Fixed Prosthetics

In this workbook you will find details about the area

of dentistry that deals with fixed prosthetics (crowns,
bridges, veneers & inlays).
These will include the materials these can be made
from along with details about the laboratory work
required for each option.
At the back of the workbook you will find an exercise

RoE Links are 1,2,4,5 and case

study

which may help you to 'test' your

knowledge of this subject.
We should note that whatever the prosthetic, the patient will need
to
have 2 appointments (1 preparation & 1 fitting) as some of the work
is done
by specialized dental technicians in a dental laboratory.

If we begin by looking at a description of the items that fall into this

area of dentistry, along with a brief description of the functions we
would expect it
to perform

Crowns • A large
restoration used
when a tooth is
badly broken
down.
• It is a shell
covering at least
3/4 of the natural
crown
• It should restore
function and
appearance

Bridges • A restoration
which replaces 1
or more missing
teeth
* It can not be
removed by the
patient

Inlays • an alternative to
amalgam /
composite
restorations
• they are used
when extra
strength is
needed
 Veneers • a facing made to
cover the labial
surface of
anterior teeth
• they can be used
to alter the
appearance of
teeth

So if we start to look in detail at each of these options

Starting with

Crowns
• Crowns are fixed prostheses that can be used when
- a tooth is heavily restored and showing signs of failure e.g.
cracked cusps or repeated fractures
- a tooth has been root filled - these tend to become brittle overtime
- a tooth is discoloured, a poor shape or malaligned
- a tooth is a poor shape and a denture needs to be made and the
tooth used as a retentive abutment
• Crowns are permanently cemented onto an individual tooth
• Crowns can be made in a number of materials, including
Acrylic, Porcelain. Gold or Gold / Nickel Alloy with a Porcelain
surface
• The choice of material depends on
- whereabouts in the mouth the crown is to be placed - e.g.
masticatory pressures
- the aesthetics needed - e.g. if the crown is to be placed in
the anterior of the mouth it needs to be 'tooth coloured'
- the
condition of the natural tooth
~ the patient's wishes

So to look at the materials available

Acrylic
• Less commonly used these days
• It was used before the development of the acid etch
technique to repair fractured incisors in young children
• Acrylic was used instead of porcelain to allow for
replacements as the tooth completed its eruption
• Acrylic caused some problems, which included
1. it was is an irritant to the gingiva - to avoid this the dentist
used to leave a small space between the edge of the crown
and the gingiva which meant that the 'join' was not hidden
 2. the acrylic discoloured over time
3. the acrylic also wears down reasonably quickly

3.

Porcelain
• This is a strong material which gives a good final appearance
• Despite its strength it is also brittle and therefore can not
cope with the forces put on the posterior teeth during eating
• it is a translucent material which mimics the way light passes
through natural teeth

Gold
• This is very strong material, even when it is thin
• It is very useful for posterior teeth as it will withstand the
masticatory forces
• It is not routinely use for anterior crowns as its appearance is
generally unacceptable

Gold / Nickel Alloy with a Porcelain facing

• A combination of materials which gives both good strength
and a good appearance
• It can be used in any area of the mouth
• When used a a facing bonded to gold or nickel alloy,
porcelain looses its translucent quality, the metal blocks this,
so the finished crown may appear' flat'
• Sometimes, to overcome this lack of translucency the incisal
tip is made of porcelain only, with no metal backing

* note - there are other material options which are used less
commonly -full details of these are included at the back of this
workbook

* Whatever the material the preparation is roughly the same

If we work our way through this, noting any special instruments or

materials as we go
It is likely that a local anaesthetic will be needed, so this should be
administered first
(If the tooth is non-vital then the local may not be necessary)
An alginate impression of the opposing arch is then taken
An occlusal registration is also taken - using softened pink wax or a
specific occlusal registration material
The tooth is prepared by reducing its overall dimensions by 1mm for
metallic or porcelain crowns or 1.5mm for bonded crowns
The dentist will use tapered fissure, diamond burs in the high-speed
handpiece.
He /she will try to produce as near parallel sides as possible with no
undercuts. This will give the finished crown the most effective
retention
This preparation will leave a 'dentine peg' with a rim or edge all the
way around. The rim is known as the Cervical Margin
This is the join or margin where the crown will meet the natural tooth
Ideally this join would be above the gingiva (supra-gingival) although
it can be below the gingiva (sub-gingival) to help with appearance -
it is often sub-gingival on anterior teeth which avoids a thin black
line being seen
It is usual to always place the margin supra-gingivally on the lingual
/ palatal surfaces, as these are not seen

5.
 4. To allow the dentist to have a clear view (& later a clear
impression) of the margin the dentist may use Gingival Retraction
Cord
This cord is gently pushed into the gingival crevice, causing the
gingiva to be moved very slightly out of the way
The cord can be soaked in adrenaline - this causes the gingiva to
retract and any bleeding to be reduced (vaso-constrictor action)
5. Once the dentist is happy with the preparation he /she will take a
further impression, this time using an elastomer impression material
This is known as the Working Arch Impression A further, more
detailed impression can be taken using a 'wash' over this working
arch impression
6. Once a satisfactory impression has been taken a temporary
crown can be prepared and cemented onto the prepared tooth.
The gingival retraction cord should be removed The patient
should be given any care instructions
7. At some point during this procedure a shade should be taken
(for porcelain St bonded crowns).
This should be noted on both the patient's record card and the
laboratory instruction sheet
8. Finally a further appointment should be made for the patient
to return for the finished crown to be cemented This will vary
from practice to practice depending upon the laboratory used

Having briefly mentioned impressions we should now take a more detailed

look at these

As we are aware, once the preparation of a tooth is complete the dentist

needs to make a record of it to send to the dental laboratory

This record takes the form of impressions which can be taken in a number of
ways and a number of materials
 If we look at these

Starting with the types of impression material that may be used

Impression materials fall generally into 2 groups

Elastic Materials This group includes: -

• Hydrocolloids
• Elastomers

Rigid Materials This group includes:-

• Impression Compounds
• Plaster
• Zinc Oxide & Eugenol Paste

So to look in detail at these materials Starting with

Hydrocolloids
• The most commonly used material in this group is Alginate
• It is a powder mixed with water using a flexible mixing bowl and an alginate
mixing spatula
• It is easy to mix and an inexpensive material
• It is used for taking impressions for:-
- opposing arch models for crown, bridge, inlay and veneer construction
- models for the construction of full and partial dentures
~ models for the construction of removable orthodontic appliances ~ study
models
- models for the construction of special trays, bleaching trays and
orthodontic retainers
• It produces a relatively accurate impression, however it is not accurate enough
to be used for the working model for fixed prosthetics
• Alginate powder is a mixture of calcium salt, alginate salt (Sodium
potassium alginate) and filler
• The powder needs to be fluffed up before dispensing, a measuring scoop is
used to dispense the alginate powder. The water, at room temperature is
dispensed using a measuring cup
• Once dispensed the alginate is mixed by adding the water all at once, folding it
into the powder and then vigorously spreading the mix against the sides of the
mixing bowl. This process is called Spatulating
• In very simple terms as you spatulate you mix the calcium salts with the alginate
salts forming the smooth, stiff, creamy mix you are familiar with. The mix should
be free from air bubbles
• As with all chemical reactions temperature affects the speed of the reaction
- the higher the temperature the quicker the reaction
• Impressions that are taken with hydrocolloids are not stable for long periods of
time; they need to be cast into a more permanent material as soon as possible
• Alginate impressions need to be kept damp NOT wet and should be
decontaminated and covered with a damp gauze and stored in a sealed plastic
bag (to retain the humidity) before transporting to the dental laboratory

8.
 Elastomers (Addition Silicones)
• These are the materials used for the fine detail impressions needed once
the preparation is complete
• They are supplied in a number of ways:-
- tubs of heavy-bodied putty with a liquid or paste activator (Express,
Provil)
- Tubes of light-bodied paste with liquid or paste activator (Provil,
President)
- Preloaded "gun syringes" which mix the constituents automatically
(President, Extrude)
- There is now a machine on the market that mixes these materials
• In general terms the heavy-bodied putty materials are used for the bulk of
the impression while the light-bodied paste materials are used for recording
the very fine detail
• There are 2 methods of using these materials - details are given at the back
of this workbook
• When we use these materials we need to take care to remove our gloves
and wash off any powder from our hands as it has been shown that the
powder may affect the setting properties, sometimes slowing it down,
sometimes stopping it altogether
• Impressions taken with elastomer materials are more stable and if needs be
can be left for some time before casting, although it is always best to
transport impressions to the laboratory as soon as possible

So now

Impression Compounds
• These are little used these days as more recently developed materials have
superseded them
• They come in 2 types - cakes and sticks
• The cakes are red or brown in colour and are used mainly for the 1st
impression during denture making
• The sticks tend to be green and are used in the impression technique called
Copper Ring Technique
* a description of this technique is included at the back of this workbook
• Both types are hard and rigid when supplied and need to be softened before
use
• The cakes are softened in a bath of hot water (approximately 55 - 60
degrees)
• The sticks can be softened using a flame

9.
 So now

Impression pastes
• These are 2 pastes made of Zinc Oxide and Eugenol (in colour they are red
and white)
• The 2 pastes are mixed equally together until an even colour is achieved
• This material is very sticky, it will stick to everything it touches, so patient's
lips need to be smeared with Vaseline in order to protect them
• They are mainly used during denture / reline work

Plaster of Paris
• This material is no longer used in the mouth, although it once was!
• It is now used for producing study models, working models etc
• It is a very brittle material which needs careful handling to avoid
damage
•
After the impressions have been taken the dentist has one final job to do
during a crown preparation before the patient can be dismissed

This is to provide a temporary crown

There are a number of reasons why a temporary crown is needed

Protect & Prevent Sensitivity • Because the enamel layer is

removed during the
preparation if we did not
replace it with something
(temp crown) the patient
may complain of sensitivity
Restore Appearance • This is especially
important for
anterior preparations
• A patient would find a
Maintain Spacing & Contact • When a tooth is prepared
for a
crown it looses its
interproximal
and occlusal contacts
• If these are not replaced
with a
temporary crown the tooth
Function • As we have said the
occlusal contacts are
removed, if these are not
replaced the patient
would not be able to
 Temporary crowns can be either

Pre-formed Custom made

Pre-formed
• These can be made of either acrylic or aluminium
• They are supplied in a number of sizes and shaped
• They are trimmed to shape using Bee-Bee Crown Shears

11.
Custom made
• These are made in the surgery at chairside
• The material used can be either:-~
acrylic - (Trim)
- epimine plastic - (ProTemp, Scutan)
• The basic procedure is:-
1. - an alginate impression is taken before the preparation begins
2. - the temporary material is then mixed and placed into the
impression after the preparation is complete. The impression is
then re-inserted into the mouth
3. - The material takes only a short time to set and produced a
temporary crown exactly the same shape & size as the
original tooth

Sometimes a temporary crown needs to be made in the dental laboratory

This tends to be done when a patient is having multiple teeth prepared at

one appointment Obviously it adds to the overall cost, so this needs to be
taken into account during the planning stage

Whatever the type of temporary crown is used it needs to be cemented into

place using a weak cement that is quick and easy to clean away

The materials that tends to be used is Zinc oxide & Eugenol e.g. Tempbond.
This will last for a long enough time, but is not too strong

The final notes in this section are about the details that need to be
recorded on the laboratory sheet

This should be completed before the patient leaves the surgery

The details should include

 The notation of the crown along with the type of crown
The shade required
The patients name
The date of the next appointment
The patient's age (helps the laboratory with any shading required)
Any special requirements (e.g. no occlusal metal)

While looking at crowns we should also look at a variation which is

Post Crowns

• These are often used when a tooth has had successful root canal
therapy. 'Root-filled' teeth can become brittle with time and sometimes
fracture off at the gingival margin, leaving just the root in place. Post
crowns allow us to restore these teeth, ideally being carried
out before the tooth fractures

• A post crown is a crown which is cemented onto a metallic post and core

• The post is placed into the empty root canal of a non-vital,

endodontically treated tooth

• The general method for preparing a post crown is :-

1. If the natural crown of the tooth is still present this is removed
2. The remaining root face id shaped in a similar way to the margins when
preparing a non-post crown
3. The root filling material is removed to a suitable depth from the root
canal using a special bur called a Gates-Glidden bur
"(Note - It is important to make sure the apical tip of the root canal is still
sealed with the root filling material in order to prevent infection)
4. The empty canal is then widened, generally using a special post
preparation system (there are a number on the market, a popular one is the
Parapost system)
5.This spot preparation system creates parallel-sided post holes which give
the finished post its maximum retention
6. A prefabricated metal post or a carbon fibre post is then cemented into
the prepared post hole or an impression of the prepared post hole is taken.
This impression must include a wax post which will accurately record the
shape and size of the post hole
7. If a post has been cemented the dentist can then use this to build up a
core and the crown preparation will continue as already described
8. If an impressipn has been taken, this will be sent to the laboratory and a
custom made post and core will be made. The crown will then be prepared
by the laboratory to fit this post and core. At the fit stage both the post
and core and the crown will be cemented into place
 So now to look at bridges
* Note - some of the details are the same as in crown preparation, these

will not be repeated

These are used to replace one or more missing teeth

They are cemented into the mouth and so can not be removed by the
patient

Bridges have a number of advantages over the alternative (removable

prosthesis)

There is no risk of embarrassment of a loose prosthesis 'falling out'

On the whole, the final appearance is better than with a denture
They are more hygienic than dentures
Generally only 2 appointments are needs (at least 4 for a denture)
The materials used are 'stronger'
The shades can be blended and customised in the dental laboratory to blend
in with the patient's natural teeth
They are very useful for patients who have a strong gag reflex and find
denture wearing a problem

If we begin by noting the special words used when describing the parts of a
bridge

• The supporting teeth in bridges are called Abutments / Retainers

• The 'false' or replacement teeth are called Pontics

• And now to look at the different types of bridge a dentist may use

Fixed bridges Diagrams on • this type of bridge has support

pages 25/26) from abutment teeth on both
sides of the 'gap' they can be
generally used in all areas of the
mouth as long as there are
 supporting teeth present

• they can be made in a variety of

materials (metals) with or without
porcelain facings fixed bridges
fall into 2 types:-Fixed /Fixed
Fixed / Moveable

• fixed /fixed are made in 1 solid

piece and are rigid, with no
movement, they are the simplest
type of bridge

• fixed /moveable have a joint or

stress breaking device built into
them, this allows slight
movement between the 2 halves
of the bridge. This movement
prevents stress which in turn
prevents damage either to the
supporting teeth or the bridge
itself

• either type of fixed bridge can

be cemented into place using
any of the dental cements
available e.g. zinc phosphate,
polycarboxylate or GIC
 Cantilever • in most cases only 1 abutment is
(Diagram on page 25) used, although 2 can be used
• the abutment tooth must be a
large tooth with a substantial
root to allow for good support
• this type of bridge can only be
used in certain areas of the
mouth e.g. to replace an upper
lateral incisor using the canine
as the abutment
• the main disadvantage of a
cantilever style bridge is the risk
of it becoming partially
uncemented due to leverage, if
this was thought likely then a
fixed type bridge would be used

Spring-arm Cantilever • not a widely used type of bridge,

(Diagram on page 25) this uses an abutment which is
not next to the pontic tooth, but
is some distance away
• the 2 parts are linked by a metal
arm
• it was used to replace anterior
teeth, but has fallen out of use
since acid etch techniques have
been developed
• again it needs a large abutment
tooth
• a problem can be fracture of the
metal linking arm, this would
cause the pontic tooth to
become loose
 Rochette / • a newer type of bridge, which
Maryland uses the acid etch technique
(Diagram on and
page 26) needs much less tooth
reduction
• the pontic tooth is made with
2
metal wings sticking out from
the sides
• these wings are bonded to
the
adjacent teeth, holding the
pontic in place
• the wings can be:-
Perforated = Rochette Solid =
Maryland
• one problem with this type of
bridge is the likelihood of it
Now to move on to

Veneers

Porcelain veneers can be used to restore an anterior tooth when the tooth
is reasonably intact, maybe with just 1 largish restoration, or if the tooth is
discoloured as with fluorosis or tetracycline staining

A veneer gives a good a aesthetic result without destroying much tooth

tissue

If we look at the main points about veneers

• Only a tiny amount of enamel needs to be removed on the labial surface

of the tooth

• This leaves the lingual / palatal surfaces and the interproximal surfaces
untouched (sometimes a dentist will include the interproximal surface,
just a fraction, to help to hide the join)

• The veneer is made in the laboratory, they need to have the same
impressions as previously looked at

• The finished veneer will look like a false nail / flaked almond

• The veneer is bonded to the tooth using composite materials

• It is essential that the tooth is free of all debris, saliva etc otherwise the
 bonding process may fail

• The composite materials usually are supplied as a kit (Veneer bonding

kit) and may include tints that can be added to the base mix to slightly
alter the basic shade

• Whilst veneers are strong once they are bonded to the tooth, they are
very fragile before, so they need very careful handling

• The fitting surface will be prepared by the dental laboratory and should
not be toughed before fitting

• It is best to let the dentist be the one who handles the veneer - pass it
to him in the packaging the laboratory provides - this will avoid
embarrassing accidents!

Veneers can also be used to close diastemas, change the shape of

Mis -aligned / mis-shaped teeth

The instruments and materials used in the preparation are the same as already
looked at during crown preparation

• As a 'temporary' veneer the dentist may cover the prepared tooth

surface using a composite material. It is usual for the dentist only to
etch the composite onto the tooth surface in 1 place (the centre of the tooth) This
makes the temporary easy to remove at the fit appointment

And so to the final fixed prosthetic

Inlays

As with veneers we will only look at the main points about inlays

Inlays are used to replace large fillings which may have failed and / or where
amalgam / composite materials are not suitable

They are mainly used on posterior teeth (veneers fit crowns being used
on anterior teeth)

They are made in the dental laboratory in either gold or porcelain so tend to be a
more expensive treatment option

A special type of composite which is much stronger (it contains a higher

level of filler than regular composite materials) can also be used. These
are also constructed in the dental laboratory
 The cavity is prepared in a similar way to a regular restoration but the dentist will
not make any undercuts

The dentist will aim to prepare the walls of the cavity as parallel as possible and
the floor of the cavity as flat as possible - this is because the inlay is placed into
the tooth as one whole piece, not in increments
as with composite

The equipment and materials used are the same as already looked at,
however there are a couple of different ways in which the impressions
can be taken. These are known as Direct and Indirect and details are
included at the back of this workbook

Types of Crown

1. Full Gold Crown (FGC) or Full Veneer Crown

Over 60% gold, usually has a "shamfer" finish and needs only a small
amount of tooth reduction. The colour of the gold may not be acceptable to
the patient. Gold gives us the best marginal fit

2. Precious Metal Alloy Crown (PMA)

A crown type with over 45% gold content, usually 'silver' coloured. This type
of crown tends to become tarnished

3. Non Precious Metal Alloy Crown (Non PMA)

Similar to above but usually 33% gold

4. Precious Metal Alloy, Porcelain Bonded Crown (PMP)

The metal is the same as the above option, but this type of crown has
porcelain bonded to the metal to give a better aesthetic finish. It needs more
tooth reduction to allow for the porcelain

5. Non Precious Metal Alloy Bonded Crown (Non PMP)

As above, but non precious metal is used

6. Gold and Acrylic Facing Crown

60% gold content. Acrylic is used as the facing material instead of
porcelain; this is mechanically locked to the metal. The acrylic tends to wear
down quickly and can discolour so this option is not used much

7. Porcelain Jacket Crown (PJC)

An all porcelain crown no metal is used. This is a weak crown with a large
amount of tooth reduction needed. It tends to be only used for anterior
teeth

8. McLean I Seed Crown

Similar to a porcelain jacket crown, but with platinum foil which adds
 strength

9. Castable Glass Crown (Willi's Glass Crown, Dicor)

This is an expensive option. The glass is cast and is coloured on the inside.
These crowns are very strong but can fracture after a number of years

10. Acrylic Crown

An option which is little used, this gives poor tooth colour, but needs little
tooth reduction. It can be used on developing teeth
20.
11. 3/4 or Partial Gold Veneer Crown
The material is the same as for a full gold crown. It may be more acceptable
to the patient as only a small amount of gold shows. Needs only a small
amount of tooth reduction

12. Basket Crown

This is a variation on the above, the gold covers all but the buccal surface
with the natural tooth showing through a 'window'. This type of crown gives
a poor appearance, but is strong and needs little tooth reduction

Impression Techniques

Copper Ring Technique

This is an impression method which is not used very much these days. It can be
used for taking an impression of a single crown preparation.

The method is:-1. A piece of soft copper

tubing, which is the correct size, is used
2. This should fit around the circumference of the tooth and can be shaped
using crown scissors or / and green abrasive stones
3. The copper ring is then filled with soft green stick impression compound
(*Note - other impression materials can be used) 4. The filled
copper ring is then firmly pressed down over the prepared
tooth
5. The impression compound is then cooled with water
6. Once cool, the copper ring & impression compound is carefully removed
from the tooth

Elastomer Impression Technique

A more modern method using the non-reversible elastomer impression

materials that are now available. This technique can be used for all
impressions e.g. crowns, bridges fit inlays

The method is :-1. A well fitting impression tray is

selected and coated with adhesive
2. Before the preparation, the mixed putty type (heavy bodied) material is
loaded into the prepared tray and placed into the mouth until set
3. After preparation the paste type (light bodied) material is 'washed' over
the putty impression and replaced into the mouth, again until set
4. Once set the final impression can be carefully removed from the mouth

Direct Impressions

Used for recording inlay impressions

The method is :-
1. A piece of inlay wax is heated in a flame and then pressed into the
prepared cavity
2. It is cooled and then trimmed and shaped to the correct shape and
Occlusion
3. Once this is done the wax is removed from the cavity using a probe or
sprue (a small length of wire) taking care not to bend or distort the wax

4.The wax impression is then securely attached to the laboratory sheet,

taking care to avoid the fitting surface and marginal edges
5. The impression is then transferred to the laboratory where it is coated
with a layer of semi-liuid material (known as investment material) which is
similar to dental plaster. This can then be cast up and the inlay prepared

The Indirect Technique

Again used for inlay impressions

The method is :-
1. An accurate impression of the prepared cavity and adjacent teeth is
taken using one of the methods described above
2. Along with these impressions a bite registration is also taken
3. Models are then prepared at the laboratory, mounted on an articulator

Now test your knowledge of this subject. Try to complete them

 without looking back at the information given in this workbook.

1. Bee-bee shears are required when the following procedure is being

carried out:
a)cutting celluloid matrix strips to length
b)shaping denture teeth
c) shaping temporary crowns
d)adjusting porcelain veneers

3. Give 4 examples of bridge design

cord is soaked in
3. Gingival retraction
_________________________________________________________and is
used to_________________________________________________________

4. Suggest 1 disadvantage for each of these types of crown

Type of crown Disadvantage

Porcelain Jacket Crown

Acrylic Jacket Crown

Full Gold Crown

5. Bridges cemented with a composite material are called

___________________________________________________________

6. Patients should be advised to clean beneath a fixed-fixed type bridge

with :
a)dental woodsticks
b)dental floss or tape
c) a toothbrush
 d) superfloss
12. Complete this chart

Details Correct dental name

The natural teeth used to
support the false teeth in a
The tooth replacing the
missing natural tooth

13. A porcelain veneer can be used to achieve a more acceptable

appearance when a tooth has been discoloured by
a) smoking
b) fluorosis
c) using a coloured toothpaste
d)poor oral hygiene

14. Give examples of the 2 types of impression materials used in prosthetics

Elastic materials Rigid materials

15. On a seperate piece of paper write out a suggested 'lay-up' for a

porcelain jacket crown preparation and impression

Make sure you include all items that you may need from the start of the
treatment through to discharging the patient

Please make sure you put your name on this work