusal to B (section BC) are resistive and all points gingival to B
(section AB) are not resistive. The same results are obtained with the Zuckerman circle, where
all points outside of the circle (section BC) are resistive and all points inside (section AB) are
nonresistive. The Weed technique predicts that all points on side AC are not resistive because
they are inside the Weed circle. This contradicts the Lewis and Zuckerman results, indicating
that the Weed hypothesis is not valid.
M.H. Parker / Dent Clin N Am 48 (2004) 387396 391

Weed and Baez [7] presented a method using a boundary circle centered
on the opposing margin to evaluate an opposing wall (see Fig. 2). Their
hypothesis was that if the intersection of the taper line (side of the
preparation) with the horizontal height line falls inside of the circle, it
indicates lack of resistance form. Points of the preparation outside of the
circle have resistance form. They incorrectly concluded that their hypothesis
was valid; it identies tapers as being nonresistive that in fact provide
resistance form [8]. Using an ingenious application of geometry, Zuckerman
[20], similar to Weed, used a boundary circle but centered his circle at the
center of the base of the preparation with a radius one half of the base radius
used by Weed. The points of the side of the preparation within the circle are
nonresistant, whereas all points on the preparation wall that are outside of
the circle provide resistance form. Because the Weed and Zuckerman circles
are dierent, the techniques are contradictory. Zuckermans result is
consistent with the mathematical derivation of Lewis and Owen and has
a mathematical basis for acceptance. Weed concluded that a 3.5-mm high
preparation with a 10-mm base would lack resistance form with a conver-
gence angle of 22 (total occlusal convergence of 44 ). Using Zuckermans
diagram, the formula for the limiting taper is 0.5 Arcsine (2H/B), which gives
22.2 (total occlusal convergence of 44.4 ); 22 falls in the resistive area. The
occlusal half of the preparation wall that falls within Weeds boundary circle
is above the intersection with the perpendicular line used in the Lewis
method for evaluating resistance form. This reveals a contradiction and
indicates an error in the Weed method for determining which tapers are
adequate to provide resistance form.
The resistance form at each point also can be evaluated by drawing
a direction of arc arrow, which is an arc of the circle centered on the
opposite margin [8]. At the point being evaluated, if the direction of the
arrow is into the preparation, that point has resistance form; if it is away
from the preparation, it does not. This technique can be used to evaluate all
preparation shapes, not just straight-walled preparations. Because all
direction of arcs on the same radius line of concentric circles are parallel,
comparing the direction of arc at a point on any radius line of any circle
(centered on the opposite margin) with the preparation reveals whether the
direction is away from or into the preparation wall. In Fig. 2, by visualizing
the direction of arc provide by the Weed circle (which is centered on the
opposite margin), from A to B the direction is away from the preparation
wall; from B to C the direction is into the preparation wall. This supports
the fact that all points on the wall from B to C are resistive, contradicting
Weeds results.

Laboratory studies evaluating resistance form


Laboratory studies evaluating resistance form of cemented castings as
a function of taper have resulted in a linear relation between the variable
392 M.H. Parker / Dent Clin N Am 48 (2004) 387396

measured and taper. Weed [7] used an Instron (Instron Corp., Canton,
Massachusetts) machine to force cemented castings from metal dies, and
Wiscott [21] developed a cyclic testing apparatus measuring the load level at
which 50% of the samples survived 106 stress cycles. Both studies produced
linear results with no sudden drop observed in the load level required to
dislodge the crowns as taper was increased. These results seem to contradict
the on-o nature of resistance form. Based on his results, Wiscott states that
the concept of limiting taper expressing itself clinically as an all-or-nothing
phenomenon is unrealistic [21], but one would not expect to see the on/o
nature of resistance form expressed if only preparations having resistance
form in the on category were evaluated. That is what happened in both
studies. For a symmetrical straight-walled preparation with 10 of total
occlusal convergence (5 axial inclination on each side) to lack resistance
form, its height would have to be less than 0.7 mm, less than any die studied
by Wiscott. Therefore, all samples had resistance form, and no on/o
boundary eect was seen. It is dicult to make a symmetrical straight-
walled die lack resistance form. For example, the limiting taper for
a symmetrical 4-mm-high, 10-mm-wide preparation equals 0.5Arcsine2H/B
or 26.6 , for a total occlusal convergence of 53.2 . This may seem excessive,
but it is more challenging to achieve the resistive tapers with the clinical
preparations of teeth than it is in the lab with a lathe-cut metal die.
There are clinical preparations that lack resistance form [4]. One must be
wary of uneven margins, which can make a preparation with parallel walls (0
taper) lack resistance form (Fig. 3) [8]. Rounding of sharp occlusal surfaces is
another factor that increases the likelihood that clinical preparations will lack
resistance form. These factors are commonly seen in the preparation of
tipped molars. The tapers used in lab studies may be more consistent with
ideal recommended guidelines than what is achieved clinically. Students
attempting to meet a 12 criterion did not result in achieving that goal [22].
Realizing and accepting that much larger preparation tapers are seen
clinically than normally are advocated as standards should allow us to
examine larger tapers for lab studies to explore the on/o nature of resistance
form. The studies must ensure that there are preparations in the on and
o categories. A clinical study of crowns that have failed by dislodgment
reveals that almost all failures are on preparations lacking resistance form,
supporting the premise that a reasonable standard for acceptable preparation
taper is that it provides resistance form [10]. It also supports the premise that
a relationship exists between clinical success/failure and the all-or-none
nature of resistance form.

Methods to enhance resistance form


Preparation modications to provide resistance form to a nonresistant
preparation include crown lengthening, shoulder preparation, proximal box
or groove, occlusal isthmus, and pins or posts [20]. Grooves provide a marked
M.H. Parker / Dent Clin N Am 48 (2004) 387396 393

Fig. 3. A diagrammatic representation of the preparation of a tipped mandibular molar that


has perfectly parallel mesial and distal walls with a total occlusal convergence angle of 0 . There
is no resistance form at any point on the mesial wall (even though it is longer than the distal
wall). This is illustrated by the three direction-of-arc arrows moving away from the wall at
points D, E, and F (with center of rotation the opposing margin A). It is also illustrated by the
Lewis method that says all points below point C lack resistance form because that is the
intersection of the perpendicular radius from the center of rotation (point A). For the mesial
wall of this preparation, there is no possible adequate preparation taper to provide resistance
form. Buccal or lingual grooves must be used to ensure this preparation has resistance form.

increase in measured resistance values in laboratory studies [16,23]. An


interesting aspect of the groove is that if the direction of rotation arcs away
from one wall of the groove, it must arc into the other wall, so it provides
resistance coming or going (Fig. 4). To ensure resistance form on molar
preparations, grooves should be used routinely [4]. In preparing the walls of
the tooth, care must be taken to ensure there are no undercut margins.
Considerable preparation taper is required, especially in the molar region, to
assure that margins are not undercut and that common draw is achieved by
being able to visualize all preparation walls. In contrast, grooves can be
placed with almost no fear of undercuts. Because the margins are not
involved, any undercuts that are accidentally produced can easily be waxed
out in the lab and do not cause a problem. It is far better to place grooves on
a routine basis in molar preparations to ensure resistance form and deal with
the possibility of undercuts when and if they occur. Because theoretically
only one point is needed to provide resistance form [8], short grooves can be
eective. The groove can be envisioned as having three walls, so a groove
on the buccal surface has a mesial, distal, and lingual surface providing
resistance to mesial, distal, and lingual rotation. To obtain the benet of the
lingual wall, it is necessary to hold the bur in the line of draw and not lay it
against the side of the preparation, which may be more tapered. The tooth
394 M.H. Parker / Dent Clin N Am 48 (2004) 387396

Fig. 4. Adding a groove (HIJKLM) to the preparation in Fig. 3 aects the resistance form.
Where the direction of arc arrow from E to F is away from one wall of the groove, it directs into
the other wall so that one of the two opposing walls provides resistance form at each level. For
the portion of the groove below the center of rotation, it is the mesial wall of the groove that has
resistance form (indicated by the heavy line from L to M). For the portion of the groove above
the distal margin, it is the distal wall of the groove from I to J that is resistive.

structure in which the groove is placed is expected to withstand torquing


forces to prevent crown rotation, so it must be structurally sound. In placing
grooves, look for and use sound tooth structure.

Summary
Clinical evidence indicates that resistance form is one of the essential
elements in crown preparation design to ensure clinical success. The on/o
nature of resistance form lends itself to the theoretical determination of
minimally acceptable tapers. The boundary between resistive and non-
resistive tapers can be determined at each point on a preparation (limiting
taper) or for the entire preparation (limiting average taper). Using average
height-to-base ratios for incisor, canine, premolar, and molar preparations,
minimally acceptable guidelines can be determined for symmetrical
preparations. The short wide molar with the small height-to-base ratio is
the most dicult tooth preparation to achieve resistance form, and grooves
should be used routinely. The average guidelines for taper do not apply to
preparations with uneven margins, which are frequently seen with tipped
mandibular molars. It is possible to have perfectly parallel opposing mesial
and distal walls and not have resistance form. Buccal and lingual grooves
solve the problem. Every tooth must be analyzed individually. The Lewis,
M.H. Parker / Dent Clin N Am 48 (2004) 387396 395

Zuckerman and direction of arc techniques for evaluating resistance form


are consistent, but the results do not agree with those of the Weed method.
Laboratory studies have produced a linear relation between measured
failure loads and taper but have failed to provide tapers in the o region
of resistance form. Thus, the relation of failure load to taper has not been
evaluated over the on or o boundary. It is anticipated that in properly
designed laboratory studies the continued linear relationship will not be seen
across this boundary and that adding grooves to nonresistive preparations
will require much larger loads to produce failure. The clinical data indicate
that there is a relationship between clinical success or failure and the on/o
nature of resistance form.

References
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length of service and reasons for replacement. J Prosthet Dent 1985;56:41621.
[2] Goodacre JC, Bernal G, Rungcharassaeng K, Kan JYK. Clinical complications in xed
prosthodontics. J Prosthet Dent 2003;90:3141.
[3] Lewis RM, Owen MM. A mathematical solution of a problem in full crown construction.
J Am Dent Assoc 1959;59:9437.
[4] Parker MH, Malone KH, Trier AC, Striano TS. Evaluation of resistance form for
prepared teeth. J Prosthet Dent 1991;66:7303.
[5] Walton TR. An up to 15-year longitudinal study of 515 metal-ceramic FPDs: part 1.
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[7] Weed RM, Baez RJ. A method for determining adequate resistance form of complete cast
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[12] Caputo AA, Standlee JP. Biomechanics in clinical dentistry. Chicago: Quintessence; 1987.
[13] Dykema RW, Goodacre CJ, Phillips RW. Principles of tooth preparation. In: Pederson D,
editor. Johnstons modern practice in xed prosthodontics. 4th edition. Philadelphia:
W.B. Saunders; 1986. p. 24.
[14] Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Principles of tooth
preparation. In: Bateman LA, editor. Fundamentals of xed prosthodontics. 3rd edition.
Chicago: Quintessence; 1997. p. 11936.
[15] Nordlander J, Weir D, Stoer W, Ochi S. The taper of clinical preparations for xed
prosthodontics. J Prosthet Dent 1988;60:14851.
[16] Woolsey GD, Matich JA. The eect of axial grooves on the resistance form of cast
restorations. J Am Dent Assoc 1978;97:97880.
[17] Owen CP. Retention and resistance in preparations for extracoronal restorations: part II.
Practical and clinical studies. J Prosthet Dent 1986;56:14853.
396 M.H. Parker / Dent Clin N Am 48 (2004) 387396

[18] Jorgensen KD. The relationship between retention and convergence angle in cemented
veneer crowns. Acta Odontol Scand 1955;13:35.
[19] Kaufman EG, Coelho DH, Colin L. Factors inuencing the retention of cemented gold
castings. J Prosthet Dent 1961;11:487502.
[20] Zuckerman GR. Resistance form for the complete veneer crown: principles of design and
analysis. Int J Prosthodont 1988;1:3027.
[21] Wiskott HW, Nicholls JI, Belser UC. The eect of tooth preparation height and diameter
on the resistance of complete crowns to fatigue loading. Int J Prosthodont 1997;10:20715.
[22] Smith TS, Gary JJ, Conkin JE, Franks HL. Eective taper criterion for the full veneer
crown preparation in preclinical prosthodontics. J Prosthodont 1999;8:196200.
[23] Potts RG, Shillingburg HT, Duncanson MG. Retention and resistance of preparations for
cast restorations. J Prosthet Dent 1980;43:3038.
Dent Clin N Am 48 (2004) 397416

Restoration of endodontically
treated teeth
Steven M. Morgano, DMDa,b,*,
Antonio H.C. Rodrigues, DDS, MSDa,c,
Carlos Eduardo Sabrosa, DDS, MSD, DScDd
a
Department of Restorative Sciences and Biomaterials, Boston University Goldman
School of Dental Medicine, 100 East Newton Street, Room G219 Boston,
MA 02118-2392, USA
b
Division of Postdoctoral Prosthodontics, Boston University Goldman School of
Dental Medicine, 100 East Newton Street, Room G219, Boston, MA 02118-2392, USA
c
Division of Graduate Fixed Prosthodontics, School of Dentistry, Catholic University,
Dom Jose Gaspar 500, Belo Horizonte, MG 30000, Brazil
d
Department of Operative Dentistry, Universidade do Estado do Rio de Janeiro,
Av. Ataulfo de Paiva 482 sl. 502, Rio de Janeiro, RJ 22440-030, Brazil

Endodontic therapy is used routinely in contemporary dentistry, but


a satisfactory restorative solution is necessary after the root canal has been
treated. There are a variety of materials and techniques advocated for
restoring pulpless teeth, and hundreds of studies devoted to this subject have
been published in the dental literature. Although knowledge and un-
derstanding of the complications associated with pulpless teeth have
improved over the last few decades, this topic remains complex and con-
troversial [1]. These restored pulpless teeth are not always trouble free,
regardless of the restorative method used; however, a restorative approach
that is consistent with contemporary scientic knowledge improves the
prognosis [1].
The issue of restoring pulpless teeth is commonly associated with the topic
of posts. At one time, a post was regarded as a method of reinforcing
a pulpless tooth [2]. Nevertheless, most contemporary studies have suggested
that a post weakens the tooth rather than reinforcing it [1,36].

* Corresponding author. Division of Postdoctoral Prosthodontics, Boston University


Goldman School of Dental Medicine, 100 East Newton Street, Room G219, Boston, MA
02118-2392, USA.
E-mail address: smorgano@bu.edu (S.M. Morgano).

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.011
398 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416

Increasing the probability of success of single-rooted pulpless teeth restored


with posts and cores
Despite its weakening eect on the tooth, a post is indicated when there is
inadequate remaining coronal tooth structure to retain a core for an articial
crown, and the majority of single-rooted pulpless teeth are restored with
posts and cores. A 10% complication rate was calculated for teeth restored
with posts in a comprehensive meta-analysis of clinical studies in xed
prosthodontics [7]. Although it is impossible to determine the reasons for
most of these reported complications, misunderstanding by dentists of
contemporary biomechanics could be responsible for some of these
complications. Dentists seem slow to adapt their treatment approaches to
new knowledge [8]. A comprehensive nationwide survey of dentists
philosophies and techniques of restoring endodontically treated teeth re-
ported by Morgano [8] in 1994 indicated major dierences in the dentists
beliefs and treatment methods. For example, approximately 50% of the
respondents believed in the ability of a post to reinforce a pulpless tooth [8].

Length of the post


A classic retrospective study of the clinical outcomes of restored
endodontically treated teeth by Sorensen and Martino [4] indicated that
longer posts were associated with higher success rates. When the length of
the posts equaled the length of the clinical crowns, the failure rate was 2.5%.
Posts that were one quarter the length of their respective clinical crowns
recorded a failure rate of 25%a tenfold increase [4]. A study of teeth with
vertical root fractures by Fuss et al [9] reported that two-thirds of the posts
associated with vertically fractured endodontically treated teeth were
extremely short, terminating in the cervical third of the roots. In vitro
biomechanical studies also have suggested that better stress distribution
occurred with longer posts [1012].

The ferrule eect


A post in a pulpless tooth can transfer occlusal forces intraradicularly and
predispose to vertical fracture of the root [3,5]. If the articial crown extends
apical to the margin of the core and encircles sound tooth structure for 360 ,
the crown serves as a reinforcing ring or ferrule to help protect the root from
vertical fracture [6]. A number of studies have reported improved fracture
resistance for pulpless teeth restored with a ferrule [1316]. A recent in vitro
study by Isidor et al [17] that evaluated the eects of post length and ferrule
length on resistance to dynamic loading of bovine teeth in vitro reported that
the mean resistance to failure was greatest for the group restored with
a combination of the longest posts (10 mm) and the longest ferrules (2.5 mm).
S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416 399

A ferrule also helps to protect the integrity of the cement seal of the
articial crown. An in vitro study by Libman and Nicholls [18] reported that
there was improved resistance to fatigue failure of the cement seal of the
crown when the crown margin extended at least 1.5 mm apical to the margin
of the core. Torbjorner et al [19] retrospectively evaluated the clinical success
and failure characteristics of teeth restored with posts and articial crowns
and reported a higher potential for the fracture of posts when the cemented
crowns did not provide a ferrule eect. Also, if the margin of the crown and
the margin of the core are at the same cervical level, the retention of the
crown depends entirely on the retentive capacity of the post, and the post is
more likely to become dislodged.
A contrabevel has been advocated when preparing a tooth for a cast post
and core to produce a cast core with a collar of metal that encircles the tooth
and serves as a secondary ferrule independent of the ferrule provided by the
cast crown [20]. Nevertheless, there seems to be little advantage to this
secondary ferrule as a component of the core [21]. A study by Loney et al [22]
reported signicantly higher mean stresses with collared cores, suggesting
that incorporating a ferrule as an integral part of a cast core was undesirable.
Because there is no pulp to expose with a pulpless tooth, many dentists
believe they can over prepare the coronal portion of a pulpless tooth to
provide maximal space for the dental laboratory technician to develop the
best esthetic result with the articial crown. However, current knowledge
suggests that dentists should be conservative of coronal tooth structure when
preparing pulpless teeth for complete crowns to ensure an adequate ferrule
eect. The most commonly accepted guideline for this ferrule is a minimal
height of 1.5 to 2 mm of intact tooth structure above the crown margin for
360 around the circumference of the tooth preparation [1]. If insucient
tooth structure remains coronal to the gingival margin to develop this
ferrule, surgical crown lengthening [23] or orthodontic extrusion [24] should
be considered to expose additional tooth structure. Extraction of the tooth
with replacement by conventional or implant-supported prosthodontics is
usually a better option whenever an adequate ferrule cannot be obtained [1].

Apical seal
After preparation of a root canal for a post, the only barrier against
reinfection of the periapical region is the remaining gutta percha. To avoid
violation of the apical seal, the dentist should retain at least 4 to 5 mm of
apical gutta percha [25,26]. This minimal amount of gutta percha may limit
the length of the post; however, when there is a conict between the
guidelines for the posts length and the length of the apical seal, preservation
of an intact apical seal must prevail. Also, once the post space has been
prepared, the post should be cemented as soon as is practical because
delaying the placement of the post can increase the potential for apical
leakage [27].
400 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416

Design of the post for conservation of radicular tooth structure


Preservation of radicular tooth structure is a vitally important consider-
ation when selecting the design of the post. Posts may be parallel sided or
tapered. Two studies of tapered posts reported an increased potential for
wedging stresses within the root [28,29]. However, another study suggested
no dierence in stress distribution between tapered and parallel-sided posts
that were designed with adequate length [11]. Custom-made cast posts and
cores are potentially more conservative of tooth structure compared with
prefabricated posts because the custom cast post is designed to t the tooth.
With a prefabricated post, the dentist must instrument the root to allow it to
t the dimensions of the post. This issue is especially important for teeth with
small tapered roots, such as maxillary lateral incisors and mandibular
incisors [30]. The thin tapered roots of these incisors can be weakened
substantially if instrumented to t a prefabricated post [30].
With single-rooted teeth, slightly tapered posts are easier to place because
most roots are tapered and the root canal had been previously instrumented
with tapered endodontic les to form a continuously tapering cone before
obturation. Tapered posts help preserve dentin in the apical region of the
post, reducing the chances of excessive removal of dentin in this area [31]. A
tapered post is less retentive than a parallel-sided post [32], but a clinical
study of tapered posts reported no problems with retention when the lengths
of the posts were adequate [33].
Overall guidelines for posts in pulpless single-rooted teeth
Custom-made cast posts and cores are the recommended post system for
single-rooted teeth when substantial coronal tooth structure is missing. Fig.
1 summarizes the desirable features of a cast post and core for a single-
rooted tooth. For the best chances of success, the dentist should remove the
gutta percha to the desired depth without removing any additional tooth
structure; this should be followed by removal of the endodontic sealer from
the walls of the root canal with a rigid engine reamer (Fig. 2). The post
should be designed to t the available space in the prepared canal [6]. The
post should be as long as practical, with a slight taper. A minimum of 4 to 5
mm of gutta percha must be preserved. There should be a positive stop for
the core on the coronal tooth structure to prevent the post from being forced
apically, and the crown should provide a 1.5- to 2-mm or greater ferrule.
Commonly, premolars, whether single-rooted or dual-rooted, are restored
with a similar protocol. With a dual-rooted maxillary rst premolar, one
canal is usually chosen for the post, and placement of the post in the palatal
canal is generally preferred [34].

Increasing the probability of success of pulpless molars


Sorensen and Martino [4] reported an extremely high failure rate for
posterior pulpless teeth when these teeth lacked a restoration that covered
S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416 401

Fig. 1. For the highest probability of success, (1) the cast post should follow the natural taper
of the instrumented root canal, conserving as much radicular tooth structure as possible; (2)
the post should be as long as practical, preserving 4 to 5 mm of apical gutta percha seal; (3) the
coronal tooth structure should be prepared to provide a positive apical stop for the core; and (4)
the articial crown should encircle at least 1.5 to 2 mm of sound tooth structure apical to
the margin of the core for 360 .

the cusps, and Aquilino and Caplan [35] found a signicantly improved
success rate for pulpless teeth that were crowned (Fig. 3). These
retrospective clinical studies strongly support the placement of a crown or
onlay on a pulpless posterior tooth. Premolars usually are restored with
crowns supported by cast posts and cores, but molars are most often
restored with crowns supported by direct core reconstructions. Materials
that have been recommended for use as direct cores include silver amalgam,
composite resin, and glass ionomer-based materials [36].
402 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416

Fig. 2. The gutta percha should be removed to the desired depth with exible, bud-shaped
rotary instruments (Gates Glidden Drills; Moyco Union Broach, York, PA) or with a heated
instrument. Residual endodontic sealer should be removed from the walls of the canal with
rigid, straight-sided engine reamers (Peeso Reamers; Moyco Union Broach).

Selection of direct core material


When there is substantial residual coronal dentin, the choice of core
material is relatively unimportant [1]. However, when only several millimeters
of tooth structure remain coronal to the gingival margin, the physical
properties of the core reconstruction profoundly inuence the long-term
prognosis of the restored pulpless tooth [37]. Silver amalgam is the core
material of choice when strength is critical [37,38]. When more than half of
the coronal tooth structure remains, composite resin in combination with
a prefabricated post can be used eectively [1].

Fig. 3. Access preparation for endodontic treatment of posterior teeth requires substantial
removal of coronal tooth structure and destroys the continuity of the occlusal surface.
Uncrowned teeth are subject to fracture as a result of normal intraoral occlusal forces (large
arrow). Placement of an articial crown restores the continuity of the occlusal surface and
encircles the tooth (small arrows) to resist fracture.
S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416 403

Glass ionomer materials and several composite core materials contain


a uorosilicate inorganic component that releases trace amounts of uoride,
which may continue for up to 5 years [39,40]. Nevertheless, clinically
relevant cariostatic properties have not been established with these uoride-
containing core materials [1]. Glass ionomer-based core materials (including
various forms of modied or reinforced glass ionomer materials) are
brittle and incapable of resisting occlusal loads [37]. These materials are
indicated only as a method to block undesirable undercuts and should be
avoided in situations where the core must resist functional forces [1].
When there is substantial coronal tooth structure above the gingival
margin and the molar possesses a deep pulpal chamber, a silver amalgam
core reconstruction alone (without a post) has been reported to be highly
successful [41,42]. When the residual tooth structure is judged incapable of
supporting and retaining the core, a prefabricated post can be used to
augment the retention of the core [1]. A prefabricated post with direct core
reconstruction, followed by a complete crown, is a common restorative
approach for an endodontically treated molar [43].
A custom cast post-and-core system can be used for molars, but problems
commonly occur with the development of a path of insertion for the casting,
and a two-piece restoration is often required. Also, substantial coronal
tooth structure is inevitably removed when a path of insertion is developed
for the casting. Prefabricated posts with direct cores are more practical for
coronoradicular stabilization of pulpless molars and allow preservation of
maximal coronal tooth structure. Although silver amalgam is the most
mechanically sound core material, it is dicult to place when there is limited
remaining tooth structure above the gingival margin. Silver amalgam has
a prolonged setting time compared with composite resin and requires rigid
support during the placement, condensation, and setting process. Tradi-
tional matrix bands are dicult to apply and may not support condensation
pressures required for silver amalgam when much of the coronal tooth
structure is missing [44]. A hollowed-out acrylic resin provisional crown can
be used as a matrix for the silver amalgam core (Fig. 4) [4547].

The ferrule eect


The restored molar requires a traditional ferrule in which the margin of
the complete crown covers 1.5 to 2 mm of sound tooth structure apical to
the margin of the core for 360 . When there is little remaining coronal tooth
structure and the furcation is very high, crown lengthening is not usually an
option (Fig. 5), and the long-term prognosis of the tooth is poor.

Overall guidelines for restoring pulpless molars


Preservation of coronal and radicular tooth structure improves the
probability of success of a restoration for a pulpless molar. Direct cores are
404 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416

Fig. 4. (A) Mandibular molar to be reconstructed with a prefabricated post and a silver
amalgam core to serve as an abutment to a xed partial denture (FPD). (B) A narrow-diameter
prefabricated post was cemented in the distal root, the molar retainer for the provisional FPD
was hollowed out, and the provisional FPD was cemented with temporary cement. (C) Silver
amalgam was condensed by using the crown shell as a matrix and allowed to set for 24 hours.
(D) Completed foundation restoration includes a custom-cast post and core for the premolar
and a prefabricated post with silver amalgam core for the molar.

potentially more conservative of tooth structure; consequently, they are


usually preferred over cast cores. Silver amalgam is the recommended
core material under most circumstances. A prefabricated post may be
used to improve the retention of the core, and a nal restoration that
completely covers the cusps is indicated to avoid catastrophic fracture of
the tooth.
S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416 405

Fig. 4 (continued )

Prefabricated posts
There are various types and brands of prefabricated posts (Fig. 6). In
a survey of dentists reported in 1994, 40% of general dentists in the United
States reported using prefabricated posts most of the time, and the parallel-
sided serrated post was the most popular type [8]. Passive posts are most
commonly used in the United States [8]. Posts that actively engage radicular
tooth structure with threads are more retentive but can predispose the root
to fracture [38,4850]. Retention of a cemented passive post is greatest when
the post is parallel sided and has a roughened surface. A narrow-diameter,
parallel-sided serrated post can be used eectively in a pulpless molar to
augment the retention of the direct core; however, parallel-sided posts are
406 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416

Fig. 5. Endodontically treated mandibular molar with widely spread roots and a high
furcation. Prognosis is poor because crown lengthening is not possible to develop a ferrule.
Extraction and replacement with an implant-supported crown oers a more favorable prognosis
as a denitive restoration.

more dicult to use with single-rooted teeth and dual-rooted premolars


because of the natural taper of their roots (Fig. 7) [6].
Fiber reinforced epoxy resin posts
Several brands of ber-reinforced epoxy resin posts are commercially
available. These posts were originally reinforced with carbon bers, which

Fig. 6. Examples of commercially available prefabricated posts.


S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416 407

Fig. 7. The use of prefabricated parallel-sided posts of acceptable length in anterior teeth and
premolars is dicult because of the natural taper of the roots.

are black [51]. Modications to these ber-reinforced posts include coating


the post with quartz bers to mask the black color or replacing the carbon
bers with quartz bers or glass bers to improve the esthetic result [5254].
In vitro studies have indicated that these posts are not as strong as
conventional posts, and their strength degrades signicantly in vitro after
storage in water, thermocycling, and cyclic loading [5155].
Some investigators have suggested that these ber-reinforced epoxy resin
posts possess inherent exibility that is similar to the exibility of natural
dentin, allowing the posts to behave similar to the radicular dentin, absorb
stresses, and prevent root fractures [5658]. Nevertheless, an elastic modulus
comparable to human dentin as measured in vitro does not ensure that the
clinical behavior of the post will be similar to the clinical behavior of
radicular dentin. The root is a hollow tube, and the post is a rod within this
tube surrounded by a layer of composite resin luting agent. The radically
dierent shape of a root compared with the conguration of the post
408 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416

Fig. 8. Anterior tooth restored with a complete crown supported by a ber-reinforced post and
composite core. Normal intraoral forces (large arrow) may cause the post to ex, producing
micro-movement of the core and failure of the cement seal of the crown (small arrow).

combined with the interposed composite resin luting agent suggest that the
exural characteristics of the post do not match that of the root. Another in
vitro study indicated that the form of the post itself inuenced its rigidity
and reported that a smooth, ber-reinforced epoxy resin post was less
exible than the serrated version of the post [59].
A exible post can cause failure of the cement seal at the margin of the
articial crown, especially when the ferrule is minimal (Fig. 8). Because the
post is bonded to the root and the crown is cemented to the composite core,
the crown remains in place, and the problem of leakage at the crown margin
is dicult to detect.

Zirconia posts
Posts composed of zirconium oxide, a material that has been used in
medicine for orthopedic implants, have also been marketed [6063]. These
all-ceramic posts were originally designed for use with a composite core to
improve the esthetic qualities of all-ceramic crowns because it was assumed
that a metal post and core would impede light transmission through the
ceramic crown. However, a recent study has reported that translucent all-
S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416 409

ceramic crowns supported by cast posts and cores made from yellow gold
alloy do not appreciably alter the esthetic outcome when the gold core is
polished; therefore, the esthetic advantage of these ceramic posts can be
questioned [64]. Ceramic materials are tough and have high compressive
strengths, but because of their poor tensile strengths they may fracture when
subjected to sheer stresses [65]. To compensate for their brittle nature, these
posts are made relatively wide, requiring substantial removal of radicular
tooth structure. At this time, little is known about the long-term survival of
these all-ceramic posts, and they seem to have limited applicability.

Woven-ber composite materials


The use of cold-glass, plasma-treated, polyethylene woven bers
embedded in conventional resin composite has been advocated for the
coronoradicular stabilization of pulpless teeth [66,67]. Nevertheless, a study
of woven-ber composite posts and cores reported that these posts are weaker
than cast metal posts and cores [68]. Reinforcement of the woven-ber
composite material with a smaller-diameter prefabricated post improved the
mechanical properties signicantly, but the strength did not approach that of
a cast metal post and core [68]. This material presents disadvantages similar
to those of the ber-reinforced epoxy resin post systeminferior strength
combined with undesirable exibility.

Dental cements
The post is retained in the prepared post channel with dental cement. The
primary factors that inuence the durability of the bond of the post to the root
are compressive strength, tensile strength, and adhesive qualities of the
cement. Further considerations concerning the selection of a material to
cement posts include the cements potential for plastic deformation, micro-
leakage, and water imbibition. Also, the cements handling characteristics
during mixing and seating of the post and the nature of the setting reaction of
the cement can play a role in the survival of a cemented post in vivo. The
currently available dental cements include zinc phosphate, polycarboxylate,
glass ionomer, resin-modied glass ionomer, and resin cements. These
dierent classes of cements have advantages and disadvantages, and some
should be avoided for use as a cementing medium for endodontic posts.
Another relatively new cement, compomer, is rarely advocated for posts.
Zinc phosphate cement has been used for decades to cement dental
restorations and has a long history of success. The primary disadvantages of
this cement are solubility in oral uids, especially in the presence of acid,
and lack of true adhesion.
Polycarboxylate and glass ionomer cements are also soluble in oral uids,
but they can chemically bond to dentin [69,70]. Polycarboxylate cements
have been shown to undergo plastic deformation after cyclic loading, which
410 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416

is a major disadvantage [71]. Glass ionomer cement releases uoride [72,73],


but the ability of this leached uoride to provide long-term protection
against dental caries in dentin has never been proven [74]. Resin-modied
glass ionomer cements are stronger than conventional glass ionomer
cements and also release uoride [75,76]. Adhesive resins are essentially
insoluble in oral uids and possess high compressive strengths [77].
A primary disadvantage of conventional glass ionomer cement is its
setting reaction. This cement does not reach its maximal strength for many
days [78,79]. Therefore, any recontouring of the core with a dental hand-
piece on the day of cementation of the post can potentially disturb the set
of the cement and weaken the immature cement lm [1].
Resin-modied glass ionomer cement contains hydrophilic resins that
slowly imbibe water, causing the cement lm to gradually expand [80,81]. One
in vitro study suggested that this expansion of the cement could fracture all-
ceramic crowns relatively soon after cementation [82]. However, a more
recent study found no potential for fracture of all-ceramic crowns cemented
with resin-modied glass ionomer cement after 60 weeks of storage in vitro in
100% humidity [83]. Nevertheless, this cement should be used with caution. If
this cement can expand and cause fracture of all-ceramic crowns, it could
possibly cause vertical fracture of the roots if used to cement posts (Fig. 9).
Some studies of resin cements have reported signicantly higher retentive
values for cemented posts [8487], whereas others have reported conicting
results [8890]. Reactions between dental resins and eugenol can explain the
diametrically opposing results reported in some in vitro studies. The setting
reaction of most dental resins is adversely aected by the presence of
eugenol, and most endodontic sealers contain eugenol [1]. Also, some
commercially available resin cements are technique sensitive and dicult to
use for the cementation of posts [89].

Fig. 9. It has been postulated that delayed expansion of resin-modied glass ionomer cement
can fracture an all-ceramic crown (A). This expansion also is a concern with posts because root
fracture is possible (B).
S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416 411

If fundamental biomechanical principles are followed when designing


and placing a post, it seems unlikely that the type of cement used for
cementation plays a signicant role in the overall prognosis of a restored
pulpless tooth. Conventional cements, such as zinc phosphate cement, can
be used eectively for this purpose.

Problems and complications with posts


The most common complications reported in the literature for posts are
dislodgment of the posts, fracture of the roots, and dental caries [7]. Shorter
posts are less retentive than longer posts and are more likely to concentrate
stresses in the root, increasing the potential for post dislodgement or root
fracture (Fig. 10) [912]. The ferrule has been shown to substantially reduce
stresses within the cervical portion of a tooth restored with a post and
complete crown [1218,91], and this ferrule can also reduce the potential for
dislodgment or fracture of the post itself [1,19].
Although there are many factors that can predispose to dental caries,
a exible post or exible core can generate stresses within the cement seal of
the articial crown, producing leakage at the margin of the crown and
eventual caries. Because most crowns are radiopaque, this type of problem is
dicult to detect radiographically and may not become apparent until severe
destruction of the remaining tooth structure has occurred [92]. A rigid post
and core with a relatively long ferrule can help protect against this problem.

Fig. 10. Tooth with a short post and fractured root displaying typical radiographic appearance
(arrow). Note the thickened periodontal ligament space and widened lamina dura, resembling
an upside-down J.
412 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416

Summary
A pulpless tooth has commonly lost substantial tooth structure as a result
of previous restorations, dental caries, and the access preparation for
endodontic therapy. Consequently, a pulpless tooth requires a restoration
that conserves and protects the remaining tooth structure. Although there
are many new materials available for the restoration of pulpless teeth, the
prognosis of these teeth relies primarily on the application of sound
biomechanical principles rather than on the materials used for the
restoration.
Posts and cores are commonly required with pulpless teeth. A longer post
that preserves 4 to 5 mm of the apical gutta percha seal combined with an
articial crown that provides a ferrule eect oers the best chances of
success [17]. Custom-cast posts and cores are generally recommended for
anterior teeth and most premolars, and prefabricated posts with direct cores
are commonly preferred for molars. Complete crowns or onlays that cover
all cusps are recommended for all posterior pulpless teeth regardless of the
amount of remaining coronal tooth structure to reduce the chances of
fracture of these teeth.

References
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knowledge and future needs. J Prosthet Dent 1999;82:64357.
[2] Kantor ME, Pines MS. A comparative study of restorative techniques for pulpless teeth.
J Prosthet Dent 1977;38:40512.
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Dent Clin N Am 48 (2004) 417431

Cervical margin design with contemporary


esthetic restorations
Terry E. Donovan, DDS*, Winston W.L. Chee, BDS
University of Southern California School of Dentistry, University Park MC0641,
925 West 34th Street, Los Angeles, CA 90089-0641, USA

The contemporary dentist has a wide variety of options to use in the


restoration of extensively damaged or previously restored teeth. Metal-
ceramic and all-ceramic crowns are used frequently to restore esthetics and
function. One of the essentials for success with either option is proper tooth
preparation, which includes proper selection and preparation of the cervical
margin of the preparation [1,2].
Regardless of the margin geometry, proper placement of the prepared
gingival margin in relation to the free gingival margin, the epithelial
attachment, and the alveolar housing is imperative. Wherever the esthetic
demands permit it, margins should be placed in a supra-gingival location [3
6]. In many patients, margins must be placed in an intra-crevicular position
to hide those margins with healthy gingival tissue and thus provide an
acceptable esthetic result. Clinicians need to understand that placing
a cervical margin in an intra-crevicular position is an exercise in precision.
If the margin is placed a short distance from the free gingival margin, a minor
amount of gingival recession may result in exposure of the margin and
esthetic failure. A margin placed too deep in the sulcus risks the possibility of
biologic width violation and concomitant chronic gingival inammation
(Fig. 1) [7,8].
There are two potentially useful landmarks to guide the clinician in
accurate margin placement. A generally useful guideline is to place cervical
margins 0.5 mm apical to the healthy free gingival margin [9]. A more precise
method is to sound through the attachment to probe the crest of the alveolar
bone and to place cervical margins at least 4 mm coronal to that alveolar crest
[10]. With either landmark, it is critical that the prepared cervical margin
follow the scalloped anatomy of the alveolar bone, the attachment, and the

* Corresponding author.
E-mail address: tdonovan@usc.edu (T.E. Donovan).

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.013
418 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431

Fig. 1. (AC) When cervical margins are placed too close to the epithelial attachment, biologic
width is violated. This results in a typical chronic inammatory response.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431 419

gingival tissues. The most common error made by clinicians is to atten the
cervical margin in the inter-proximal areas, thereby violating biologic width
and eliciting a chronic inammatory response (Fig. 2).
Several geometric margin designs are available for consideration with
metal-ceramic crowns. Dierent margin designs are indicated in dierent
clinical situations [11]. Specic criteria must be used to assist the clinician in
determining which margin design is optimum for a given clinical situation.
The following criteria for margin selection seem reasonable:
1. The selected margin must provide a predictable level of marginal
integrity.
2. To minimize plaque accumulation, the selected margin must present
smooth materials to the gingival sulcus.
3. In some situations, the margin also must provide acceptable esthetics.
Not all designs meet all of these criteria. Selection of an inappropriate
cervical margin design can have deleterious consequences.
There are many problems that can result from improper preparation and
placement of cervical margins. These include biologic width violation, metal
margins showing through thin marginal gingiva, recession exposing the
tooth/restorative interface, opacity in the cervical third of the restoration,
and roughness of the cervical margin, which contributes to plaque accumu-
lation. Biologic width violations are primarily a function of margin placement
and are independent of margin design. Gingival recession is primarily a
result of improper soft tissue management and is independent of margin de-
sign [5,6]. The other problems can be resolved by proper selection and prep-
aration of the appropriate cervical margin.
With metal-ceramic crowns, there are ve potential cervical margins to
consider. These include the knife-edge, the chamfer, the shoulder or butt
joint, the beveled shoulder, and the slant shoulder or disappearing margin

Fig. 2. The biologic width has been violated in the inter-proximal area because the cervical
margin does not follow the scalloped anatomy of the attachment and the underlying alveolar
housing.
420 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431

(Fig. 3). Each of these cervical margin congurations is considered relative


to the three criteria listed previously.
One of the most important considerations in selecting a cervical margin
design is the ability to consistently and predictably provide excellent
marginal integrity. The termination of knife-edge margins is often dicult
to read on the gypsum die, so t is often compromised inherently with this
design. The thin metal margins are also prone to distortion during the ring
of the ceramic veneer, further reducing marginal delity. Such margins also
have the potential for metal display and hence inherently lack esthetics.
Thus, knife-edge margins should not routinely be used with metal-ceramic
restorations [12]. Their use should be limited to situations where a root has
been amputated due to periodontal disease or with cusp fractures where
a knife-edge margin cannot be avoided.
The chamfer margin should also be avoided with metal-ceramic crowns
due to the relative inherent lack of specicity of depth and due compromised
marginal integrity as a result of distortion of the metal framework during
porcelain ring [13,14]. Distortion of cervical margins is a complex
phenomenon that relates to the composition of the metal alloy and the
cervical geometry of the margin. It is generally believed that the lower the
melting temperature of the alloy, the greater the marginal distortion.
With high gold alloys it has been demonstrated that chamfer margins
distort considerably more than shoulder or shoulder-bevel margins. Many
clinicians prefer to use such gold colored alloys for single-unit restorations in
the anterior area because the oxide layer with these alloys is readily masked
with a thin layer of opaque porcelain. Gold-palladium alloys, which are
recommended for xed partial dentures and posterior restorations, do not
display similar dierences in distortion with dierent margin designs [15].

Fig. 3. Various cervical margin congurations.


T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431 421

Although there is conicting evidence regarding the etiology of the


distortion, it is generally believed that the majority of the distortion occurs
during the degas cycle and is primarily the result of the release of strains that
develop during the casting and cooling process [16,17]. Whatever the cause,
chamfered margins should be avoided with porcelain-metal crowns because
of their lack of prescribed depth and because of this fundamental
compromise in marginal integrity with high gold alloys.
There are three cervical margin designs that seem to meet the criterion
related to acceptable marginal integrity. These include the shoulder, the
shoulder-bevel, and the slant shoulder. Although denitive studies related to
the slant shoulder and distortion are not available, the shoulder and
shoulder-bevel margin seem to resist distortion due to the inherent bulk of
metal at the margin.
The shoulder and shoulder bevel also meet the criterion related to the use
of smooth materials in the gingival crevice. This is critical to long-term
periodontal health because rough materials accumulate and retain plaque
more readily than do smooth materials [1820]. The shoulder can be used
with a metal margin, which can be highly polished, or with a porcelain
margin, which results in glazed porcelain in the sulcus. The shoulder-bevel
margin has a collar of metal 1 mm or more in width and thus places highly
polished metal in the sulcus (Figs. 4, 5) [21].
The slant shoulder can be used with a metal collar or with the so-called
disappearing margin [22]. If a metal collar is used, it can be highly polished
and thus can be acceptable as it relates to plaque accumulation. However, the
disappearing margin is inherently rough due to the presence of three dierent
materials at the terminus of the margin [11]. This margin design places
oxidized metal, opaque porcelain, and body porcelain in the vicinity of the
marginal terminus, and each of these materials has an inherent lack of
smoothness [23]. Oxidized metal is approximately 75 times rougher than
polished metal. Opaque porcelain is substantially rougher than glazed
porcelain, and the body porcelain in this position is often porous because it
tends to shrink toward the greater mass of porcelain coronal to the margin
(Fig. 6). These dierent rough materials with their inherent interfaces present
a rough surface to the gingival sulcus and may predispose the patient to
increased plaque accumulation and retention.
The third criterion to be considered when selecting a cervical margin design
is the esthetic potential of the design. When used appropriately, the shoulder-
bevel margin has a polished metal collar of 1 mm or more. This is because
a steep bevel of approximately 60 should be used to maximize the slip-joint
eect and close the margin [21]. This steep bevel results in a substantial metal
collar. This provides the best initial t before ring the porcelain; this t is
maintained through all of the ceramic ring cycles [2427]. The metal can be
highly polished; however, the problem with this design is esthetics.
It once was believed that adequate esthetics could be achieved by hiding
the metal collar in the sulcus, but experience has proved this to be
422 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431

Fig. 4. (A, B) These restorations have used a shoulder-bevel margin that provides optimum
marginal integrity and a smooth, polished surface.

unpredictable at best. Thus, the shoulder-bevel margin should be used only


in situations where esthetics is not important (Fig. 7). The margin can be
placed partially in the sulcus, in an equi-gingival position, or a supra-
gingival position. With the metal display inherent with this margin, it is
recommended that the patient give informed consent when it is indicated.
In situations where esthetics is important, the clinician has three options.
The rst is to use an all-ceramic crown. Although the potential life span of
most all-ceramic options has improved in recent years, metal-ceramic crowns
may provide a longer service [28,29]. However, several all-ceramic systems
provide excellent esthetics with improved longevity and can be used with
relative condence on anterior teeth. All-ceramic alternatives should be
avoided on posterior teeth.
Although there are several all-ceramic systems available, the cervical
margin design with all the systems is similar. A shoulder margin with
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431 423

Fig. 5. The use of a shoulder margin with a porcelain labial margin results in smooth, glazed
porcelain in the gingival crevice.

a rounded internal angle should be prepared to end at approximately 90 to


the external angle of the labial or buccal surface. A slight slant of no more
than 5 is acceptable. The margin should be as smooth as possible, and, to
provide optimum esthetics and strength, should be between 1.2 and 1.5 mm
in depth (Fig. 8). This design provides adequate bulk for esthetics and
strength and places the cervical margin in compression during function. It
also permits the restoration to be glazed without rounding of the terminal
ceramic margin. If a more pronounced slant is produced, tensile forces occur
in function, which can result in half-moon fractures in the cervical area. It is

Fig. 6. The disappearing margin design results in multiple materials and interfaces at the
marginal terminus that are inherently rough and may have a deleterious eect on plaque
accumulation and retention.
424 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431

Fig. 7. (A, B) These restorations are not visible with a normal or exaggerated smile and the
shoulder-bevel margin was used, providing optimum t with a smooth, polished surface.

also dicult, if not impossible, to avoid rounding of the thin wedge of


porcelain during glazing when a pronounced slant is prepared.
When a metal-ceramic restoration is indicated, the porcelain labial margin
(shoulder) and the disappearing margin (slant shoulder) can be used. Because
of the inherent roughness of the disappearing margin, the slant shoulder
should be used only where indicated, and that is when the cervical margin of
the restoration must be placed a considerable distance down the root surface
[30]. In this position, excess tooth structure would have to be removed to
accommodate a classic shoulder margin.
In patients with a low smile line, the slant shoulder with a metal collar
should be considered. However, if the smile exposes the cervical portion of
the restoration, a disappearing margin is the margin of choice. This design
hides the metal but, due to the relative lack of bulk of porcelain in the cervical
area, results in an opacious appearance due to the proximity of the opaque to
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431 425

Fig. 8. All-ceramic margins should provide a shoulder with a rounded internal angle and
should be between 1.2 and 1.5 mm in width.

the surface (Figs. 9, 10). This can be masked with intrinsic coloration by some
master ceramists but often is an esthetic deciency of this margin design.
The margin of choice in esthetic situations when using metal-ceramic
crowns is a shoulder design with a porcelain labial margin. This design allows
for an adequate thickness of ceramic material at the margin so that
a predictable esthetic result is assured, provides excellent strength, and places
glazed porcelain in the gingival sulcus (Figs. 11, 12) [31].
Several techniques have been described for fabricating porcelain margins,
and all seem to provide acceptable results if the margin has been prepared
properly and the technician pays meticulous attention to detail [3242]. It

Fig. 9. The disappearing margin eectively hides the metal margin but often results in cervical
opacity.
426 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431

Fig. 10. (A, B) If patients accept characterization, cervical opacity can often be masked with
internal coloration.

has been shown theoretically and experimentally that shoulder margins can
be fabricated with acceptable ts. Sucient expansion is achieved with
casting investments, or internal expansion is achieved with the appropriate
thickness of die spacer [43,44]. With proper technique, marginal gaps of 6 to
34 lm can predictably be achieved, which is well within the realm of clinical
acceptability [4547].
The preparation of the porcelain labial margin is identical to that of the all-
ceramic crown, with the exception that the shoulder margin is prepared only
on the labial or buccal surfaces. The shoulder margin is carried interprox-
imally to the proximal-lingual line angle, and a chamfer or beveled shoulder
margin is prepared on the lingual half of the tooth (Fig. 13). The shoulder
should be at 90 to the external surface and 1.2 mm in width. It should be
smooth, and hand instrumentation is generally recommended to achieve
a planed surface [48].
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431 427

Fig. 11. (A, B) The porcelain margins illustrated combine good marginal integrity with
excellent esthetics.

Some authorities recommend the use of a 360 porcelain margin. This


approach is proposed because it theoretically permits improved light
transmission and improved esthetics. In the opinion of the authors, this
unnecessarily complicates the laboratory phase of fabrication and provides,
at best, minimal benet.
Another issue that has generated controversy in recent years is where
the gingival extension of the metal substructure should terminate relative to
the shoulder margin. The classic technique extends the metal framework
to the axio-gingival line angle. Technicians have recently advocated
shortening the metal framework and terminating it anywhere between 1 and
3 mm from the shoulder margin. A recent study has demonstrated that light
transmission is improved with the metal cut back 1 mm from the shoulder and
that increased cutbacks do not result in signicant improvement in light
428 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431

Fig. 12. These metal-ceramic restorations with porcelain labial margins provide acceptable
esthetics when the margins are hidden with healthy gingival tissues.

transmission [49]. The same study found that a cutback of 2 mm or more


resulted in signicant weakening of the restoration. Based on this information,
it is recommended that the metal framework be cut back 1 mm from the
shoulder margin.

Summary
When preparing teeth for esthetic crown restorations, the clinician must
determine which cervical nish line is appropriate for each specic clinical

Fig. 13. The preparation for porcelain labial or buccal margins mandates a shoulder margin on
the buccal half of the tooth and a shoulder bevel or chamfer on the lingual half. The premolar
has been prepared for a porcelain shoulder margin, and the molar has been prepared for
a shoulder-bevel margin.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431 429

situation. All cervical margins must be placed in the correct position relative
to the free gingival margin, the epithelial attachment, and the alveolar
housing.
With all-ceramic crowns, the optimum nish line is a shoulder margin
with rounded internal angle with a width of 1.2 to 1.5 mm. This depth may
have to be reduced to 1.0 mm with triangular-shaped teeth. It should meet
the external surface of the tooth at an angle of 90 .
With metal-ceramic crowns, knife-edge margins and chamfer margins
should generally be avoided due to concerns with t. Shoulder-bevel margins
are the margins of choice in situations where esthetics is not important
because of their documented ability to provide optimum t and the ability to
polish the inherent metal collar.
Shoulder margins with a labial or buccal porcelain margin are indicated in
situations where esthetics is paramount. These margins should be prepared at
90 to the external tooth surface, should be exceptionally smooth, and should
have a width of 1.2 mm. The metal substructure should be nished 1.0 mm
from the shoulder margin to permit optimum light transmission without
sacricing strength.
Slant shoulder margins are necessary when the tooth preparation extends
some distance on the root surface. In situations where these margins are not
visible, they should use a metal collar. In situations where the smile exposes
these margins, the disappearing margin approach should be used.

References
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gingival inammation. J Periodontol 1974;45:151.
[4] Christensen GJ. Marginal t of gold inlay castings. J Prosthet Dent 1966;16:297.
[5] Donovan TE, Cho GC. Soft tissue management with metal-ceramic and all-ceramic
crowns. J Calif Dent Assoc 1998;26:107.
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the importance of soft tissue management. Periodontol 2000;27:121.
[7] Ingber JF, Rose LF, Coslet JG. The biologic width: aconcept in periodontics and
restorative dentistry. Alpha Omegan 1977;70:62.
[8] Kois JC. The restorative-periodontal interface: biologic parameters. Periodontol 2000
1996;11:29.
[9] Block PL. Restorative margins and periodontal health: a new look at an old problem.
J Prosthet Dent 1987;57:683.
[10] Kois JC. Altering gingival levels: the restorative connection, part I. Biologic variables.
J Esthet Dent 1994;6:3.
[11] Donovan TE, Prince J. An analysis of margin congurations for metal-ceramic crowns.
J Prosthet Dent 1985;53:153.
[12] Hunter AJ, Hunter AR. Gingival crown margin congurations: a review and discussion.
Part I: terminology and widths. J Prosthet Dent 1990;64:548.
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[13] Shillingberg HT, Hobo S, Fisher DW. Preparation design and margin distortion in
porcelain-fused-to-metal restorations. J Prosthet Dent 1973;29:276.
[14] Faucher RR, Nicholls JI. Distortion related to margin design in porcelain-fused-to-metal
restorations. J Prosthet Dent 1980;43:149.
[15] Richter SK, Aquilino SA, Svare CW, Turner KA. Change in marginal t as related to
margin design, alloy type, and porcelain proximity in porcelain-fused-to-metal restora-
tions. J Prosthet Dent 1988;60:435.
[16] Bryant RA, Nicholls JI. Measurement of distortion in xed partial dentures resulting from
degassing. J Prosthet Dent 1979;42:515.
[17] Bridger DV, Nicholls JI. Distortion of ceramo-metal xed partial dentures during the ring
cycle. J Prosthet Dent 1981;45:507.
[18] Wise MD, Dykema R. The plaque-retaining capacity of four dental materials. J Prosthet
Dent 1975;33:178.
[19] Clayton JA, Green E. Roughness of pontic materials and dental plaque. J Prosthet Dent
1970;23:407.
[20] Podshadley A. Gingival response to pontics. J Prosthet Dent 1968;19:51.
[21] McLean JW, Wilson AD. Butt joint versus beveled gold margin in metal-ceramic crowns.
J Biomed Mater Res 1980;14:239.
[22] Sozio RB. The marginal aspect of the ceramo-metal restorations: the collarless ceramo-
metal crown. Dent Clin N Am 1977;21:787.
[23] Padilla MT, Bailey JH. Margin conguration, die spacers, tting of retainers/crowns, and
soldering. Dent Clin N Am 1992;36:743.
[24] Gavelis JR, Morency JD, Riley ED, Sozio RB. The eect of various nish line
preparations on the marginal seal and occlusal seat of full crown preparations. J Prosthet
Dent 1981;45:136.
[25] Gilboe DB, Thayer KE. Beveled shoulder concept: full gold crown preparation. J Can
Dent Assoc 1980;46:519.
[26] Preston JD. Rational approach to tooth preparation for ceramo-metal restorations. Dent
Clin N Am 1977;21:683.
[27] Dedmon HW. The relationship between open margins and margin design on full cast
crowns made by commercial laboratories. J Prosthet Dent 1985;53:463.
[28] Cho GC, Donovan TE, Chee WWL. Rational use of contemporary all-ceramic crown
systems. J Calif Dent Assoc 1998;26:113.
[29] Donovan TE, Cho GC. The role of all-ceramic crowns in contemporary dentistry. J Calif
Dent Assoc 2003;31:565.
[30] Bishop K, Briggs P, Kelleher M. Margin design for porcelain fused to metal restorations
which extend onto the root. Br Dent J 1996;180:177.
[31] Hunter AJ, Hunter AR. Gingival margins for crowns: a review and discussion. Part II:
discrepancies and congurations. J Prosthet Dent 1990;64:636.
[32] Goodacre CJ, Van Rockel NB, Dykema RW, Ullman RB. The collarless metal-ceramic
crown. J Prosthet Dent 1977;38:612.
[33] Sozio RB, Riley EJ. A precision ceramic-metal restoration with a facial butted margin.
J Prosthet Dent 1977;37:517.
[34] Toogood GD, Archibald JF. Technique for establishing porcelain margins. J Prosthet
Dent 1978;40:464.
[35] Vryonis P. A simplied to the complete porcelain margin. J Prosthet Dent 1979;42:592.
[36] McLean JW. The science and art of dental ceramics, vol. 2. Chicago: Quintessence; 1980.
[37] Prince J, Donovan TE, Presswood RG. The all porcelain margin for ceramo-metal
restorations: a new concept. J Prosthet Dent 1983;50:793.
[38] Prince J, Donovan TE. The esthetic ceramo-metal margin: a comparison of techniques.
J Prosthet Dent 1983;50:185.
[39] Schneider DM, Levi MS, Mori DF. Porcelain shoulder adaptation using direct refractory
dies. J Prosthet Dent 1976;36:583.
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[40] Kessler JC, Brooks TD, Keenan MP. The direct lift-o technique for constructing
porcelain margins. Quintessence Dent Technol 1986;10:145.
[41] Hurtado AJ. A metal-ceramic restoration with a porcelain labial margin: a modied direct
lift method. J Prosthet Dent 1986;56:380.
[42] Wiley MG, Hu TL, Trebilcock C, Girvan TB. Esthetic porcelain margins: a modied
porcelain-wax technique. J Prosthet Dent 1986;56:527.
[43] Pascoe DF. Analysis of the geometry of nishing lines for full crown preparations.
J Prosthet Dent 1978;40:157.
[44] Syu JZ, Byrne G, Laub LW, Land MF. Inuence of nish line geometry on the t of
crowns. Int J Prosthodont 1993;6:25.
[45] Hunt JL, Cruickshanks-Boyd DW, Davies EH. The marginal characteristics of collarless
bonded porcelain crowns using a separating medium technique. Quintessence Dent
Technol 1978;9:21.
[46] Boyle JJ, Naylor WP, Blackman RB. Marginal accuracy of metal-ceramic restorations
with porcelain facial margins. J Prosthet Dent 1993;69:19.
[47] Morris HF. Quantitative and qualitative evaluation of the marginal t of cast ceramic,
porcelain shoulder, and cast metal full crown margins. J Prosthet Dent 1992;67:1992.
[48] Zena RB, Kahn Z, von Fraunhofer JA. Shoulder preparations for collarless metal-ceramic
crowns: hand planning as opposed to rotary instrumentation. J Prosthet Dent 1989;62:273.
[49] OBoyle KH, Norling BK, Cagna DR, Phoenix RD. An investigation of new metal
framework designs for metal-ceramic restorations. J Prosthet Dent 1997;78:295.
Dent Clin N Am 48 (2004) 433444

Current concepts in gingival displacement


Terry E. Donovan, DDS*, Winston W.L. Chee, BDS
University of Southern California School of Dentistry, University Park MC0641,
925 West 34th Street, Los Angeles, CA 90089-0641, USA

Indirect restorations, including cast gold inlays, onlays, partial veneer


restorations and complete crowns, metal-ceramic and all-ceramic crowns,
and bonded ceramic inlays and onlays are routinely used to restore defective
teeth. These restorations frequently have cervical margins that are in-
tentionally placed in the gingival sulcus for esthetic or functional reasons. In
these situations, the clinician must make impressions that accurately capture
the prepared cervical nish lines and permit the fabrication of accurate dies
on which the restorations are fabricated.
There is evidence that inadequate impressions are frequently forwarded
to commercial laboratories, and the chief deciency seen in such impressions
is inadequate recording of the cervical nish lines [1,2]. The primary reason
for not adequately capturing marginal detail is decient gingival displace-
ment technique.
The procedure used to facilitate eective impression making with intra-
crevicular margins is gingival displacement as opposed to gingival
retraction [3]. The goal of the procedure is to reversibly displace the
gingival tissues in a lateral direction so that a bulk of low-viscosity impression
material can be introduced into the widened sulcus and capture the marginal
detail (Fig. 1) [4,5].
A bulk of impression material is required to obtain maximum accuracy
and to improve the tear strength of the material so that it can be removed
from the mouth intact with no tearing [6,7]. The critical sulcular width in
this regard seems to be approximately 0.2 mm. A width of less than 0.2 mm
results in impressions that have a higher incidence of voids in the marginal
area, an increase in tearing of the impression material, and a reduction in
marginal accuracy [8]. It is imperative that a small amount of impression
material ows beyond the prepared margin (Fig. 2). This permits accurate
trimming of the recovered die (Fig. 3).

* Corresponding author.
E-mail address: tdonovan@usc.edu (T.E. Donovan).

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.012
434 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444

Fig. 1. The gingival tissues need to be displaced laterally to permit injection of a bulk of low-
viscosity impression material into the sulcus.

Many clinicians have diculty with gingival displacement procedures


primarily because they have not mastered eective soft tissue management
procedures [9,10]. One critical factor in this regard is to ensure that the gingival
tissues are in an optimum state of health before making the impression [11].
Making impressions with inamed marginal gingival tissues can be dicult
and requires aggressive procedures that may result in gingival recession.
Quality provisional restorations are essential to establish an improved
environment to facilitate oral hygiene procedures to improve and maintain
gingival health [12,13]. The location of the prepared cervical margin within
the sulcus is critical to long-term gingival health and to impression making.
The optimum position of the margin is 0.5 mm from the healthy free gingival
margin or 3.0 to 4.0 mm from the crest of the alveolar bone and must follow
the natural scalloped form of the attachment and alveolar housing [14,15].
If the gingival tissues are healthy and the cervical margin is placed in the
appropriate position, gingival displacement is a relatively simple, atraumatic
procedure. Most of the diculties with gingival displacement result from
attempting to make impressions when the tissues are clinically inamed, when
clinically there is inadequate attached gingiva, or when prepared margins are
placed too deep in the sulcus.
Techniques for gingival displacement have been classied as mechanical,
chemical, surgical, and combinations of the three [16,17]. The method of
gingival displacement used by the majority of practitioners is a combination
of mechanical-chemical displacement using gingival retraction cords along
with specic hemostatic medicaments [18]. A small number of dentists use

Fig. 2. A denite amount of impression material must ow beyond the prepared margin to
facilitate trimming of the gypsum die.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444 435

Fig. 3. Trimming of gypsum die is a simple procedure when eective gingival displacement
procedures result in excellent impressions.

surgical methods, including rotary gingival curettage and electro-surgery,


but these are generally used as ancillary procedures in conjunction with
mechanical-chemical techniques.
There are three main variations of the mechanical-chemical technique for
gingival displacement. They include the single cord technique, the double
cord technique, and the infusion method of gingival displacement [1921].
Each of these techniques can be used eectively and are described in detail
below. Before describing these techniques, a discussion of dierences in
retraction cords and medicaments may be useful.
Retraction cords are supplied in three basic designs, including twisted
cords, knitted cords, and braided cords. There is little scientic evidence to
dierentiate one type of cord from another; thus, the selection of which
design of cord to use is determined by operator preference. The authors
prefer to use braided or knitted cords [22].
One key to eective displacement is to use a cord of sucient diameter to
provide adequate displacement so that adequate bulk of impression material
can be introduced into the sulcus. The largest cord that can be atraumati-
cally placed in the sulcus should be used (Fig. 4) [5,16]. The primary error
made by inexperienced dentists is to use a cord that is too small in diameter.
These small-diameter cords are placed with minimal trauma; however, they
do not provide adequate lateral displacement of the gingival tissues.
There are numerous hemostatic medicaments that have been advocated
for use with gingival retraction cords, and some of these medicaments have
been extensively studied [2333]. A review of the literature demonstrates
that four medicaments seem to provide adequate displacement and uid
control and seem to be safe in that they do not produce iatrogenic soft
tissue damage when used appropriately [18]. These medicaments include
aluminum potassium sulfate, aluminum sulfate, aluminum chloride, and
epinephrine.
The local use of epinephrine as a gingival displacement medicament has
the potential to cause signicant systemic side eects. The systemic eects of
epinephrine have been studied extensively, and most researchers have
concluded that epinephrine should not be used for routine gingival dis-
placement [3447].
436 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444

Fig. 4. The largest diameter cord that readily ts into the gingival sulcus should be used.

The literature on the absorption and eects of epinephrine from gingival


retraction cords is somewhat contradictory. In correlating data from various
studies, it is safe to conclude that under certain conditions epinephrine from
retraction cords is absorbed systemically. Conditions that limit absorption are
not clear, but increased absorption seems to occur with increased exposure of
the vascular bed and with an increase in the total amount of epinephrine used.
Increased doses may occur with the use of stronger concentrations of the
medicament or with the use of multiple cords when making impressions of
multiple prepared teeth.
Other factors related to the total dose of epinephrine received by a patient
include the epinephrine administered in the local anesthetic solution and any
endogenous epinephrine that may be secreted by the patient in reaction to
stress or discomfort associated with the dental procedures. Epinephrine is
contraindicated in patients with hyperthyroidism and in patients taking
monoamine oxidase inhibitors or tricyclic antidepressants for depression, b-
blockers, or cocaine. It also is contraindicated in diabetics and cardiovas-
cular patients.
Determining which patients may be classied as cardiovascular patients
can be dicult. Although many patients are clearly identied as a result of
taking a careful medical history, many patients are unaware of incipient
problems. Even though the majority of dentists routinely take blood pressure
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444 437

and pulse records, resting pulse rates, resting blood pressure records, and
resting electrocardiograph records miss approximately 45% of latent
cardiovascular problems [48].
Clinicians should avoid using epinephrine for gingival displacement
because of the signicant number of contraindications for the use of
epinephrine and the uncertainty of any given patients cardiovascular status.
Other equally eective medicaments have no systemic manifestations and are
preferred. Fortunately, the use of epinephrine for routine gingival displace-
ment has decreased over the years. In 1985, 79% of dentists routinely used
epinephrine for retraction [18]. A recent article indicated that routine use had
declined to 25% of respondents [49].

Techniques for gingival displacement


Gingival displacement can be accomplished using several dierent
techniques. Common to all of them is the use of a retraction cord along
with a chemical medicament. No clinical study has demonstrated the
superiority of one technique over another, so the choice of which procedure
to use depends upon the presenting clinical situation and operator preference.

The single cord technique


The single cord technique is indicated when making impressions of one to
three prepared teeth with healthy gingival tissues. It is relatively simple and
ecient and is probably the most commonly used method of achieving
gingival displacement.
1. Tooth preparation is accomplished and cervical margins are dropped
carefully to their pre-determined intra-crevicular position.
2. A length of gingival retraction cord is selected to specically match the
anatomy of each individual gingival sulcus. The largest-diameter
braided (First String; Clinicians Choice Dental Products, London,
Ontario) or knit cord (Ultrapack Cord; Ultradent Dental Products, Salt
Lake City, Utah) that ts in the sulcus should be used.
3. The cord is soaked in the medicament of choice (eg, Hemodent; Premier
Dental Products, Norristown, Pennsylvania).
4. Excess medicament is blotted from the soaked cord with a sterile cotton
sponge. The cord is carefully packed into the sulcus in a counterclock-
wise direction.
5. After the cord is in place, the tooth preparation is carefully inspected to
ascertain that the entire cervical margin can clearly be visualized and
that there is no soft tissue impediment to easy injection of the impression
material to capture all of the cervical margin detail (Fig. 5). If there is
excess soft tissue blocking easy access, it can be displaced with an
additional small section of cord or excised with an electro-surgery unit
or soft tissue laser (Fig. 6).
438 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444

Fig. 5. After the cord is in place, the prepared tooth should be carefully examined to determine
that the entire cervical margin can be visualized.

6. At this point it is critical to wait 8 to 10 minutes before removing the


cord and making the impression. The cord needs time to eect adequate
lateral displacement, and the medicament needs time to create
hemostasis and crevicular uid control.
7. Before removing the cord, the cord should be soaked in water to allow it
to be easily removed from the sulcus. Removal of the cord when dry is
traumatic and tears the inner epithelial lining and initiates hemorrhage
[50].
8. The tooth preparation(s) should be gently dried and the impression
made.

Fig. 6. If excess soft tissue obscures the prepared cervical margin, it should be removed using
electro-surgery or a soft tissue laser.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444 439

The double cord technique


The double cord technique is routinely used when making impressions of
multiple prepared teeth and when making impressions when tissue health is
compromised and it is impossible to delay the procedure [20]. Some
clinicians use this technique routinely for all impressions (Fig. 7).
1. A small-diameter cord (Deknatal 2/0 Surgical Silk Suture Material; J.
Deknatal, Queens Village, New York) is placed in the sulcus. The ends
of this cord should be cut so that they exactly abut against one another
in the sulcus. This cord is left in the sulcus during impression making,
and if the cord is too short (creating a space between the ends) or too
long (creating overlapping ends), it may become impregnated into the

Fig. 7. With the double cord technique: (A) A small-diameter cord with no medicament is rst
placed in the depth of the sulcus. (B) A larger-diameter cord with the medicament is placed
above the small-diameter cord. After waiting 8 to 10 minutes, the large-diameter cord is soaked
in water and removed. The small-diameter cord is left in the sulcus during impression making.
440 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444

Fig. 7 (continued )

impression. This can create diculties later in pouring the impression


and trimming the dies.
2. A second cord, soaked in the hemostatic agent of choice, is placed in the
sulcus above the small-diameter cord. The diameter of the second cord
should be the largest diameter that can readily be placed in the sulcus.
3. After waiting 8 to 10 minutes after placement of the large cord, the
second cord is soaked in water and removed. The preparation(s) are
dried, and the impression is made with the primary cord in place.
4. After successfully making the impression, the small-diameter cord is
soaked in water and removed from the sulcus.
This technique can be used with single or multiple preparations. It is
especially useful with multiple preparations where gingival uid exudate can
seep over the prepared cervical margins of the last teeth to be impressed
after cord removal.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444 441

The infusion technique of gingival displacement


The infusion technique for gingival displacement uses a signicantly
dierent approach from the single or double cord techniques [21].
1. After careful preparation of the cervical margins in an intra-crevicular
position, hemorrhage is controlled using a specically designed dento-
infusor with a ferric sulfate medicament. Two concentrations of ferric
sulfate, 15% (Astringedent; Ultradent Dental Products, Salt Lake City,
Utah) and 20% (Viscostat; Ultradent Dental Products, Salt Lake City,
Utah), are available. The 20% material is preferred because it is less
acidic than the 15% solution and does not remove the smeared layer of
dentin from the prepared tooth.
2. The infusor is used with a burnishing motion in the sulcus and is carried
circumferentially 360 around the sulcus. The medicament is extruded
from the syringe/infusor as the instrument is manipulated around the
gingival sulcus.
3. When hemostasis is veried, a knitted retraction cord (Ultrapack
Retraction Cords; Ultradent Dental Products) is soaked in the ferric
sulfate solution and packed into the sulcus.
4. Advocates of this technique recommend leaving the cord in place 1 to 3
minutes.
5. The cord is removed, the sulcus is rinsed with water, and the impression
is made.
In the opinion of the authors, this technique is eective in achieving
hemostasis, but, because the cord is left in place for only 1 to 3 minutes, it
may not provide adequate lateral displacement to permit an adequate bulk
of impression material into the sulcus. It is not recommended that the cord
be left in the sulcus for longer times because histologic data are not available
to demonstrate that it is safe to do so.
The dento-infusor and the 20% ferric sulfate have proven to be an
eective ancillary technique for control of hemorrhage when using the single
cord technique. Occasionally, even with careful technique, isolated areas of
bleeding may occur when the cord is removed from the sulcus. In such
situations, the infusor and medicament can be used in the sulcus with rm
burnishing pressure for approximately 15 seconds. This predictably controls
hemorrhage.
When using ferric sulfate materials, patients should be forewarned that
the tissues may be temporarily darkened. The tissues take on a blue-black
appearance that usually disappears in a few days.

The every other tooth technique


When making impressions of anterior tooth preparations, it is critical
that no damage is done to the gingival tissues that may result in recession.
With teeth with root proximity, placing retraction cord simultaneously
442 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444

around all prepared teeth may result in strangulation of the gingival papillae
and eventual loss of the papilla. This creates unesthetic black triangles in the
gingival embrasures.
This undesirable outcome can be prevented with the every other tooth
technique. This can be used with the single or double cord technique.
Retraction cord is placed around the most distal prepared tooth. No cord
is placed around the prepared tooth mesial to this tooth. Retraction
procedures are completed on alternate teeth. If, for example, teeth #5
through #12 are prepared, cords would be placed around teeth #5, #7, #9,
and #11. The impression is made; gingival displacement is accomplished on
teeth #6, #8, #10, and #12; and a second impression made. A subsequent
pick-up impression allows fabrication of a master cast with dies for all eight
prepared teeth.

New materials
As with other procedures in restorative dentistry, a few relatively new
products and techniques have been introduced. These include strips of
a sponge-like synthetic polymer that expands after insertion into the sulcus.
This material can theoretically be placed in the sulcus with no local
anesthetic and thus results in minimal trauma [51,52]. Another material is
supplied in a syringe and is designed be injected into the unretracted sulcus
(Expasyl; Kerr Dental Products, Romulus, Michigan). Once in the sulcus it
theoretically expands and provides displacement and hemostasis. The
predictability and ecacy of these materials has yet to be established.

Summary
Gingival displacement is an important procedure with fabricating
indirect restorations. Gingival displacement is relatively simple and eective
when dealing with healthy gingival tissues and when margins are properly
placed a short distance into the sulcus.
The most common technique used with gingival displacement is use of
gingival retraction cords with a hemostatic medicament. Retraction cords of
sucient diameter should be used to provide adequate lateral displacement
to create a mean sulcular width of 0.2 mm. Epinephrine containing re-
traction cords should be avoided.
Several techniques have proven to be relatively predictable, safe, and ef-
cacious. No scientic evidence has established the superiority of one tech-
nique over the others, so the choice of technique depends on the presenting
clinical situation and operator preference.

References
[1] Christensen GJ. What category of impression material is best for your practice? J Am Dent
Assoc 1997;128:10268.
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[2] Winstanley RB, Carrotte PV, Johnson A. The quality of impressions for crowns and
bridges received at commercial dental laboratories. Br Dent J 1997;183:209.
[3] Holmes HM. Gingival displacement, not retraction. Dent Survey 1968;35.
[4] Nemetz H. Tissue management in xed prosthodontics. J Prosthet Dent 1974;31:628.
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Dent Clin N Am 48 (2004) 445470

A review of contemporary impression


materials and techniques
Terry E. Donovan, DDS*, Winston W.L. Chee, BDS
University of Southern California School of Dentistry, University Park MC0641,
925 West 34th Street, Los Angeles, CA 90089-0641, USA

The contemporary restorative dentist has a host of excellent impression


materials available for making impressions in xed prosthodontics, implant
dentistry, and operative dentistry. With proper material selection and
manipulation, accurate impressions can be obtained for fabrication of
tooth- and implant-supported restorations. However, a majority of im-
pressions sent to commercial laboratories for conventional xed prostheses
are decient in several respects [1,2]. One of the major deciencies is that the
prepared subgingival margins of tooth preparations are frequently in-
adequately recorded in the impression. This results in a restoration with less
than adequate marginal integrity.
A second common deciency is failure to follow basic principles inherent
to the manipulation of impression materials. Stock trays are used ex-
tensively, and the importance of control of bulk is ignored. Putty/wash
materials also are used extensively, usually in an inappropriate manner,
resulting in impressions with less than optimal accuracy.
This situation is not a result of deciencies in the impression materials but
rather is a result of inadequate understanding by operators of the principles
of manipulation of impression materials. Many unacceptable impressions
are the result of errors in other stages of the restorative procedure, such as
improper margin location and overall soft tissue management [3].
This article outlines the ideal properties of impression materials and
explains the importance of critical manipulative variables. Available im-
pression materials are analyzed relative to these variables, and several
specialized impression techniques are described. Special attention is paid
to polyvinyl siloxane (PVS) impression materials because they have become
the most widely used impression material in restorative dentistry [4].

* Corresponding author.
E-mail address: tdonovan@usc.edu (T.E. Donovan).

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.014
446 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470

A number of ideal properties for impression materials can be identied.


These include accuracy, elastic recovery, dimensional stability, ow,
exibility, workability, hydrophilicity, a long shelf-life, patient comfort,
and economics. Impression materials vary considerably in relation to these
ideal properties, and these dierences may provide a basis for the selection
of specic materials in specic clinical situations.

Accuracy
There are two aspects to evaluating the accuracy of impression materials.
According to American Dental Association specication #19, elastomeric
impression materials used to fabricate precision castings must be able to
reproduce ne detail of 25 lm or less. All currently available impression
materials meet this specication. PVS impression materials are the best in
this regard, and reversible hydrocolloid (a water-based impression material)
is the worst, although it can meet the 25-lm limit [5]. Dierences in detail
reproduction are not likely of major clinical consideration because the
limiting factor in the system is the ability of gypsum die materials to replicate
ne detail. The corresponding specication for gypsum die materials is 50 lm.
Most die materials do considerably better than this but fall far short of the
impression materials in their ability to reproduce ne detail.
There are signicant dierences in the ability of various viscosities of
impression materials to reproduce ne detail. In general, the lower the
viscosity of impression material, the better it records ne detail. The putty
materials, in general, cannot reproduce ne detail at the 25-lm level and are
required only to record detail of 75 lm [6]. One of the deciencies of some
putty/wash techniques is that, often, critical areas of the tooth preparation,
including cervical margins, are recorded in putty material (Fig. 1). This has
a deleterious eect on the accuracy of the gypsum die.
A second aspect of accuracy is dimensional accuracy, which is evaluated
by measuring tooth-to-tooth distances within the same quadrant and cross
arch. There is some evidence that reversible hydrocolloid is slightly superior
to the elastomers in this respect [7]. However, it is likely that there are greater
dierences resulting from the use of dierent die stones or the manipulation
of the gypsum than exist between dierent types of impression materials.
Most of the impression materials available today provide superb
accuracy if they are manipulated correctly. Although PVS materials are
likely to be more accurate than other materials, dierences in accuracy
(assuming correct manipulation) are likely not clinically signicant.

Elastic recovery
Impression material needs to be able to ow readily into undercut areas
in the mouth, set in that position, and to be able to rebound back to its
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 447

Fig. 1. One deciency of the putty/wash techniques is that the prepared margins are captured in
part with putty material, which is unable to record ne detail 25 lm or less.

original shape when the set impression is removed from the mouth. This
process is called elastic recovery. No impression material has 100% elastic
recovery, and, for all impression materials, the greater the depth of the
undercut, the greater is the permanent distortion of the impression material.
PVS impression materials have the best elastic recovery at over 99% elastic
recovery with a specic test undercut [8]. This property, coupled with the
excellent dimensional stability of PVS materials, makes it the most accurate
material for second pours.
The operator need not delay pouring of the impression to allow elastic
recovery to occur. Elastic recovery occurs almost instantaneously as the
impression is removed from the mouth or the primary cast [8]. An excellent
procedure to maximize the elastic recovery of the impression material is to
eliminate or block out any undercuts in the tooth preparation before making
the impression. This can be accomplished with any of the modied or resin-
modied glass ionomer products on the market. Many operators neglect to
do this on the premise that the undercuts can be blocked out by the
laboratory technician. Although this is possible, this approach forces the
impression material to spring out around the undercut and is thus
responsible for distortion that could easily be avoided.

Dimensional stability
An ideal impression material would be dimensionally stable over time
and thus could be poured at the convenience of the operator. Because there
is no by-product to the chemical setting reaction of addition silicones, PVS
materials possess ideal dimensional stability. They can be poured at the
convenience of the operator and are the impression material of choice if the
impression is to be sent to the laboratory where the dentist loses control of
448 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470

when it is poured. PVS impressions can be poured immediately after


removal from the mouth, or hours, days, and even weeks after making the
impression.
Other impression materials should be poured within prescribed time
limits to obtain maximum accuracy. Water-based impression materials, such
as reversible and irreversible hydrocolloid, are composed of 80% water and
hence are subject to the phenomena of imbibition (absorption of water) and
syneresis (evaporation of water). If either of these phenomena occurs, the
impression is distorted. These impressions should be poured up within 10
minutes of removal from the mouth and should not be wrapped in a moist
paper towel as seems to be common practice. The impression can easily
absorb water from the wet towel and thus distort before pouring.
Condensation silicone impression material produces ethyl alcohol as
a by-product of the setting reaction. Polysulde rubber produces water as
a by-product of the setting reaction. These volatile by-products tend to
evaporate from the surface of the set impression, resulting in distortion.
These impression materials should be poured no more than 30 minutes after
removal from the mouth.
Polyether impression materials can absorb water from the atmosphere.
Whereas most impression materials shrink over time due to continued
polymerization and loss of volatile by-products, polyether materials swell
over time due to water sorption [9,10]. Thus, it is recommended that, for
maximum accuracy, polyether impression materials be poured within 1 hour
of removal from the mouth.

Flow and exibility


Impression materials need to readily ow into the minute details of the
cavity preparations and accurately capture grooves, pinholes, and cervical
margin detail. Most commercial products provide light-body or syringe
materials for this purpose. These are used with heavy-body or tray materials
to provide more rigidity to the impression and to help force the lower
viscosity material into the gingival sulcus.
Early versions of light-body materials possessed excellent ow character-
istics, but the materials tended to ow o of the prepared tooth with time,
which posed problems when attempting to make an impression of several
prepared teeth at one time. Most of the newer PVS products and polyethers
are thixotropic and stay where they are syringed but ow readily when the
heavier body tray materials are placed over the top of them.
Impression materials vary from one another with regard to exibility.
Polyether impression materials tend to be more rigid than the other
materials, and this can be a problem when dealing with long, thin prep-
arations of periodontally involved teeth. Fracture of delicate gypsum dies is
a common occurrence due to the rigidity of polyether materials. Another
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 449

problem related to this rigidity is tearing of the impression material in the


gingival sulcus. The tear strength of polyether materials is adequate, but due
to the rigidity of the set impression, signicant force must be used to remove
the impression, and this sometimes exceeds the tear strength of the material.
More recent generations of polyether have slightly improved in this regard
but are still slightly more rigid than PVS materials.
PVS materials are reasonably sti but seem to fall below the threshold
where problems with fracture of dies are common. Reversible hydrocolloid
is the least rigid of all materials and may be the material of choice when
making impressions of multiple periodontally compromised teeth.
With certain impressions, such as dual arch impressions, it is ad-
vantageous to use a very rigid impression material. Many of the commonly
used double-bite trays are somewhat exible, and a rigid impression
material can compensate for this exibility. Polyether materials, which are
thixotropic, work well in these cases, and many of the new PVS materials
have specic components to provide the essential rigidity.

Workability
The advent of auto-mix devices for mixing elastomeric impression
materials has dramatically improved the workability of these materials. The
sophisticated electronic mixing devices (eg, Pentamix; 3M-ESPE, St. Paul,
Minnesota) and the simpler mixing guns used by the majority of systems
provide a standardized mix with fewer inherent porosities, increased
working time, and an economic savings due to less waste of material.
Working times can be varied by the manufacturer, and most auto-mix
devices provide materials with standard-set and quick-set capabilities. When
using the dual arch technique for a single-crown preparation, the operator
may opt for a quick-set material with a short working time. When making
a full-arch impression with several prepared teeth, the clinician may choose
a material with a longer working time. When making impressions of
multiple prepared teeth, the clinician may also opt to refrigerate the low-
viscosity material, which increases working time without sacricing
accuracy [11].

Hydrophilicity
Reversible hydrocolloid impression materials are truly hydrophilic and
can eectively make accurate impressions in the presence of moisture. The
wet technique purposefully lls the gingival sulcus with water before
making the impression and then relies on the water-loving tendency of the
material to ow into the sulcus and capture the prepared subgingival
margins in the impression.
450 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470

Polyether impression materials also are hydrophilic, as witnessed by their


tendency to absorb moisture from the atmosphere. However, polyether
materials require a dry preparation surface to make an acceptable im-
pression. All rubber-like elastomeric impression materials require a dry eld
for making impressions.
Most of the manufacturers of the newer PVS impression materials claim
their materials are hydrophilic. Although this is technically correct, it is
misleading because it implies that excellent impressions can be made in a wet
environment, which is not true.
A material can technically be classied as hydrophilic if the contact
angle that water makes with it is below a specic angle. The original PVS
materials were very hydrophobic and produced very high contact angles.
Later formulations included nonionic surfactants in the materials, and this
improved the wettability and lowered contact angles. Some of the newer
PVS materials include technology that grafts the surfactants to the silicone
polymer, which further improves wettability and reduces the contact angle.
These improvements make it signicantly easier to pour PVS materials
without incorporating voids, but they do not make it possible to make
acceptable impressions in a wet environment.

Shelf-life
The exact shelf-life of impression materials is not known, but it is not
advisable to use materials that have passed the expiry date established by the
manufacturers. The clinician should become familiar with the code used by
the manufacturer of the products being used and insure that current materials
are consistently provided. It is arbitrarily suggested that no more than 6
months supply of impression material should be kept on hand at any time.

Patient comfort
Contemporary materials are far more patient friendly than the old
polysulde rubber materials or reversible hydrocolloid that had to use bulky
water-cooled trays. Contemporary materials are essentially colorless,
odorless, and tasteless. The rigidity of polyether materials can be a dis-
advantage, particularly if the patient has existing xed prostheses or has
multiple open gingival embrasures due to loss of periodontal support. In
these situations, it is advisable to use a more exible material and to block
out the undercuts with utility wax before impression making. The use of the
dual-arch impression technique, where appropriate, is also pleasant for
patients in that it uses a minimal amount of material and avoids the
necessity of an opposing arch impression.
When full-arch impressions are indicated, the use of a custom tray is
advocated (Fig. 2). Some studies indicate that custom trays are more
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 451

accurate than stock trays, but even if both are suciently accurate, the level
of patient comfort with custom trays is substantially improved. In addition,
signicantly less material is used, and it has been speculated that the
material savings alone plus the reduced number of remakes more than
absorb the cost of making the tray [12].

Economic factors
There can be signicant dierences in the cost of impression materials.
Reversible hydrocolloid is less expensive that elastomeric materials, but
there are costs associated with conditioning and tempering baths and costs
for water-cooled trays. Polyether and PVS materials are similar in cost and
are more expensive than competing elastomers. However, it is likely true in
most practices that dierences in the costs of impression materials are of
minimal consequence. Practitioners can reduce costs by using auto-mix
devices, by using the dual-arch technique when indicated and custom trays
for full-arch impressions, and by reducing the number of remakes.

Principles of impression material manipulation


Proper manipulation of impression materials is probably more important
in determining the accuracy of an impression than which type of material is
selected. Several manipulative variables are important to obtain maximum
accuracy. These include provision of a uniform bulk of material, insuring
that the material adequately adheres to the impression tray, pouring the
impression at the appropriate time, using the optimum viscosity materials,
and adequate mixing and use of proper disinfection procedures.

Fig. 2. Full arch impressions with multiple preparations should be made with custom trays. Use
of custom trays provides optimum accuracy, conserves material, and provides patient comfort.
452 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470

Uniform bulk
All impression materials shrink slightly upon setting. Reversible
hydrocolloid material is chilled using water cooler trays, and as the material
cools, shrinkage occurs as a thermoplastic event. Elastomeric impression
materials set by means of polymerization reactions with monomeric units
forming polymer chains. When clinical setting begins, substantial cross-
linking of the polymer chains has occurred. With these materials there is
a slight amount of polymerization shrinkage. To obtain the most accurate
impression, it is imperative to use a relatively uniform amount of bulk in
the impression so that there is uniform shrinkage throughout the body of
the impression. This shrinkage is counteracted by slight expansion of the
gypsum casting material.
Dierent impression materials require dierent cross-sectional thick-
nesses of impression material to provide optimum accuracy. Water-based
impression materials, such as reversible and irreversible hydrocolloid,
provide maximum accuracy with a cross-sectional thickness of 4 to 6 mm
[13]. This thickness is achieved with the use of a properly sized stock tray.
Elastomeric impressions are most accurate when used with a cross-
sectional thickness of approximately 2 mm [14]. This thickness is optimally
provided with a custom tray. Numerous articles have compared accuracy of
impressions made with a custom tray with the accuracy of impressions made
with a stock tray [1524]. Although a few recent studies indicate that
impressions for single restorations can be adequately made with PVS
impression material in a stock tray, these studies generally demonstrate
improved accuracy with custom trays.
The dierence in cross-sectional thickness of material in a stock tray
is only about 1.5 to 2 mm thicker than that in a custom tray [25]. This
mandates precision in fabrication of the custom tray because small dif-
ferences in cross-sectional thickness can aect accuracy. Custom trays
should be constructed on the diagnostic cast using one layer of base plate
wax as a spacer. Trays can be fabricated with polymethylmethacrylate
(PMM), photo-cure bisacryl materials (Triad; Dentsply International,
Milford, Delaware), or PVS putty materials [26]. PMM trays should be
fabricated at least 24 hours in advance to insure stability.
Occlusal stops are critical for proper orientation of the tray in the mouth.
Three occlusal stops are ideal, with at least one stop posterior to the prepared
teeth. Stops should be placed on nonfunctioning cusp tips to minimize
distortion in the area of the stops. Stops are prepared by removing the base
plate wax from the nonfunctioning cusp tips with a hand instrument. The
wax spacer should be covered with tin foil before making the tray to facilitate
removal the wax from the tray and to prevent incorporation of a wax residue
on the internal surface of the tray due to the inherent exotherm that occurs
during the setting reaction of the PMM tray material. This residue can
interfere with the proper functioning of tray adhesives.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 453

Adhesion of the impression material to the tray


It is imperative that the impression material adheres to the tray. With
proper adherence, the impression material shrinks toward the tray as it
polymerizes. This results in a slightly larger die, which is preferable to
a smaller die.
Adhesion is achieved through the use of specic chemical tray adhesives.
Adhesives must be matched to the impression material and should be
painted in a thin layer on the internal of the tray and the tray borders.
Painting the adhesive on the tray at least 7 to 15 minutes before making the
impression permits formation of adequate bond strength of the material to
the tray [27].

Pouring of impression materials


One of the most important manipulative variables with impression
materials is the time limit after removal from the mouth to when the
impression is poured. Water-based materials should be poured within 10
minutes of removal from the mouth. The major component of these
impressions is water, which evaporates at room temperature. This water loss
is accompanied by distortion and is minimized by rapid pouring.
Condensation silicones produce ethyl alcohol as a by-product of the
setting reaction, and evaporation of the alcohol results in distortion. The
identical phenomenon occurs with polysulde rubber, where the by-product
is water. These materials should be poured within 30 minutes for maximum
accuracy.
Polyether materials can absorb water from the atmosphere and thus
should be poured within 1 hour for maximum accuracy. PVS impression
materials are stable because there is no volatile by-product to the reaction
and because they do not give o or absorb water. This dimensional stability
permits pouring of the impression at the convenience of the operator.

Viscosity control
Elastomeric impression materials are supplied in a number of viscosities,
ranging from very low viscosity to very high viscosity putty materials. The
main dierence between the dierent viscosities is the amount of inert ller
in the material. Two rules of thumb regarding dierent viscosity materials
are (1) the lower the viscosity, the better the ne detail reproduction and (2)
the lower the viscosity, the greater the polymerization shrinkage during the
setting reaction. Thus, the optimum method of impression making is to use
as little low-viscosity material as possible to capture the ne detail of the
prepared margin, grooves, box-forms, etc., and the bulk of the impression
should be made with high-viscosity material. The heavy-body material helps
push the light-body material into the gingival sulcus and results in minimal
distortion due to polymerization shrinkage.
454 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470

Monophasic PVS and polyether materials are supplied by many


manufacturers. In theory, such materials do not provide the same level of
accuracy as proper use of a combination of low-viscosity/high-viscosity
materials, but the actual dierences in accuracy are so small that they are
likely not clinically signicant. The convenience of having to use only one
viscosity of materials makes monophasic materials practical.

Adequate mixing
Most elastomeric impression materials are provided as base/catalyst
systems. When separate tubes of base and catalyst material are provided,
hand mixing is required. Usually, the base and catalyst materials are of
contrasting colors, and generally equal lengths of both materials are
extruded on the mixing pad. The materials then should be vigorously
stropped until a homogeneous material is obtained.
Almost all contemporary impression materials are dispensed using some
type of auto-mix system. These systems provide optimum mixing of the
material with signicantly fewer inherent voids, extend the essential working
time of the material, and reduce waste of the material because they are
loaded from the dispenser directly into the syringe or tray [28,29].

Disinfection
Microorganisms in the oral cavity can be transmitted from impressions to
the dental laboratory [30]. The clinician must disinfect impressions before
pouring the cast or sending the impressions to the dental laboratory. An
alternative to disinfecting impressions is to use disinfected die stones [31].
This approach avoids potential distortions related to procedures essential
for disinfecting impressions.
The rst step of any disinfecting technique is to rinse the impression in
tap water. This step removes a signicant portion of the microorganisms
from the impression. Disinfection techniques involve spraying the impres-
sions with disinfection agents or immersion of the impression materials in
chemical agents such as sodium hypochlorite [32]. PVS materials are stable
in this regard, but special care must be taken with water-based materials and
polyethers to insure that adequate immersion times are used to eliminate
microorganisms but that extended immersion times are avoided to prevent
excess imbibition of the disinfecting solution and distortion of the
impression.

PVS impression materials


PVS impression materials have been on the market since the mid-1970s
and have garnered the lions share of the contemporary market. PVS
materials have the best ne detail reproduction and elastic recovery of all
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 455

Fig. 3. These casts have unpolymerized impression material on the margins of the preparations
as a result of indirect inhibition of polymerization of the PVS material by latex gloves.

available materials. Because there is no by-product to the setting reaction,


they possess remarkable dimensional stability and are odorless and tasteless
and pleasant for patients. They are provided with a wide variety of
viscosities, rigidities, and working and setting times, so they can be used in
a variety of clinical situations. There are specic manipulative variables that
are important to achieving maximum performance with PVS impression
materials.
PVS materials have one disadvantage: PVS materials have a signicant
interaction with latex. Any contact of unpolymerized PVS material with
latex results in inhibition of polymerization of the impression material. This
can occur if the clinician mixes putty materials while wearing latex gloves or
if latex gloves were worn before mixing [33,34]. Direct inhibition of
polymerization also can occur if the impression material is in contact with
a rubber dam [35].
Indirect inhibition of polymerization also can occur intra-orally when
latex gloves contact tooth preparations and the surrounding periodontal
456 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470

Fig. 4. Custom trays can be fabricated from PMM acrylic resin, light-cured resin, or PVS putty
materials.

tissues during tooth preparation and gingival displacement procedures


[3638]. Such inhibition of polymerization is often subtle and limited to
small isolated areas of the surface of the impression. It is often not detected
with the initial inspection of the impression and may be noticed after only
pouring and separation of the gypsum casts (Fig. 3). The presenting signs of
inhibited polymerization are a lm of unset material in isolated areas or the
presence of a sticky, slippery substance on the surface of the impression. It is
similar to the feel and appearance of the oxygen-inhibited layer that is seen
with photo-cure composite resin restorative materials. Although these
isolated areas of inhibited polymerization are subtle and not easy to detect,
depending upon their location, they can render the impression unusable.

Fig. 5. Occlusal view of arch requiring impressions of implants and prepared teeth.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 457

Fig. 6. Custom impression copings on preliminary cast of preparations.

Clinicians must inspect impressions and recovered casts carefully to insure


contamination of critical areas has not occurred.
The mechanism of inhibition of polymerization is not known but is
thought to result from contamination of the chloroplatinic acid catalyst of
the PVS material with unreacted sulfur present in natural latex gloves [39].
Natural latex gloves contain sucient concentrations of free sulfur for this
to occur. Synthetic latex gloves, vinyl gloves, and the powder commonly
found on gloves do not cause this inhibition of polymerization.
Sulfur-containing gingival retraction chemicals may contribute to the
inhibition of polymerization [40]. Based on available evidence, it seems that
contemporary hemostatic agents do not cause inhibition of polymerization

Fig. 7. The segmental impression with tooth preparations and impression copings.
458 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470

Fig. 8. Arch with resultant denitive restorations on teeth and tissue bar on implants.

of PVS materials. Although clinicians detect such inhibition frequently in


areas where gingival retraction was performed, it is likely that this inhibition
is the result of contamination with latex gloves during the preparation and
retraction procedures [41].
Clinicians should avoid touching tooth preparations and adjacent
gingival areas with latex gloves. When this is not avoidable, wearing vinyl
gloves over latex gloves is recommended. Once contamination of the
preparations has occurred, it is not likely that cleansing with water will
adequately remove it. Routine cleansing of tooth preparations with our of
pumice may be indicated before impression making.

Fig. 9. When radicular attachments are used to retain over-denture bars, impressions of the
dowel space may be necessary to fabricate working casts.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 459

Fig. 10. Typical impression for fabrication of indirect dowel cores.

Putty/wash impression techniques


There are three approaches to putty/wash impressions. One approach is
appropriate and acceptable, another can provide acceptable impressions but
has some potential drawbacks, and a third approach is unacceptable [4].
An excellent technique for putty/wash impressions is to use the putty
material to fabricate a custom tray. It is fabricated in the same manner as
with PMM materials or light-cure materials. One layer of base plate wax is
placed over the diagnostic cast as a spacer, and wax is removed from
nonfunctioning cusps to provide occlusal stops. A putty impression is made
in a stock tray, and a PVS putty custom tray results (Fig. 4).

Fig. 11. Silver plated cast obtained from the impression in Fig. 10.
460 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470

Fig. 12. Occlusal view of pontic sites on an uncorrected impression.

A second approach is to use a relieved putty impression. In this


technique, a pre-operative putty impression is made intra-orally. Plastic
sheets may be placed over the teeth to prevent material from entering
gingival embrasures. In the area where the teeth are to be prepared,
impression material is removed with a bur or scalpel to provide relief, and
the impression is washed or relined with low-viscosity PVS impression
material.
This approach can be successful, but there are two potential pitfalls. It is
dicult to conne the wash materials to the area of the relieved impression,
and some wash material enters the unrelieved impression. This results in an

Fig. 13. The corrected impression is made with the provisional restorations seated in the master
impression.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 461

Fig. 14. The provisional restoration indexed to the master cast with corrected pontic contours.

inaccurate occlusal pattern for the resultant cast. Thus, the entire
impression, rather than just the relieved area, should be washed. This
creates the potential problem of hydraulic distortion of the putty material as
the impression is seated in the mouth. This is impossible to detect on
a clinical level but may have a deleterious eect on the accuracy if the
impression and resulting restoration.
The third approach to putty/wash impressions is the so-called simul-
taneous or squash technique. With this technique, a stock tray is loaded
with putty material, and the syringe material is injected around the prepared
tooth or teeth. The tray containing the putty material is squashed over the

Fig. 15. Occlusal view of the pontic sites after the corrected soft-tissue cast is poured against the
provisional restoration.
462 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470

Fig. 16. Occlusal view of the pontic and peri-implant soft tissue to be captured in the
impression.

syringe material, and the impression is made with the putty material and the
syringe material setting simultaneously. This approach is unacceptable
because it is impossible to control the thickness of impression material and
excess bulk is used. It is impossible to control what material records the
margin detail of the preparation(s). Usually portions of the prepared margin
are captured in the putty, and putty materials are essentially decient in
their ability to record marginal detail [6].
It is generally recommended that complete arch impressions should be
made wherever possible; however, there are numerous clinical situations
where specialized impression techniques can be used to great advantage.

Fig. 17. Impression of the tooth preparations, implant copings, and provisional restorations.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 463

Fig. 18. Provisional restoration with the overimpression removed.

Dual-arch impression technique


When one or two posterior teeth are prepared for indirect restorations, it
is often advantageous to consider using the dual arch or double-bite
impression technique [26]. This technique captures the prepared teeth, the
opposing arch, and the occlusal articulation in maximum intercuspation
(MIP) simultaneously. Several studies have demonstrated that this
technique, when indicated, can provide a simple but accurate method for
fabricating restorations using the conformative maxillo-mandibular relation
[4245].
The dual-arch technique can be used successfully as long as the operator
understands the indications and contraindications of the procedure. This
technique should be used with a maximum of two prepared teeth. There
should be unprepared stops anterior and posterior to the prepared teeth.

Fig. 19. The soft tissue contours are registered with the modied impression technique.
464 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470

Fig. 20. Resultant denitive restoration.

The dual-arch technique should be used only with patients that have existing
anterior guidance. Because a half-arch impression is used, no recording of
the contralateral arch guidance is made. If the patient does not have existing
anterior guidance, nonworking (balancing) interferences may be introduced
in the new restorations.
For this technique to be successful, the patient must be able to close
completely in MIP with the impression tray in place. This should be tested
diagnostically before the preparation appointment so a custom tray can be
fabricated if the patient cannot close in the correct position. The patient
should be instructed to close in MIP with the tray out of the mouth. The
operator should visually note the nature of the contact on the contralateral
side and verify the patient is in MIP using Mylar shim-stock (Silver Mylar
Strips; Du Pont, Wilmington, Delaware). Once this is veried, the dual-arch
impression should be placed in position, and the patient should be
instructed to again close in MIP. This should be in the identical position
to that previously achieved, and this should be conrmed visually and with
Mylar strips. Finally, when the tooth or teeth are prepared, Mylar strips on
the contra-lateral side should be used as the patient closes into the
impression material to conrm the patient has closed in the MIP position.
The presence of third molars, a rapidly ascending ramus, or excess soft
tissue distal to the molars often prevents complete closure with the tray in
place. The double-bite technique should not be used in these patients.
Rigid metal trays are ideal for this technique (Quad Trays; Clinicians
Choice, London, Ontario). Rigid PVS or polyether materials should be used
as well. Many plastic-mesh trays are available for this technique, but they
should be avoided because they are too exible. Often the buccal-lingual
width of the arch is wider than the trays. The resilient tray exes outward
when the impression is made and rebounds when the impression is removed
from the mouth, thus permanently distorting the impression.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 465

The advantages of the dual arch technique include its clinical simplicity
and the accurate recording of the MIP position. An additional advantage
is that a closed-mouth technique is used that eliminates any mandibular
exure that might be associated with opening [46]. The laboratory
procedures associated with the technique are slightly more complicated
but can easily be handled once the technique is understood by the dentist
and the laboratory technician.

The segmental impression technique


It is frequently necessary to make a simultaneous impression of many
prepared teeth. In spite of the improvements in materials and the
convenience of auto-mix systems, this can be dicult due to inherent limits
in working time and diculties maintaining moisture control. The
segmental impression technique oers a procedure that predictably permits
making a successful impression with multiple prepared teeth [47].
The technique can be used with any impression material but is optimally
used with auto-mix PVS materials. With this technique, the arch to be
impressed is broken down into easily managed segments. This usually is
arbitrarily determined as two prepared teeth per segment. Individual custom
trays are fabricated on the diagnostic cast for each segment. One millimeter
of wax relief is provided, and the trays should extend 3 mm past the gingival
margin of the prepared teeth because there are no occlusal stops and because
the gingival tissues must prevent over-seating of the trays. These trays may
be made using PMM acrylic resin or PVS putty material. They can be made
individually or as one tray that is individualized by sectioning with a disc or
scalpel. If made of PMM acrylic resin, these trays should be made 24 hours
in advance. All of the individual trays must be able to seat simultaneously
on the cast.
If PMM trays are used, the appropriate adhesive is applied to the internal
of the trays. Conventional gingival displacement procedures are completed.
After an appropriate time, low-viscosity material is mixed and loaded into
a syringe and one of the segmental trays. Retraction cords are removed from
the sulci in the designated segment, impression material is injected around
the preparations, and the tray is seated to place. Excess extruded material is
removed from around the tray, and the impression material is allowed to set.
The tray is not removed. This procedure is repeated with each of the
segments until each segmental impression is in place. At this point an over-
impression is made with a compatible impression material in a stock tray.
This impression is then handled in a conventional manner.
This segmental impression technique has proven useful in extensive cases
and when moisture control is dicult in specic patients. It also can be
useful when making simultaneous impressions of implants and prepared
teeth.
466 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470

Tooth/implant impressions
Dental implants have become an integral part of restorative dentistry,
and frequently impressions for master casts include implants and prepared
teeth. In these situations, implant copings can reduce access to the prepared
teeth and impede the extrusion of impression material to the margins of
the prepared teeth. A useful method to precisely record the detail of
the prepared teeth and the implants is to use a combination of cus-
tom impression trays to impress the prepared teeth and then place the im-
plant impression copings and make an over-impression of the arch (Fig. 5)
[4851].
With this technique, the teeth must be preliminarily prepared, and a cast
of these prepared teeth must be obtained to fabricate the custom impression
trays. A wax spacer of approximately 1 mm is placed around the prepared
teeth, and PMM acrylic resin custom trays are fabricated with external
undercuts to facilitate pick up with an over-impression (Fig. 6). The
appropriate impression adhesive is applied to the custom tray(s) internally
and externally and allowed to dry. If the margins of the tooth preparations
are within 0.5 mm of the gingival margin, no gingival displacement is
required. A heavy-bodied PVS impression material is placed in the in-
dividual custom tray and is seated over the preparation(s). The heavy-body
impression material is allowed to set, and the impression tray is removed
and the impression is inspected for completeness and lack of voids. The
impression and tray are perforated through the occlusal surface with a #6
round bur. This preliminary impression is then lled with light-body
material and replaced over the prepared teeth. The hydraulics of this
technique force impression material beyond the prepared subgingival
margins. The implant copings are then attached, and an over-impression
is made (Figs. 7, 8).

Indirect dowel cores


A frequent clinical nding with endodontically treated teeth is insucient
coronal tooth structure. In these situations, a custom-cast dowel and core
restoration are required to obtain adequate resistance, and retention form is
required to retain the denitive restoration [5254]. A direct or an indirect
technique can be used to obtain a pattern for the cast dowel and core.
The indirect technique of obtaining dowel patterns is indicated when
multiple dowel cores are required or when radicular attachments are to be
used (Fig. 9) [55]. One of the diculties of making impressions of dowel
spaces is the entrapment of air in the apical portion of the canal. A
predictable technique to consistently and accurately record the canal space
is to use a 25-gauge local anesthetic needle as a vent to allow air to escape as
the impression material is injected into the dried canal space [56]. The needle
is gradually removed while the low-viscosity material is injected into the
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 467

canal. An appropriately sized plastic impression dowel that was previously


coated with the corresponding impression adhesive is inserted into the canal
[27]. The procedure is repeated as necessary with multiple dowels. The
impression dowel(s) are then incorporated into an over-impression to obtain
a working cast (Figs. 10, 11).

Impressions as a communication aid with dental technicians


Impressions can be valuable tools for communicating soft tissue
landmarks to technicians [57]. The pontic form of choice in the esthetic
zone is the ovate pontic [58]. Conventional impressions do not transfer the
pontic ridge form accurately because the soft tissue loses its morphology
shortly after removal of the provisional restoration.
The technique of choice to accurately replicate this soft tissue
morphology is to make an additional impression with the provisional
restorations in place on the abutment teeth [59]. First, the primary im-
pression of the abutment preparations is made in a conventional manner.
Then a second impression is made with the provisional restorations in place.
This impression is made with putty viscosity material. This putty impression
is removed, and the provisional restorations are inserted into the in-
dentations in the impression. The putty impression with the embedded
provisional restorations is then indexed to the working cast, and the residual
ridge area is repoured with a soft tissue cast material (Figs. 1215). The
resultant cast can be used by the technician to accurately form the denitive
restoration with ovate pontic forms where indicated.
This technique also can be used with implant-supported xed prostheses.
An over-impression that incorporates the provisional restoration can
transfer the peri-implant soft tissue contours to the master cast (Fig. 16)
[6063]. When the peri-implant and pontic soft tissue relationships require
transfer, the implant supported provisional restoration can be incorporated
into the impression, and a soft tissue cast can be poured against the
undersurface of the pontics (Figs. 1719). This accurately transfers the intra-
oral soft tissue morphology and allows the technician to fabricate the
denitive restoration with dened soft tissue boundaries (Fig. 20) [61].

Summary
Clinicians have an excellent array of impression materials and techniques
to use in the fabrication of tooth- and implant-supported restorations.
Obtaining maximum accuracy of impressions is critical to the provision of
precise restorative dentistry.
Based on the quality of impressions sent to commercial laboratories, it
seems that many impressions fall far short of the level of quality made
possible by current impression materials. The clinician is urged to review
468 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470

contemporary principles of impression materials and to make impressions


consistent with those principles. Clinicians are also urged to familiarize
themselves with the various specialty impression techniques available and
to use them when indicated.

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Dent Clin N Am 48 (2004) 471486

Jaw relation records for xed prosthodontics


Rachel S. Squier, DMD, MDSc
Department of Prosthodontics and Operative Dentistry, University of Connecticut
School of Dental Medicine, 263 Farmington Avenue Farmington, CT 06030-1615, USA

Jaw relation records are a fundamental and crucial component of pro-


viding accurate, high-quality xed restorations. A disciplined and ecient
practitioner understands that the use of accurate records minimizes the
need for intraoral adjustments before prosthesis delivery and can there-
fore reduce overall treatment time and cost. Because all dental materials
have their inherent limitations and because there exists variability in intra-
oral conditions, learning to minimize discrepancies in making jaw relation
records is critical.
This article reviews the concepts of jaw relation records (or interocclusal
records) and discusses the selection of interocclusal records for a variety of
clinical situations. In addition, articulator choice, the purpose of a facebow,
and materials for jaw relation records are discussed. Some pearls are
oered to help avoid common problem areas, including making impressions,
pouring impressions, mounting casts, and making interocclusal records.

General principles
If the goal of restorative treatment is to maintain a patients pretreatment
intercuspation and vertical dimension of occlusion (VDO), casts should be
mounted in a manner that maintains the same tooth-to-tooth relationship
that existed before treatment. This maximum intercuspal position (MIP)
facilitates treatment and works with the patients existing occlusion. The
vast majority of cases treated fall within this MIP category. The situation
becomes more dicult if a patient requires extensive treatment or if the
VDO needs to be altered. In these circumstances, a reproducible maxillo-
mandibular position from which treatment is performed is essential and

E-mail address: squier@up.uchc.edu

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2004.01.001
472 R.S. Squier / Dent Clin N Am 48 (2004) 471486

requires a centric relation record made at the terminal hinge axis. This
article deals with situations where the patients MIP and VDO do not
change as a result of treatment.

Function of the jaw relation record


Jaw relation records, or interocclusal records, have the following functions:
(1) They provide the stability or support that the casts of the remaining
dentition lack, (2) they reduce chair time for the delivery of the restoration, (3)
they reduce the likelihood of making restorations in hyperocclusion or with-
out occlusal contacts, and (4) they reduce the chance of perforation of re-
storations being inserted with excessive adjustment or having to adjust the
opposing dentition inappropriately.
For opposing casts to relate well, there must be a tripod of vertical support
and horizontal stability between the two casts. A minimum of three widely
spaced tooth-to-tooth contacts should be present during mounting to ensure
adequate stability. Casts that rock or wobble due to an insucient tripod
require an interocclusal record to stabilize them before mounting. Full-arch
working and opposing casts frequently have sucient occluding natural teeth
to accurately position the casts in a stable MIP occlusion, and horizontal
stability is generally present when there is good intercuspation between teeth.
However, in a patient with worn occlusal surfaces, although a solid vertical
tripod may be obtained, the horizontal stability may be inadequate to
accurately mount the casts. The goal of the interocclusal record is to provide
the support or stability that the casts of the remaining dentition lack.
Interocclusal records used to mount casts in MIP can be separated into
two categories: (1) records made when a tripod of vertical support is avail-
able from the remaining tooth-to-tooth contacts (an existing tripod inter-
occlusal record) and (2) records made when a tripod of vertical support is
not available from the remaining tooth-to-tooth contacts (a created
tripod interocclusal record) [1].

The existing tripod interocclusal record


When there is a tripod of widely spaced contacts and good intercuspation
of the teeth, an interocclusal record is not needed. In this situation, hand
articulation is the most accurate means of mounting a mandibular cast to
a maxillary cast. Practitioners frequently waste time and materials making
an interocclusal record when one is not needed. In addition, the use of an
interocclusal record when hand articulation is sucient creates a potential
for error because the record can often prevent the casts from fully inter-
cuspating (Figs. 1 and 2). Therefore, full-arch impressions made for a mini-
mum number of teeth being restored usually need no interocclusal record
due to the number of intact occlusal contacts.
R.S. Squier / Dent Clin N Am 48 (2004) 471486 473

Fig. 1. (A) An existing tripod of widely spaced contacts with good intercuspation of the teeth
does not require an interocclusal record. (B) An interocclusal record was unnecessarily made
and will most likely prevent the two casts from articulating well.

In patients where vertical support is adequate but horizontal stability is


lacking, an interocclusal record is needed to mount casts. Elastomeric
materials such as polyvinylsiloxane are ideal for making interocclusal
records where only horizontal stability is needed [2,3]. However, their
accuracy can be compromised if they are not properly trimmed. These
records should be carefully trimmed to remove all areas of the record that
contact soft tissues and the axial surfaces of the teeth (Fig. 3). This is done to
minimize the areas where the casts and the record touch, allowing the
practitioner to visualize how the casts seat into the record and ensuring that
the record provides only the horizontal support, with the contacting teeth
providing the vertical support.
Rigid materials, such as resins or waxes, can also be used to make existing
tripod records where horizontal stability is compromised. However, unlike
the elastomeric materials, the rigid materials should be used only for
segmental records and not for full-arch interocclusal records because they
could cause an inadvertent increase in the VDO if used incorrectly. These
rigid materials require adequate interocclusal space, such as between
a prepared tooth and its opposing teeth.
474 R.S. Squier / Dent Clin N Am 48 (2004) 471486

Fig. 2. (A) An interocclusal record was made unnecessarily. (B) Removal of the interocclusal
record shows that it was not needed due to a good tripod of vertical support and horizontal
stability.

The created tripod interocclusal record


A tripod of opposing teeth is present but without occlusal contacts
A practitioner has to create a tripod of vertical support where one does
not exist to mount opposing casts. A classic example of a created tripod
interocclusal record is a fully dentate patient who has teeth #18 through #20
prepared for a xed partial denture. Although the teeth are well positioned
around the dental arch, the tooth preparations prevent the existence of the
third leg of the tripod. In this situation, the tripod has to be created so that
the working and opposing casts can be mounted accurately. The materials
best suited for this purpose are those that are soft at placement and then
become rigid before their removal from the mouth, such as waxes, resins,
zinc oxide and eugenol pastes, and impression plasters. The materials of
choice for the general practitioner are resins (DuraLay [Reliance Dental,
Worth, Illinois] or GC Pattern Resin [GC America, Alsip, Illinois]) or
waxes. Resin placed conservatively between the tooth preparations and the
opposing teeth creates the needed leg of the tripod for mounting (Fig. 4).
The practitioner should avoid the elastomeric materials for this situation
because these materials exhibit compressibility and rebound, often resulting
R.S. Squier / Dent Clin N Am 48 (2004) 471486 475

Fig. 3. (A) An interocclusal record that has not been trimmed. (B) An interocclusal record that
has been trimmed properly on one side to remove all areas of the record that contact soft tissues
and the axial surfaces of the teeth. The other side has not been fully trimmed to demonstrate the
dierence in the amount of material needed.

in an inaccurate mounting that may lead to the need for excessive adjust-
ments upon delivery of the restoration or the possibility of no occlusion
between the restoration and the opposing teeth.

Opposing teeth are absent at one or more desired tripod stops


When teeth are absent at one or more potential tripod stops, a record
base-occlusion rim is indicated to obtain support from the edentulous ridge.
The practitioner may use a record base-occlusion rim made on a cast or can
make an intraoral segmental interocclusal record composed of rigid setting
materials that do not displace the soft tissues of the edentulous ridge at the
time of placement. If the choice is a record base-occlusion rim, the record
base must be made on the cast(s) that is to be mounted and not on earlier
made diagnostic casts [4]. A record base made on one cast does not
predictably transfer to another cast due to dierences between the casts.
These discrepancies are the result of minor dierences in soft tissue dis-
placement and tooth position and dierences from the dimensional accuracy
of impression materials and dental stones.
476 R.S. Squier / Dent Clin N Am 48 (2004) 471486

Fig. 4. Interocclusal record made with a rigid autopolymerizing resin. In a distal extension
situation, resin placed conservatively between the tooth preparation and the opposing tooth
creates the needed leg of the tripod for mounting the casts.

The record base is adapted to the edentulous portion of the cast and often
to the lingual surfaces of the remaining teeth to enhance stability and
retention (Fig. 5). Record bases usually are made from light-activated resin
or autopolymerizing resin. The occlusion rim is able to function only as
a substitute for a leg of a tripod when the record base is stable in the mouth
and on the cast. The occlusion rim can easily and cheaply be made from
baseplate wax to imprint the cusp tips of the opposing teeth, or other mate-
rials may be used, including metal-impregnated wax or the more rigid of
the elastomeric interocclusal recording materials (eg, Blu-Mousse; Parkell,
Farmingdale, New York).
If the working cast with crown preparations contains the edentulous
areas where tripod stops are desired, the record base cannot be made until
the nal impression is made, poured, and separated and the cast is trimmed.
This usually requires that the patient make a separate brief appointment for
a jaw relationship record before fabrication of the restorations. However, if
the edentulous areas are located in the opposing arch, the practitioner who
has planned ahead may have the record base-occlusion rim made on the
opposing cast before the nal impression visit, allowing the interocclusal
record to be made at the nal impression appointment.
Because of the popularity of the elastomeric materials for interocclusal
records, they are often abused. One situation where this is the case is when
there is an absence of a tripod of support and there is a need to create the
tripod. Polyvinylsiloxane and polyether are ineective materials when
creating a tripod of support due to their inherent compressibility. Although
the materials are easy to use for interocclusal records, their use during the
mounting of the casts can be technique sensitive. It is dicult to objectively
determine the amount of force that should be exerted on the casts when
mounting them with the interocclusal record. Too much force can cause
compression of the elastic record, resulting in some part of the casts placed
R.S. Squier / Dent Clin N Am 48 (2004) 471486 477

Fig. 5. (A) A light-activated resin record base with wax occlusion rim for making an
interocclusal record. (B and C) Light-activated resin record bases with respective interocclusal
records made in an elastomeric recording material. Note how the record bases are supported by
the lingual surfaces on the remaining teeth and that a minimum of recording material is used to
record only the cusp tips of the opposing teeth.

too closely together, and too little force can allow for inadequate seating of
the cast into the record, resulting in casts that are too far apart. Therefore,
despite the relative accuracy and dimensional stability of elastomeric
materials and their ease of use and convenience, their use in these cir-
cumstances is likely to result in an inaccurate mounting and subsequent
478 R.S. Squier / Dent Clin N Am 48 (2004) 471486

diculty in delivering the nal restoration(s) because of no occlusion or


a resulting heavy occlusion.

The use of prosthesis frameworks


For a variety of clinical conditions, a xed metal framework or a metal
framework for a removable partial denture can be used to support an
interocclusal record. The benet of using a metal framework to support an
interocclusal record is that the metal framework usually has more stability
and retention than a record base-occlusion rim. For instance, when one is
remounting casts after the metal try-in of xed restorations, the recording
material may be added directly to the metal framework [5]. The framework
may carry an elastic material to make a segmental existing tripod record or
a rigid material to contact the opposing teeth and make a created tripod
record. When a practitioner requests a metal framework to be returned for
try-in before porcelain application, not only should the metal be examined
for t, but also the opportunity should be taken to verify the accuracy of the
articulation of the working casts. The added time in verifying the articu-
lation could save considerable time at the insertion appointment.
When fabricating xed restorations in combination with a removable
partial denture (RPD), jaw relation records are often dicult due to the
diculty in achieving good stability of a record base and occlusion rim. The
tted framework of the RPD can be used as a record base, and the occlusion
rim can be formed directly into the meshwork areas [4,5] (Fig. 6). The
framework adds retention and stability for an interocclusal record, thereby
increasing its accuracy.

Articulator choice
When fabricating xed and removable prostheses, the use of an ad-
justable articulator usually reduces the amount of intraoral adjustment

Fig. 6. A tted RPD framework used as a record base and the occlusion rim formed directly
into the meshwork areas. The framework adds retention and stability for the interocclusal
records, thereby increasing its accuracy.
R.S. Squier / Dent Clin N Am 48 (2004) 471486 479

needed. A more anatomically sized articulator, such as a programmed


adjustable or a semiadjustable articulator, better reproduces the mandibular
border movements compared with a simple hinge articulator. An articulator
that is more true to human size allows the restoration to be adjusted by the
technician to a greater degree and to a closer approximation of the patients
intraoral situation. A full-size adjustable or semi-adjustable articulator is an
excellent investment for the dentist who does a substantial amount of crown
and bridge.

Purpose of a facebow
The purpose of a facebow transfer is to orient the maxillary cast to
the transverse axis of the articulator. Its use is limited to adjustable and
semi-adjustable articulators. Facebows are not necessary if there will be no
change in the VDO. However, if any alteration of the VDO is planned, as in
a full-mouth rehabilitation, a facebow (and a full-sized articulator) should
be used. Another positive aspect of using a facebow is that it makes it easier
to mount a maxillary cast to a full-sized articulator.

Avoiding errors and inaccuracies


Inaccuracies in jaw relations can be caused by a number of factors besides
a poor interocclusal record. Errors can be introduced anywhere from im-
pressions to cast accuracy to problems with the articulation of the casts.
These areas are often overlooked and are as important for overall accuracy
as the interocclusal record.
All impression materials, all dental stones or plasters, and all inter-
occlusal materials have inherent inaccuracies: they shrink or expand. Learn-
ing how to minimize these inaccuracies improves the end product and results
in a more successful outcome to the practitioner and to the patient.
Accuracy of dental casts and their subsequent successful articulation are
essential when trying to maximize quality while minimizing treatment time
with a patient. The following pearls elucidate common problem areas and
discuss how to handle them.

Movement during setting of material


Movement of the impression tray during the setting time of the im-
pression material leads to inaccuracy. Minor movement while making an
impression for study casts may not be too harmful in the overall scheme
of treatment; however, the same movement for a nal impression is
detrimental to the fabrication of a xed restoration. Once the tray with
impression material is seated in the mouth, it is essential that any movement
480 R.S. Squier / Dent Clin N Am 48 (2004) 471486

by the operator or the patient be prevented. An impression tray should


never be left in a patients mouth without being stabilized by the practitioner
or dental assistant. Additionally, a patient should not be allowed to close
into a full-arch impression tray at any time; the practitioners or dental
assistants ngers should prevent this from occurring.

Impression material dislodged from the impression tray


Dislodged impression material occurs most frequently with alginate
impression material. If a plastic stock tray is used and if the impression tray
is not adequately painted with adhesive, the alginate has to rely solely on the
perforations in the tray and may separate from the tray as the impression is
removed from the mouth. This may happen with a metal stock tray as well
because adhesive is generally not used in these trays for added security. Once
distorted, the alginate cannot be pushed back into place; a new impression
has to be made. This separation of alginate from the impression tray may be
overlooked as a non-essential factor or may go unnoticed. Separation of the
impression material from the tray is a common cause of inaccurate casts.
Although less likely than with alginate, the same separation of impression
material from an impression tray may occur with elastomeric nal impres-
sion materials. After removing any impression from a patients mouth,
the overall adherence of the impression material to the tray should be
examined. This step reduces cast inaccuracies and the resultant errors in
the fabrication of a restoration.

Laying alginate on tabletop with long extensions


Alginate impression material that is unsupported by an impression tray is
under stress. Using an impression tray that does not adequately match
a patients arch size runs the risk that a large portion of the alginate will
be unsupported and therefore may become distorted. In addition, after
an alginate impression is made, the practitioner usually places it on
a countertop with the overextended alginate in direct contact with the at
surface. Any direct pressure on the unsupported alginate distorts the
impression. Ideally, an impression as discussed would be made and then
disinfected and poured in dental stone while being held in a holding tree
so the impression tray hangs from its handle rather than rests on the
countertop (Fig. 7).

Pouring casts on time


Certain impression materials, such as reversible and irreversible hydro-
colloids (alginate), must be poured promptly after making an impression, or
rapid distortion occurs. After disinfection of either impression material,
a cast should be poured immediately. Failure to do so causes loss of water
R.S. Squier / Dent Clin N Am 48 (2004) 471486 481

Fig. 7. (A) An overextended alginate should never be placed directly into contact with a at
surface. This causes distortion of the unsupported alginate material and results in an inaccurate
cast. (B) Ideally, an alginate impression with distal extensions should be placed in a holding
tree where the impression hangs from its handle rather than rests on a countertop during
disinfection and pouring in dental stone.

from the impression material. This loss of water distorts an impression and
produces inaccuracies in the cast that aect the working dies for a xed
restoration or the articulation of the casts. It is important when using
any impression material to read the manufacturers recommendations for
the maximum time allowable before pouring the impression to reduce
inaccuracies.

Casts have major blebs on occlusal surfaces aecting articulation


The majority of dental casts have blebs on the occlusal surfaces of the
teeth. If they are large enough and go unnoticed, the articulation of casts
can be signicantly altered, leading to a false mounting of the casts. The
occlusal surfaces of the teeth on the casts should be free of these blebs, which
interfere with the proper relationship of the casts. After impressions are
poured and before mounting the casts, the occlusal surfaces should be
examined and freed of any major blebs that would interfere with an accurate
intercuspation of the teeth.
482 R.S. Squier / Dent Clin N Am 48 (2004) 471486

Hand articulate whenever possible


In a fully dentate patient with good maximum intercuspation and a widely
spaced tripod, the most accurate method of relating casts is by hand
articulation. The use of an interocclusal record in such a situation can result
in (1) the inability to accurately mount the casts due to the thickness of the
recording materials (see Figs. 1 and 2), (2) wasted time, and (3) wasted
material and, therefore, money.

Heels of the casts touch


Casts that are improperly trimmed may have interferences that make
mounting dicult. One common site for this is the heel of the casts. Casts
that extend too far posteriorly behind the retromolar pad and the maxillary
tuberosity often interfere when the casts are mounted. Sometimes this goes
unnoticed, especially when these extensions are preceded by edentulous
areas. Touching heels prevents interocclusal records from tting accurately
to the casts and results in inaccurate mountings.

Mush bites
When a patient is asked to bite into a large amount of material, it is often
impossible to determine whether their teeth are coming into contact with
one another because the amount of material obscures the practitioner from
visualizing good tooth contact (Figs. 8 and 9). In addition, when applying
the material for this type of record, if part of it sets while the rest of it is
dead soft, the accuracy is compromised. In general, interocclusal records
should be made with a minimum of material between the teeth or applied to
a record base.

Mouth open during triple tray impression


When a patient bites into a large amount of impression material, the teeth
frequently do not make contact. Triple tray impressions are notorious for
this because it is often dicult to visualize tooth contact with the impression
material in a patients mouth (Fig. 10). It may not be noticed until the dental
laboratory pours the impression and mounts the casts that the patient had
not closed completely. When using triple trays, it is essential that the
practitioner runs the patient through the motion and discusses with them
what it should feel like when they close down through the material. One
should not assume that the patient would close all the way through the
material without proper instruction. In addition, the teeth on the opposite
side of the arch to be impressed should be examined, and contacts should
be visualized between the teeth before making the impression. When the
impression is seated in the mouth and the patient closes, the practitioner
should re-examine these same tooth contacts to ensure that they are the
R.S. Squier / Dent Clin N Am 48 (2004) 471486 483

Fig. 8. (A) This patient was asked to bite into a large amount of putty material as an
interocclusal record. (B) In the laboratory, it was clear from the marks on the adjacent teeth
that the mush bite prevented the patient from fully closing. In addition, there was insucient
occlusal reduction of the tooth preparations. In this situation where the restorations serve as the
third leg of the tripod, a more rigid interocclusal material, such as resin, would be preferred over
an elastomeric impression material due to increased accuracy.

same. If not, there is likelihood that the patient did not close correctly or
fully through the impression material.

Casts moved during articulation


When mounting dental casts onto an articulator, it is essential that the
maxillary and mandibular casts be joined in such a way as to avoid any
potential movement. Even in patients with good intercuspation, if the casts
are not held immobile during mounting, any slight movement translates into
some amount of discrepancy. There are multiple methods of mounting casts.
The best method is the use of a combination of rigid sticks and compound
or sticky wax (Fig. 11). The casts must be dry when using these materials to
avoid any movement. Sticky wax placed directly onto the opposing teeth can
also be used; however, when the sticky wax is removed, the teeth often break
o the cast or are severely broken.
484 R.S. Squier / Dent Clin N Am 48 (2004) 471486

Fig. 9. A similar patient situation to Fig. 8 illustrating the same principles.

Using a second pour of your nal impression


Most practitioners send their nal xed impressions to a dental labo-
ratory to be poured. The laboratory does the cast and die work and re-
turns the restoration to the dentist. An important and often overlooked
service that the laboratory can provide is to pour a second unsectioned cast
of the nal impression. This second pour may be more accurate than the
cast with sawed dies for adjusting the occlusion and the contacts. The dies of
a working cast have some amount of mobility due to the pindexing system,
a fact that makes getting perfect contacts dicult. In addition, the adjacent
and opposing teeth on a stone cast invariably are abraded during restoration
fabrication. Using a solid, unsectioned second pour allows the dental
technician to examine the proximal and occlusal contacts achieved on the
working casts and to improve these contacts when decient before returning

Fig. 10. A triple tray impression can be problematic because it is often dicult to visualize
tooth contacts with a large amount of impression material in a patients mouth. In this case, it is
clear that the teeth on the opposite side of the arch are not contacting. If the tooth contacts are
not the same as without the impression in the mouth, there is likelihood that the patient did not
close correctly or fully through the impression material, and the impression should be remade.
R.S. Squier / Dent Clin N Am 48 (2004) 471486 485

Fig. 11. The best method of mounting maxillary and mandibular casts on an articulator to
avoid any potential movement is to join the dry casts with a combination of rigid sticks and
compound. Before joining the two casts, the heels of the casts were checked for any interference.
Note that the maxillary cast has already been mounted using a facebow, and the articulator has
been inverted to mount the mandibular cast after the two have been joined rigidly.

the restoration to the dentist for delivery. This step can reduce the number
of returns of the restorations to the laboratory for the addition of proximal
and occlusal contacts and can make delivery of nal restorations easier and
more pleasurable.

Materials for interocclusal records


The most commonly used materials for interocclusal records are the fast-
setting elastomeric interocclusal registration materials or wax. Elastomeric
materials such as polyvinylsiloxane are well suited for making interocclusal
records where only horizontal stability is needed. However, their accuracy
can be compromised if they are not properly trimmed. These records should
be carefully trimmed to remove all areas of the record that contact soft tissues
and the axial surfaces of the teeth. This is done to minimize the areas where
the casts and the record touch, allowing the practitioner to visualize how the
casts seat into the record and ensuring that the record provides only the
horizontal support with the contacting teeth providing the vertical support.
To assure accuracy, only cusp tips of opposing teeth should be registered in
the material used. Excess material that ows on the axial surfaces of natural
teeth invites error when repositioning the working casts in the registration.
The following adage says it well: In most instances, a minimal amount of
registration material will give a maximum amount of accuracy.

Summary
This article discusses and reviews general principles of jaw relation
records, including the purpose of a jaw relation record and the concept of
486 R.S. Squier / Dent Clin N Am 48 (2004) 471486

a tripod of vertical support with adequate horizontal stability to allow


opposing dental casts to be mounted accurately on an articulator. The use of
the MIP position for the vast majority of patients is favored when the goal
of restorative treatment is to maintain a patients pretreatment intercuspa-
tion and vertical VDO. In addition, articulator choice, purpose of a facebow,
and materials for jaw relation records are discussed. Common errors in
making impressions, pouring impressions, mounting casts, and making
interocclusal records are elucidated, providing the practitioner important
information with which to avoid inaccuracies that may lead to additional
time spent making intraoral occlusal adjustments at the insertion of xed
restorations.

Acknowledgments
The author thanks Dr. Martin Freilich for his expertise and guidance in
the writing of this article.

References
[1] Freilich MA, Altieri JV, Wahle JJ. Principles for selecting interocclusal records for
articulation of dentate and partially dentate casts. J Prosthet Dent 1992;68:3617.
[2] Balthazar-Hart Y, Sandrik JL, Malone WFP, Mazur B, Hart T. Accuracy and dimensional
stability of four interocclusal recording materials. J Prosthet Dent 1981;45:58691.
[3] Fattore LD, Malone WFP, Sandrik JL, Mazur B, Hart T. Clincial evaluation of the
accuracy of interocclusal recording materials. J Prosthet Dent 1984;51:1527.
[4] McGivney GP, Castleberry DJ. McCrackens removable partial denture prosthodontics.
8th ed. St. Louis: CV Mosby; 1989.
[5] Warren K, Capp N. A review of principles and techniques for making interocclusal records
for mounting working casts. Int J Prosthodont 1990;3:3418.
Dent Clin N Am 48 (2004) 487497

Interim restorations
David G. Gratton, DDS, MS*,
Steven A. Aquilino, DDS, MS
Department of Prosthodontics, College of Dentistry, University of Iowa,
Iowa City, IA 52242-1001, USA

Interim restorations are an essential part of xed prosthodontic


treatment. Patients must be provided with an interim restoration from
initial tooth preparation until the denitive prosthesis is placed. An interim
prosthesis is dened as a xed or removable prosthesis, designed to
enhance esthetics, stabilization or function for a limited period of time, after
which it is to be replaced by a denitive prosthesis. Often such prostheses are
used to assist in determination of the therapeutic eectiveness of a specic
treatment plan or the form and function of the planned denitive
prosthesis [1]. The term provisional prosthesis is often used as a synonym
for interim prosthesis [1]. The requirements of an interim restoration are
essentially the same as for the denitive restoration, with the exception of
longevity and possibly the sophistication of color [2].

Basic requirements of an interim restoration


The requirements of an interim restoration are to provide pulpal
protection, positional stability, maintenance of occlusal function, cleans-
ability, strength, retention, and esthetics [3]. These requirements can be
subdivided into biologic and biomechanical categories.

Biologic requirements
An interim restoration must maintain the health of the pulpal and
periodontal tissues [4]. Once the dentinal tubules are exposed through tooth
preparation, the internal adaptation, the marginal integrity of the interim
restoration, and the provisional luting agent help protect the pulp from the

* Corresponding author.
E-mail address: david-gratton@uiowa.edu (D.G. Gratton).

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.007
488 D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497

adverse eects of bacterial microleakage and chemical and thermal


irritation. For endodontically treated teeth, the interim restoration should
help maintain the biologic seal and prevent coronal microleakage that may
result in the contamination of the root canal system [5]. Patients undergoing
complex xed prosthodontic treatment over extended periods of time should
be provided with properly adapted interim restorations. These interim
restorations must be evaluated at regular intervals because provisional
luting agents are subject to relatively rapid dissolution [6].
An important role of the interim restoration is to maintain the health of
the periodontal tissues. This is accomplished by maintaining marginal
integrity and by ensuring that the gingival contours do not impinge on the
periodontal tissues and are smooth and highly polished. Proper emergence
proles are essential to maintaining gingival health. Over-extended and
over-contoured gingival contours cause gingival irritation and increase
plaque retention and may lead to inammation and subsequent recession of
the marginal gingiva [7]. Concerning esthetics, appropriate emergence
proles and proximal contours are essential for maintaining interdental
papilla form. When fabricating interim xed partial dentures, appropriate
pontic form is essential in maintaining the health and esthetic contours of
the gingival tissues overlying the edentulous ridge.

Biomechanical requirements
Interim restorations must be able to withstand the functional forces of
mastication without fracture or displacement. This is particularly true for
interim xed partial dentures. In addition, the interim restoration must
maintain the position of the prepared teeth and the stability of inter- and
intra-arch relationships through the establishment of optimum proximal
and occlusal contacts. Maintenance of these contacts prevents the prepared
teeth or opposing teeth from mesial or distal drifting and supraeruption. It is
essential that interim xed partial dentures maintain the interabutment
relationship recorded during the nal impression procedure until the
denitive prosthesis is placed. Anterior interim restorations must maintain
the appropriate protrusive and lateral guidance for the patient.

Diagnostic potential of interim restorations


Interim restorations serve as valuable diagnostic tools in xed
prosthodontics. Most practitioners would not attempt to deliver a denitive
removable prosthesis without a preliminary evaluation of the prosthesis
through a wax try-in. In xed prosthodontics, the interim restoration serves
as a functional and esthetic try-in. Through duplication of the diagnostic
wax-up, the interim restoration helps determine if the proposed prostho-
dontic solution for the presenting condition satises the patients functional
requirements and esthetic expectations [2,8]. A properly adapted and
contoured interim restoration can serve as a guide to determine if there is
D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497 489

adequate retention and resistance form for the functional requirements of


the prosthesis and if optimal tooth reduction has been provided to satisfy
the biomechanical, physiologic, and esthetic requirements of the planned
restoration.
As the complexity of the proposed prosthodontic treatment increases,
the importance of the interim restoration as a key diagnostic tool is magni-
ed. Changes in vertical dimension of occlusion, centric occlusal contact
relationships, and anterior guidance can most readily be evaluated with
properly designed interim restorations. Changes in tooth length, contour,
incisal edge position, lip support, occlusal or incisal plane, and tooth color
can also be best evaluated with the interim restoration [2,4,912].
Interim restorations also aid in adjunctive therapies associated with xed
prosthodontics. This is especially true for periodontal therapy. Removal of
the interim restoration enhances access for periodontal control procedures
and aids in the diagnosis and decision-making associated with periodontally
compromised teeth. Properly designed interim restorations serve as ex-
cellent guides to periodontal surgical procedures, such as crown lengthen-
ing, ridge augmentation, and pontic site development procedures. Interim
restorations may also aid in pre-prosthetic endodontic and orthodontic
therapies [13].
Once the dentist and patient are satised with the interim prosthesis
function, phonetics, and esthetics, a duplicate of the interim restoration
serves as a guide for the laboratory technician in the fabrication of the
denitive prosthesis. In this way, the interim restoration ensures a predict-
able, functional, and esthetic denitive prosthesis [2].

Materials for interim restorations


Contemporary materials for the fabrication of single- and multiple-unit
interim restorations are for the most part resin based. They dier with
regard to method of polymerization, ller composition, and monomer type.
They include auto-polymerizing and dual curing resins, such as poly (methyl
methacrylate) (PMMA), poly (ethyl methacrylate) (PEMA), polyvinyl (ethyl
methacrylate) (PVEMA), bis-GMA resins, bis-acryl resin composites, and
visible light cured (VLC) urethane dimethacrylate resins. In selecting
a material for an interim restoration, consideration should be given to the
physical properties of the material. Clinically relevant physical properties
include strength, rigidity, reparability, exothermic reaction, polymerization
shrinkage, marginal integrity, and color stability.

Strength and rigidity


One of the limitations of resin-based interim restorations is their relatively
poor strength. The exural strengths of interim restorative materials vary
490 D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497

within material chemical classes and between chemical classes of materials;


therefore, it is dicult to predict the exural strength of a provisional material
on the basis of generic composition alone [14].
In general, PMMA has been shown to exhibit the greatest strength of the
methacrylate acrylic resins [15,16]. The bis-acryl composite resins have been
shown to have the highest modulus of rupture and exural elastic modulus of
all provisional material types [17], whereas the PMMA resins have been shown
to have higher exural strength than composite resin [18]. Others researchers
have found no signicant dierence between the strength of PMMA and
composite resin provisional materials [16]. Some of this confusion may be due
to a lack of standardization of testing methodologies reported in the literature
and a lack of correlation between various testing methodologies and the
functional strength requirements of interim prostheses in vivo.
The newer bis-acryl resin composite provisional materials seem to exhibit
an enhanced microhardness over the traditional PMMA provisional
materials, which may be an indicator of their resistance to wear [19].
The fracture toughness, or the resistance to crack propagation, has been
shown to be highest for PMMA, followed by bis-GMA composite resin and
PEMA [20]. Urethane dimethacrylate resin has also been shown to have
high fracture toughness values [21]. The bis-GMA composite resin materials
seem to be more brittle than PMMA and therefore more likely to fracture in
long-span xed partial denture applications.
In the event of clinical fracture of an interim xed prosthesis, an
understanding of the strength of the repaired prosthesis is helpful.
Unfortunately, the repaired strength of all interim restorative materials is
signicantly less than the strength of the original unrepaired prosthesis, with
the bis-acryl materials demonstrating an 85% decrease in transverse
strength after repair [22].

Reinforcement
To enhance the mechanical properties of acrylic resins, various reinforcing
techniques have been advocated. These have included glass bers, nylon
bers, aluminum and sapphire whiskers, polycarbonates, metal strengtheners,
and carbon graphite bers [15,2326]. The eectiveness of these strengthening
mechanisms varies, with the over-riding requirement being adequate bond
formation between the reinforcing material and the parent resin. If there is not
an adequate bond, the ller may act as an inclusion body and weaken the
prosthesis. In addition, although the incorporation of materials such as
polyethylene and carbon graphite bers has been shown to increase the moduli
of elasticity of commonly used provisional xed partial denture materials,
technical diculties and esthetic concerns have prevented their widespread use
[15]. If these ber reinforcements protrude from the interim restoration
surface, they may be dicult to polish and can act as a wick, attracting oral
bacteria.
D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497 491

Exothermic reaction
For all interim materials, the potential for pulpal injury exists during the
fabrication of direct interim crown or xed partial denture restorations due
to the heat generated during the exothermic setting reaction [27]. In vivo
investigation has determined that a 10 F (5.6 C) increase in pulpal
temperature resulted in a 15% loss of vitality of tested pulps, a 20 F
(11.2 C) increase in pulpal temperature resulted in a 60% loss of pulpal
vitality, and a 30 F (16.8 C) increase in pulpal temperature resulted in 100%
pulpal necrosis [28]. The temperature increase during polymerization of
PMMA has been shown to be signicantly higher than that for PVEMA,
VLC urethane dimethacrylate, and bis-acryl composite resin, with the VLC
urethane dimethacrylate exhibiting signicantly less polymerization tem-
perature increase than the other resins [29]. In a study that compared two
auto-polymerizing bis-acryl resins with three dual-cured bis-acryl resins, the
peak polymerization temperature of the auto-polymerizing bis-acryl resins
was signicantly higher than that of the three dual-cured bis-acryl resins
[30]. Peak polymerization temperature increases have been associated with
the volume of acrylic resin [31].
Contrary to manufacturer claims, all resin materials used in the
fabrication of interim prostheses exhibit an exothermic reaction. In general,
PMMA exhibits the greatest exothermic reaction, followed by PVEMA,
PEMA, bis-acryl composite, and VLC urethane dimethacrylate resins. In
addition to the chemical class of material used, various fabrication
techniques have been shown to substantially inuence the peak temperature
rise during direct fabrication of interim restorations [3234].
The clinician should limit the thermal insult to the pulp by selecting an
appropriate interim material, minimizing the volume of material, and
choosing an appropriate fabrication technique.

Color stability
As patients become more esthetically aware and demanding, it is
paramount that the clinician provides an esthetically acceptable interim
restoration. The shade selected for the interim prosthesis should match the
adjacent and opposing teeth and should not exhibit a color shift during the
time of provisionalization. Interim restoration color instability may be due
to the incomplete polymerization of the material, sorption of oral uids,
surface reactivity, dietary habits, and oral hygiene. Historically, the PMMA
provisional materials were found to be more color stable than PEMA and
PVEMA provisional materials [3538]. As with other physical properties,
color stability cannot be predicted solely on the chemical classication of the
material [3941]. Surface nish may also contribute to the propensity of
provisional materials to stain, with porous unpolished surfaces exhibiting
signicantly more darkening than highly polished materials [35].
492 D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497

Fabrication techniques
Multiple techniques exist for the fabrication of interim restorations.
Essentially, a matrix is required to form the external contours of the interim
restoration. The internal adaptation of the interim restoration can be
formed directly on the prepared tooth or teeth (the direct technique) or on
a stone cast of the prepared tooth or teeth in the dental laboratory (the
indirect technique).

Matrices
For either technique, a matrix is required to create the external axial and
occlusal contours of the interim restoration. Prefabricated or preformed
aluminum, tin, stainless steel, polycarbonate, and cellulose acetate external
crown forms are available in various tooth sizes and shapes. They are
limited to single-unit restorations and may require substantial adjustment to
achieve appropriate proximal contours and occlusion. These crown forms
are usually relined directly with a resin-based material to achieve in-
dividualized internal adaptation and marginal t [4].
The use of a custom matrix is preferable for the fabrication of multiple
unit and complex interim restorations [42]. These matrices are fabricated
from thin vacuum-formed materials or elastomeric impression materials.
Whereas a duplicate stone cast of the diagnostic wax-up is required for
thermoplastic vacuum-formed materials, a polyvinyl Siloxane putty
material is convenient to use and can be adapted directly to the stone cast
or the diagnostic wax-up of the proposed restoration, resulting in precise
anatomic detail. The use of a polyvinyl siloxane material as the matrix has
been shown to signicantly reduce peak polymerization temperatures as
compared with the use of a vacuum-formed polypropylene matrix material
[32,33]. Other materials that have been advocated for use as a custom matrix
include wax, thermoplastic resins, and irreversible hydrocolloid impression
materials.

Direct technique
The direct technique involves the use of a mold or matrix that is related
intraorally to the prepared teeth. The matrix is made from a preoperative
diagnostic cast or from a diagnostic wax-up. After tooth preparation, the
matrix is trial tted in the patients mouth. The prepared teeth are washed,
gently dried (not desiccated), and lubricated with petroleum jelly. Any
surrounding composite resin restorations should also be lubricated with
petroleum jelly. The selected provisional material is mixed according to the
manufacturers instructions and placed into the matrix; care is taken not to
incorporate any air bubbles. The matrix with the provisional restorative
material is then seated over the prepared teeth and allowed to polymerize.
At this point, careful attention must be paid to the working and setting
D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497 493

times of the material being used to minimize heat build-up due to the
exothermic reaction and to prevent the restoration from becoming locked
into any undercuts on the preparation or adjacent gingival embrasures [33].
Using the air water syringe may aid the dissipation of the heat generated. To
prevent pulpal damage or locking of the interim restoration on the
preparations, some advocate that the interim restoration be removed after
the rubbery stage has been reached and allowed complete polymerization
outside the mouth. This technique is problematic with PMMA resins due to
their polymerization shrinkage. It is more appropriate for the bis acrylics,
which have less polymerization shrinkage as compared with PMMA. An
on-o technique is advocated to prevent locking the interim restoration
on to the preparations during polymerization. After the provisional material
has reached the rubbery stage, the interim restoration is teased partially o of
the preparations and reseated several times throughout the setting reaction
while the area is ushed with water as a coolant until polymerization is
complete [34]. Unfortunately, this technique has been shown to result in
relatively poor marginal integrity [43]. Other researchers advocate letting the
restoration achieve nal set in situ but emphasize the need to continually ush
the area with water to prevent thermal damage to the pulp. This technique is
not realistic; the interim prosthesis will likely be dicult to remove due to the
presence of interproximal undercuts on the teeth adjacent to the preparations.
The advantage of the direct technique is that it is the most ecient use of
time and materials because no intermediate impression or stone cast is
required. The disadvantages of the direct technique are that the freshly cut
dentin and the vital pulpal tissues are exposed to the heat generated during
the exothermic polymerization reaction and to the free monomer or other
irritating chemicals present in the unpolymerized interim restorative
materials. The direct technique is well suited for single crowns and short-
span (up to three units) xed partial dentures.

Indirect technique
A similar, although more complex, protocol is followed when the
indirect technique for interim restoration fabrication is planned. After tooth
preparation, an irreversible hydrocolloid impression or a fast setting
multipurpose nonaqueous elastomeric impression is made of prepared teeth.
The impression is poured in fast setting plaster or stone. The decreased
strength of the dental plaster can be helpful when removing the interim
restoration from the cast. The matrix is trial tted to the cast, and
modications are made to the matrix or cast until complete seating of the
matrix is achieved. A separating medium (petroleum jelly or tinfoil substitute)
is applied liberally to the prepared teeth, adjacent teeth, and tissues on the cast.
The desired provisional material is mixed according to the manufacturers
instructions and carefully loaded into the matrix. The matrix is then
positioned over and rmly seated onto the cast until complete seating of the
494 D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497

matrix is achieved. A gypsum core can be used in conjunction with the matrix
to ensure full seating and to optimize the interim restorations occlusal vertical
dimension [42]. The matrix can be stabilized with elastic bands and the cast/
matrix assembly placed in warm water in a pressure pot to increase density and
to optimize the physical properties of the completely polymerized restoration.
The indirect technique has several advantages over the direct technique
for interim restoration fabrication. Because the provisional materials do not
polymerize intraorally, the pulpal tissues are not exposed to the exothermic
polymerization reaction or to unreacted free monomer or other chemical
irritants. Because the amount of heat generated is proportional to the
volume of material used, the indirect technique is most often indicated for
the fabrication of interim restorations for multiple crowns or complex xed
partial dentures with multiple pontics where the exothermic reaction cannot
easily be controlled intraorally. Although the indirect technique has been
described as more accurate [44], incomplete capture of preparation margins
and polymerization changes may require repair or reline of the restoration
intraorally.
The main disadvantage of the indirect technique is that an intermediate
impression and stone cast are required to fabricate the interim restoration,
resulting in increased time and materials required for fabrication.

Indirect-direct technique
A combination of the two techniques is proposed to provide a relatively
atraumatic means to achieve the most accurate tting interim prosthesis [4].
The technique involves the fabrication of a thin shell indirectly on
a minimally reduced cast of the proposed restorations. These shells are
relined with the provisional restorative material intraorally. This technique
combines the best marginal accuracy with the least potential for thermal
damage to the pulpal tissues. However, as with the indirect technique, the
indirect-direct technique requires greater time and laboratory support.

Marginal integrity
Regardless of the technique used in fabrication, one of the key require-
ments of an interim prosthesis is to provide a denitive marginal seal to
prevent pulpal sensitivity, provisional cement washout, bacterial ingress, and
secondary caries or pulpal necrosis. A denitive marginal seal also promotes
optimal periodontal and gingival health and facilitates the impression and
cementation procedures and maintenance of the gingival architecture [45].
The specic technique used in the fabrication of an interim restoration has
a signicant impact on the resultant marginal integrity. Having the material
polymerize completely and undisturbed intraorally on the tooth preparation
or on a gypsum cast of the preparation provides the most accurate marginal
adaptation [43]. However, this method is impractical with the direct
technique because leaving the material undisturbed leads to locking the
D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497 495

interim restoration on to the prepared tooth. Although the indirect technique


has been found to produce signicantly more accurate marginal integrity
than the direct technique, the amount of improvement between the direct and
indirect techniques is material specic [43,44]. In addition, for adequate
marginal integrity, the indirect technique requires a complete and accurate
impression of the preparation nish line. A direct reline procedure seems to
improve the marginal integrity of directly and indirectly fabricated interim
restorations [46]. It is important to provide adequate internal room for the
reline material and to provide an escape vent to optimize marginal
adaptation. When comparing the marginal integrity of provisional materials
fabricated using the same technique, in vitro results suggest that marginal
delity is more dependent on the specic product than on the chemical
classication of the material [47,48].

Summary
Interim restorations are a critical component of xed prosthodontic
treatment. In addition to their biologic and biomechanical requirements,
interim restorations provide the clinician with valuable diagnostic informa-
tion. They act as a functional and esthetic try-in and serve as a blueprint for the
design of the denitive prosthesis. In selecting a material for the fabrication of
a single crown or multi-unit interim restoration, the clinician must consider
multiple factors, such as physical properties (eg, exural strength, surface
hardness, wear resistance, dimensional stability, polymerization shrinkage,
color range and stability, and radiopacity), handling properties (eg, mixing
time, working time, predictable and consistent setting time, ease of trimming
and polishability, and repairability), patient acceptance (eg, smell and taste),
and material cost. There is no one material that meets all requirements [16].
Complicating the clinicians ability to choose a material is the fact that the
material classication alone of a given product is not a predictor of clinical
performance. However, some clinical trends are noteworthy. For single-unit
restorations, the bis-acryl materials oer many desirable properties. They tend
to have low exothermic reactions, minimal polymerization shrinkage, minimal
odor and objectionable taste, and relatively quick setting reaction and are easy
to trim and marginally accurate. In addition, many of the bis-acryl provisional
materials oer convenient cartridge delivery systems, which may allow for
more consistent mixes [49]. Disadvantages include their brittleness and
increased cost, which are not as critical for single-unit interim restorations.
For multi-unit, complex, long-term interim xed prostheses, the PMMA
provisional materials remain the material of choice. They have high exural
strength, good reparability, high polishability, acceptable marginal t, good
color stability, excellent esthetics, and cost eectiveness.
The clinician must have a thorough knowledge of the handling
characteristics and properties of the interim restoration material selected.
496 D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497

The technique used for fabrication will most likely have a greater eect on
the nal result than the specic material chosen.

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Dent Clin N Am 48 (2004) 499512

Casting alloys
John C. Wataha, DMD, PhD*, Regina L. Messer, PhD
Medical College of Georgia School of Dentistry, Augusta, GA 30912-1260, USA

Dental casting alloys play a prominent role in the treatment of dental


disease. This role has changed signicantly in recent years with the
improvement of all-ceramic restorations and the development of more
durable resin-based composites. However, alloys continue to be used as the
principal material for xed prosthetic restorations and will likely be the
principal material for years to come. No other material has the combination
of strength, modulus, wear resistance, and biologic compatibility that
a material must have to survive long term in the mouth as a xed prosthesis.
The compositions and types of casting alloys available to the dental
practitioner have changed signicantly over the past 25 years. Before the
deregulation of the price of gold in the United States in the early 1970s,
gold-based alloys, with gold comprising over 70 weight percentage (wt %) of
the composition, were virtually the only type of alloy used for xed
prostheses, with or without ceramic veneers [1]. Fluctuations in the price
of gold in the early 1980s (and more recently palladium) and the need
for superior modulus and strength have since spurred the development of
alternative alloys. Initially, these newer alloys were primarily gold based
with less gold (3550 wt %). However, todays practitioner may select from
alloys based on palladium, silver, nickel, cobalt, and titanium, among others
[1]. Furthermore, alloys within each of these groups are diverse, and the
practitioner faces a bewildering array of choices. Because of the long-term
role these materials play in dental treatment, the selection of an appropriate
alloy is critical from technical, ethical, and legal perspectives.
Although uses for pure metals such as gold foil and platinum foil exist in
dentistry, the main role for metals in dentistry has been in alloys. Alloys are
mixtures of metals and nonmetals. Alloys are used for xed prostheses
rather than pure metals because pure metals do not have the appropriate
physical properties to function in these types of restorations. For example,
the tensile strength of pure gold is 105 MPa. By adding 10 wt % of copper,

* Corresponding author.
E-mail address: watahaj@mail.mcg.edu (J.C. Wataha).

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.010
500 J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512

this strength increases to 395 MPa [1,2]. With the appropriate addition of
other elements and proper casting conditions, the strength increases to over
500 MPa. Even more impressive is the increase in hardness: from 28 kg/mm2
for pure gold to nearly 200 kg/mm2 for a typical gold-based casting alloy.
Thus, the use of alloys provides physical and biologic properties that are
required for successful, long-term xed prostheses.

Properties of alloys important to clinical performance


Color
A few properties of dental alloys are important to their clinical performance.
Color would seem to be an obvious such property. The color of alloys is often
described as being yellow or white. These limited terms are inadequate
because the range of alloy colors is much greater, encompassing reddish,
brownish, and even greenish tints. Furthermore, the term white is a meta-
llurgical term that does not describe the silver color ascribed to these alloys by
most clinicians and patients. In any case, the color of casting alloys has little to
do with the physical, chemical, dental, or biologic performance of the alloy [3].
The prevailing bias is that yellow alloys cost more, are more biocompatible,
and corrode less; however, these biases are not true. Thus, although the color
of an alloy may be an important social or esthetic consideration for the patient,
color has little or no bearing on clinical cost or performance and should not be
used by the practitioner to judge potential clinical performance.

Phase structure
When metals and nonmetals are mixed to create an alloy, they have
varying degrees of solubilities in each other [4]. The ability of elements to
dissolve in each other is similar to compounds encountered in everyday life,
such as alcohol and water or vinegar and oil. If most of the components of
the alloy dissolve in one another, the alloy is described as a single-phase alloy
and has a more or less homogeneous composition throughout. If one or more
components are not soluble in the other, then two or more phases form in the
solid state, each having a dierent composition. In this case, the alloy is
described as a multiple-phase alloy. Single-phase alloys are generally easier to
manipulate (ie, easier to cast) and have lower corrosion rates than multiple-
phase alloys [3]; however, multiple-phase alloys may be etched for bonding
and may be signicantly stronger than single-phase alloys [1,2]. Before 1975,
the majority of alloys were single phase, being based on gold, which is
miscible with silver, copper, and palladium [4]. Todays alloys often use more
complex chemistries based on other elements that are not soluble in each
other. A typical nickel-based alloy has 8 to 10 dierent metals and 3 or 4
distinct phases. The phase structure of an alloy is not discernible by the
naked eye, so the clinician must rely on laboratory or manufacturer
information to know an alloys phase structure.
J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512 501

Grain size
A second important microstructural feature of casting alloys is their grain
size. Grains are crystals of the alloy that form upon solidication from small
nuclei, much as ice crystals form from water. As an alloy cools from the
liquid state, these crystals grow until they meet each other at boundaries
called grain boundaries. The size of the grains is inuenced by factors such as
the cooling rate of the alloy, the presence of special nucleating elements such
as iridium, heat treatment after casting, and the composition of the alloy [5].
For gold-based alloys, a small (\30 lm) grain size has been shown to
improve tensile strength and elongation [6]. For base-metal alloys, small,
dispersed secondary phases (each with a small grain structure) are critical to
the strength of the alloys. In other base-metal alloys, the grains are large and
may approach 1 mm in diameter [7]. These large grains, which do not have
anisotropic properties, may be a clinical liability if they occur in critical areas
such as the connectors between units of a multiple-unit xed restoration. As
with phase structure, grain structure is not visible to the naked eye.

Strength and hardness


The compressive strength of all dental casting alloys is suciently high
that it is not a consideration for clinical performance; however, tensile
strength varies considerably among alloys. A tensile strength above 300 MPa
is necessary to avoid fracture of alloys in high-risk areas such as between
pontics of a multiple-unit xed restoration [2]. Because tensile strength is
dicult to measure in practice, most manufacturers cite yield strength
instead. The yield strength in tension is the stress required to permanently
deform an alloy by a given amount, expressed as a percentage of the length of
the specimen being tested. This percentage oset (normally 0.1% or 0.2%)
indicates a permanent deformation of the alloy and is relatively reproducible.
Information on yield strength is easily obtainable from the manufacturer.
The hardness of an alloy must be sucient to resist wear from opposing
teeth or restorations and not so hard as to wear enamel (which has a Vickers
hardness of 340 kg/mm2) [1] and other materials such as porcelain. In
practice, a Vickers hardness less than 125 kg/mm2 makes an alloy susceptible
to wear, and a hardness greater than enamel may wear existing teeth [2].
However, wear is a complex phenomenon, and predicting clinical wear based
on hardness alone is not advisable [8]. Information on hardness is commonly
available from manufacturers.

Alloy solidus and t


The shrinkage properties of alloys force the practitioner to consider this
property. When a molten alloy solidies from the liquid state during casting,
a large amount of shrinkage occurs but is compensated for by the addition of
molten metal from the reservoir in the casting ring. However, once all of the
502 J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512

metal in the restoration has solidied, the shrinkage as the alloy cools from
its solidus to room temperature cannot be compensated for by the addition of
liquid. If the dimensions of the hot casting were the right clinical size, then the
nal cooled casting would be too small because of this shrinkage. The higher
the solidus temperature, the more shrinkage occurs; these shrinkage values
range from about 0.3% to 0.5% for high-gold alloys with solidi of about
950 C to nearly 2.5% for nickel- and cobalt-based alloys with solidi of
1300 C to 1400 C [9]. The shrinkage must be compensated for by expansion
of the die, application of die spacers, the use of special expanding investment
mechanisms, or increasing the burnout temperature of the investment. The
risk of ill-tting crowns is much greater for alloys with high solidi, and this
factor is a signicant consideration in the choice of alloys.

Corrosion
Perhaps no property has captured as much attention in recent years as
alloy corrosion. The degree of corrosion, which results when one or more
components of the alloys is oxidized, is critical to the long-term success of
a xed prosthesis for several reasons. Corrosion may compromise the
strength of the restoration, leading to catastrophic failure [2] or the release of
oxidized components may discolor natural teeth, porcelain veneers, or even
the soft tissues in severe cases [10]. Corrosion may leave the restoration itself
esthetically unacceptable because of the formation of pits or colored patinas.
The electrons released during corrosion may be detectable by the patient as
a shock (galvanic corrosion) that can be disconcerting and even debilitating.
Released metallic components may cause an undesirable metallic taste
leading the patient to request that the restoration be removed.
The measurement of corrosion is complex, and although many
investigators have tried to predict corrosion of an alloy based on its
composition, such predictions are dicult at best. Corrosion may be
quantied by measuring the current ow associated with metal oxidation or
the concentrations of released metals. These measurements may be made
under a variety of conditions in vitro or, in some cases, in vivo. Although
corrosion is clearly visible to the naked eye when it is severe (such as rust on
iron), most corrosion of dental casting alloys is insidious and invisible to the
naked eye. Manufacturers of alloys must measure corrosion by specic
(ASTM or ISO) standards to gain ISO or ADA certication of their alloys,
and this information is usually available from manufacturers, although it is
not commonly reported in brochures. Because corrosion generally results in
the release of mass from the alloy into the oral environment, it is related in
complex ways to alloy biocompatibility [10].

Biocompatibility
Biocompatibility is best described as how an alloy interacts with and
aects biologic systems. Although the interactions between an alloy and
J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512 503

tissues may take many forms, the release of elements from the alloy into the
oral cavity is a primary focus of alloy biocompatibility because most adverse
biologic eects, such as allergy or inammation, have been attributed to such
release [3,10,11]. In this sense, biocompatibility is related to the corrosion of
an alloy. However, care must be taken not to assume poor biocompatibility
on the basis of elemental release alone because the ability of tissues to tolerate
this element release varies widely [12]. In theory, the biocompatibility of
casting alloys could be predicted on the basis of their corrosion properties,
but in practice, this strategy has proven almost impossible because of the
complex dynamics of release of multiple elements and the interactions among
them. Thus, direct assessment of biocompatibility, by in vitro, animal, or
clinical tests, is necessary.
One common misperception of dental casting alloys is that they may be
inert in the oral environment [3]. The placement of a material into the oral
cavity creates active interfaces through which the body aects the material
and the material aects the body. Regardless of the material placed, these
interactions occur. Thus, inertness of dental casting alloys is not possible.
Furthermore, the interactions that occur are dynamic and may change as the
environment of the interface changes. For example, the development of
periodontal inammation, changes in occlusal loading, or a change in diet
may alter the way the alloy and oral tissues interact. Additional research is
need in this area.
The biocompatibility of alloys may have legal implications for dental
practitioners. Litigation by patients over issues of biocompatibility is rare
but usually involves reactions of taste, inammation, or infectionpur-
portedly from elemental release from casting alloys [10]. These allegations
by patients are dicult to prove conclusively but can be avoided altogether
by careful selection and proper manipulation of the alloys by laboratories
and the practitioner. Procedures such as casting, soldering, polishing, or
porcelain application may alter the nominal corrosion properties of casting
alloys and their biologic behavior if these procedures are improperly
performed [2,7,10].

Porcelain application
The application of porcelain to casting alloys plays a prominent role in the
restoration of teeth with xed prostheses, and several properties of casting
alloys are particularly important to the long-term integrity of the porcelain
alloy restoration. The failure (through debonding or cracking) of porcelain
on a porcelainmetal restoration is a signicant and often emergent clinical
problem that is expensive, time consuming, and inconvenient to repair.
Furthermore, the failure of the porcelain may not occur for months or years
after the restoration is placed. Avoiding these failures is more desirable than
trying to correct them. One property of casting alloys that is critical to the
successful long-term integrity of porcelainmetal bonds is the melting range
504 J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512

of the alloy. The alloy solidus (lower temperature of the melting range) must
be at least 50 C higher than the temperature needed to apply the porcelain
(including degassing) or the alloy substructure will deform as the porcelain is
applied [9] These distortions are commonly referred to as sagging and are
exacerbated by thin metal substructures or long spans. Certain types of
casting alloys, such as Pd-Cu alloys, are prone to sagging and should be
avoided in these situations [2].
More insidious is the problem of residual stress in the porcelain of
a porcelainmetal restoration as the porcelain and alloy cool after ring [1].
These stresses result from dierences in the amount of shrinkage that occurs
as the materials cool. The coecient of thermal expansion is used to quantify
such shrinkage, and a higher coecient of thermal expansion implies that
more shrinkage will occur on cooling (and more expansion on heating). To
avoid residual stresses in porcelainmetal restorations, a matching of
coecient of thermal expansion (CTE) for the porcelain and metal are
necessary [1,2]. In practice it is nearly impossible to get the CTE to match
over the wide range of cooling temperatures, so current practice is to design
the metal to have a slightly (0.5/ C) greater CTE than the porcelain [1]. Thus,
the metal shrinks slightly more, and the porcelain, which is bonded to the
metal, will be in compression. Compressive stresses are better tolerated by
the porcelain than tensile stresses because of the brittle nature of porcelain,
and porcelainmetal restorations using this paradigm are generally more
stable long-term. In practice, the manufacturer controls the CTE of the alloy
and the porcelain, but the laboratory or practitioner should use only
combinations of porcelain casting alloys recommended by the manufacturer.
Porcelain bonds to most casting alloys through a metal oxide formed on
the metal surface during the degassing stage of porcelain application.
Properties of the oxide layer such as oxide color, thickness, and strength vary
widely by alloy type and are critical to the strength and esthetics of the
porcelainmetal bond [13]. Almost all oxides are brittle, and therefore the
thickness of the oxide layer should be minimized to avoid failure of
the porcelainmetal bond within this layer. Alloys based on nickel and cobalt
commonly form thick oxides, and it is common laboratory practice to
remove some of the oxide before porcelain application [9]. On the other
hand, alloys based on gold or palladium form thinner oxide layers because of
the nobility of these metals. In general, oxide-forming elements such as tin or
gallium must be added to gold- or palladium-based alloys to ensure adequate
oxide formation [1,9]. Because some of these oxide formers are lost during
casting (which is an oxidizing process), the re-use of gold- and palladium-
based alloys may result in inferior porcelainmetal bonds unless sucient
(usually at least half) new metal is added to the casting. Although these issues
are beyond the direct control of the practitioner, they exemplify the need of
the practitioner to choose a high-quality dental laboratory.
The color of the oxide layer must be properly managed to ensure the
correct shade of a porcelainmetal restoration. Although the oxide and metal
J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512 505

are covered by opaquing porcelain, the eectiveness of the opaque in


masking the oxide color and the thickness required to do so vary signicantly
by alloy type. Nickel-, silver-, cobalt-, and palladium-based alloys have
grayer oxides that are harder to mask and tend to make teeth have lower
color values and grayer hues. Furthermore, the thicker layers of opaque
required to mask these gray colors reduces the thickness available for
subsequent layers of dentin and enamel porcelain and ultimately reduces the
esthetics of the porcelain [1,2]. Gold-based alloys generally have lighter white
to yellow oxides that are easier to mask and more congruent with the normal
hues of human dentin.
For some casting alloys, release of elemental vapor during application of
the porcelain can discolor porcelain. Alloys containing high amounts of
silver and copper are most likely to cause this porcelain discoloration (termed
greening) [1,2]. Laboratories also must be careful to ensure that the mue
of the porcelain oven does not become contaminated with these elements,
leading to porcelain discoloration in subsequent uses of the oven.

Soldering
Soldering of alloys is highly dependent on the type of alloy and may be
a signicant factor in the clinicians choice of alloy. Soldering becomes even
more complex if porcelainmetal restorations are involved. Aside from the
issues of soldering below the solidus of the alloys (at least 50 C is generally
a safe margin) [2], the compatibility of solders and uxes is not straightfor-
ward. If the treatment plan requires soldering wires, clasps, attachments, or
pontics, then the ability of the alloy to be reliably soldered must be
considered. In general, gold-based alloys are most easily soldered compared
with palladium-, nickel-, silver-, or nickel-based alloys. Furthermore, the
heating that occurs during soldering is more likely to alter complex phase
structures of basemetal alloys than of high-noble alloys.

Classes of alloys currently available


Casting alloys are categorized several ways, but the classication system
most used by dental practitioners is the American Dental Association (ADA)
compositional classication system. The ADA system divides casting alloys
into three groups on the basis of wt % composition [1]. The high-noble alloys
are those with a noble metal content (sum of gold, palladium, and platinum)
of at least 60 wt % and a gold content of at least 40 wt %. Most gold-based
alloys before 1975 fell into this category. The noble alloys must contain at
least 25 wt % noble metal but have no specic requirement for gold content.
Finally, the predominantly base-metal alloys contain less than 25 wt % noble
metal, with no other specication on composition. The ADA has adopted
symbols for each of these classes of alloys to aid the practitioner in knowing
to which category a given alloy belongs (Fig. 1). This classication system is
506 J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512

Fig. 1. Symbols adopted by the ADA for its three major classications of alloys based on
composition.

more encompassing than the previous classication system it replaced in


1984, which focused primarily on gold-based alloys.
The ADA also classies alloys on physical properties of yield strength and
elongation (Table 1) [1]. Four categories of alloys are dened in this scheme.
Soft alloys are dened for use in low-stress conditions under which the
restoration bears no signicant occlusion. Medium alloys are recommended
for conditions of moderate stress and light occlusal stress. Hard alloys are
recommended for full occlusal loads with single units or short-span xed
partial dentures, and very hard alloys are recommended for removable
partial dentures and longer-span xed partial dentures. Each casting alloy is
therefore dened by two ADA classication systemsone for composition
and one for physical strength. The subsequent discussion focuses on
compositional classications, recognizing that within each compositional
class a variety of physical properties are available.

High-noble alloys
High-noble dental casting alloys (Table 2) can be divided arbitrarily into
those based on gold-platinum (Au-Pt), gold-palladium (Au-Pd), or gold-
copper-silver (Au-Cu-Ag). Of these groups, the rst two alloy types are
appropriate for full-cast or porcelainmetal applications. The latter group is
appropriate only for full-cast applications because of its higher silver and
copper content and its lower melting range. The Au-Pt alloys are the newest
of the high-noble alloys and were designed to avoid the use of palladium,
which became expensive and biologically controversial between 1995 and
1999. Both of these issues have since resolved, but this class of alloys is still
J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512 507

Table 1
Classication of casting alloys by physical properties
ADA designation Yield strength (MPa, in tension) Elongation (%)
Soft \140 18
Medium 140200 18
Hard 201340 12
Extra-hard [340 10

available. These alloys are complex metallurgically because gold and


platinum are not completely soluble in one another and are generally
strengthened by a dispersed zinc phase. Some formulations contain silver to
strengthen the alloy through solid solution hardening with gold [2]. These
alloys are white (silver) in color and have a moderately high melting range
and moderate hardness, modulus, and strength. Because of their high noble-
metal content ([97 wt %), they are expensive. Their corrosion is highly
variable depending on the phase structure and appropriate manipulation of
the alloy by the laboratory. Au-Pt alloys are especially susceptible to
overheating, which can disrupt the dispersed zinc phase and increase its
corrosion signicantly.
The Au-Pd alloys are a common type of high-noble alloy used for
porcelainmetal and full-cast restorations, but they are more common in
porcelainmetal applications (see Table 2). These alloys have moderate
strength, elastic moduli, and hardness and have a moderately high melting
range. The Au-Pd composition is sometimes supplemented with silver to
increase the physical properties via solid solution hardening with gold and
palladium. Au-Pd alloys are nearly always single-phase alloys and are always
white in color because the Pd concentrations are greater than 10 wt % [2].
The corrosion of these alloys is low in biologic environments, even at low pH
or during toothbrushing [14,15].
The Au-Cu-Ag high-noble alloys (see Table 2) have a long history of use in
dentistry for full-cast restorations (they are compositionally equivalent to the
old type III casting alloys). These alloys generally are yellow in color and
have moderately high yield strengths and hardness but only moderate elastic
moduli. Because copper and silver are miscible with gold, these alloys are
almost always single phase, which makes them easy to cast and solder. They

Table 2
Selected properties of major types of high-noble alloys
Yield
Solidus- Elastic Vickers strength
liquidus Phase modulus hardness (tension,
Alloy type ( C) Color structure (static, GPa) (kg/mm2) 0.2%, MPa)
Au-Pt (Zn)a 10601140 Yellow Multiple 6596 165210 360580
Au-Pd (Ag)a 11601260 White Single 105 280 385
Au-Cu-Ag 905960 White Single 100 210 450
a
In many formations.
508 J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512

also can be head hardened by heating to about 600 C and then letting the
alloy cool to room temperature slowly [2]. Their relatively low melting range
makes them castable using gypsum-bonded investments and gas-air torches.

Noble alloys
Noble alloys are much more compositionally diverse than high-noble
alloys because they include gold-based alloys and those based on other
elements such as palladium or silver (Table 3). They are comprised of four
groups: Au-Cu-Ag, Pd-Cu-Ga, Pd-Ag, and Ag-Pd. The Au-Cu-Ag noble
alloys are similar in composition and metallurgy to the high-noble Au-Cu-Ag
alloys. They were developed in the early 1980s when the price of gold
dramatically increased, making their high-noble counterparts too expensive.
These alloys have decreased gold content and compensate for the reduced
gold by increasing copper, silver, or palladium. These alloys have moderate
moduli of elasticity but are higher in hardness and yield strength than their
high-noble counterparts. Depending on the amount of silver or copper
present, Au-Cu-Ag alloys may be used in porcelainmetal applications but
are more commonly used for full-cast restorations. The melting range of these
alloys is lower than that of their high-noble counterparts if the copper or silver
has been supplemented, and the color of these alloys varies from yellow to
reddish-yellow to silver depending how the reduced gold is compensated for
in the composition. For example, alloys with 10 wt % or more of palladium
have a silver color, whereas those with 20 to 30 wt % of copper are more
reddish in color [2]. Most often single-phase alloys, the Au-Ag-Cu alloys
generally have poorer corrosion properties than their high-noble counter-
parts if the copper or silver has been increased to more than 15 wt % [12].
The Pd-Cu-Ga alloys are the most metallurgically complex of the noble
alloys (see Table 3). They nearly always have multiple phases, but their
corrosion is highly variable depending on the specic nature of the phases.
The phase microstructure of these alloys is complex and dependent on how
the alloy is manipulated [16]. This manipulation dependence makes selection
of an experienced laboratory paramount. The Pd-Cu-Ga alloys are among
the strongest alloys used in dentistry for cast restorations and are 25% stier
Table 3
Selected properties of major types of noble alloys
Yield
Solidus- Elastic Vickers strength
liquidus Phase modulus hardness (tension,
Alloy type ( C) Color structure (static, GPa) (kg/mm2) 0.2%, MPa)
Au-Cu-Ag-(Pd)a 880930 Yellow/white Single 100 250 690
Pd-Cu-Ga 11451270 White Multiple 127 280 580
Pd-Ag 11851230 White Multiple 125 275 620
Ag-Pd 9901045 White Multiple 93 230 480
a
In many formations.
J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512 509

than any of the high-noble alloys or the Au-Cu-Ag noble alloys. These
alloys have high melting ranges and must be cast using induction-casting
and special high-temperature investments [1,2]. They are dicult to nish
and polish. Depending on the amount of copper and its high-temperature
volatility, the Pd-Cu-Ga alloys are useful for porcelainmetal applications.
However, the higher melting range of these alloys makes them more dicult
to ensure a good t of the restoration intraorally. These alloys also are
susceptible to sag during porcelain application.
The Pd-Ag and Ag-Pd alloys are essentially a continuum of the same alloy
system but are dierent in terms of their manipulation and clinical
performance (see Table 3). Of the two groups, the Pd-Ag alloys are far more
common in dentistry and are far superior in strength, corrosion resistance,
modulus, and hardness. The Pd-Ag alloys are used for porcelainmetal
restorations, but the high silver content of the Ag-Pd systems makes them
unusable for anything but full-cast restorations. Because palladium has a very
high melting point (over 1400 C), the Pd-Ag alloys (which typically contain
over 60 wt % Pd) have high melting ranges, and obtaining good clinical t of
these alloys depends heavily on properly compensating for casting shrinkage.
Furthermore, these alloys require the use of induction-casting and high-
temperature investments. Of all the noble and high-noble alloys, the Pd-Ag
alloys have the highest moduli, making them most suitable for long-span xed
partial dentures; however, even these alloys are not as sti as the nickel- or
cobalt-based alloys. The Ag-Pd alloys are usually only in the noble category by
the use of a minimal amount of Pd (25 wt %) or a combination of palladium
and gold totaling 25 wt %. The physical and corrosion properties of these
alloys are inferior, and they oer few advantages over the base-metal alloys.

Predominantly base-metal alloys


The base-metal alloys can be arbitrarily divided into four groups: Ni-Cr-
Be, Ni-Cr, Ni-high-Cr, and Co-Cr (Table 4). The rst three groups are closely
related in composition and many physical properties but are fundamentally
dierent in their corrosion properties. These alloys may be manufactured with
or without trace amounts (0.1 wt %) of carbon. When used for cast
restorations, these alloys generally do not contain carbon. However, when
used for partial denture frameworks, carbon is generally added and is a potent
enhancer of yield strength and hardness (but not modulus) [7]. All alloys in this
group may be used for full-cast or porcelainmetal restorations, and all are
silver in color. From the standpoint of porcelain application, these alloys all
form heavy, dark oxide layers that are more dicult to esthetically manage
than those formed by alloys in the noble and high-noble alloy groups. The
base-metal alloys share high physical properties, and these alloys have the
highest moduli of any alloys used for cast restorations. They are all equally
dicult to solder because of their propensity for formation of surface oxides.
510 J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512

Table 4
Selected properties of major types of predominantly base-metal alloys
Solidus- Elastic Vickers Yield strength
liquidus Phase modulus hardness (tension,
Alloy type ( C) Color structure (static, GPa) (kg/mm2) 0.2%, MPa)
Ni-Cr-Be 11601270 White Multiple 192 350 325
Ni-Cr 13301390 White Multiple 159 350 310
Ni-high-Cr 12501310 White Multiple 205 205 180
Co-Cr 12151300 White Multiple 155 155 390

The nickel-based alloys in this group may have chromium contents of


approximately 14 wt % with (Ni-Cr-Be) or without (Ni-Cr) beryllium (see
Table 4). Beryllium is used primarily to lower the melting range of the alloy to
a point where gypsum-bonded investments can be used for casting [9]. In the
United States, the beryllium-containing forms of these alloys are most
commonly used. Although beryllium is advantageous in terms of casting
manipulation of this alloy by the laboratory, the Ni-Cr-Be alloys corrode far
more than their non-Be counterparts [12,17]. This corrosion is particularly
evident in acidic environments. In some studies, the amount of nickel released
from these alloys in an acidic environment in 30 minutes is more than that
released in 1 year in a neutral environment [14]. The Ni-high-Cr alloys are the
most corrosion resistant of the Ni-based group and have Cr contents of over
20 wt %. These alloys are the most common of the Ni-based alloys used in
Europe. The corrosion of these alloys is far better than the Ni-Cr-Be alloys but
not as good as many alloys in the noble or high-noble groups. The common
hypersensitivity to nickel (10% to 20% by most estimates [18]) makes use of
any of the Ni-based alloys a higher biologic risk than many others.
Co-Cr alloys are the most common base-metal alternative for patients
known to be allergic to nickel (see Table 4). Unfortunately, cobalt is the
second-most common metal allergen, and cobalt allergy should be ruled out
before these alloys are substituted for nickel-based alloys. With the exception
of titanium-based alloys, the Co-Cr alloys have the highest melting ranges of
the casting alloys, and laboratory manipulation (casting, nishing, and
polishing) of these alloys is dicult. The surface oxide of Co-Cr alloys is
particularly dicult to mask, and the compatibility of coecients of thermal
expansion between these alloys and porcelains may be problematic.

Clinical selection of alloys


The selection of an alloy for a cast restoration is ultimately the legal and
ethical responsibility of the practitioner, but this decision often is made by
the dental laboratory. Given the complexities of the decision, its abrogation
to the dental laboratory is not surprising. However, given the long-term
consequences of this decision on the oral health of the patient, selection of
casting alloys should be made primarily by the practitioner with consultation
J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512 511

from the dental laboratory. The practitioner often focuses on the cost and
color of the alloy as major factors in this decision, but cost and color are the
least important factors in selecting a material for a successful prosthesis.
Furthermore, the initial cost of the alloy is often a poor indicator of the
overall long-term cost of the restoration. If the restoration fails because of
poor clinical performance and must be replace prematurely, the costs of these
repairs (in patient discomfort, time, and money) will far exceed the initial
savings of using a cheaper but inferior alloy.
The selection of a casting alloy is best customized for a particular clinical
situation. The systemic health of the patient should be the rst consideration,
and the practitioner should avoid alloys that contain elements to which the
patient is hypersensitive. These elements are most commonly nickel and
cobalt, although allergies to palladium and gold have been reported. The
complete composition of the alloys therefore must be considered by the
practitioner in this regard because even trace elements can elicit reactions
through disproportional corrosion from grain boundaries or secondary
phases [12]. The physical requirements of the alloy are also a primary
consideration. For example, if the restoration involves long spans, then an
alloy with the highest modulus of elasticity is advisable, particularly if the
prosthesis is porcelainmetal. The t of the restoration depends to a large
extent on the ability of the laboratory to manage casting shrinkage. This
issue is most dicult with high-melting alloys. The tensile strength is
important if the restoration involves connectors between multiple units and if
these connectors are narrow occlusal-gingivally because of short clinical
crowns, periodontal considerations, or esthetic requirements. The color of
the alloys oxide may be important in porcelainmetal restorations.
Finally, practitioners should maintain records of the materials that they
use for cast restorations and should give patients this information. The
Identalloy system is a convenient means to maintain good dental records and
inform patients [1]. Most manufacturers supply laboratories with stickers
that contain the name and composition of the their alloys, and most good
laboratories supply these stickers to the practitioner upon request.
Practitioners should use this, or other means, to maintain records of the
materials used. These records are important to help diagnose future problems
that might occur (biologic reactions or mechanical failures) and are
important legal resources to defend the practitioner in the event of litigation.

Acknowledgments
This work was supported by grants from Metalor Technologies, SA
(Neuchatel, Switzerland) and the Whitaker Foundation. The authors thank
Metalor Technologies, SA for their support of alloy research over years and
the Whitaker Foundation for their support of biomedical research in the
area of alloy corrosion.
512 J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512

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dental materials. 11th edition. St. Louis: Mosby; 2002. p. 44978.
[3] Wataha JC. Principles of biocompatibility for dental practitioners. J Prosthet Dent 2001;
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Dent Clin N Am 48 (2004) 513530

Dental ceramics: current thinking and trends


J. Robert Kelly, DDS, MS, DMedSc
Dental Clinical Research Center, Department of Prosthodontics and Operative Dentistry,
University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030, USA

Background concepts in ceramics science and fracture


There are two useful concepts that help demystify dental ceramics by
providing a structure within which to organize thinking. First, there are only
three main divisions to the spectrum of dental ceramics: (1) predominantly
glassy materials, (2) particle-lled glasses, and (3) polycrystalline ceramics
[13]. Dening characteristics are provided for each of these ceramic types.
Second, virtually any ceramic within this spectrum can be considered as
being a composite, meaning a composition of two or more distinct
entities. Many seemingly dierent dental ceramics can be shown to be
similar or closely related to each other when reviewed within the framework
of these two simplifying concepts. Additionally, the rationale behind the
development of ceramics of historic and recent interest can be more easily
understood. Two examples of the utility of these concepts include these
statements: (1) Highly esthetic dental ceramics are predominantly glassy,
and higher strength substructure ceramics are generally crystalline; and (2)
the history of development of substructure ceramics involves an increase in
crystalline content to fully polycrystalline. Tables 1 and 2 provide basic
composition details and commercial examples of many esthetic and
substructure dental ceramics organized by these three main divisions.

Predominantly glassy ceramics


Dental ceramics that best mimic the optical properties of enamel and
dentin are predominantly glassy materials. Glasses are three-dimensional
(3-D) networks of atoms having no regular pattern to the spacing (distance
and angle) between nearest or next nearest neighbors; thus, their structure is
amorphous, or without form. Glasses in dental ceramics derive principally
from a group of mined minerals called feldspar and are based on silica
(silicon oxide) and alumina (aluminum oxide); hence, feldspathic porcelains

E-mail address: kelly@nso1.uchc.edu

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2004.01.003
514 J.R. Kelly / Dent Clin N Am 48 (2004) 513530

Table 1
Esthetic ceramics: basic composition, uses, and commercial examples
Base Fillers Uses Commercial examples
Predominantly glassy ceramics
Feldspathic glass Colorants Veneer for ceramic Alpha, VM7 (Vita)
Opaciers substructures, inlays, Mark II (Vita)
High-melting onlays, veneers Allceram (Degudent)
glass
particles
Moderately lled glassy ceramics
Feldspathic glass Leucite Veneer for metal substructures, VMK-95 (Vita)
(1725 inlays, onlays, veneers Omega 900 (Vita)
mass%) Vita Response (Vita)
Colorants Ceramco II (Dentsply)
Opaciers Ceramco 3 (Dentsply)
High-melting IPS d.SIGN
glass (Ivoclar-Vivadent)
particles Avante (Pentron)
Reex (Wieland Dental)
Highly lled glassy ceramics
Feldspathic glass Leucite Single-unit crowns, Empress (Ivoclar)
(4055 inlays, onlays, veneers OPC (Pentron)
mass%) Finesse All-Ceramic
Colorants (Dentsply)
Opaciers

belong to a family called aluminosilicate glasses [2]. Glasses based on


feldspar are resistant to crystallization (devitrication) during ring, have
long ring ranges (resist slumping if temperatures rise above optimal), and
are biocompatible. In feldspathic glasses, the 3-D network of bridges formed
by silicon-oxygen-silicon bonds is broken up occasionally by modifying
cations such as sodium and potassium that provide charge balance to non-
bridging oxygen atoms. Modifying cations alter important properties of the
glass, for example, by lowering ring temperatures or increasing thermal
expansion/contraction behavior.

Particle-lled glasses
Filler particles are added to the base glass composition to improve
mechanical properties and to control optical eects such as opalescence, color,
and opacity. These llers are usually crystalline but can also be particles of
a higher melting glass. Such compositions based on two or more distinct
entities (phases) are formally known as composites, a term often reserved in
dentistry to mean resin-based composites. Thinking about dental ceramics as
being composites is a helpful and valid simplifying concept. Much confusion is
cleared up in organizing ceramics by the ller particles they contain (and how
much), why the particles were added, and how they got into the glass.
J.R. Kelly / Dent Clin N Am 48 (2004) 513530 515

Table 2
Substructure ceramics: basic composition, uses, and commercial examples
Glass Fillers Uses Commercial examples
Highly lled glassy ceramics
Feldspathic glass Leucite Inlays, onlays, veneers, Empress (Ivoclar)
(4055 mass%) single-unit crowns OPC (Pentron)
Finesse All-ceramic
(Dentsply)
Feldspathic glass Aluminum oxide Single-unit crowns Vitadur-N (Vita)
(55 mass%)
Lanthanum Aluminum oxide Single-Unit crowns, In-Ceram Alumina
(70 vol%) anterior three-unit (Vita)
bridges
LABS Aluminum oxide Single-unit crowns, In-Ceram Zirconia
(50 vol% three-unit bridges (Vita)
Zirconium oxide
(20 vol%)
Modied Lithium disilicate Single-unit crowns, Empress 2 (Ivoclar)
feldspathic glass (70 vol%) anterior three-unit 3G (Pentron)
bridges
Polycrystalline ceramics
Aluminum oxide \0.5 mass%a Single-unit crowns Procera (Nobel Biocare)
Zirconium oxide Yttrium oxide Single-unit crowns Procera (Nobel Biocare)
(35 mass%)a
Zirconium oxide Yttrium oxide Single-unit crowns, Cercon (Dentsply)
(35 mass%)a Three-unit bridges, Lava (3M-ESPE)
Four-unit bridges (?) Y- (Vita)
Abbreviation: LABS, aluminoborosilicate.
a
Dopants.

The rst llers to be used in dental ceramics contained particles of a cry-


stalline mineral called leucite [1,2]. This ller was added to create porce-
lains that could be successfully red onto metal substructures [4,5]. Leucite has
a high thermal expansion/contraction coecient (20  106/ C) compared
with feldspathic glasses (8  106/ C). Dental alloys have expansion/
contraction coecients around 12 to 14 (106/ C). Adding about 17 to 25
mass% leucite ller to the base dental glass creates porcelains that are
thermally compatible during ring with dental alloys. Metal-ceramic systems,
rst developed in 1962, are used to fabricate 70% to 80% of xed prostheses.
Moderate strength increases can also be achieved with appropriate llers
added and uniformly dispersed throughout the glass, a technique termed
dispersion strengthening. The rst successful strengthened substructure
ceramic was made of feldspathic glass lled with particles of aluminum
oxide (55 mass%) [6]. Leucite also is used for dispersion strengthening
at concentrations of 40 to 55 mass%, which is much higher than needed
for metal-ceramics. Commercial ceramics incorporating leucite llers
for strengthening include a group that are pressed into molds at high
516 J.R. Kelly / Dent Clin N Am 48 (2004) 513530

temperature (OPC, Pentron [Wallingford, Connecticut]; Empress, Ivoclar-


Vivadent [Schaan, Liechtenstein]; and Finesse All-Ceramic, Dentsply
Prosthetics [York, Pennsylvania]) and a group provided as a powder for
traditional porcelain build-up (OPC Plus, Pentron; Fortress; Mirage Dental
Systems [Kansas City, Kansas]).
Beyond thermal expansion/contraction behavior, there are two major
benets to leucite as a ller choice for dental ceramicsthe rst intended
and the second probably serendipitous. First, leucite was chosen because its
index of refraction is close to that of feldspathic glasses, an important match
for maintaining some translucency. Second, leucite etches at a much faster
rate than the base glass, and it is this selective etching that creates
a myriad of tiny features for resin cements to enter, creating a good
micromechanical bond.

Glass-ceramics (special subset of particle-lled glasses)


Crystalline ller particles can be added mechanically to the glass, for
example by mixing together crystalline and glass powders before ring. In
a more recent approach, the ller particles are grown inside the glass object
(prosthesis or pellet for pressing into a mold) after the object has been
formed. After forming, the glass object is given a special heat treatment
causing the precipitation and growth of crystallites within the glass. Because
these llers are derived chemically from atoms of the glass itself, it stands to
reason that the composition of the remaining glass is altered as well during
this process termed ceraming. Such particle-lled composites are called
glass-ceramics. The material Dicor (Dentsply), the rst commercial glass-
ceramic available for xed prostheses, contained ller particles of a type of
crystalline mica (at 55 vol%) [7]. More recently, a glass-ceramic containing
70 vol% crystalline lithium disilicate ller has been commercialized for
dental use (Empress 2; Ivoclar-Vivadent).

Polycrystalline ceramics
Polycrystalline ceramics have no glassy components; all of the atoms are
densely packed into regular arrays that are much more dicult to drive
a crack through than atoms in the less dense and irregular network found in
glasses. Hence, polycrystalline ceramics are generally much tougher and
stronger than glassy ceramics. Polycrystalline ceramics are more dicult to
process into complex shapes (eg, a prosthesis) than are glassy ceramics. Well-
tting prostheses made from polycrystalline ceramics were not practical
before the availability of computer-aided manufacturing. In general, these
computer-aided systems use a 3-D data set representing the prepared tooth
or a wax model of the desired substructure. This 3-D data set is used to create
an enlarged die upon which ceramic powder is packed (Procera; Nobel
Biocare, Goteborg, Sweden) or to machine an oversized part for ring by
machining blocks of partially red ceramic powder (Cercon, Dentsply
J.R. Kelly / Dent Clin N Am 48 (2004) 513530 517

Prosthetics; Lava, 3M-ESPE [Seefeld, Germany]; Y-Z, Vita Zahnfabrik [Bad


Sackingen, Germany]). These approaches rely upon well-characterized
ceramic powders for which ring shrinkages can be predicted accurately [8,9].
Polycrystalline ceramics tend to be relatively opaque compared with
glassy ceramics; thus, these stronger materials cannot be used for the whole-
wall thickness in esthetic areas of prostheses. These higher-strength ceramics
serve as substructure materials upon which glassy ceramics are veneered to
achieve pleasing esthetics. Laboratory measures of the relative translucency
of commercial substructure ceramics are available for a single-layer of
materials and for those that are veneered [10,11]. Although laboratory mea-
sures of opacity have equated some polycrystalline ceramics to cast alloys,
all ceramic substructures transmit some light, whereas metals do not.

Substructure ceramics
The development of higher-strength ceramics for veneered all-ceramic
prostheses can be represented as a transition toward increases in the volume
percentage of crystalline material with decreasingly less glass and nally no
glass. In 1965, McLean [6] reported on the strengthening of a feldspathic
glass via addition of aluminum oxide particles, the same year that General
Electric rst applied that new technology (dispersion strengthening of
glasses) to high-tension power line insulators. In the late 1980s, a method
was developed to signicantly increase the aluminum oxide content (from
55 mass% to 70 vol%) by rst lightly ring packed alumina powder and
then inltrating the still porous alumina compact with glass [12]. During the
rst light ring, adjacent alumina particles become bonded where they
touch, forming a 3-D network of linked particles. Inltration involves a
low-viscosity glass drawn into the porous alumina network by capillary pres-
sure, forming an interpenetrating 3-D composite (the alumina and glass
being continuous throughout the ceramic and neither representing an
isolated ller). Although, with only 70 vol% aluminum oxide, this
ceramic (In-Ceram Alumina; Vita) has strength and fracture toughness
identical to many 100% polycrystalline alumina ceramics.
Two key developments allowed fully polycrystalline ceramics to become
practical for xed prostheses: (1) the availability of highly controlled
starting powders and (2) the application of computers to ceramics
processing. Unlike glassy ceramics, polycrystalline ceramics cannot be
pressed as a fully dense material into slightly oversized molds (molds that
have expanded just enough to compensate for cooling shrinkage as is done
in the casting of metals). Polycrystalline ceramics are formed from powders
that can be packed only to 70% of their theoretical density. Hence,
polycrystalline ceramics shrink around 30% by volume (10% linear) when
made fully dense during ring. For the nal prostheses to t well, the
amount of shrinkage needs to be accurately predicted and compensated for.
Well-characterized starting powders that can be uniformly packed are
518 J.R. Kelly / Dent Clin N Am 48 (2004) 513530

a prerequisite for achieving predictable and reproducible shrinkage.


Research in ceramics-processing science from the late 1980s through the
1990s led to the commercial availability of powders suitable for dental use.
Almost simultaneously with high technology, powder renement came the
development of computer-aided machining and the ability to capture and
manipulate 3-D data sets.
Two approaches are oered commercially for fabrication of prostheses
from polycrystalline ceramics, both of which create oversized greenware
(unred part) using 3-D data sets and the specic shrinkage characteristics
of well-behaved starting powders. In the rst approach, an oversized die is
manufactured based on 20,000 measurements taken during the mechanical
scanning of a laboratory die. Aluminum oxide or zirconium oxide is pressed
onto the oversized die and predictably shrunk during ring to become well-
tting, single-crown substructures (Procera, Nobel Biocare) [8]. In the
second approach, blocks of partially red (10% complete) zirconium oxide
are machined into oversized greenware for ring as single- and multiple-unit
prostheses substructures (Cercon, Dentsply Prosthetics; Lava, 3M-ESPE; Y-
Z, Vita). In these systems, individual blocks are bar coded with the actual
density of each block (for the ne-tuning of shrinkage calculations), and the
milling machines can keep track of the number of blocks milled and
automatically change milling tools to assure accuracy of t [9].

Transformation-toughened zirconium oxide


Transformation-toughened zirconia, a polycrystalline ceramic now
available for dentistry, needs further explanation because its fracture
toughness (and hence strength) involves an additional mechanism not found
in other polycrystalline ceramics. Fracture toughness and strength are
discussed in more detail below, but it is sucient here to understand
toughness as meaning the diculty in driving a crack through a material.
Unlike alumina, zirconium oxide is transformed from one crystalline
state to another during ring. At ring temperature zirconia is tetragonal,
and at room temperature it is monoclinic, with a unit cell of monoclinic
occupying about 4.4% more volume than when tetragonal. Unchecked, this
transformation was unfortunate because it led to crumbling of the material
on cooling. In the late 1980s, ceramic engineers learned to stabilize the
tetragonal form at room temperature by adding small amounts (38
mass%) of calcium and later yttrium or cerium. Although stabilized at room
temperature, the tetragonal form is metastable, meaning that trapped
energy exists within the material to drive it back to the monoclinic state. The
highly localized stress ahead of a propagating crack is sucient to trigger
grains of ceramic to transform in the vicinity of that crack tip. In this case,
the 4.4% volume increase becomes benecial, essentially squeezing the crack
closed (ie, transformation decreases the local stress intensity).
With fracture toughness twice or more that of alumina ceramics,
transformation-toughened zirconia represents a potential substructure
J.R. Kelly / Dent Clin N Am 48 (2004) 513530 519

material. Possible problems with these zirconia ceramics may involve long-
term instability in the presence of water, porcelain compatibility issues, and
some limitations in case selection due to their opacity. However, as of this
writing, 3-year clinical data involving many posterior single-unit and three-
unit prostheses (plus one ve-unit) have revealed no major problems
(discussed more fully below).

Strength and fracture toughness


There are three inter-related properties that often are quoted regarding
ceramics intended for structural purposes: (1) strength, (2) fracture toughness,
and (3) susceptibility toward chemically assisted crack growth. Because
strength is the most frequently encountered property in professional and
advertising literature, some discussion regarding the meaning and application
of strength is warranted. The main point to understand about strength is that it
is not an inherent material property, meaning that strength values depend on
the condition of the material and how the test was conducted [13]. Fracture
toughness (discussed below) is more an inherent property of ceramics and is
increasingly seen as being more useful when comparing commercial materials.

Strength
Strength is a global measure of three things: (1) the type and size of failure-
starting aws and their distribution, (2) the fracture toughness, and (3) the
inuence of water. If all three things are well controlled to faithfully represent
clinical prostheses, then comparisons based on strength have some meaning.
Flaws are most often the result of processing steps (dental laboratory and
dentist) used to fabricate prostheses, but aws can also be inherent to the
material. Hence, the best measure of strength comes from testing parts that
have received all dental laboratory and dentist processing steps. Because it
often is not practical to fabricate standardized test specimens (eg, bend bars)
using all dental laboratory and dentist steps, the condition of the test
specimen may not reect the condition of nished prostheses, and reported
strengths may not be meaningful. On the other hand, although actual
prostheses adequately reect the processing condition of the ceramic, stresses
in prostheses at the point of failure (ie, strength) are dicult to calculate. In
addition, most attempts to duplicate clinical loading of prostheses, especially
single-unit crowns (crunch the crown tests), create failure from articial
damage produced during testing that is never seen clinically [14].
It has been known since 1958 that water decreases the strength of most
glasses and ceramics. Water, acting chemically at crack tips, allows the slow
growth of cracks under conditions where growth would not occur otherwise.
Ceramics dier in sensitivity to water, a fact not well controlled for or taken
into account in strength testing of dental ceramics or in published
comparisons of strength data. Water is available to any surfaces exposed
to saliva, but it also is available to cementation surfaces from dentinal
520 J.R. Kelly / Dent Clin N Am 48 (2004) 513530

tubules. All dental cements allow water (from saliva and dentin) to reach
internal ceramic surfaces by diusion.
Strength also is generally reported only for single materials. Prostheses
often are made of multiple materials having dierent properties. The
performance of such prostheses may depend as much on variables related to
the use of multiple materials, such as bond strengths, residual stresses at
material interfaces due to thermal contraction mismatches, and interfacial
stresses during loading arising from mismatches in material stiness (elastic
moduli). For example, one type of all-ceramic three-unit prosthesis was
found to fail clinically primarily from stresses and aws within connectors at
the core-veneer interface [15]. Similarly, single-unit crowns have been
reported to fail from their internal (cementation or intaglio) surface due to
chewing loads, not from damage or stresses on their occlusal surface [1618].
With the cementation surface being at risk, survival probabilities can be
inuenced by the type of cement used or the surface treatment given.
Thus, strength is more of a conditional measure than an inherent material
property and must be used cautiously (if at all) in judging the likely clinical
performance of a new ceramic system. One better measure for comparing the
structural performance of ceramics is fracture toughness, but this is limited in
describing single material behavior. Overall, the case for clinical trial data
becomes compelling given the factors discussed here that may inuence clinical
success and yet remain absent from laboratory testing protocols.

Fracture toughness
Because ceramics fail via crack growth from existing aws, it is useful to
have some measure of the ease with which this happens. Tensile loads
(pulling) create stresses (load per area) at crack tips. As loads increase, the
intensity of crack tip stresses rises rapidly. Purely straight opening, without
the crack sliding or shearing, is termed mode I opening (mode one), and
the stress intensity caused by this is designated by the letter K; thus, the
stress intensity at a crack tip in simple mode I opening is written as KI. At
some critical stress intensity, conditions are right for the crack to become
unstable and separate the ceramic part into two pieces.
Critical stress intensities for mode I opening, written as KIC (with units of
MPa  m) are generally not dependent on the condition of the material
(ie, they are aw size insensitive) and can be used to compare dierent
materials. KIC values for metal-ceramic porcelains are 0.9 to 1.2; for
leucite-reinforced dental ceramics KIC values are 1.5 to 1.7 (eg, Empress,
Ivoclar); and for alumina KIC values are 4.5 (eg, In-Ceram, Vita; Procera,
Nobel Biocare), with transformation toughened zirconia ranging from 8 to
12 and metal alloys starting around 20.

Role of metal in strengthening


The role that the metallic substructure provides toward clinical durability
is not well understood. Therefore, it is dicult to assess which characteristics
J.R. Kelly / Dent Clin N Am 48 (2004) 513530 521

of a metal casting need to be retained in substructures formed by alternative


metal-forming technologies such as foils, electroforming, or melt-inltrated
capillary networks. It often is stated that porcelain needs to be supported
by the metal framework. It is not dened what supported means.
There are a number of conceivable mechanisms by which metal castings
might contribute to the longevity of veneering porcelain. First, porcelain
needs to be protected from developing tensile stress in the vicinity of aws
located in critical areas. This implies that the metal might inuence stress
distributions within the porcelain, particularly at surfaces and interfaces.
Second, where such stresses develop, porcelain benets if the growth of aws
into cracks is suppressed. This implies that metal, well bonded to porcelain,
might bridge the base of cracks (resisting further opening). Third, aws
that may eventually cause failure grow more slowly if kept dry. This implies
that another role the cast metal substructure may play involves keeping
water from entering the crack (eliminating chemically assisted crack
growth).

Clinical concepts and performance issues


Advantages of all-ceramic versus metal-ceramic systems
All-ceramic systems
Esthetic advantages are real when the completely light-blocking metal is
replaced, even by an opaque ceramic. All-ceramic systems can provide
a better esthetic result for a wider range of patients than can metal-ceramics
because a wide range of translucency-opacity (or value in the Munsell
color system) can be achieved with commercially available ceramic systems.
Other advantages relate as much to soft tissue health as to esthetics. Lesser
amounts of plaque and adherence molecules are recovered from ceramic
surfaces than from gold alloys or amalgam, and intra-oral plaque of
a qualitatively healthier composition can form on ceramic surfaces [1921].
It often is acceptable to leave the margin of all-ceramic prostheses supra-
gingival or at the gingival margin, with the added benet of more
predictable and less traumatic impression making. Emergence proles are
less likely to be over-contoured, as is often the result with metal-ceramic
prostheses due to eorts to provide a thicker layer of porcelain to mask the
opaque-metal surface.

Metal-ceramic systems
Advantages of metal-ceramic systems lie in their predictable structural
performance, their versatility, and that fact that less knowledge is required
for choosing an appropriate system. The structural performance of metal-
ceramic systems remains far better than for any all-ceramic system. As is
discussed in more detail below, bulk failure and porcelain cracking aect
522 J.R. Kelly / Dent Clin N Am 48 (2004) 513530

approximately 5% to 10% of single-unit prostheses by around 6 years.


Success rates are generally higher for anterior than for posterior single-unit
prostheses. Less clinical data are available for three-unit prostheses, and not
all systems have been well studied. Conversely, structural problems related
to the porcelain can be as low as 3% to 4% at 10 years for metal-ceramic
prostheses (nontitanium), and 74% can still be in service at 15 years with
the majority of problems being biologic (secondary caries, periodontal
disease, and endodontic failures) [2224]. Porcelain survival on titanium
substructures has not been nearly as good, even at 6 years, due to inherent
problems at the titaniumporcelain interface [25,26].
Metal-ceramic systems are well enough developed that little special
knowledge is required for their routine use. Most practitioners are likely
unaware of which metal-ceramic systems their laboratory provides, and any
system is generally suitable for anterior single-unit and posterior multi-unit
prostheses. Successful use of all-ceramic systems requires a higher level of
knowledge to maximize the esthetic result and to choose appropriately for
structural longevity. All-ceramic systems are more commonly prescribed by
specialty-level practices serving patients placing a premium on esthetics.

Decisions based on simple failure statistics


Initial survival data (12 years) is commonly presented regarding new all-
ceramic systems, often rst as a research meeting presentation and then
repeated in advertising. Along with the limited observation times, two other
aspects can render such studies dicult to interpret and to use for making
comparisons. Many of these studies use simple survival rates based on the
number of units surviving divided by the total number of units delivered. For
example, in Figs. 1 and 2, results from two hypothetical studies are presented
with the number of units cemented each month represented by light bars and
the number that failed in any month represented by an overlaid dark bar.
Studies A and B have both cemented 60 units, both have had ve failures, and
both have been active for 2 years. Given these last facts, investigators in both
cases could be temped to claim 92% success at 2 years (55/60).
Looking more critically at the studies in Figs. 1 and 2 reveals two striking
problems. First, crowns in both studies have been under examination for
dierent periods of time. For example, the investigators in Study B did not
have as much early success at recruiting patients, with the bulk of crowns
not having been cemented until early in the second year. Second, neither
study has crowns that have been under observation for the full 2 years.
Simple survival data can be distorted, especially in early data.
Results from both studies are presented in Figs. 3 and 4 as probability of
survival plots using Kaplan-Meier statistics, where the crowns are represented
only for the period of time under observation. Additional methods exist to
account for crowns (patients) lost to the study. This analysis (Figs. 3 and 4)
demonstrates that neither investigation should report 92% success and that
J.R. Kelly / Dent Clin N Am 48 (2004) 513530 523

Number of Units Delivered


Failed Units
10

12 24
Time (months)
Fig. 1. Frequency of crowns cemented per month in Study A. Grey bars represent the number
of cemented crowns. Overlaid dark bars represent the number of failed crowns in any given
month.

the crowns of Study B are failing miserably. Such life table analysis allows
clinicians to make valid comparisons among clinical trial data.

Survival literature for all-ceramic restorations


Veneers
Ceramics are particularly well suited for veneer restorations. With limited
exceptions [27,28], porcelain veneers fabricated from a wide variety of
ceramics have failure rates (loss of retention or fracture) of \5% as reported

Number of Units Delivered


Failed Units
10

12 24
Time (months)
Fig. 2. Frequency of crowns cemented per month in Study B. Grey bars represent the number
of cemented crowns. Overlaid dark bars represent the number of failed crowns in any given
month.
524 J.R. Kelly / Dent Clin N Am 48 (2004) 513530

Cumulative Survival (%)


100
95%
80 92%
83%

60

40

20

3 6 9 12 15 18 21 24
Time (months)
Fig. 3. Life table analysis (Kaplan Meier) of crowns in Study A calculating actual survival per
month.

from eleven studies of generally 3 years to 5 years duration [29]. Materials


and clinical and performance issues related to the use of ceramic veneers are
well covered in two relatively recent review articles [29,30].

Inlays and onlays


The most extensively studied ceramic inlay/onlay restorations are those
fabricated via the Cerec computer-aided design/computer-aided machining
system (Sirona; A.G., Bensheim, Germany). Two ceramics were available
when most published studies were initiated: a felspathic porcelain (Mark I;
Vita) and a mica-lled glass (Dicor; Dentsply). Systematic analysis of 15

Cumulative Survival (%)


100

80 87%

60 63%

40

33%
20

3 6 9 12 15 18 21 24
Time (months)
Fig. 4. Life table analysis (Kaplan Meier) of crowns in Study B calculating actual survival per
month.
J.R. Kelly / Dent Clin N Am 48 (2004) 513530 525

clinical trials found a mean survival rate of 97.4% over 4.2 years with
excellent color stability and wear [31]. An 8-year follow-up of 16 patients,
each receiving two inlays, reported that 3 of the 32 restorations fractured
[32]. Cerec inlays and onlays (200 restorations) provided in a private
practice were reported to have a survival rate (Kaplan-Meier) of 90.4%
over 10 years with failures being due to ceramic fracture (53%), tooth
fracture (20%), and endodontic problems (7%) [33]. One of the leucite-
reinforced pressed ceramics has also been relatively well studied as an
inlay/onlay material (Empress, Ivoclar). A literature review of six clinical
trials reported that survival rates ranged from 96% at 4.5 years to 91% at
7 years [34].

Single-unit crowns
Four ceramic systems have received notable attention in peer-reviewed
literature: (1) a leucite-reinforced glass (Empress, Ivoclar), (2) a glass-
inltrated alumina (In-Ceram Alumina, Vita), (3) a glass-inltrated
magnesium aluminate spinell (In-Ceram Spinell, Vita), and (4) a poly-
crystalline alumina (Procera, Nobel Biocare). In most cases, fracture rates
seem to be lower for anterior crowns than for molar crowns, with the lowest
failure rates for posterior restorations being reported for the high fracture
toughness/high strength alumina-like and alumina materials (In-Ceram
Alumina and Procera).
The glass-inltrated material based on magnesium aluminate spinell (a
more translucent, but lower strength cousin of the glass-inltrated alumina)
seems to be indicated for anterior restorations. One 5-year study of 40
anterior crowns reported a 97.5% survival rate (Kaplan-Meier) [35]. Data
for anterior versus posterior leucite-reinforced crowns seem to trend toward
higher survival for anterior teeth [36], but this can be nonsignicant
statistically [37], and one contrary study exists [38]. This confusion is likely
due to in part to the inclusion of premolar crowns in the posterior
category and the relatively low number of failing crowns and studied
restorations (ie, low statistical power). In a review of six clinical trials, the
survival rate for leucite-reinforced crowns (Empress, Ivoclar) ranged from
92% to 99% at 3 to 3.5 years [39].
Studies of crowns having substructures of the higher toughness/strength
alumina-based ceramics (In-Ceram Alumina, Vita; Procera, Nobel Biocare)
report generally similar results for both materials. No bulk fracture was
reported for 28 anterior and 68 posterior In-Ceram crowns at 4 years [40]. In
a private practice setting, 223 In-Ceram crowns had a survival rate of 96%
after 3 years, with anterior crowns trending toward higher survival (98%)
than premolars or molars (94%) [41]. In a 4-year university trial of 80 In-
Ceram crowns (73% anterior, 27% posterior), one molar crown fractured
and the marginal ridge of one premolar crown chipped [42]. Of 97
Procera alumina crowns followed for 5 years, three crowns experienced
bulk fracture, and two had some loss of veneering porcelain [43]. The 5- and
526 J.R. Kelly / Dent Clin N Am 48 (2004) 513530

10-year survival rates reported in another study of Procera crowns were


98% and 92%, respectively [44].

Multi-unit prostheses
Two all-ceramic systems have been recommended by their manufacturer
for anterior three-unit prostheses: a glass-inltrated alumina (In-Ceram
Alumina, Vita) and lithium disilicate glass-ceramics (Empress 2, Ivoclar;
G3, Pentron). In a study of 18 In-Ceram Alumina prostheses (64%
cantilevered two-unit and 36% three-unit) with 62% involving a posterior
tooth, the survival rate (Kaplan-Meier) was 93% at 5 years and 83% after
10 years [45]. There do not yet seem to be peer-reviewed publications
regarding the clinical performance of multi-unit prostheses fabricated with
lithium disilicate glass-ceramics.
Two other all-ceramic systems are being recommended for posterior
three-unit prostheses by their manufacturers: a glass-inltrated alumina/
zirconia (In-Ceram Zirconia, Vita) and transformation toughened poly-
crystalline zirconia (Cercon, Dentsply Prosthetics; Lava, 3M-ESPE; Y-Z,
Vita). Ongoing trials of zirconia prostheses are heavily focused on posterior
multi-unit prostheses, including studies at the University of Zurich (58
posterior prostheses; three-unit, four-unit, and one ve-unit), Saarland
University (38 posterior multi-unit prostheses), University of Gottingen (62
posterior prostheses; three-unit and four-unit), and the Louisiana State
University (20 posterior three-unit prostheses). Although results from these
trials have yet to be fully published, updates have been presented at
international research meetings with no instances of bulk fracture reported.
The longest trial, at the University of Zurich, recently completed the 3-year
recall for all active patients.

Practical aspects
Choosing a system by translucency (value)
Many leaders in the use of all-ceramic and metal-ceramic systems
recommend choosing a system based on the value (Munsell lightness-
darkness scale) of the dentition being restored. Opaque teeth (often whitish)
are best matched using an opaque substructure; this includes many of the
highly crystalline ceramics and metal-ceramic systems. Highly translucent
teeth (often grayish) are dicult to match unless the substructure allows
more light transmission than is characteristic of metals and opaque
ceramics. Most systems allow the incorporation of internal coloration,
variations in incisal translucency, and the addition of opalescence. If an all-
ceramic system is to be chosen, consideration should be given to the
structural indications developed from clinical data and manufacturer
recommendations.
J.R. Kelly / Dent Clin N Am 48 (2004) 513530 527

Etching and bonding


One classic piece of research demonstrated that the rst commercial
glass-ceramic crowns (Dicor, Dentsply) had a much higher survival rate
(Kaplan-Meier) over 16 years if they had been etched and cemented with
a resin cement rather than being non-etched and cemented with a zinc
phosphate cement [46]. The improved clinical survival of later feldspathic
ceramics having roughly similar strengths and toughness to Dicor (eg,
Empress, Ivoclar; Mark II, Vita) is widely thought to be at least partially
due to their ability to be etched and form strong bonds with resin cements.
For ceramics other than Dicor, a possible relationship between bonding and
clinical success remains conjecture, but this concept has led to the technique
being almost universally applied.
The rst requirement for forming a micromechanical bond is the presence
of small components within the ceramic that can be selectively attacked
by acids (etched) at a higher rate than surrounding ceramic. The selective
etching of crystalline leucite, leaving behind microscopic glassy crypts, is the
most common dental example. A second requirement for good bond
formation relates to the size of the structure(s) formed by etching and how
well they are still attached to the remaining bulk ceramic. For example,
some selective etching of In-Ceram Alumina is possible, but the scale of
roughness that develops is insucient for good bond formation. Poly-
crystalline ceramics can be etched, revealing the boundary between
crystalline grains, but these etched grain boundaries provide little micro-
mechanical retention.
Chemical bonding is possible with virtually all dental ceramics but only
with the use of resin cements containing special adhesive molecules. The
durability of chemical bonding between resin cements and substructure
ceramics has not been denitively addressed.

Glazing versus polishing


Auto glazing (ring in air) and polishing are two options for nishing the
surface of esthetic porcelains. These techniques received recent attention in
a review of a number of studies comparing prepared surfaces using visual,
microscopic, and prolometry measures [47]. All studies agree that glazing
can produce a smooth porcelain surface. However, polishing can produce as
smooth a surface that can be more esthetically similar to natural enamel.
Many authorities favor polishing given that a higher level of control is
possible over nal surface nish and that an added ring can add problems
and time to the delivery appointment.

Repair
Approaches to the repair of porcelains have recently been reviewed [48].
Repair often oers a cost-eective alternative to replacement. Repair
528 J.R. Kelly / Dent Clin N Am 48 (2004) 513530

involves the bonding of resin-based products to remaining porcelain. The


porcelain-resin bond is formed by etching the surface to create micro-
mechanical attachment features and by the application of silane coupling
agents to provide some chemical interaction between the silicon-based
ceramic and carbon-based resins. It is reported that porcelain repair systems
form durable bonds to fractured porcelain and exposed metal surfaces [48].

Summary
Ceramics are widely used in dentistry due to their ability to mimic the
optical characteristics of enamel and dentin and their biocompatibility and
chemical durability. Most highly esthetic ceramics are lled glass composites
based on aluminosilicate glasses derived from mined feldspathic minerals.
One common crystalline ller is the mineral leucite, used in relatively low
concentrations in porcelains for metal-ceramic systems and in higher
concentrations as a strengthening ller in numerous all-ceramic systems. In
general, the higher the fraction of polycrystalline components, the higher is
the strength and toughness of a ceramic. The development of substructure
ceramics for xed prosthodontics represents a transition toward fully
polycrystalline materials. Although the strength of a dental ceramic can be
a meaningful number, it is not an inherent property and varies due to
testing parameters that are often not well controlled to optimize clinical
relevance. Fracture toughness is a far more inherent measure of the
structural potential of a ceramic and represents a more easily compared
value. Clinical data for all-ceramic systems are becoming available, and
results exist for many commercial materials, providing guidance regarding
clinical indications.

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Dent Clin N Am 48 (2004) 531544

Contemporary all-ceramic xed partial


dentures: a review
Ariel J. Raigrodski, DMD, MS
Department of Restorative Dentistry, School of Dentistry, University of Washington,
D-780 Health Sciences Center, 1959 Northeast Pacic Street,
Box 357456, Seattle, WA 98195-7456, USA

Several restorative systems for fabricating all-ceramic xed partial


dentures (FPDs) have been tested and are being tested in clinical studies
for their long-term success. Yttrium tetragonal zirconia polycrystals (Y-
TZP)-based systems are the most recent version being tested. With the
emphasis on the use of computer-assisted design/computer assisted-
manufacturing (CAD/CAM) technology, various production techniques
have been developed for enhancing the fabrication of consistent and
predictable restorations in terms of strength, marginal t, and esthetics.
Because clinical data evaluating their performance are limited, the use of
these systems in a predictable manner is considered by many to be
controversial [1], and metal-ceramic FPDs remain the gold standard in
terms of predictability.
In a recent clinical retrospective study evaluating 515 metal-ceramic
FPDs, Walton [2] calculated that the cumulative survival rate of FPDs was
96% for 5 years, 87% for 10 years, and 85% for 15 years of service. This
cumulative survival rate was not related to the number of units restored by
an FPD. Two hundred ninety-nine of the evaluated FPDs were three-units.
In light of these ndings demonstrating the expected survival rate of the
current standard of care, all-ceramic FPDs should demonstrate at least
a similar survival rate in clinical studies to be considered as a predictable
restorative alternative.
Walton also reported that modes of failure for metal-ceramic FPDs
were tooth fracture (38%), periodontal breakdown (27%), loss of re-
tention (13%), and caries (11%) [3]. An earlier study showed that the
primary cause of failure was dental caries (38%); other modes of failure
included delamination of the veneering porcelain, cement wash, defective

E-mail address: araigrod@u.washington.edu

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.008
532 A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544

margins, abutment fracture, post and core/root fracture, periodontal


disease/abutment mobility, and periapical lesion resulting from pulpal in-
volvement [4].
Campbell and Sozio [5] found, in an in vitro study evaluating statically
loaded all-ceramic and metal-ceramic FPDs, that ceramic FPDs developed
vertical cracks in the connector region before failing, whereas the metal-
ceramic FPDs developed cracks at the intaglio surface of the pontic before
failing. Kelly et al [6] demonstrated in vitro and in vivo that the exclusive
mode of failure in all-ceramic FPDs was a fracture of the connectors. These
ndings were further supported in several clinical studies evaluating all-
ceramic FPDs [710]. Thus, the primary cause of failure reported for all-
ceramic FPDs differs from that reported for the metal-ceramic FPDs. To
prevent such a failure, the connectors of all-ceramic FPDs must have
sufcient height and width. The strength and therefore the minimal critical
dimensions of these connectors are exclusively dependent on the type of
ceramic material used for the core material.
To ensure long-term success of metal-ceramic FPDs, the minimal critical
dimensions recommended for the connectors are 2.5 mm (occlusogingival
height) by 2.5 mm (buccolingual width), providing a connector surface area
of 6.25 mm2 [11,12]. These dimensions are most likely to be successfully
achieved in the anterior and posterior segments, thus making the proper
diagnosis and patient selection for this type of restoration relatively simple.
This is not the case for all-ceramic FPDs. Due to their primary mode of
failure and the brittleness of ceramics, the required connector dimensions
are larger than the ones recommended for metal-ceramic FPDs. This may
be a major contributing factor in restricting the versatility of their use.
Therefore, appropriate diagnosis, patient selection, and conception of the
requirements of proper ceramic framework design are crucial for the success
of these restorations.

Framework design
The clinical fracture resistance of FPDs is related to the size, shape, and
position of the connectors and to the span of the pontic. The basis for the
proper design of the connectors and the pontic is the law of beams: Deection
of a beam increases as the cube of its length, it is inversely proportional to its
width, and it is inversely proportional to the cube of its height [13]. A three-
point bending test is one of the most commonly used tests to determine the
modulus of rupture or the transverse exural strength of a rectangular beam
made of a brittle material [14,15]. When occlusal forces are applied directly
through the long axis of an all-ceramic bridge connector, compressive stresses
develop at the occlusal aspect of the connector at the marginal ridge, and
tensile stresses develop at the gingival surface of the connector. These tensile
stresses contribute to the propagation of microcracks located at the gingival
surface of the connector through the core material in an occlusal direction
A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544 533

and may lead to a fracture. The most common mode of failure of all-ceramic
FPDs is a fracture of the connectors, with 70% to 78% of the cracks
originating from the interface between the core and the ceramics [6]. Oh et al
[16] demonstrated in a nite element analysis and a fractographic analysis
that connector fracture was initiated at the gingival embrasure and that
a larger radius of curvature at the gingival embrasure reduces the con-
centration tensile stresses, thus affecting the fracture resistance of the FPD.
Oh and Anusavice [17] demonstrated the same in an in vitro study. To
promote achieving the required connector dimensions without compromising
the health of the supporting tissues, it was suggested to fabricate the gingival
and lingual aspects of the connectors out of the framework material
exclusively [18]. In addition, the span of the pontic should not exceed the
length of a rst mandibular molar, depending on the properties of core
material and framework design.

Evolution
A high-alumina ceramic for the fabrication of FPD pontic structures
was rst introduced by McLean in 1967 [19]. In 1982, he introduced the
platinum-bonded alumina FPD to reduce the problem of fracture through
the connector area while eliminating the traditional cast-metal framework
[20]. However, this restorative option was not feasible due to a high rate of
failure at the connector sites.
New developments in dental ceramics have led to the introduction of
new systems for all-ceramic FPDs. The In-Ceram alumina system (Vita
Zahnfabric, Bad Sackingen, Germany), which uses high-temperature,
sintered-alumina glass-inltrated copings for all-ceramic crowns, was
introduced for the fabrication of three-unit anterior FPDs [21]. To fabricate
the framework the ceramist can use the slip-casting technique or copy
milling technique with prefabricated partially sintered blanks. The trans-
verse exural strength of the framework material was demonstrated to be
about 446 MPa [22]. With this system, the minimal critical dimensions for
the connectors are 4 mm occlusal/gingivally and 3 mm buccal/lingually [18].
The Empress II system (Ivoclar North America, Amherst, New York)
uses a lithium-disilicate glass framework that is veneered with uoroapatite-
based veneering porcelain. The framework is fabricated with the lost-wax
and heat-pressure technique or is milled out of prefabricated blanks. The
transverse exural strength of the framework material ranges between 350
and 400 MPa [23]. Although these glass-containing materials allow the
fabrication of relatively translucent restorations, it is recommended that
these restorations be etched and adhesively cemented to enhance their
strength. The system is conned to fabricating three-unit FPDs that replace
a missing tooth anterior to the second premolar. The minimal critical
dimensions for the connectors are 4 to 5 mm occlusal/gingivally and 4 mm
buccal/lingually [8].
534 A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544

The Procera AllCeram Bridges system (Nobel Biocare, Goteborg,


Sweden) uses a densely sintered high-purity aluminum-oxide framework
[24]. The framework is waxed-up as two single copings on the abutment
teeth and a central pontic, which are then scanned in the same manner as
in the fabrication of densely sintered high-purity aluminum-oxide crowns.
They are milled individually and are fused together with a special veneering
ceramics at the connector. The transverse exural strength of the framework
material ranges between 500 and 650 MPa [25,26]. The minimal critical
dimensions for the connectors are 3 mm occlusal/gingivally with a surface
area of 6 mm2 [27].
The In-Ceram Zirconia system (Vita Zahnfabric) uses a glass-inltrated
alumina with 35% partially stabilized zirconia framework. To fabricate the
framework, the ceramist may use the slip-casting technique or copy-milling
technique with prefabricated partially sintered blanks. The transverse
exural strength of the framework material ranges between 600 and 800
MPa [21,28]. For the In-Ceram Zirconia restoration, the recommended
minimal critical dimensions for the connectors are 4 mm occlusal/gingivally
and 3 mm of buccal/lingually. Due to esthetic limitations of the system
resulting from the opacity of the framework, the system is recommended for
fabricating posterior ceramic FPDs [28]. The lack of required space for
desired connector dimensions frequently contraindicates the fabrication of
an all-ceramic FPD.

Recent core materials and technologies


The most recent core materials for all-ceramic FPDs are the yttrium
tetragonal Y-TZP-based materials. Y-TZP-based materials were initially
introduced for biomedical use in orthopedics for total hip replacement and
were highly successful because of the materials excellent mechanical
properties and biocompatibility [1]. In the early 1990s, the use of Y-TZP
expanded into dentistry (endodontic posts and implant abutments) [2932],
and Y-TZP is currently being evaluated as an alternative core material for
full-coverage restorations such as all-ceramic crowns and all-ceramic FPDs
[3335].
Yttrium oxide is a stabilizing oxide added to pure zirconia to stabilize it
at room temperature and to generate a multiphase material known as
partially stabilized zirconia. The exceptional mechanical properties of Y-
TZP (high initial strength and fracture toughness) are due to the unique
physical property of partially stabilized zirconia. Tensile stresses acting at
the crack tip induce a transformation of the metastable tetragonal zirconium
oxide form into the monoclinic form. This transformation is associated with
a local increase of 3% to 5% in volume. This increase in volume results in
localized compressive stresses being generated around and at the tip of the
crack that counteract the external tensile stresses acting on the fracture tip
[36]. This physical property is known as transformation toughening.
A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544 535

The long-term stability of ceramics is closely related to subcritical crack


propagation and stress corrosion caused by water in the saliva reacting with
the glass, resulting in decomposition of the glass structure, which leads to
increased crack propagation in glass-containing systems. However, glass-
free systems having a polycrystalline microstructure, such as Y-TZP, do not
exhibit this phenomenon. Therefore, their long-term stability may be
enhanced. In in vitro studies, Y-TZP bars demonstrated a exural strength
of 900 to 1200 MPa [3638]. In vitro studies on Y-TZP FPDs (with different
connector dimensions) under static load demonstrated fracture resistance
between 1800 to more than 2000 N. Under cyclic load simulating a 5-year
clinical load, the fracture resistance of posterior three-unit bridges cemented
with glass ionomer cement was 1457 N, which was well beyond the 1000 N
required [39,40].

Patient selection and treatment planning


As part of the diagnosis and decision-making process in selecting the
appropriate treatment option for an individual patient, the edentulous space
must be evaluated in terms of the available interocclusal distance. To
facilitate patient selection for all-ceramic FPDs, one must conrm adequate
prospective height for the framework material and veneering ceramics
before determining the restorative system of choice. A 4-mm clinical
measurement with periodontal probe from interproximal papilla to the
marginal ridge of the prospective abutment indicates adequate connector
height for most contemporary systems for all-ceramic FPDs (Fig. 1). At
times the available space for the connector may be restricted by reduced
interocclusal distance, which may make it difcult to achieve the required
connector dimensions without compromising the biologic demands of open
embrasures needed for facilitating plaque control and adequate oral hygiene
(Fig. 2). The following clinical scenarios lead to reduced interocclusal
distance; therefore, alternative treatment options rather than all-ceramic
FPDs must be considered [27].
1. A deep vertical overlap with a reduced horizontal overlap leading to
a deep bite in the anterior maxillary segment (Class II Division II) that
may not allow sufcient labiolingual connector width
2. An opposing tooth that is supraerupted into the edentulous space that
cannot be corrected with minor enameloplasty only and that may be
accompanied with mesial drift of a prospective molar abutment tooth
into the edentulous space
3. Prospective abutment teeth with short clinical crowns that may restrict
the height of the connector
The concentration of heavy stresses in the connector area increases
the risk of catastrophic fracture. Therefore, it is mandatory to evaluate
prospective abutments in terms of their periodontal health with an emphasis
536 A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544

Fig. 1. Preoperative lateral view in maximum intercuspation. The opposing teeth did not
dramatically supraerupt in a manner that contraindicates the fabrication of a Y-TZPbased all-
ceramic FPD.

on abutment mobility. Prospective abutments exhibiting increased mobility


should not be used as a foundation for all-ceramic FPDs. The use of all-
ceramic FPDs with a cantilever design is questionable (the pontic acts as
a lever that is depressed under occlusal forces) due to the possibility of
developing heavy stress at the connector. Finally, heavy bruxers who exhibit
parafunctional activity should not receive all-ceramic FPDs.

Design and manufacturing of Y-TZPbased FPD frameworks


A Y-TZPbased FPD framework is designed using conventional waxing
techniques or CAD. Optimal CAD software allows technicians to custom
design an FPD framework while combining traditional concepts of design

Fig. 2. Preoperative lateral view of a patient missing his left mandibular rst molar. A
measurement of the distance between the marginal ridge and the free gingival margin conrmed
that adequate prospective connector height (4 mm) exists for the fabrication of a Y-TZPbased
all-ceramic FPD.
A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544 537

with material-derived requirements. Several Y-TZPbased restorative


systems for crowns and FPDs have been described in scientic abstracts
and in peer-reviewed articles.
The Cercon system (Dentsply Ceramco, Burlington, New Jersey) requires
conventional waxing techniques for designing the Y-TZPbased infrastruc-
ture. The DCS-Precident, DC-Zirkon (Smartt Austenal, Chicago, Illinois)
and the Lava (3M ESPE, St. Paul, Minnesota) systems each use a dierent
type of CAD technology with dierent features and design options (Fig. 3)
[3335]. Once the design of the framework is completed, the data are
transferred to a milling unit for fabricating the framework. The data are
transferred from the CAD unit to the CAM unit, or a conventional wax-
pattern is scanned as with the Cercon system. The Cercon system and the
Lava system use partially sintered Y-TZPbased blanks for milling the
infrastructures, whereas DCS-Precident, DC-Zirkon infrastructures are
milled from fully sintered Y-TZPbased blanks. With a partially sintered
milled framework, the size has been increased to compensate for shrinkage
(20% to 25%) that occurs during nal sintering. The milling process is
faster, and the wear and tear of hardware is less than when milling from
a fully sintered blank [3335]. Studies show that clinically acceptable
marginal t is maintained (Figs. 4, 5) [41,42]. The proponents of partially
sintered frameworks claim that microcracks may be introduced to the
framework during the milling procedure, whereas the proponents of milling
of a fully sintered blank claim that the marginal t is superior because no
shrinkage is involved in the process.

Features of Y-TZPbased restorations


Most of the advantages of Y-TZPbased FPDs described here validate
the use of Y-TZPbased materials for all-ceramic crowns and all-ceramic

Fig. 3. A view of the CAD FPD framework designed on the computer (Lava; 3M ESPE,
St. Paul, Minnesota).
538 A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544

Fig. 4. Lingual view of the completed framework tted to the working dies. Note the excellent
marginal t.

FPDs. The use of all-ceramic restorations increases the depth of trans-


lucency and light transmission across the entire restoration [43]. Some of the
zirconia-based systems use a single white shade for the core (eg, Cercon,
DCS-Precident). The Lava Y-TZP core is relatively translucent and has
a masking ability that allows successful coverage of metal cores or
discolored teeth. Once milled, it can be colored into one of seven shades
(corresponding to the Vita-Lumin shade guide) before the nal sintering
procedures. This allows the development of the shade of the restoration
from its intaglio surface all the way to the outer aspect of the veneering
porcelain (Fig. 6). The ability to control the shade of the core may also
eliminate the need to veneer the lingual and gingival aspects of the
connectors in cases were the interocclusal distance is limited and the
required connector dimensions are barely achieved. In addition, the palatal
aspect of anterior crowns and FPDs may be fabricated exclusively of the

Fig. 5. Buccal view of the completed framework tted to the working dies. Note the excellent
marginal t.
A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544 539

Fig. 6. Buccal view of the framework try-in. Note the excellent blending of the framework with
the gingival tissue and the open gingival embrasures for oral hygiene maintenance.

core material in patients who lack space for lingual veneering porcelain [44].
Special feldspathic veneering porcelains were designed to match the Y-TZP
based frameworks in terms of physical and optical properties, with
a coefcient of thermal expansion closely matched (Fig. 7) [44].
Clinicians may place the nish line of a tooth preparation at the free
gingival margin or slightly below it (0.5 mm) without compromising the
esthetic result (Fig. 8). This reduces the possibility of iatrogenic periodontal
disease [4547]. Moreover, the ability to place the nish line at or below the
free gingival margin facilitates the making of an accurate impression.
Ceramic materials in general are considered to be great insulators. All-
ceramic systems have reduced thermal conductivity, resulting in less thermal
sensitivity and potential pulpal irritation [8].

Fig. 7. The completed restoration before cementation. Note the blending of the Y-TZPbased
framework with the veneering porcelain.
540 A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544

Fig. 8. Postoperative lateral view in maximum intercuspation 6 months postcementation of the


Y-TZPbased FPD.

A small percentage of the population is hypersensitive to dental alloys


containing noble and base metals, such as palladium and nickel. Metal-free
ceramic systems eliminate this problem [4853]. The high biocompatibility
of Y-TZP was evaluated in in vitro and in vivo studies with no reported
local or systemic adverse reactions to the material [5457]. The ndings of
a recent study also demonstrated that fewer bacteria accumulated around
Y-TZP than titanium [58].
YTZ-Pbased cores present with a metal-like radiopacity that enhances
radiographic evaluation of the restoration in terms of marginal integrity,
adequate excess cement removal, and prospective secondary decay (Fig. 9)
[44].
As a result of their mechanical and physical properties YTZ-P-based
FPD frameworks require a relatively small connector area compared with
their predecessors, ranging between 7 and 16 mm2 [27].

Limitations
The main limitation of Y-TZPbased all-ceramic FPDs is that in many
cases their use may be contraindicated because of a lack of required
dimensions for the prospective connector resulting from restricted
interocclusal distance, prospective abutment mobility, or severe parafunc-
tion. When all-ceramic FPD systems do not t precisely, a new denitive
impression must be made because they cannot be sectioned and soldered like
metal-ceramic FPDs. The other limitation is the lack of long-term clinical
data on the success of these restorations.

Clinical procedures
Clinical procedures and radiographic evaluation are similar to those used
with metal-ceramic FPDs. Metal-ceramiclike preparation design, which
A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544 541

Fig. 9. Postoperative radiograph demonstrates the metal-like radiopacity of the Y-TZPbased


FPD.

is within the clinicians comfort zone, is recommended with rounded line


angles and rounded nish lines, such as deep chamfer or a rounded
shoulder. The nish line may be placed at the free gingival margin or slightly
below it (0.5 mm) when possible without compromising the esthetic result
[44].
With Y-TZPbased materials, adhesive cementation is not mandatory,
and traditional cementation procedures can be used predictably. Adhesive
cementation may be technique sensitive, especially if the nish line is placed
deep into the gingival sulcus because of previous restorations, decay, or the
need to enhance retention. In these cases, adequate moisture control may
not be successful, leading to a compromised adhesive cementation pro-
cedure and compromising the longevity of the restoration [44].

Summary
Because of their material-inherent advantages, Y-TZPbased all-ceramic
restorative systems may allow clinicians to use traditional clinical
procedures similar to those used in the fabrication of metal-ceramic restora-
tions in terms of preparation design and cementation procedures. With
Y-TZPbased systems that use a CAD/CAM technology, ceramists use
new techniques and technologies in addition to traditional ones. Such
new technologies may allow the production of consistent high-quality Y-TZP
frameworks in terms of design and fabrication, strength, fracture toughness,
and stress-corrosion resistance. They are esthetic, have clinically acceptable
marginal t, and allow the ceramist to use traditional veneering procedures
with the compatible esthetic porcelain. In addition, such systems may prove to
be simple to handle and less technique sensitive from a clinical standpoint
while providing patients with esthetic and functional restorations. Although
542 A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544

clinical data on the success of these restorations are limited, anecdotal


evidence and initial observations made in ongoing clinical studies are
promising. The long-term results of these studies are paramount to the
assessment of their long-term success and for the establishment of more
specic guidelines for proper patient selection that will ensure long-term
predictable esthetic and functional success.

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Dent Clin N Am 48 (2004) 545562

Fiber-reinforced composite prostheses


Martin A. Freilich, DDS*, Jonathan C. Meiers, DMD
Prosthodontics & Operative Dentistry, University of Connecticut School of Dental Medicine,
263 Farmington Avenue, Farmington, CT 06030-2649, USA

Metal-free prosthetic dentistry continues to gain interest. Although the


metal alloys contribute great strength and stiness to restorations and
prostheses, they do so at a considerable esthetic liability. Two somewhat
divergent metal-free approaches to xed tooth replacement continue to be
developed for a variety of clinical applications. These are all-ceramic and
all-polymeric systems. The polymeric prostheses are the subject of this
article and generally consist of a particulate composite veneer supported by
a ber-reinforced composite (FRC) substructure. Two maxillary canine to
central incisor FRC-supported xed partial prosthesis are shown in Fig. 1.
FRC-supported polymeric prostheses have undergone much recent
testing in the laboratory and the mouth [16]. These prostheses can be
fabricated by the dental technician in the dental prosthetic laboratory or at
chairside by the dentist in the dental operatory. The veneer materials used
for the chairside-fabricated prostheses are light polymerized hybrid or
microll composites typically found in the dental oce. The laboratory-
fabricated prosthesis (including the FRC substructure) also is light
polymerized but may have an additional heat polymerization component
and may use vacuum or pressure. This provides more complete polymer-
ization for better exure properties of the substructure and wear resistance
and color stability of the veneer [7].
The FRC material is a combination of ber and a resinous matrix. A
variety of FRC materials exhibiting a wide variety of mechanical exure
properties are commercially available. The mechanical properties of FRC
materials are primarily dependent upon ber type, ratio of ber to matrix
resin, ber architecture (ie, unidirectional, woven, or braided), and quality
of impregnation of ber and resin. Examples of dierent ber architecture
are shown in Figs. 2, 3, and 4. Examples of dierent quality of ber
impregnation are shown in Figs. 5 and 6.

* Corresponding author.
E-mail address: freilich@nso2.ichc.edu (M.A. Freilich).

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2004.01.005
546 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562

Fig. 1. Two anterior full-coverage (three-unit) xed partial dentures replacing the maxillary
lateral incisors. These prostheses are made in the dental laboratory with a FiberKor
(unidirectional pre-impregnated glass) substructure and Scupture composite veneer. (From
Freilich MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical
dentistry. Chicago: Quintessence; 2000; with permission.)

Some manufacturers produce a dry ber that requires hand impregnation


by the technician or dentist (eg, Ribbond, [Ribbond, Inc., Seattle,
Washington]; GlasSpan, [Glas Span, Inc., Exton, Pennsylvania]; Construct
[SDS/Kerr, Orange, California]). Some of the commercially available FRC
materials are machine impregnated with resin by the manufacturer (eg,
everStick, [StickTech, LTD, Turku, Finland]; FiberKor, [Pentron, Inc.,
Wallingford, Connecticut]; Vectris [Ivoclar/Vivaclent, Amherst, New York]).
These machine-impregnated materials are also known as pre-impregnated
FRC materials. The exure properties and characteristics of a number of
dierent commercially available FRC materials are shown in Table 1. This
table demonstrates the wide variety of exure properties dependent upon the
aforementioned characteristics. This is particularly true for the properties of
elastic modulus (rigidity) and elastic limit (strength at permanent de-
formation). Rigidity of the FRC substructure is critical to the integrity of

Fig. 2. Magnied view of Ribbond, nonimpregnated woven polyethylene ber. (From Freilich
MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry.
Chicago: Quintessence; 2000; with permission.)
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 547

Fig. 3. Magnied view of Connect, nonimpregnated braided polyethylene ber. (From Freilich
MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry.
Chicago: Quintessence; 2000; with permission.)

Fig. 4. Magnied view of a unidirectional pre-impregnated FRC.

Fig. 5. Unidirectional glass ber poorly wetted (impregnated) by surrounded resin matrix
resulting in very poor exure properties. (From Freilich MA, Duncan JP, Alarcon EK, Eckrote
KA, Goldberg AJ. The design and fabrication of ber-reinforced implant prostheses. J Prosthet
Dent 2002;88:44954; with permission.)
548 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562

Fig. 6. Unidirectional glass ber properly wetted (impregnated) by surrounded resin


matrix resulting in good exure properties. (From Freilich MA, Meiers JC, Duncan JP, Goldberg
AJ. Fiber-reinforced composites in clinical dentistry. Chicago: Quintessence; 2000; with
permission.)

the veneer made from a fairly brittle material, such as particulate composite.
The ultimate exure strength of manufacturer-impregnated (also known as
pre-impregnated), unidirectional, glass FRC materials range from over 500
to 1000 Mpa. This is greater than the exure strength of noble ceramic
alloys [8]. In this article, the clinical tooth replacement applications of FRC-
supported prostheses are organized into two categories: laboratory-
fabricated prostheses and chairside prostheses.

Laboratory-fabricated prostheses
Laboratory-fabricated FRC prostheses can be retained by teeth or
implants. The polymer prostheses include a surface that does not wear
opposing tooth enamel, and the substructure does not require waxing,
casting, or soldering procedures during fabrication. Supported by a strong,
metal-free substructure, the esthetic qualities of the FRC polymer prostheses

Table 1
Flexure properties of FRC products
Flexure Strength elastic Strength
Product modulus (GPa) limit (MPa) ultimate (MPa)
FibreKor 28.3 471 539
everStick 24.3 605 739
Vectris 28.9 516 614
GlasSpan 13.9 266 321
Construct 8.3 59 222
Ribbond 3.9 56 206
Abbreviation: FRC, Fiber-reinforced composite.
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 549

Fig. 7. Tooth preparations for posterior intracoronal (inlay) FRC prosthesis. (From Freilich
MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry.
Chicago: Quintessence; 2000; with permission.)

can be outstanding. Potential concerns for these prostheses are water


sorption, loss of surface luster and fatigue resistance over time, and the
technique sensitivity associated with an adhesive luting approach at
delivery.
For tooth-retained FRC prostheses, the composite retainers can be
bonded to abutment teeth. This allows enhanced retention for available
axial wall height. This also permits the use of a conservative tooth
replacement prostheses where intracoronal (inlay) preparations are made on
minimally restored abutment teeth. This inlay bridge design has proven
unsuccessful where a metal alloy substructure is used and retainers have not

Posterior FRC Tooth Preparation

occlusal isthmus
(1.0 mm depth)

proximal step
(1.0 mm axial depth)

shoulder/deep chamfer finish line


(1.2 - 1.5 mm)

Fig. 8. Drawing of full-coverage posterior tooth preparation exhibiting consistent axial depth
of preparation to the nish line around the entire circumference of the tooth, the proximal step
(on the side adjacent to the edentulous space), and the occlusal isthmus. (From Freilich MA,
Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry. Chicago:
Quintessence; 2000; with permission.)
550 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562

Anterior FRC Tooth Preparation

linguoproximal step
(1.0 mm axial depth)

shoulder/deep chamfer finish line


(1.2-1.5 mm)

Fig. 9. Drawing of the full-coverage anterior tooth preparation also exhibiting consistent axial
depth of preparation around the entire circumference of the tooth and the linguoproximal step.
The proximal aspect of the step is only needed adjacent to the edentulous area. (From Freilich
MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry.
Chicago: Quintessence; 2000; with permission.)

been bonded to the abutment teeth. Tooth preparation designs of full and
partial coverage FRC prostheses are shown in Figs. 7, 8, and 9.
Data have shown that substructure design is a key ingredient of the
clinical success of FRC prostheses. Increased substructure bulk added at the
pontic region (high volume design) provides additional rigidity along with
greater vertical support of the veneer material. Successful chemical bonding
of the veneer composite to the FRC substructure is another critical element
of clinical success. The maintenance of the air-inhibited layer on the external
surface of the completed substructure seems to be a crucial element in

Fig. 10. Full-coverage retainer FiberKor unidirectional glass substructure with less than
adequate bulk placed in the edentulous region. (From Freilich MA, Meiers JC, Duncan JP,
Eckrote KA, Goldberg AJ. Clinical evaluation of ber-reinforced xed bridges. JADA
2002;133:152434; Copyright 2002 American Dental Association. All rights reserved.
Reprinted by permission.)
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 551

Fig. 11. Full-coverage retainer FiberKor unidirectional glass substructure with optimal bulk
(high-volume design) placed in the edentulous region. This design results in better
substructure rigidity and better support of the composite veneer material. (From Freilich
MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry.
Chicago: Quintessence; 2000; with permission.)

achieving this bond. Examples of FRC substructures are shown in Figs. 10,
11, and 12. Two separate clinical studies of FRC prostheses made with
Stick (StickTech LTD, Turku Finland) and FiberKor (Pentron Corp,
Wallingford, CT) have demonstrated [90% survival of partial and full
coverage prostheses for up to 5 years [4,6]. Examples of various prosthesis
designs are shown in Figs. 13, 14, and 15.
Implant-retained FRC prostheses can be screw retained or luted to the
implant abutment. In contrast with tooth-supported prostheses, the
component of the FRC prosthesis retainer that provides an attachment to
the implant abutment can be premanufactured. This is because the implant
abutment is generally not custom made but is machined by the
manufacturer. For luted prostheses, a woven FRC coping can be used to
make this underside or foundation of the retainer. The remainder of the
FRC substructure can be bonded directly to these copings. An example of
a luted FRC substructure can be seen in Fig. 16. For screw-retained FRC
prostheses, a cylinder with a screw channel that ts directly to the implant

Fig. 12. Partial-coverage retainer (intracoronal) FiberKor unidirectional glass substructure


with high-volume design placed in the edentulous region.
552 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562

Fig. 13. Underside of FRC-supported, full-coverage retainer prosthesis before delivery.

abutment becomes an integral component of the substructure. An example


of a titanium ceramic cylinder with horizontal grooves on the facial and
lingual surfaces and proximal boxes is shown in Fig. 17. These design
characteristics of the cylinder enable the FRC to be reliably attached. The
horizontal grooves provide macro-mechanical retention and the proximal
boxes provide vertical support to the FRC. The etched and silanated
ceramic coating (titanium ceramic; Vident, Brea, California) provides an
opaque mask of the alloy and micro-mechanical retention to the FRC.
These xed partial and complete FRC implant prostheses continue to be
developed and tested by our research group. The implant prosthesis
substructure exhibits the high volume design features and external surface
air-inhibited layer mentioned previous. An example of a complete arch
implant prosthesis substructure is shown in Fig. 18. For the partial
prostheses, a light/heat/vacuum polymerized particulate composite veneer is
placed over the FRC substructure. For complete, xed detachable (hybrid)
prostheses, polymethylmethacrylate (PMMA) and denture teeth are used to
provide nal form and occlusal function. These materials are applied using
many widely accepted fabrication techniques commonly used by the dentist
and laboratory technician. These include procedures for the verication of
the accuracy of the master cast, wax try-in of the denture teeth, and the
processing of the PMMA prosthesis supra structure [9,10]. Examples of
completed FRC implant prostheses are shown in Figs. 19 and 20. The
advantages of using ber-reinforced polymer materials to fabricate implant
prostheses are listed in Box 1.

Chairside prostheses
One of the most exciting and potentially useful applications for pre-
impregnated FRC technology is its use in replacing missing teeth in a timely
and cost-eective manner. The ability to deliver a functional, esthetic tooth
replacement with no to minimal tooth preparation to the adjacent abutment
teeth in a single visit is a realistic treatment option with our current adhesive
technologies and reinforced composites. The increase in physical properties
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 553

Fig. 14. Posterior three-unit FRC prosthesis seen in situ.

Fig. 15. Completed intracoronal retainer FRC prosthesis.

Fig. 16. Luted implant prosthesis substructure made with pre-impregnated unidirectional
(FiberKor) and woven glass (Sticknet) components. (From Freilich MA, Duncan JP, Alarcon
EK, Eckrote KA, Goldberg AJ. The design and fabrication of ber-reinforced implant
prostheses. J Prosthet Dent 2002;88:44954; with permission.)

that ber reinforcement provides to particulate composites allows for an


improved approach over earlier methods that used denture teeth as pontics
[11,12]. This new approach eliminates the disadvantages posed by the
incompatibility of the dierent chemistries between the particulate luting
composite and the acrylic pontic and results in a much stronger connector
between the pontic and the abutment teeth when compared with particulate
composite alone. This provides the potential for long-term clinical service
[13]. Consequently, what was once thought of as a purely short-term or
temporary solution can sometimes be considered as a more denitive
remedy for those patients who cannot aord a conventional xed-tooth
replacement. Potential clinical applications for chairside-fabricated FRC
prostheses include situations where the abutment teeth may be of
554 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562

Fig. 17. Screw-retained titanium ceramic cylinders placed on implant abutment replicas located
within a master cast. In addition to the ceramic surface that provides an opaque mask and resin
adhesion, the grooves on the facial and lingual surfaces and proximal boxes exhibited by the
cylinders provide macro-mechanical retention and support, respectively, to the incorporated
FRC.

Fig. 18. Completed screw-retained implant prosthesis substructure including titanium ceramic
cylinders and pre-impregnated unidirectional glass FRC.

Fig. 19. (A) Completed three-unit, screw-retained FRC implant prosthesis. (B) Completed
three-unit luted FRC implant prosthesis.
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 555

Fig. 20. Completed full-arch xed detachable (hybrid) FRC-supported implant prosthesis
beforeplacement in mouth. (From Freilich MA, Duncan JP, Alarcon EK, Eckrote KA,
Goldberg AJ. The design and fabrication of ber-reinforced implant prostheses. J Prosthet
Dent 2002;88:44954; with permission.)

questionable stability or in place of a provisional removable prosthesis


immediately after anterior implant placement but before loading. Addi-
tionally, this technology can be used for immediate xed-tooth replacement
after extraction, after traumatic loss of a tooth, or for space maintenance in
pediatric or adolescent patients.
We have investigated the concept of designing pre-formed substructures
that can be used to quickly provide a platform for creating a bridge at
chairside rather than having to fabricate a chairside bridge from scratch
using particulate composite and FRC components [1416]. This approach
helps reduce time and technique sensitivity in the delivery of chairside
bridges. We have developed this concept to provide the clinician with the
ability to replace a missing tooth in the same way that the fabrication of
a provisional crown can be expedited by using a preformed shell.
FRC can easily be manipulated into a pre-formed (pre-fabricated)
substructure that has polymerized and nonpolymerized elements. The
wing element is not polymerized and provides an attachment to the
adjacent abutment teeth as they are adapted, polymerized, and bonded to
the facial or lingual surfaces. The pontic element is rigid because it is
already polymerized and consists of unidirectional FRC but in greater bulk.
After attaching the wings to the abutment teeth, the dentist veneers the
pontic element with light polymerized particulate (restorative) composite.
These prefabricated substructures (frameworks) can be designed to have one

Box 1. Why use FRC in Implant prosthodontics?


 Good flexure properties of some FRC materials
 Saves time and cost because no casting or soldering
 Chemical bond of resin veneer to substructure
 No need for opaque application to substructure
 Avoids concerns of corrosion and toxicity
556 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562

Fig. 21. Layout showing the pieces of Splint-Itmaterial required to fabricate the rst generation
of prefabricated FRC framework shown in Fig. 22. (From Meiers JC, Freilich MA. Chairside
prefabricated ber-reinforced resin composite xed partial dentures. Quintessence Int
2001;32:99104; with permission.)

or two wings to allow double abutment or a cantilever approach and only


replace a single tooth. Figs. 21 through 25 show the basic design concepts of
FRC prefabricated frameworks and how they can be used. The basic
construction consists of pieces of FRC that are cut to provide the wing
attachments to the abutment teeth and a support for the pontic tooth shape
(Figs. 21 and 22). During this development process there have been three
generations of basic designs. The rst had a nearly fully completed pontic
for the particular missing tooth (Fig. 23-1). The second design featured only
a basic pontic body that required chairside veneering to nish the shape
(Fig. 23-2). These two designs used Splint-It unidirectional and woven pre-
impregnated glass bers (Pentron) in their fabrication. The current design
features just a basic framework support for the pontic requiring a total

Fig. 22. The pre-fabricated FRC framework formed from the Splint-It pieces shown on Fig. 1
and then the nished product ready for chairside use. The pontic in this design was designed to
t specic spaces. This one was for a mandibular incisor. The foil protects the wings from
premature polymerization and allows for exibility in adapting them to the tooth surfaces.
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 557

Fig. 23. The three generations of pre-fabricated FRC bridges: generations 1 and 2 used Splint-
It as the pre-impregnated FRC material, and generation 3 is designed from everStick.
Generation 1 is the rst design using a fully formed pontic shape duplicating the replacement
tooth. Generation 2 used a partial pontic form that required more chairside work to develop the
nal pontic form. Generation 3 had only an FRC pontic substructure that required complete
development of the pontic shape after placement. Each had its own advantages and
disadvantages.

placement of the pontic shape at chairside (Fig. 23-3). This scaled-down


design allows for a more universal application of pre-fabricated frameworks
and reduces the work involved in their fabrication. EverStick unidirectional
pre-impregnated glass bers (StickTech) have been used to create this

Bonding Layer
Dentin
FRC Layer

Particulate
Composite
Layer
Enamel
Etched Enamel/Resin Tags

Fig. 24. Cross-sectional diagram showing the concept of a cohesive unit of adhesive resin/
particulate luting resin and FRC at the etched tooth interface. (From Meiers JC, Freilich MA.
Chairside prefabricated ber-reinforced resin composite xed partial dentures. Quintessence Int
2001;32:99104; with permission.)
558 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562

Fig. 25. Diagrams depicting tooth replacement options. (A) A dual-wing pre-fabricated FRC
approach to replacing a missing tooth. (B) A cantilever approach involving only one abutment
tooth. These can be placed on the facial or lingual surfaces of the abutment teeth, depending on
occlusion. (From Meiers JC, Freilich MA. Chairside prefabricated ber-reinforced resin
composite xed partial dentures. Quintessence Int 2001;32:99104; with permission.)

framework. These pre-fabricated frameworks are made for maxillary and


mandibular anterior and premolar designs and stored in a light-safe foil
wrap to be used when needed. Covering the wings in a light-protected foil
allows them to be kept in a exible, nonpolymerized state until they
are placed and light polymerized by the operator at chairside. The
pre-impregnated matrix of the Splint-It and everStick FRC material allows
for a strong chemical cross linking between it and the air inhibited layer of
the adhesive resin/luting resin/enamel interface, which creates a unied
resin/glass ber network from the etched enamel surface to the external
surface of the FRC wing (Fig. 24). This is achieved by having the wings in
a nonpolymerized state (protected by the foil layer when the framework is
created) when they are placed on the abutment surface. We have not seen
any failures with these bridges at the wing/enamel interface. This indicates
that a strong attachment between the enamel and FRC framework can be
obtained with no mechanical preparations created in the abutment teeth for
additional support. The frameworks can be adapted for dual-wing or single-
wing abutment support (Fig. 25), depending on the clinical situation (ie,
a full permanent or temporary crown on one of the potential abutment teeth
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 559

Fig. 26. Dual-wing pre-fabricated chairside FRC bridge. (A) Patient with missing #23, facial
view. (B) Patient with missing #23, lingual view. (C) Appearance of pre-fabricated FRC
framework (everStick) showing pontic support, facial view. (D) Lingual view of pre-fabricated
FRC framework. Note the lack of bulk on the lingual and the good adaptation of the wings to
the lingual contour of the abutment teeth. Compare with (B). (E ) Facial view of completed
pontic on pre-fabricated FRC framework. (F ) Lingual view of completed pontic. Compare with
Fig. 26B and D.

or for short-term use). The wings are intended to be placed without


mechanical preparation on the abutment teeth. The ability to thin the FRC
with pressure along with its translucency allows the wings to be placed in
a labial position, if lingual occlusion does not permit this approach, and
they can be easily masked with a thin facial veneer.
560 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562

Fig. 27. Cantilever pre-fabricated chairside FRC bridge. (A) Patient with extracted #9 and bone
augmentation awaiting future implant placement. An immediate cantilever FRC bridge was
treatment planned to replace #9 until implant placement. (B) Lingual view of pre-fabricated
framework (everStick) showing wing adapted to lingual surface of #8. (C ) Facial view of
nished pontic #9 on cantilever chairside FRC bridge. (D) Lingual view of nished cantilever
chairside FRC bridge showing intimate adaptation of lingual wing on #8.

Clinical cases
Figures 26 through 28 show some examples of chairside bridges made
from pre-fabricated FRC frameworks.

Dual-wing anterior chairside bridge


Fig. 26 (AF) shows the replacement of a missing mandibular lateral
incisor with a dual-winged pre-fabricated bridge approach. The abutment
teeth are isolated and the pre-fabricated framework modied to have the
wings shortened to t the proximal surfaces of the two abutment teeth. The
abutment teeth are etched, adhesive is applied, the framework is placed
using a hemostat holding the pontic in position, and the wings compressed
with a gloved nger to intimately adapt to the lingual contours of the
abutment teeth, after which the compressed FRC wing with the luting resin
composite is light cured (Fig. 26C and D). The external pontic surface is
then built using particulate composite to the desired shape (Fig. 26E and F).

Cantilever anterior bridge over a healing extraction site


Fig. 27 shows a cantilevered bridge series. This approach is appealing to
patients and clinicians because it allows a rapid solution to tooth
replacement that involves only one abutment tooth. The added strength
imparted at the connector area by the FRC allowed for the concept of this
design, and it has proven to be predictable for up to 6 months. This approach is
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 561

Fig. 28. Premolar FRC pre-fabricated chairside bridge. (A) Patient with missing #5. The
mesial-occlusal amalgam in #4 will be removed to allow room to place a wing of the pre-
fabricated bridge into the preparation. (B) The pre-fabricated framework (everStick) has been
placed onto the abutment teeth. The wing placed into the mesial-occlusal preparation of #4 has
been polymerized in a bed of owable resin. The foil on the lingual of #6 has protected this wing
from polymerization and will be removed next to allow adaptation and attachment. (C )
Occlusal view of completed FRC chairside bridge showing pontic and wing adaptation to the
abutment teeth. (D) Buccal view of completed FRC chairside bridge showing good esthetics and
functional relationships.

normally used when the bridge is to function for a short period of time.
Examples of its use include the edentulous area that is a future implant site and
as a tooth replacement covering the implant immediately after placement but
before loading. In both of these cases, the usual removable provisional
prosthesis (ipper) is replaced by a xed prosthesis. Preparation of the
abutment tooth surface receiving the wing is not needed, and when the bridge
needs to be removed, the removal of the FRC wing from the abutment has
proven to be easily accomplished with essentially no loss of enamel.

Replacement of a missing premolar


Fig. 28 illustrates a posterior application. We have used these frame-
works to replace premolars. In these situations, the premolar or molar
abutments are prepared with an occlusal slot to receive the wing(s). If
a canine is one of the abutments, the wing is placed on the buccal or palatal
surface with no preparation.
562 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562

References
[1] Behr MRMLRCCHG. Glass-bre-reinforced-composite xed partial dentures on dental
implants. J Oral Rehabil 2001;28:895902.
[2] Behr M, Rosentritt M, Ledwinsky E, Handel G. Fracture resistance and marginal
adaptation of conventionally cemented ber-reinforced composite three-unit FPDs. Int J
Prosthodont 2002;15:46772.
[3] Eckrote KA, Burstone CJ, Freilich MA, Messer GE, Goldberg AJ. Shear in exure of ber
composites with dierent end supports. J Dent Res 2003;82:2626.
[4] Freilich MA, Meiers JC, Duncan JP, Eckrote KA, Goldberg AJ. Clinical evaluation of
ber-reinforced xed bridges. JADA 2002;133:152434.
[5] Gohring TN, Schmidlin PR, Lutz F. Two-year clinical and SEM evaluation of glass-ber-
reinforced inlay xed partial dentures. Am J Dent 2002;15:3540.
[6] Vallittu PK, Sevelius C. Resin-bonded, glass ber-reinforced composite xed partial
dentures: a clinical study. J Prosthet Dent 2000;84:4138.
[7] Park S-H. Comparison of degree of conversion for light-cured and additionally heat-cured
composites. J Prosthet Dent 1996;76:6138.
[8] Anusavice KA. Phillips science of dental materials. 10th edition. Philadelphia: WB
Saunders; 1996.
[9] Freilich MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical
dentistry. Chicago: Quintessence Publishing; 1999.
[10] Freilich MA, Duncan JP, Alarcon EK, Eckrote KA, Goldberg AJ. The design and
fabrication of ber-reinforced implant prostheses. J Prosthet Dent 2002;88:44954.
[11] Ibsen RL, Neville K. Adhesive restoraive dentistry. Phildelphia: WB Saunders; 1974.
[12] Littman H, Regan DJ, Rakow B. Provisional temporization with acid-etch resin technique.
Clin Prev Dent 1973;2:1416.
[13] Goldberg AJ, Burstone CJ. The use of continuous ber reinforcement in dentistry. Dent
Mater 1992;8:197202.
[14] Freilich MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical
dentistry. Chicago: Quintessence; 2000.
[15] Meiers JC, Freilich MA. Chairside prefabricated ber-reinforced resin composite xed
partial dentures. Quintessence Int 2001;32:99104.
[16] Meiers JC, Kazemi RB, Freilich MA. Direct intra-oral applications of ber-reinforced
composites: the inuence of FRC on particulate resin composite to enamel shear bond
strengths. In: Vallittu PK, editor. The Second International Symposium on Fibre-
Reinforced Plastics in Dentistry. Turku, Finland: Department of Prosthetic Dentistry and
Biomaterials Research, Institute of Dentistry; 2002.
Dent Clin N Am 48 (2004) 563566

Index
Note: Page numbers of article titles are in boldface type.

A Ceramics, dental. See Dental ceramics.


Alginate, laying on tabletop, 480, 481 Color, color vision confusion and, 343
Alloys, Ag-Pd, 509 hue as attribute of, 344, 345
application of porcelain to, 503505 light and, 342
Au-Cu-Ag, 507508 organization and specication of,
Au-Pu, 507 343344
biocompatibility of, 502503 perception of, 342343
casting, 499512 shade communication and, 355
American Dental Association visual selection of shade and, 345
classication of, 505506, Color matching, advances in, 341358
507 light sources for, 344346
classes of, currently available, 505510 visual shade-matching environment
clinical selection of, 510511 and, 344346
Co-Cr, 510
color of, 500 Colorimeters, lter, digital cameras as, 349
corrosion of, 502 shade-taking devices and, 348
for xed prosthetic restorations, 499 Crown(s), all-ceramic, 422423, 425
grain size of, 501 reduction depth for, 377, 378
high-noble, 506508 shoulder nish lines for, 371, 374
interactions with environment, 503 all-metal, chamfer nish lines for, 370,
Ni-Cr-Be, 509, 510 371
noble, 508509 depth of reduction for, 374375
Pd-Ag, 509 metal-ceramic, 422, 424, 425
Pd-Cu-Ga, 508509 chamfer nish lines for, 370,
phase structure of, 500 372373
predominantly base-metal, 509510 reduction depth for, 375, 376, 377
properties of, important to clinical reduction depths for, 372377
performance, 500505 resistance form and, 387
soldering of, 505
solidus and t of, 501502
strength and hardness of, 501 D
Dental casting alloys, 499512
C Dental ceramics, all-ceramic systems, 521
Cardiovascular patients, identication of, survival literature for, 523526
436 clinical concepts of, and performance
Casting alloys, 499512 issues in, 521526
American Dental Association versus metal-ceramic systems,
classication of, 505506, 507 advantages of, 521522
composition, uses, and commercial
Casts, hand articulation of, 473, 474, 482 examples of, 514, 515
heels of, touching, 482 current thinking and trends in,
movement during articulation, 483, 485 513530
with major blebs on occlusal surfaces, etching and bonding of, 527
481 for inlay/onlay restorations, 524525

0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S0011-8532(04)00045-X
564 Index / Dent Clin N Am 48 (2004) 563566

Dental ceramics (continued ) cantilever anterior bridge over healing


for multi-unit prostheses, 526 extraction site, 560561
for single-unit crowns, 525526 chairside, 552559
for veneer restorations, 523524 clinical cases illustrating, 559, 560561
fracture toughness and, 520 dual-wing anterior chairside bridge
glass, 516 using, 559, 560
glazing of, versus polishing of, 527 ber architecture for, 545548
metal-ceramic sysytems, 521522 exure properties of, 548
metal in "strengthening" of, 520521 for replacement of missing premolar,
particle-lled glasses, 514516 561
polycrystalline, 516517 implant-retained, 551552, 553, 554
practical aspects of, 526528 laboratory-fabricated, 548552
predominantly glassy, 513514 material for, 545
repair of, 527528
Fracture(s), toughness of dental ceramics
science of, and fracture, background
and, 520
concepts of, 513
simple failure statistics on, decisions
based on, 522523 G
strength of, 519520
substructure for, 517518 Gingival displacement, current concepts in,
transformation-toughened zirconium 433444
oxide, 518519 for eective impression, 433
translucency of, 526 technique(s) of, classication of,
434435
Dentures, all-ceramic xed partial, decient, 433
contemporary, 531544 double cord, 439440
dimensions for connectors in, 532 "every other tooth," 441
evolution of, 533534 infusion, 440441
framework design for, 532533 new, and new materials, 441
in vitro study of, 532 single cord, 437438
patient selection and treatment trimming gypsum die in, 435
planning for, 535536
recent core materials and
technologies for, 534535 H
retrospective studies of, 531532 Hue, as attribute of color, 344, 345
Y-TZP-based, clinical procedures
for, 541 Hydrocolloid impression materials,
design and manufacturing reversible, 446, 449
of, 537, 538
features of, 538540
limitations of, 540541 I
Impression(s), as communication aid with
Dowel cores, indirect, for retention of
dental technicians, 460464, 467
restoration, 458, 459, 466467
custom trays for, 450451
Dual-arch impression technique, 463465 deciencies of, causes of, 445
disinfection of, 454
dual-arch technique for, 463465
E eective, for gingival displacement, 433
Endodontically treated teeth, restoration of, nal, second pour of, 484485
397416 putty/wash techniques for, 456,
459462
Epinephrine, as gingival displacement segmental technique for, 465
medicament, 435436, 437 tooth/implant, 456, 457, 458, 466
triple tray, position of mouth for,
F 482483, 484
Fiber-reinforced composite prosthesis(es), Impression material(s), accuracy of,
545562 evaluation of, 446
advantages of, 552, 555 adequate mixing of, 454
anterior full-coverage, 545, 546 adhesion to tray, 453
Index / Dent Clin N Am 48 (2004) 563566 565

and techniques, contemporary, M


445470 Margin(s), cervical, congurations of,
cost of, 451 419420
dimensional stability of, 447448 designs of, for acceptable
dislodged from impression tray, 480 marginal integrity, 421
elastic recovery of, 446447 placement of, landmarks for,
ow and exibility of, 448449 417419
hydrophilicity of, 449450 providing marginal
ideal properties of, 446 integrity, 420
low-viscosity, gingival displacement in, too deep in sulcus, 417, 418
434 porcelain labial, preparation of, 426,
manipulation of, principles of, 451454 428
uniform bulk and, 452 shoulder-bevel, 421, 422
patient comfort and, 450451
polyvinyl siloxane as, 445, 446, 447, Metals, for alloys in dentistry, 499
454458 Molars, single-rooted, post and core
advantages of, 454455 restoration of, direct core material for,
disadvantage of, 455 402403, 404405
inhibition of polymerization of, ferrule for, 403, 406
455458 guidelines for, 403404
pouring of, 453 increasing success of,
promptly, 480481 400401, 402
setting of, movement during, 479480
shelf-life of, 450 "Mush bites," 482
viscosity control and, 453454
workability of, 449
O
Interim restoration(s), 487497 Occlusion, vertical dimension of, 485
basic requirements of, 487489
biologic requirements of, 487488
biomechanical requirements of, 488 P
color stability of, 491 Polyether impression materials, 450
diagnostic potential of, 488489
direct techniques of fabrication of, Polyvinyl siloxane, as impression material,
492493 445, 446, 447, 454458
exothermic reaction to, 491
Porcelain, application of, to alloys, 503505
fabrication of, techniques for, 492495
indirect-direct technique of fabrication Prosthesis(es), ber-reinforced composite.
of, 494 See Fiber-reinforced composite
indirect technique of fabrication of, prosthesis(es).
493494 xed or removable, 487
marginal integrity of, 494495
materials for, 489491 Prosthesis frameworks, for xed
matrices for, 492 prosthodontics, 478
reinforcement of, 490 Prosthodontics, xed, jaw relation records
strength and rigidity of, 489490 for, 471486
Interocclusal records, materials for, 485 articulator choice and,
478479
avoiding errors and
inaccuracies in,
J 479485
created tripod interocclusal
Jaw relation records, for xed record and, 474478
prosthodontics, 471486 existing tripod interocclusal
record and, 472473,
474
facebow for, purpose of,
L 479
Light sources, for color matching, 344346 function of, 472
566 Index / Dent Clin N Am 48 (2004) 563566

Prosthodontics (continued ) Shade-taking devices, 347355


prosthesis frameworks for, colorimeters and, 348
478 currently available, 349353
vertical dimension of design of, 348
occlusion and, 471 limitations of, 353355
spectrophotometers and
Pulpless teeth, molars, single-rooted, post
spectroradiometers, 349
and core restoration of. See Molars.
single-rooted, post and core Soft tissue landmarks, impressions for
restoration of, and length of post, communication of, 460464, 467
398
Spectrophotometers, for color
apical seal and, 399
measurement, 349
complications with, 411
dental cements for, 409411 Spectroradiometers, for color measurement,
design to conserve radicular 349
tooth structure, 400
ferrule length and, 398399
ber reinforced epoxy resin T
posts in, 406408 Tooth/implant impressions, 456, 457, 458,
guidelines for posts in, 400, 466
401, 402
prefabricated posts for, Tooth preparation(s), designing of, 359385
405409 guidelines for, 359362
success of, 398 occlusocervical/incisocervical
woven-ber composite dimension and, 362364
materials for, 409 ratio of occlusocervical/incisocervical
zirconia posts in, 408409 to faciolingual dimension,
364365
total occlusal convergence and,
359362, 363
R
Resistance form, crowns and, 387 Tooth (teeth), endodontically treated,
evaluation of, 388389 restoration of, 397416
in tooth preparation, 387396 preparation of, resistance form in,
laboratory studies evaluating, 391392 387396
methods to analyze, 390391 prepared, circumferential form of,
methods to enhance, 392394 365366, 367, 368
on/o nature of, 389390 nish line form, 369371
preparation taper for, minimally nish line location, 367369
acceptable, 388390 guidelines for preparing, 380382
use of, clinical outcomes following, line angle form, 377378, 379
387 reduction uniformity of, 367, 369
surface texture of, 371, 380
Restorations, esthetic, contemporary, pulpless. See Pulpless teeth.
cervical margin design with, 417431
interim. See Interim restoration(s). Total occlusal convergence, 359362, 363
provisional, in gingival displacement,
434 V
Retraction cords, in gingival displacement, Veneer restorations, dental ceramics for,
435, 436 523524
Vertical dimension of occlusion, 471
S
Segmental impression technique, 465 Y
Yttrium tetragonal zirconia polycrystals, for
Shade communication, color and, 355
xed partical dentures, 531, 534535,
Shade guides, 346347 537541
I
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