Contents

Preface vii

Preface to t he thi rd edition

Acknowledgeme nts x

Part I Crowns

I Ind icat ions and co r nraindic attons for crow ns 3

2 Types of crown 24

J Designing crown preparatio ns 41

4 O cclusal co ns ide ra tio ns 62

5 Planning and making cro wns as

6 C linical techniques for crown co nstruction 100

Part 2 Bridges

7 Indicat io ns for bridges compa red w ith partial dentu res

and implant -re tain ed pro sth ese s 149

8 Types of bridge 173

9 Compo nents of br idges: reta iners, panties and

connecto rs 191

10 D esigning and planning bridges 207

II C linical te chni ques for bridge constru ction 222

Part l Splints

12 Fixed splints 24 1

Part 4 Failures and repair s

I] Crown and bridge failures and repa irs 2SS

Further read ing 27 5

Index 279
 Preface
Theaim of this book is to answer at leas t as many
of the questi o ns beginn ing w ith 'why' as t ho se
that begin w it h "how'. A textbook is no t the ideal
medium for t each;ng practica l. clinical or techni-
cal procedures. These are ben learnt at the ch air-
side and in the laboratory. However. the mass of
material wh ich must be learnt . usually in a
restricted timetable, in t he clinic and laborato ry
means th at there is ofte n insufficient t ime t o
answer the ques t io ns, 'Why am I doi ng this!' or,
'When should I not do t his?' o r eve n, 'W hat on
earth can I do here?'
The book is meant for clinicians. bot h under-
graduate and pos tgraduate . and so altho ugh the
emphasis is o n trea t me nt plann ing, cr o w n and
bridge de sign and t he r elated t heo ry, clinical
techniques are also described in so me detai l.
Laboratory tech nique is. th ough, almo st
completely o m itted, both to keep the book to
manageable propo rtions and because most clini-
cians no lo nger undertake th is them se lves . It is
neverthele ss abund antly clear th at a good
standard of laboratory wo rk is as important as
the other phases in th e construction o f crown s
and br idges . The process may be divided into
three stages:
Initial decisio n making and mouth prepara tio n
Clinical procedures
Technical pro ced ures.
. sho uld strive for perfe ctio n (if we kno w w hat
The pur pos e o f this bo ok is to help qu ite a lot
with the first stage, rather less w ith the second
(a boo k canno t replace clinical expe rience ) and
hardly at all w ith the third.
The inten tio n is to help solve real clinical
problems. T he st udent Sitti ng in a te chnique
laborato r-y faced w ith an arch of int act perfectly
formed natura l or artificial tee th planning to
unde rt ake 'idea l' cr o w n prepara tio ns will find
litde help he re. It may be good initial teach ing to
cut 'classic' prepa ra tions, but th is is o nly part of
the tra ining towards so lVi ng the real pro ble ms of
real patients in the real wo rld . The opi nions
expressed in a textboo k can only a go a little way
further towards solving these problems.
Und ergra du ate and po stgrad uat e students need
also to ta ke adva ntage of th eir o w n and others'
clinical e xpe rience and learn by t hinking about
t he ir clinica l problem s and ta lking abo ut them
wit h others . Making th e right dec isio n is as impor-
ta nt as e xec uting th e tr-ea tm e nt we ll.
The re is no reference to 'ca se selectio n' o r
'patient selectio n' for t he techniqu e s desc ribe d.
Tha t is no t the way things are in practice . There
it is ne ce ,sar y to se lec t the appro pr iate tec hnique
for t he patient in front o f you rath er t ha n se le ct
th e patien t fo r th e technique. Th ings are d iffe re nt
in dental schools. It often hap pen s th at in o rde r
to pr ovide a balanced range of e xpe rience for
undergrad uate st ude nts in a limited pe r iod of
time . patients are se lected to go on to pa rticular
waiting lists to provide a flow of 'clinical ma terial'
for th e st udents ' needs. This may be necessary
but the attitudes it sometimes develops are
unfo rtunate . The essential fea ture o f any profes-
sion is th at it attempts to solve the problems o f
its clients before conce rn ing itsel f w ith ItS o wn
we lfare .
Because this is th e approach, clinical
photogra phs or at least pho tographs of ex tracted
teet h or casts, are used to illustrate th e text in
prefere nce to line dra wings, except wh ere a
pho tograph is impractical. Pho tographs are used
eve n w he n th e w o rk show n is no t 'pe rfect'. No
apo logy is mad e for th is. In re ality, altho ugh we
pe rfe ction is in a give n case, an d we often do
no t), w e will frequ en tly not achieve it. It is mo re
realisti c to ta lk about levels of acce pta bility. T his
is not to ad vocate unnecessary co mprom ise, but
to reco gn ize that in many sit ua tions a co mpro-
mise (fro m knowl ed ge , not ign o rance ) is neces-
sary. Afte r all, the ideal w ould be to prevent
car ies, traum a and co ngenital deformity so that
cro wn s and bridges we re no t necessary in the
first place . O nce th ey are neede d the re is already
a situation th at is le ss th an perfect.
So me of the wo rk photographed is mine . some
is undergra duate and postgraduate student wo rk
w ith a greater or lesse r amount of help by teach-
e rs , some of the technical w o r k is carried out by
Planning and
making crowns
and bridges

Third Ed ition

Bernard G N Smith
8DS , PhD, MSc, MRD, FDSRCSEng, FDSRCSEdin

Pro fessor of Conser vonve Dentistry

The United Medical and Dental Schools, Guy's Hospitaj, London
 Preface to the
third edition
The purpose of t his book and the way it is
written remain as set out in the original preface.
The developments in this field continue apace
and are reflec te d in th is third editi o n by mo r e
than one hund red new colo ur photographs and
revisio ns to the text o f every chapter. Some of
the ea rlie r line drawings have also been re placed
by co lou r photogra phs.
Some restorations and techniques are now used
less and so the emphasis on them has been reduced
or they have been dropped altogether. This app lies
particularly to ant erio r partial crowns altho ugh the
importa nce of posterior partial cro wns remains.
N ew sections have been added on implant
retained pr osth eses. in particular emphasising
their role in t he repla ceme nt of missing teeth in
compariso n w ith bridges an d partial de nt ure s.
The level of detail is sufficie nt to assist with the
initia l t reatment plannin g process but t here is no
attempt to provide deta ils of the detailed planning
for imp lants or the ir construction which are
sub jects bey ond th e sc ope o f this book.
Another change is to put gr eater emphasi s on
fixed-mo veable designs for posterior m inimal-
preparatio n bridges an d ca ntilever desig ns for
anterior minimal-preparatio n bridges. O ther
additions include changing atti tu des towards
co mposite and porce lain ve nee rs, methods for
producing m ino r ax ial tooth mo ve me nt and
cr own lengthening procedures in treating wo rn
dentitions and the introduction of t he aut orrux
gun sim plifying t he mixing and placing of many
impressio n and ot he r mate r ials.
Some restoration s wh ich are no lo nger made
are sti ll included in relatio n to their maimenance
and repair .
 Acknowledgements
The fo llowing have lent photographs but for
reason s ex plained in the preface. specific credit
is not given to each o ne . I am . however.
extremely grat eful to t he m fo r their ge ne ro sity:
Chris Allen; David Bartlett; N icholas Capp; John
Cardwell; Russe ll Gr eenwood; l eslie Howe;
George Kantorowicz: Bernard Keise r ; O rthomax
Limited , Bradford; David Parr; Ian Potter; Joh n
Richar ds: David Ric ketts ; Paul Robi nson : M ichael
Thoma s: John W alte r; Katherine W ar ren ; Tim
W ats on.
Other help with illu strations has been given by:
Ruth Alle n; Osama Atta ; De nnis Bailey: Peter
Ch ittenden; Cottrell and Co., l ondon : Usha
Desai; Terence Freeman ; June Hodgkin; Orode nt
Limited. W indso r: Pete r Pilecki; Peter Rhind;
Nicho las Taylor: Leslie W ilcox. Bill Shar pling has
helped co nsiderably wit h t he illust ratio ns fo r the
th ird ed itio n.
Permission to re pro duce Figure 4.11, which
fi rst appeared in Rest orative De ntistry , has been
kindly given by A E Morgan Publicat io ns Limited.
Part I Crowns
 I Indications and
www.allislam.net contraindications
Problem
for crowns
Before the acid-etch retent io n syst em, co mpos ite
resin restorative mate rials and efficient, simp le pin
retention systems were developed. crowns were
the only way of res toring many teeth that can now
be rescored by these other mea ns. At the same
time. mo re patients are kee ping more of their
teeth for lon ge r and are ex pec ting faulty teeth to
be repaired rather th an ex t rac te d. The refore.
although th e re are fewe r indications (or crowning
teeth than there were, mo re teeth are actually
being crowned than ever before. About two
million crowns per year are made in the UK
National Healt h Service , representing 2-3 crowns
per week per de ntist. This figure has more than
doubled between 1980 and 1990 . Similar increases
have occurred in mos t Western co untries.
When th e only cho ice for a t ooth was a crown
or extract ion. the decision was relatively simple.
Now, with more optio ns it is more difficult. Th is
chapter discusses the current indications for
crowns and their alternatives, and guides the reader
towards a decision . However, clinical decisio n
making is the very substance of th e dentis t's work
and cannot be do ne by tex tbook inst ruct io ns: do
not expect a set of dear rules to fo llow. Each set
of clinical judgements and decision s must be unique ,
taken in the context of the patient 's circumstances .
Genera l ind icatio ns for extra-co ro nal
restorat io ns
Crowns versus fillings
Most dental res torat ions are prov ided as treat-
ment for dental caries. O nce the initial lesio n has
penetrated the enamel, the car ies spreads along
the enamel-dentine junct io n and balloo ns out in
dentine towar ds th e pulp. Th e growth of t he
carious lesio n is much faster in de ntine than it is
in e namel, so th e e name l becomes und e rmined
and then sudde nly co llapses int o the cavity.
Because of this. our fo refat hers thought that
caries started inside the tooth and worked its
way to t he surface . Today, many carious lesio ns
are de te ct ed and t re ated at an ea rly stage whi le
t he e name l is st ill largely intact. Indeed, eve n
mo re lesions are preve nted from occurring at all.
Since caries pr oduces mos t o f its damage inside
the toot h rat her th an on the surface. the
commonest type of restoration is intra-coronal.
O fte n. sou nd enamel has to be cut away to give
access to the caries. Only very rarely is the
su rface of a toot h exte nsively destroyed by caries
leaving a base of so und dentine, and it is th ere-
fore mo st unusual in t he tr eatme nt of prim ar y
caries fo r an ex t ra -coronal rest orat io n (a crown)
to be made on a pr e paratio n consisting of intact
dentine. W hen seco ndary caries develops around
existing filli ngs. intra-coronal restorations are still
more co nservative and more closely relate to the
pattern of deve lopme nt of cari es th an cr o wn s.
and are the refo re pr eferred w he never po ssible.
Indeed, a high carie s rate is a co nt ra indicat ion t o
crow ns. In th ese cas es th e caries sho uld be
re mo ved. the t oo th stabi lized and a prev e ntive
regime inst it ut ed befo re crowns are made .
With larger lesions and particularly when cusps
are lost. the decision between fi lling and crowning
a tooth beco mes mo re difficu lt (see pages 17- 20).
General indicat ions for crowns
Having esta blished t hat primary caries is no t a
co mmo n o r desirable rea so n for making crowns.
the following are the main indica tio ns fo r ex tra-
coro nal resto ra tions:
4
Indications and contraindications (or crowns

Figu r e r.1

General indications fo r crowns.

a This mouth has been well treat ed in th e past but the

restorations are now failing. In part icular the lat eral
incisor has lost two fillings. the pulp has d ied an d th e
tooth is discoloured. It now need s a crown (see Figur e
2.1;. page 27) .

b Trauma: the re su lt o f a blow from a hockey stick.

Tw o inciso rs have been lost and the upper right ce nt ral
incisor is fractured. expo sing t he pulp . t he frac t ure line
exte nd ing subgingivally o n t he palatal side . Th e lateral
inciso r is fractured involVing en amel and dentin e onl y.
The pulp retained its Vita li t y. Althou gh it could be
re stored in o ther ways, a crown wou ld be the m ost
satisfact o ry so lution since it would then mat ch th e
o the r anterior restorations . If the cent ra l incisor is to
be retained . it will ne ed to be cr o w ned. p robab ly as a
bridge abutment (see lat er).

c G ross toot h wear ar ising from a com bination of

erosio n and attrition . Th is has passed t he point w here
the patient can accep t th e appeara nce . and cro w ns are
necessary.

d A mode ra te deg ree of amelogenesis imperfecta in a

sixt een year o ld. The posterior teeth are affected more
than the anterio r teeth but th e upper incisors ar e
slightly d isco loured and are chipp ing away at the incisal
edg e . C rowns were made for all th e teeth exc ep t th e
lower inciso rs and th ese will be kept und e r re view.

e Dentinogenesis imperfecta in a te e nage patient . The

inciso r t eeth have been p rotected with acid- etch-
reta ined compo sit e from sho rtly after their eruptio n
and th e first molar tee th have been protected wit h
sta inles s-st eel crowns. It is now tim e t o make pe rma -
nent cro w ns for all the rema ining te eth.
Indications and controindications (or crowns
Badly broken-down teeth
Usually these teeth w ill have be en resto red previ-
ously, and may have suffered secondary ca r ies o r
parts of the tooth or resto ration may have broke n
off. Before crowns can be made t he lost de ntine
will usually nee d to be rep lace d by a suitab le co re
of restorative material (see Figure 1. 1a).
Primary t rauma
An otherwise-intact toot h may have a large
fragment br ok en off w ithout damaging t he pul p
and leaving sufficient dentine to suppo rt a crow n
(see Figure I.l b).
Tooth w ear
The processes of erosion (damage from acid other
than that produced by bacteria), attrition (mec han-
ical wear of one tooth against anothe r) and abras ion
(mechanical wear by ex traneous agents) occur in all
patients. What is remarkable is t hat teeth, which
have little capacity for regen e ration and w hich are
in constant use, do not wear out long before t he
patient dies. Altho ugh tooth wear is no rm al, if it is
excessive or occurs early in life, crowns or o ther
restorations may be needed (see Figure I. lc).
5
f Peg-shaped upper lateral incisors.
g Typical distribut ion of enamel hypoplasia, in this case
due to typhoid in the patient' s early childhood.
T he life lo ng manageme nt of excessive tooth
wear is a topic of increasing inte rest as patient s
ke e p the ir teeth longer. In ge neral th e appro ach
sho uld be :
• Earl y diagno sis and preve ntion
• Moni t o ring any further progression until t he
patie nt com plains of the ap pearance , sen sit ivity
(w hich does no t respo nd to othe r treat me nt ),
function is affected, or t he w ear reaches a
po int w here restoration s w ill bec ome tec hni-
ca lly difficult
• At this point pro vide minimal rest o ratio ns
• If t he prob lem co nt inues, pr-ovide crowns.
Hypoplastic conditions
T he se may be subd ivide d int o hereditary and
acq uired de fec ts . Examp les of the for mer are
ameloge nes is imp e rfecta (se e Figu re 1.1d) ,
dentinogen es is imperfecta (see F igur e 1.1e) and
hypodontia (for exa mp le peg-shaped upp er lateral
inc iso rs - se e Figu re 1.1 f). Exam ples o f acquired
defects are fluo ro sis, tetracycl ine stai n and enamel
hypo plas ia res ult ing fro m a major metabolic
disturbance (usually a childhood illnes s) at t he age
whe n t he e name l was develo ping (see Figure
1.1 g).
6 Indications and conf roindico tions (or crown!
To a lte r the shape or siz e or inclination
of teeth
Major cha nge s in the po sition of teeth can be
made o nly by o rt ho do ntic t rea tme nt, th ou gh
mino r change s in ap pearance can be ac hieved by
'cro w ns. T eeth ca n be mad e larger bu t no t
usua lly sma ller. Fo r exa mple. a diastema
betwee n teeth w hich t he patie nt find s unattrac-
t ive can be closed by mea ns of ove rs ized cr ow ns
(see Figur e 1.2).
To alter the occlusion
Crowns may be use d t o alter the angulati on o r
o cclusa l rel ati onships of ante r io r and post eri or
teeth as part of an occlusal reco nst ruct ion eit he r
to so lve an occl usa l pro blem or to impro ve
functio n (see C hapter 4).
A s part of another r estoration
Crowns are made to suppo rt bridges and as
com po nents of fixe d sp lints. Th ey are also mad e
to alter t he alignme nt of t ee t h to pro du ce guide
plan es for partial dentures or to car ry precisio n
attac hme nts for precision attachme nt retained
parti al de nt ures (see Parts II and III ).
Figure 1.2
C hang ing the shape and size of teeth.
Q A large midline d iast e ma th at t he patient found
aesthetically unacceptab le.
b The sa me patie nt after the central inciso rs have been
moved clo se r t ogethe r o rthodontically and all four
incisors crow ned . Th e patient m ust be w arn ed of any
compromise in the ap pearance that is anticipated - in
th is case the tri angular space t hat rem ains at the
midline. It is po ssible t o increase the width o f th e incisal
edges to fill t he space, but the w idth of the cro w ns at
the neck is determined by the width of th e roots. so
that o nly minimal e nlarge ment is po ssible without
creating uncle ansabl e overhanging crown margins .
Combin ed indications
More than o ne of the se indicatio ns may be present
so t hat, for exa mple, a broken -down posterior
tooth t hat is over-erupted and t ilted may be
crowned as a repair and at the sam e time to alter
its occl usal relat io nsh ips and its inclination , pr ovid-
ing a guide plane and rest sea t for a partial de ntu re
Multiple crowns
W ith some of th ese indicati on s. notably tooth
we ar and hypopl astic condit ions. ma ny or all of
th e teeth may need to be crowne d.
Appearance
O ne of t he pri ncipal reasons for patien ts seek ing
de nt al t re at me nt is to maint ain o r improve their
appeara nce . Relati ve pr ospe rit y, changing social
attitu des and t he success of mo de rn dental
materials mean that ex pecta t ions of go o d dental
appeara nce are rising. Few e r teet h are being
ex tracted, and when th ey a re it is at a later age,
It is mu ch le ss common no w to see a mout h such
as show n in Figur e 1.3 t han it was in t he mid
I96 0s, w he n t his photogr aph was t ake n.
Indications and co ntrai ndication s for cro wns
Figure 1.3
An att ractive appearance spoiled by unsightly teeth .
As sta ndar ds of appearanc e and expectations
rise, som e denta l defects, or types of restoration,
which at o ne time wo uld ha ve be e n tole rated, ar e
no longer acc eptable t o patients.
Co mposi te and glass io no me r restorati ons.
which have improve d cons ide r ably, st ill tend. afte r
7
Figure 1.4
The appearance of co mposite res toratio ns.
a The cent ral incisors fractured in a riding accident
eight year s previo usly. The initial co mpos ite restora-
tions were placed by the patient' s mother. a general
dent ist . They were subsequently rep laced. once by a
specialist pract ition er and once at a dental school. The
compo sites show n had been in place for three years,
and the patient was now 21 years old. She refused to
co nsider furth er attem pts at com pos ite res torations.
and crowns we re made.
b Com po site resto rat io ns to ero sion lesions at the
necks of the upper right centra l and late ral incisors, the
canine and first premolar. These have been present for
18 mo nths and are maintaining their appeara nce.
a few year s in t he mouth, t o wea r o r stain, o r
t he margin s begin to lo o k unattractive (see Fig ure
1.4). In some o f t he se cas es, ev e n t hough th e
fillings are more o r les s sat isfact o r y. the pat ie nt
may be justifie d in dem andi ng cro w ns for t he sak e
o f appearance .
8 Indications and cotvrocvdicauoos (or croWn!
In several of the general indicat io ns listed
ab ov e, for e xample. tetracycline st ain and mid-
line dia st em as. th e only reason for con sidering
c row ns is to change th e patie nt' s app earan ce. In
oth ers, for e xa mple fr acture d incisal edg e s and
t o oth w ea r, there may be other problems such
as sensit ive ex po sed den tin e or fun ction al d iffi-
cul ty as we ll as th e need t o re sto r e a ppear ance .
Appearanc e is important t o th e patient and
must t herefo re be important t o the dentist. After
t he r elief and preventio n of pain and infect io n it
is probabl y the next most important reaso n for
pr oviding de nt al treat men t.
Function
W ith mod ern cooked diets it is pos sible to mast i-
cate - and spea k - w itho ut any teeth, or wit h
co mplet e dentures, but most pat ien ts (and proba-
bly all de nt ists) wou ld not wa nt t o . As w ith
appeara nce , th is is again a quest io n of th e quality
of life. An occl ud ing set of natural, o r second
best, re stored t eeth is bette r at co ping wit h a full
va ried range of diet th an dentures.
Rest o ring fun ctio n is part of t he reason fo r
several of t he ge ne ra l indicat ions above suc h as
t he re st oration of bad ly br oken down te eth,
tooth 'wear, and providing suppo rt for bridges or
par t ial de nt ures.
Mechanical problems
Som etimes, althoug h it wou ld be po ssible to
resto re a tooth by mea ns of an Intra-cor-onal
rest orat ion , the patte rn of damage to t he tooth
gives rise t o anx iet ies abo ut t he retenti on of th e
rest o rati o n, the st re ngt h of th e rema ining t ooth
t issue, or t he st re ngt h of t he resto rative material.
Fillings fail becau se th ey fallo ut, be cau se of
se co nda ry caries, o r bec ause part of th e tooth
or part of th e re storatio n fractures. Th ese
failures are upsetting t o th e patient and emba r-
rassing t o the dentist, an d it is .th erefore tempt -
ing to prescr ibe crowns w he n there is even a
faint possibility th at o ne of these probl em s ' will
arise.
Ho we ver, crowns can also fail. If a filli ng fails,
it is oft e n po ssible -t o make a more ex te nsive
restoration or a crown . If a cr own fails, a furt her
cr own may not be po ssible and ex t rac t ion may
be all that is left .
In dec iding between a crown and a filling th ere
a re t wo co nsideration s to be weighed up . First
how re al is th e risk of mec hanical f ailure of the
filling or surro und ing too t h 'and wh at can be done
t o m inimize t his risk? Seco nd, how mu ch mo re
des truct ion of so und t o oth tissue is necessary to
make a cr own?
In ge neral, it is bette r to take th e more co nser-
vative approac h first, eve n if th is involves some
ris k of t he rest oratio n failing.•Th e alternative is to
provide far more crowns t han are strictly neces-
sa ry and perhaps give rise to even greater
probl e ms fo r t he patient late r on .
Indications for anterior crowns
Caries and trauma
All t he gen eral indications list ed above may apply
t o ant e rio r cro w ns. Before th e days of acid-etch
ret ained co mpos ite res torat ions o r glass
ion omer cemen ts, anterior crowns were
indicat ed much mo re fr equently for t he re sto ra-
tio n o f carious or fractured incisors. To day many
o f t hese te e th can be restored wit ho ut crowns:
t hes e are oft en not need ed until the pulp is
invo lved (se e Figure s 1.1 a, b).
Non-vital teeth
W hen a pulp becom es necr ot ic the toot h ofte n
discolours due to t he hae mog lobi n breakdown
products. This disco lou ratio n may be such th at it
can on ly sat isfacto rily be obscured by a crown
(se e Figure 1.5).
Tooth wear
Th e ideal approac h to problems of too t h wear
is t o preve nt the co nditio n getti ng worse by
iden t ifying th e ca use and elimin ating it as early
 Indicavons and controindicarlons for crowns 9

Figure 1.5

Th e ce nt ral incisor has a ne crot ic pulp and is grossly

d iscolo ur ed . This degre e of discoloura tion could not be
re solved by bleach ing or veneering th e t oo t h. The
periodonta l co nditio n must be impro ved before a
crown can be made suc cessfully.

as possible. Crowns should be made only w hen be costly if they ar e possible at all. However, if
the cause of t he to o t h wear ca nnot be ide nt ified after pr oper co nsideration crowns are made, th e y
or cannot be e liminated, and the damage is can dramat ically improve th e patie nt's appearance
serious. Somet imes th e rate o f tooth w ear slows in a way t hat is impo ssible by any othe r fo rm of
down or stops with no o bvious explanation and t reatme nt.
the teeth re main stable for some year s. Crowns
are not a goo d preve ntive mea sure e xce pt as a
last res ort.
To alter the shape, size o r inclination
of teeth
Hypoplastic conditions Again, treatme nt is fre que nt ly so ught at an rea rty
age an d is like ly to be com bined with orthodon-
In many of th e hypop lastic conditions th e patient tic treatment (see Figure 1.2).
(or parents) will seek treatment at an ea rly age,
often as soo n as the permanent teeth erupt. and
treatment may be ca rried o ut in co njunct io n with
orthodontic treatme nt . In some of these cas es
large numbe rs of teeth are affect ed . and so t he
As part of other rest orati ons
decision whe ther t o cr own t he m, offer some
Anterior crowns are often made as co mpo nents
alternat ive for m of t reatment, or simply leave t he
of anterior bridges and splints . They a re less ofte n
condition alone, is a fairly mo men tous o ne. Figure
needed to 'IoUppOf"t part\a~ de.ntur e'Io. Bddge.'Io and
1.6 shows several cases of tetracycline staining
splints are dea lt with in Parts II and III.
affecting many te eth. Diffe re nces in the lip
morphology. the depth of unifo rm ity of th e
colour. and th e pati ent's age and gen eral attitude
will all influence the decisio n. In t he last case illus-
trated, 16 crowns have been provided to disguise What are the altern atives to
the colour in all t he visible teet h. This is a consid- anterior crowns?
erable undertaki ng and shoul d not be e mbar ked
upon lightly by either patient o r dentist. In partic- Bleaching
ular with yo ung patients, the lifelong maint en an ce
implicat ions must be fully unde rs too d. It shou ld Som e teeth disco lo ured by a nec rotic pu lp can be
be explained that cr owns are unlikely to last th e bleach ed with hydrogen pe ro xide o r o t he r ox idiz-
(
whole of a natu ra l life t ime and replacements will ing agents (see Figure l.Za.b).
(
10
... _... ...
I lower lip covered th e gingival half o f t he lo we r inciso rs.
Restorations in composite materials
or glass ion o m er cements
The appearance o f mod ern aesthetic restorat ive
materials can be excellent (see Figur e l Ab).
Altho ugh they sometim es deterio ra te t o give the
sort of appearan ce also show n in Figure l.4 a. it
is of co urse pos sible to rep lace the m. usually
without destroying very much mo re tooth tissue.
It ca n be argued t hat wit h ra pid development of
anterio r rest orat ive mate rials, it may be pr efer-
able to re place co mpo site rest o rat ion s unti l such
time as a more durable material is available rathe r
tha n make crowns . The pr oblem is that many of
t hese patients are yo ung. attractive and mo re
Indications and contfQindications (or crowns
Figure 1.6
Tet ra cycline stain
a Mild. uniform sta ining. It is unlikely th at t reatment
will be necessary o th er th an to re place th e missing
lateral inciso rs .
b Tet racycline staining wit h severe band ing. The ex te nt
of treatment depends on th e lip line. In th is case the
and t he re fore treatment fo r t he lower teeth was not
nece ssary.
c Darke r but more uniform tetracycline staining. In t his
case a vita l bleac hing technique was used .
co ncerned wit h their appeara nce now tha n abo ut
long-term maintenance pr obl e ms wit h crowns.
It is clea r that no absolute rules can be give n
o n wheth er crowns or fillings are indicated ot her
t han to say that in ge ne ra l the mo re co nservative
pro cedures are to be preferred.
Gold ar porcelain inlays
Befo re t he adve nt of acid-e tc h re tain ed compos-
ite materials. t he co nve ntio nal way to rest o re a
fract ured incisal edge was by means of a Clas s IV
go ld inlay wit h or wit hou t a facing (see Figur e
Indicotions and contraindieations (or crowns
;
-,
l.7c). The alternative. if th e appea ran ce o f go ld
or the facing mate rial was not acce ptable. was to
make a crown . Today. acid-etch retained compos-
ite restorations have co mpletely re placed Class IV
gold inlays.
Similarly, porcelain inlays for Class V lesions
have also almost completely disappeared. This
is not because they were unsatisfactory in
appearance but because laboratory costs and
the time involved were much greater than for
composite or glass ionomer restorations.
However. there are tim es when a really durable
restoration that will not wear or discolour or
alter its surface texture may be an advantage
(see Figure 1.7d) .
II
d Extreme tetracycline sta ining with banding.
e Darkly stained teeth with fo ur teeth prepared for
crowns.
f Sixteen crowns made fo r th e patie nt shown in e. The
shade is too unifo rm and light, but thi s was at the insis-
ten ce of t he pat ient, who has rem ained hap py w ith the
appearance fo r several years. Tod ay, veneers wou ld
prob ably be used ra ther tha n crowns.
Veneer restorations
The earliest venee r restoratio ns were made from
polyacrylic and were preformed. They provided a
reasonably satisfactory and less destructive
solution to many of the problems described
earlier. in particular where multiple restorations
of inta ct teeth were needed. for example in cases
of tetracycline stain. These polyacrylic veneers are
no longer made and have been replaced by better
materials. However. some patients still have them
in place, and t hey need to be recognized and. in
most cases, re placed (see Figure 1.8a, f-I).
There is now a cho ice between two mat erials
for vene~r restorations: composite and porcelain.
 12 Indications and contra;ndications (or crOWIli

Figu r e 1.7

Alternatives to crowns
./
a A d isco loured, non-vi tal low er central incisor .

b The tooth shown in Q bleached to pr oduce a satis

factory appearance.

c A Class IV gold inlay and tooth -col oured facing. Tbi

is wearing and the res toration is unsightly, but it WI
placed many years befo re co mposites wer e availabt
and has given sat isfact ory serv ice. Th e othe r cent n
incisor has a PJc.

d Porcelain inlays res toring th e fo ur upper teeth eM

th e left . Similar re st o rati ons are to be ma de fo r th
right sid e. C ro wns wo uld be extremely difficu lt in tIi
case; co nside r. for exam ple. th e sha pe of the pre pan
tion for the uppe r right lat eral incisor. C om po site 0
glass io no mer cemen t restorations could be made btl
would need constant maintenance and p ro bably pence
leal re place me nt . Po rcelain inlays are like ly to be mor
dura ble.
 IndlCotJOns and contraindi<a[ions for crowns 13

Figure 1.8

a Po lyacrylic venee rs that are failing after several years

in the mouth . T he margins are staining and chipping.

b Brok en and e rod ed inciso r teeth .

c The same pat ient as shown in b with co mpo site

veneers th ree yea rs after being placed .

d Eroded upper central incisors.

www.allislam.net
Problem
14 Indications and controindieotions for croWlll

e Th e same patient as sho w n in d with two por celai

veneers in place.

f The same patien t as shown in Q with the po lyacryl

veneers removed and th e te eth reprepar ed.

g An in ci sal view of the prepared teeth.

h Porcelain ven eers on t he model for the pane

sho w n in f and g.
Indications and controindicotions (or crowns IS

i The etched fit surface of the porcelain veneers.

j The teeth have been isolated wit h acetate strip and

are about to be etched wit h phosphoric acid gel.

k An incisal view of th e porcelain ve neers in place. In

th is case it was necessar y to car ry t he po rce lain over
th e incisal edges beca use this had been don e with t he
previou s ven eers. When po ssible, cove ring th e incisal
edge sho uld be avo ide d since t his pr ob ably pro duces a
st ro nger restoration .

I The com pleted porcelain veneers.

16
Bo th systems can be used after simply acid-
etc hing t he enamel, or some preparation of t he
en ame l may be first carried o ut. It is easier to
produce a feather edge at t he gingival margin of
an unprepar ed tooth with co mposite than it is
w it h po rcelain, and t his is regard ed as o ne of
the advantages of com pos ite o ver porcelain if
a re latively no n- int erven t io na l approach is
prefe rred. This mea ns that composite venee rs can
be placed as a pr o vis ional res toration so that the
patient can see how much t he appearance is
improved. If the enamel has not been prepared.
this is a completely reversible procedure. and so,
if there is any doubt about th e wisdom of going
ahead wit h porcelain veneers, trial co mposite
veneers are to be reco mmen ded. The other
advantages of co mposite are that the venee rs ar e
simple a nd qu ick to apply at the chairside and
requ ire no labo rato ry pro cedures. They are
th e refore much less expensive. Th ey can also be
re paired and adapted. On t he other hand.
composite materials sometimes discolour and
wear and it is difficult to prod uce a . graduated
colour along the length of the tooth or to mask
a deeply discoloured underlying tooth (see
Figures I.Sb,c).
Po rcelain ve nee rs have beco me very po pu lar in
rece nt yea rs and have bee n succe ssful in so lving
so me probl ems . How ever, they ar e nearly as
ex pe nsive as cro wns, and alt ho ugh less e namel
nee ds to be rem o ved than for a crown, the fit at
t he gingival margin is often less satisfactory than
with a crown and t he re is anxiety about the diffi-
culty of cleaning adequately the awkward junction
between the porcelain and enamel at the approx-
imal surfaces (see Figures I.Se, k, I).
Some medium-term st udies of po rcelain
veneers have now bee n re po rted and it may we ll
be t hat the po rcelain veneer will be increasi ngly
used instea d of crowns, Although these st udies
show reason ably good res ults fo r porcelain
veneers, in one typical stu dy of veneers placed by
undergraduate de nta l students t he success rate
was o nly 73% after 4 years.
Po rce lain veneers should, if possible, be
bonded to enamel rather than dentine. In the case
of the upper right central incisor shown in Figure
I.Sd this was possible, but a large pa rt of the
labial surface of th e upper left ce ntral incisor was
e ro ded through to dentine. When this is the case
t he pr ogno sis fo r a po rcelai n venee r is less good
than when an intact e namel surface can be
Indications o" d contraindica rions for crowns
preserved after tooth preparation. Howeve r, if a
rim of enamel remains, as is the case in Figur e
I.Sd, th e n eit her t he de ntine surface may be
covered wit h a thin laye r o f glass ionomer cement
o r a de nt ine bo nding age nt may be used .
A numb er of different ways have been suggested
fo r preparing teeth for ven ee rs, the most common
of these is illust rated in Figure 1.9a.
Indications for posterior crowns
Restoration of badly broken-down
teeth
Th e mo st co mmo n indication for a pos te rior
crown is a badly br ok en-down to oth usually
res ulting from re peated restorations, eac h of
which fails in turn until finall y a cusp or lar ge r part
of the tooth fractures off. In almost all cases it is
necessary to build up a core of amalgam or other
material, usually retained by pins, before the
crown is made . Two such teeth are shown in
Figures 1.1Dc and d.
Restoration of root-filled teeth
The re is a stro ng clinical impression and some
scientific evidence t hat root-filled teeth are more
likely to fracture than teeth with vital pulps. It
follows that some thin and undermined cusps of
root-filled teeth need to be protected or
removed where similar cusps in vital teeth wou ld
be left. Together with th e original damage that
necess itated the roo t filling and the access cavity,
t his mea ns that many, but by no mea ns all, root-
filled post erio r teet h are cro wned. Th e fact that
a posterior too th is ro o t-filled is not in itself suffi-
cient justification for a crown.
As part of another restoration
In Parts II and III partial and complete crowns are
disc usse d as retainers for bridges and fixed
sp lints. In addition, they may be indicated in
co njunction wit h co nventional or precision-
attac hme nt retai ned part ial dentu re s.
 Indications and contraindicatians (or crowns 17

,
t

j
1

r
Y
,f
't
s
r Figure 1.9
e
n o A sectioned upper central incisor b A view through the confoc al c A porcelain venee r which has
tooth. Left the intact tooth . right the microscope of the margin of a been sandb lasted too much in its
tooth has been prepared for a porce lain veneer. Fro m the le ft the pre paration leaving the margin
veneer and the profile of the veneer, the luting cement, ename l deficient.
veneer is illust rated in wax. The and dentine. This is a good fit.
features of this preparatio n are that
the gingival margin is chamfer ed and
e is in enamel and the incisal edge
e preserves the bulk of the natural
It tooth. Had the incisal edge been
,f more worn the venee r prep arat ion
.r could have been taken ove r it.
d
It
y.
t-

,-
It

What are the alternatives to Pin-retained amalgam restorations

posterior crowns?
Figure 1.1 I a lso sho ws an exce llent ama lgam
Gold inlays restorat ion, whic h has also be en present fo r man y
years. A crack is visible on the m e sial pa latal
-e
figure 1.1I shows a gold inlay that has been aspect of this tooth ; this has also been present
,d
present for ma ny years. It would clearly hav e for some years. The tooth is symptomless and
in
been wro ng to ha ve d estroyed yet m ore o f t his remains vita l. It cou ld be argued that all teeth
n-
tooth in o rd e r to make a c ro wn. w it h large lesions, s uch as thi s on e, sho uld be
18 Indications and contraindicotions (or cr OWI11

Figure 1.10
Badly br o ken -down t eeth t o br
restored. Left: the toot h or
pre sentation. Right after remov
iog o ld restorations , caries and
grossly over hanging enamel.
Only at t his stage can a fin31
dec ision be made on the most
suitable restoration . These tee th
would be treated with:
Q a pin-retained amalgam
restoratio n;

b a gold inlay with cuspal

protection or a glass
ic no mer/ co mp o sit e layered
restoration to st re ngt hen the
cusps;

c a pin- o r po st -r etained core

and partial crown;

d a pin- o r po st- retained core

and co mplet e crown.
Indications and contraindications (or crowns
crowned in order t o prevent suc h crac ks o ccur-
ring. Howeve r, it is impo ssible to pr edi ct which
teeth will crack and what the effects will be. It is
therefo re not justified to cr own all te eth with
large cavities just as a pr eventive mea sure. To do
so is ove r-treatme nt and is no t cos t-effec t ive. It is
bette r to app ly a ge ne ra l policy of minimum inter-
vention, with prophyl actic res to ra tio ns o nly w hen
there is a clear risk of failure. When occ asional
fail ures, such as br o ke n cusps, do occ ur , t hese
problems can usua lly be so lved without the need
for extract ion .
Toot h-colo ure d posterior restorations
Com posite mater ials suitab le fo r poste rio r
restora t ions have been deve loped inten sive ly in
recent times. O ne reaso n fo r this is increas ing
anxiety in some par ts of t he world and in some
patients abo ut t he wisdom of co nt inuing to use
amalgam restorat ions in view of t he possible risk
of mercu ry t oxicity o r allergy. Th e subject has
received much atte nt ion in th e popular press and
in the rest of t he media. The scie nt ific evide nce
is that me rcury allergy does exist in a ve ry sm all
proportion of the po pulation , althoug h in so me
parts of t he wo rld, for e xample Japan, it appears
to be greater, prob ably due t o pat ients be ing
sensitized by eating fish conta minate d w ith
mercury t hat has got into th e marin e fo od chain.
Mercury toxicity is a pro per co ncern of
dentists, and ove r th e last 30 years o r so consid-
erable impr oveme nts have bee n made in me rcury
hygiene. Most amalgam use d now is capsu lated,
Figu re 1.11
Amalgam and go ld re st oration s. The inlay in th e secon d
molar has been pr ese nt fo r 20 years and the amalgam
in th e first molar , wh ich has just be en rep o lished, for
15 years. Th e amalgam re storat ion s in t he premo lar
teet h are more recent, and le ss sat isfactory.
avo iding t he need for liquid mercury to be avail-
ab le in bulk in th e dental surgery, and othe r
precaution s a re also used t o protect the st aff in
t he dental surge ry. It is th e staff, who are likely t o
be expo sed over a lo ng period to mercury vapo ur
sho uld me rcury hygien e not be ade quat e, who are
at risk rath e r t han individual pat ien ts. Th e re is no
re liable scient ific evide nce t hat th e me rcury fro m
amalgam rest oration s is a seri o us tox ic hazar d to
patients, desp ite o ccasio nal flurries of media hype.
It is also po ssible that t he alternatives to amalgam
may have equall y low levels of t ox ic effect.
Ne verthe less t here ar e some patien ts who will
now re fuse t o have amalgam rest oration s, and
hen ce t he re has bee n a drive to de velop sat isfac-
to ry, cost-effect ive alternatives fo r t he restora-
tio n of po steri or teeth. The mat e rials a re
improv ing yea r by year , but so me de ntis ts sti ll fee l
th at t hey are not yet co mparable to amalgam for
t he larger po st eri or re st o ratio n. T hese de ntist s
will th erefo re mo re com mo nly pr escribe crow ns
t han com pos ite rest o ration s in teeth t hat wo uld
othe rw ise be treated with an amalga m restora-
tio n. for exa mple t he tooth shown in Figur e
I. lOa. Th e t ooth shown in Figur e 1.1 0b stil l has
substa nt ial buccal and palata l cusps and a good
ridge of de nt ine betw een t he m. Howeve r, if the
tooth is subject to occ lusal st ress (and wear
facets can be seen on t he cusps) then a resto ra -
t ion e ither prot ecting or re info rcing t he cusps is
indicat ed wit h t his amo unt of tooth loss.
The re is good evidence that t he layered
restoration (a core of glass ionome r ceme nt
re placing t he de nt ine, with an occl usal surface
venee re d w ith a poste rior co mpos ite) is success-
ful in binding wea ke ned cusps togethe r and
20 Indicotions and comraindications (or crowns

Figure 1.12

a A failed MO D amalgam restoration with secondary

caries beneath bo th the boxes. The mesial surface of
the amalgam was also unsightly .

b A laborat ory proce ssed co mpos ite inlay short ly after

inser t ion.

c The same composite inlay after eight years .

Indications and contr oindicorians (or crowns
producing a st ron ger tooth th an o ne rest ored
with amalgam alone. This res torat ion is t he re fo re
being used increasingly instead o f t he MOD gold
inlay wit h cuspal cov e rage . It is. however. not a
substitu t e fo r a crown, and it is use d w he n there
is a large MOD cavity wh e re a cro wn pr ep ar ation
would simple re move all th e remaining to o th
tissue.
In an attem pt to increase wear resistance and
to minimize th e effects of po lyme rizat io n contrac-
tions, syst ems have bee n developed to process
compo site inlays o uts ide t he mo uth by a com bi-
nation of heat . press ure and light. O ne system
consists in preparing a non-undercut inlay cavity.
lubricat ing it and filling it with a light-cured
composite mate rial. Th is is cu red and then
removed from th e mo ut h and furt he r pro cessed
by heat and light in a piece of eq uipment in the
surgery. It is then ce mented wit h more compos-
ite resin. In other cases an impression is taken of
the prepared tooth and the composite inlay (o r
anlay) mad e in the labo rat o ry (see Figure 1.12 ).
Ceramic inlays
Posterio r ce ramic inlays have many of t he advan -
tages of pos terior co mposite restorations in that,
because they are bonded by the acid-e tched
system. they strengthen weakened cusps, an d
they are tooth -coloured. However. the porcelain
occl usal surface is more wea r-resista nt tha n
composite and t here is, of course, no po lymer-
ization contraction. As w ith composite inlays,
there are tw o systems: one that includes a labora-
tory stage and one that does not. W ith labora-
tory-made ceramic inlays. an impression of the
prepared toot h is se nt to th e labo rato ry and a
porcelain inlay is made by conde nsing po rcelain
into a refractory die of the tooth (sec Figure
1.1 Ja).
The chairside system co nsists in milling a
porcelain inlay from a des ign pro duced in a
compute r from a three-d ime nsional video image
of the prepa red tooth. Natu rally th is requires a
very comple x. sophisticated and expensive piece
of equipment (see Figure 1.1 3b). It is too soon to
say whether this ap proach to dental restorations
(CAD/c AM or com puter-aided design /co mputer
aided manufactu re) will be rev o lutionary or will
stay on the fringes of de nta l treatment.
21
Choosin~ the right posterior
restoration
In some of the teeth shown in Figure 1. 10 the
failure is due t o the restorat ion fract uring o r
bec omin g lost and in o t he rs it is th e too t h its e lf
that has failed. In so me t he pr o blem is seconda ry
caries. In all these cases decisio ns must be made
between restoring or extracting the tooth. and if
it is to be resto red . whe t her the pulp is hea lthy
or whethe r en do do ntic t rea t ment is necessa ry.
Leaving t hese consideratio ns to be disc usse d in
C hapter 3. and ass uming that all t hese teeth will
be restored. the next decision is whether the
appro priate restoration is:
• An ama lgam, co mpos ite or glass ion orne r cement
• A layered re storatio n of glass ionomer and .
composite
• An amalgam with addit io nal retention (for
example pins)
• A ceramic inlay
• A go ld inlay
• A go ld inlay with oc clusal pr o te ct ion (an o nlay)
• A partial cr own
• A co mplete crown
• A core of materia l to re place t he missing
den tin e follo wed by a partial crown
• A core and complete crown .
A further decis ion that must be made is whether.
if a co mplete crown is to be used . it .should be
an all-meta l or a metal- cera mic crown, or even
in som e cases an all-porcelain cro wn (see
Chapter 2 fo r a description of t hese diffe re nt
types of crown).
These decisions cannot be made without
further informatio n, and so me of this will be
gat he red fro m the histo ry. examination of the rest
of t he mout h, rad iographs. and so o n (again, t hese
matters will be discu ssed in Chapter 3). Howeve r.
eve n with all th is infor matio n it is usually also
necessary to remove th e existing restorations and
caries befor e a final deci sion can be made; Figur e
1.10 shows t he same te et h befo re and after t he
car ies and old restorations are rem oved.
The decision de pends upon three fact o rs:
• Appearance
• Pro ble ms of rete ntion
• Pro ble ms of stre ngth o f t he re maining tooth
t issue and t he restorative mate rial.
22 Indications and contraindications (or crt

Figu r e I~ 13

Q A laboratory-made ce ram ic inlay. Th e inlay

retu rn ed fro m the labo r ato ry w ith a conto ur
occl usal surface and oc clusal staining. It shou ld or
re quire cem entat io n.

b Th e Cerec ma chine . The miniature vide o cam era j

o n th e left. th e com puter and monit o r in the centr
an d the t hree-d imensi o nal milling ma ch ine on t he r ighl

c A failed co m po site res tora tion in the first premolar

to o t h is to be r e placed by a ceramic inlay.

d Th e comple te d ceramic inlay milled at t he chairside

in the Cerec machine. The mac hine pro duce s a good
fit and co ntact points that o nly require min or adjust.
ment and polishing. Ho weve r. t he oc clusa l surface is
not finished, and needs t o be adjusted and polished in
th e mouth after ce me nta tio n. T he main advantage of
the sys tem is t hat the w hole pro cedu r e is carried out
in one visit at t he chairsi d e an d th ere are no labora-
t ory stage s.
IlIdications and contra;ndications for crowns
As far as appearance is concerned. if the surface
of the tooth to be restored is visible during
common movements of the mouth. and if the
patient is concerned about appearance. a ce ramic
inlay, compos ite restoration or crown will usually
be indicated fo r large restorations .
When the problem is simply one of retention.
an amalgam restoration with additional retentive
features is usually chosen (see Figure I. 1Oa).
When the remaining tooth tissue is weak. a
layered restoration, a ceramic inlay or a cuspa l
coverage gold inlay w ill be the choice (see Figure
1I 0b).
A core and partial crown is a very satisfactory
restoratio n where a tooth previously restored
with an MOD amalgam loses its lingual or palata l
cusp. The partial crown protects the remaining
buccal cusp against occlu sal forces. and this cusp
Practical points
• Primary caries is usually best treated by intra-
coronal rather than extra-coronal restorations.
• Crowns are made to improve appearance and
function (often in that order).
23
can still provide valuable retention. often in
con junction with pins. for the core. as well as
having an acceptable appearance. If a complete
crown is made, particularly with facing. t he n t he
whole, or t he majority of the buccal cusp will be
cut off in t he preparation of the tooth, and th e
core will need much more substantial auxiliary
retentio n (see Figure 10c).
A core and complete crown is the last resort.
Figure 1.IOd shows a case where there is no
choice but to pr ovide a core and compl ete
crown.
These examples illustrate the importance of
considering all the alternatives in each case . The
temptation to look rather casua lly at th e to oth
and immediately dec ide upon a crown without
proper investigation and consideration must be
avo ided.
• Alternatives to crowns should always be
considered, and are often used in pr eference,
where practicable.
2 Types of crown

This chapter gives a ge ne ra l descriptio n of th e Th e traditio nal feldspat hic PJC is made by adapt-
various crown types together with t heir main ing a very thin platinu m foil to a die made fr om
advantages and disadvantages in re lation to: an impression of t he pre pared toot h. Po r celain
\low der ~ mi.xed with water or a special fluid, tS
• Physical properties built onto the platinum foi\ and {\'I"~ -n, ~.
• C linical co nsider at io ns furnace. All PJcs made in this way are M'ti
• Appea ra nce stre ngthened by having alumina incorporated into
• Cost
the porcelain powder. A core of high-alumina
porcelain is fired onto t he platinum foil. This high.
C ro wn s are describ ed under t he following alumina co re is opaque and needs to be covered
t\~a.\(\,&'l.... ~., -n«:J\ ..e,. ""\r4\i5.'N\...~"'- ¥"'....~ ~"'- ~'C'i\u.\W~ (en
alumina.
• Ante rior com plete crowns for vital teeth Conventional dental porcelain is physicall)
• Anterior crowns for root-filled teet h more like glass tha n the porcelain used fo/
• Anterior partial crowns domestic purposes. It is relatively brittle. anc
• Posterior com plete crowns before a PJ C is cemented it can be broken fai r~
• Posterior partial crowns easily. However. once it is cemented and
supported by the de ntine of the tooth, the force
req uired to fract ur e it is o f the same order oj
magnitude as the fo rce req uired to fracture the
Anterior complete crowns for vital enamel of a natu ral tooth.
teeth In rece nt yea rs there have been tw o develop.:
me nts in porcelain jacket crowns. The first is the
In t he anterior part of t he mo uth appearance is advent of castable ceramic systems and the
of overriding impo rtance. and so the only types second is the introduction of differe nt types 01
of crown to be considered are those with a porcelain that are fired directly onto a die made
tooth-coloured labial or buccal surface. These fall from refractory material.
into three groups: In the first of the widely available cast cera rra
systems a wax pattern of the crown is made 01
• Po rcelain jacket crowns a conventional die. invested and cast in ,
• Meta l--eeramic crowns glass/ceramic material. The casti ng is then placer
• Other types of crowns in a ceramming ove n for several ho urs. durin~
w hich it goes t hro ugh a crystallizat ion co nversion
and bec o mes muc h stronger. At this stage the
Porcelain jacket crowns (P}cs) cast ing has a clo udy-dear appearance (similar to
(see Figures 2.1a, b and c) frosted glass). It is therefore sta ined and charad
terized using co nventiona l feldspat hic porcela ins
This is the oldest type of tooth -coloured crown in a porcelain furnace. Although the commercial
and has now been in use for the best part of a available system was developed by the sam!
century. It consists of a more or less even layer company that developed domestic Pyrex glass-
of porcelain usually between I and 2 mm t hick ware. t he manufa cturers state t hat the rnateri
coveri ng the entire tooth. Figures 2. 1a, band c is not t he same as Pyrex. A number of othe
show a se lection of traditio nal fe ldspat hic po rce- cas table ceramic o r hot transfe r-mo ulded glas
lain jac ket crowns in place. ceramic systems have bee n develop ed .
Types of crown
An alte rnative approach is to fire an extra-
strong core of ce ramic material to a ref racto ry
die and the n add furthe r layers of conventiona l
feldspat hic porcelain. Once finished. t he refra c-
tory die is sandbl asted away, leaving a fitting
su rface that is slightly rou gh, aiding reten tion .
Both these syste ms ca n also be used to make
porcelain veneers .
Figure 2. 1d sho ws a cast ceramic crown and
Figures 2.1e-g show crowns made by stren gt h-
ened porcelain syste ms.
Advanta ge s
The advantages of porcelain jacket crow ns are :
Appearance Because of th eir tra nsluce ncy and
the range of te chniques and shades available, PJcs
are better able to dup licate th e appearance of a
natural tooth than any o ther type of cr own.
Brittleness The relative brittleness of a
conventio nal PJC can be regarded as an advantage,
particularly if the to oth being crowned was origi-
nally fractured in an accident. Sho uld such an
acci dent recur (which is not at all unco mmo n
amongst sports players, cyclists . children with
Class II Division I incisor relati onships, and
others). the PIC is likely to fracture rat her than the
root of the to ot h. This is still true, but to a lesse r
extent, wit h the new est types of PJc. W ith
metal-ceramic crowns. whic h are st ronger than
the remaining tooth tissue. more serious damage
such as root fracture is likely to resu lt fro m a
further accide nt. Where po ssible. the w eakest link
in the chain should be t he least impo rta nt. Th e
principle is similar to t he fuse in an electri c circ uit.
Stability Po rcelain is dimensionally and co lour
stable and is inso luble in o ral fluids.
Cost The PJc is usua lly the least ex pe nsive
anterior crown to prod uce in the labo ra tory.
Plaque Porcelain ten ds to resist plaque
accumulatio n.
Disadvantages
The disadvantages of PJcs are:
25
Marg in al fit Conventional po rcelain jacket
crowns made o n a plat inum fo il mat rix t hat is
re moved prior to ce mentati on oft en have a less
satisfactory marginal fit than cast-me ta l resto ra-
tio ns. How ever, th e marg inal fit of t he newer
type s is co mparab le to cast-metal restorat ion s.
Br ittle n ess Altho ugh the brittleness of porce-
lain crowns was descr ibed earlier as an advantage
in some situations . in others it is a disadvantage. In
some pat ients where the crown suppo rts a partial
denture o r whe re the occl usal forces are exces-
sive. porcelain crowns may fracture repeatedl y.
Re m o va l o f toot h tissue To overcome t he
pr ob lem of the brittl eness of porcelain, and to
give the crow n a natural appeara nce , there must
be an ade quate th ickness of mat e rial, and so it is
necessary to redu ce t he tooth fairly exte nsively.
weakeni ng it and t hreate ning t he pulp. Th is is
es pecially true wit h small teeth. for exam ple
lower inciso rs .
Metal-ceramic crowns (see .Sgure 2.1 i)
De ntal po rce lain can be bo nded to a variety of
me ta l alloys. The proc ess is similar to the glazing
of do mestic cast iron and st ee l bath s and basins.
T he alloys used in de ntistry fall into t hree groups:
• Preciou s meta l alloy s co ntaining a high proper-
tion of platinum and go ld
• Sem i-precio us alloys co nta ining a high propo r-
tion o f pallad ium, so met imes with silver as well
• Base me ta l allo ys containing a high pr oportion
of nickel and chromiu m.
There is a large difference in cos t bet we en th ese
alloys. but th ey all share the pr op erties of a high
me lting temperature so that porcelain ca n be
bo nded to th e surface by being fired without the
metal being melte d, properties that permit the
bon ding of porcelain without affecting its colour,
and properties allowing it to be cast. so lde red and
po lished in the den tal labo ratory.
Th e firs t of these alloys to be developed were
t he high-percentage precious metal alloys. and
these are still used. Howeve r. t heir high co st has
e nco ur aged the development o f the othe rs,
26 Types of crown

Figure 2.1

a Con vention al po rce lain jacket cr o wns on all four

upper incisors. Th is is the patient sho wn in Figure 6.10.

b A single ante rior PJc. T he upp er left central incisor

is the crown. th e o t he r teeth are natural.

c Both upper central incisors ar e PJcs wit h supragingi-

val marg ins. De spite th is. th ere is some gingival inflam-
mat ion. Th ey have bee n pre sent for about five years.

d A cast ceramic cro w n (Dicor) o n the uppe r right

central incisor.
Types of crown 27

e Strengthened po rcelain crowns (Hi-Ceram) on both

central incisor teeth .

f Empress crowns on the upper and lowe r inciso r

teeth in a patient with mild amelogenesis imperfecta.

g and h The uppe r left lateral incisor tooth has been

move d into th e position of the central incisor and
crowned with an Inceram crown (h) to resemb le the
missing central inciso r.

i A rnetat-ceramic crown on the upper late ral inciso r.

This is the pat ient shown in Figure 1. 1a.
... .
28
alth o ugh these do not yet have quit e the con ve-
nient handling properties or the pr ecision of t he
high-percentage precious metal alloys.
The pr eparation for an anteri or metal- ceramic
crown d iffers from that fo r a PJc in t w o ways; fir st
rathe r more tooth tiss ue needs to be rem oved
from the buccal surface to allow for t he t hickness
of the metal as well as po rcelain, and secon d
rat her less usually needs to be removed fro m t he
palatal or lingual surface since o nly metal will
cover at least part of t his surface.
Advantages
The main advantages of meta l-ce ramic ante rior
crowns are:
Strength The metal-ce ramic crown is a very
st ro ng restorat ion, which resists occlus al and
othe r fo rces well.
Minimum palatal reduction So me teeth .
particularly tho se severely worn by ero sion and
att ritio n that have then ove r-erupted back into
occlusion, may not be sufficiently bulky for a porc e-
. lain jacket crown pre paration with adequat e palatal
reduction, whe reas a metal-ceramic crown prepa-
ration may be possible. Figure 2.2 ill ustra tes this
pro blem in comparison with a no rmal inciso r tooth.
Adaptability The mecal-ceramic crown can be
adapted to any shape of tooth preparation
Types of crown
Figure 2.2
Sections through three sets of casts .of patients in inte r-
cuspal position showing the profile of crown preparation.
a This is a Class I Divisio n 2 incisor relationship with
deep overbite and minimal ove rjet. It oft en appears,
when loo king at t hese patients fro m in fro nt, that there
will be insufficient clearance-fer po rce lain jacke t crown
preparations. In face. the bucco-lingual th ickness of the
teeth is often normal and co nvent iona l pre parations are
possible.
b G ross e rosion of the palatal surfaces of t he upper
incisor teeth due to rec urre nt vo miting. If crowns are
t o be made, t here will not be room to pro vide a palatal
porcelain surface withou t the oc clusa l vertical dimen-
sion being increase d. Ho weve r a me tal-ceramic crown
preparation is po ssible. Because the diagnos is is erosion
(chemical damag e) rather than attrition (physical
damage), the additional st re ngth of the metal is not
partic ularly impo rta nt.
c Attri t ion has worn the lower incisors to approxi-
mately one-half their original length . A co nventio nal
crown preparat ion would not be possibl e but a one-
piece me tal-ceramic po st-reta ine d crown is. The
dotted line shows t he metal-po rc e lain junctio n.
Types o( crown
whereas th e pro cess involved in making PJcs
requires a smoot h and unifo rm pr eparation.
Additional ret ent ion can be gained in difficult
preparatio ns by the use o f pins o r grooves, which
are not possi ble with PJCs.
Can be soldered For bridges o r sp lints,
metal-ceramic crowns can be atta ched to o the r
crowns or artificial teet h by so lderi ng or casting
them toge t her. Th is cannot be done w it h PJcs.
Disadva nt ag e s
The disadvantages of metal--ee ramic crowns are:
Stre ngt h An accidental blow may result in th e
tooth pre paration or root fracturing because the
crown is stronger than the nat ural tissues.
Appearance Because of the metal framework,
it is often more difficult to match the natu ral
appearance of a tooth than w ith a PJc. particularly
at the cervical margin.
Dest ru ct io n of tooth tissue The metal-ceramic
crown requ ires mo re tooth red uctio n buccally t han
the ~ c and so is more likely to endanger the pulp.
If this too th redu ction is not sufficient - as is often
the case - the eventual crown either has a poor.
opaque appeara nce or is too bulky.
Cost Even if the re lative ly inex pe nsive base
metal alloys are used, the laboratory time taken
to construct a metal -ceramic crown is more than
for a PJc and therefore the overall cost is usually
greater. When the precious metal alloys are used,
the cost is naturally greater still.
Other types of anterior complete
crowns
Although the majori ty of ante rior crowns fall into
one of the two pr evio us grou ps, other alterna-
tives exist:
• Cast-meta l crowns wit h ce men ted porcelain
facings
• Cast-meta l crowns with acry lic or composite
facings
• Acrylic-jacket crowns.
29
A number of techniques exist fo r making
crowns with cemente d-porcelain facings, but
since t he int ro ductio n of t he meta l-c eramic
crown t hese are now o bsolete. However, a
num ber of patients still have t hese crowns, and
so the clinician needs to be able to re cognize
them (see C hapter 13).
The acrylic-faced cast-metal crown was
popul ar for a time befo re the gene ral introduc-
tion of metal--ee ramic crowns. It is still so metimes
made. since it can be more economic al than th e
metal-ce ramic crown, alt ho ugh t he re seems littl e
reaso n why th is should be, since t he time take n
to pr o duce it is rat her similar. It is also
so metimes made as a lo ng term provis ional
crown as an intermediate stage in a large-scale
oral reconstruction. The simple laboratory-
processed acry lic facing deteriorates in the mouth
by being worn away, discolouring and leaking at
the margins (see Figure 13.4).
Composite faced crowns are also use d as
lo ng-term provisional res torations. The labora-
tory-grade co mposite is cure d by an intense light
in a spe cial light box , so met imes with the addition
of heat or pressure. The cast-metal framework
need s to be mechanically reteoave for the facing.
Acrylic-jacket crowns discolo ur and wea r,
usually within a few years. Because acrylic has a
high coefficient of thermal expansion, the
co nstant fluctu at io ns in temperatu re in t he mo ut h
produce breakdown of t he margins of these
crowns, and t hey leak, often with seco ndary
caries fo rmat ion. However, labo rato ry-pro cessed
acrylic-jacket crowns are useful as provi sional
crowns, since they are more pe rman ent t han the
usual Simple temporary crowns and less costly
than cast-metal crowns. They are used when
other forms of t reatment. for examp le periodon-
ta l or orthodo ntic treatment, are necessary
befo re the fi nal cro wns can be constructed (see
C hapter 6).
Anterior crowns for root-filled
teeth
Often the endodontic acces s cavity together with
the crown pr eparation will leave insufficient
30 j ypes ot crown

Figure 2.3

a If t hese thre e teeth had not bee n extracted, they

would have had to be root-filled. The caries and old
restorations have been removed. The left-hand tooth
co uld be restored by a simple co mposi te res to ration .

...
---_~ .J. ~----__.
the centre to o th has sufficient dentine remaining for a
glass ionomer cement or com posite core followed by a
crown to be satisfactory. but th e right -hand tooth does
not have sufficient dentine. and retention by means of
a post cemented into t he root canal is ne cessary.

b Bo t h central incisors are frac t ured and have been

r oo t-fill ed.

c An incisal view of the t ee th show n in b wit h the

res torations removed (rom th e access cavities.

d The access cavit ies re st ored with glass ionomer

cement .

www.allislam.net
Problem

e and ( The teeth prepared for PJe s. The completed

crowns are show n in Figure 2.1e.
Types of crown
dentine to suppo rt a crown. In this case retentio n
is gained by means of a po st fitted into the
enlarged root canal. T hese posts are used only for
retentio n, and the idea that they add strength to
the too th has now been discou nted . Fo r th is
reason, if it is possi ble to obtain retention for t he
crown without using a po st, th is is nowadays
regarded as preferable, even though t he re is so me
t'1laence that the dentine of root-filled teet h is
more brittle tha n t hat of natura l teeth. Figure 2.3a
f/rOWS examples of teet h that woul d be resto red
'tI~ mea.ns of a simple com posite resto ration, a
glass ionomer cement or com pos ite core and
crown or a post-retained crown. There are four
tfUUps of crow ns for root-filled anterior teeth:
• Glass ionomer cement or co mposite core and
crown
• Post and core and separate crown
• One-piece po st cr own
• Other type s.
Glass ionom er cement or composite
core and crown
When sufficient dentine rem ains, the endodont ic
access cavity can be filled and missing dent ine
replaced with glass iono mer cement, which bon ds
directly to denti ne. Alternatively, de ntine bonding
agents may be used to adhere composite to the
dentine. o r the de ntin e may be etched (since
there is no lo nger a pulp) and retention achiev ed
by micromechanical interlocking of the compos-
ite bonding layer into the dentinal tubul es .
Glass ionomer cem ent has th e advantage th at
it does not co ntract o n setting, and it also
releases fluo ri de so that sho uld th e crow n margin
leak. the re is less risk of seco ndary caries devel-
oping. Composite is stronger and is rather easier
to prepare, since it cuts with a similar 'feel' to
dentine (see Figure 2.3b-f).
Post and cores and separate crowns
The crown will be either a PJc or metal--eeramic
crown as described pre viou sly. Posts and co res
may either be made in t he labo rato ry or
purchased ready -made. The fo rmer have th e
31
advantage of ada pta bility and can be used in very
tapered root cana ls t hat have suffered car ies in
the coronal part of th e root canal, in ro ot cana ls
with an oval cross secti on, and in tw o rooted
te eth where the roots are parallel.
The ready-made posts have the advantage of
normally being fitted at the same time as the
tooth is prepared, thus avoiding t he need for a
tempo rary po st crown. T hey are usually st ronger
and may be much more retentive than th e labora-
tory-mad e po sts and cores. Labo rat o ry charges
are lo wer when preformed posts are used ,
altho ugh any savings may be o utw eighed by the
ext ra clinical time taken to fit some of them.
Post shapes
There are four shapes of post (see Figure 2.4):
• Parallel-smo oth or serrated
• Tapered-smoo t h or serrated
• Parallel -threaded
• Tapered-t hreaded
Comparisons of post shapes
Parallel-smooth or serrated (see Figure
2.4b and c)
• Either preformed metal to which a compo site
core is adde d, or made with a preformed
plastic post, w hich is incorpo rat ed into a
pattern fo r a cast pos t and core
• More reten tive than tapered-smooth po sts , and
se rrations furth er increase retention
• Greater risk of lateral perforation of the root
(see Figure 6.ISb, page 121).
Tapered-smooth or serrated
• Usually laboratory-made in cast gold o r other
alloy
• Least retentive design, but if long enough and
a goo d fit. th e rete nt ion is sufficient in most
clinical circumstances (se rrations increase
rete ntion but we aken t he post)
• Easy to prepare and easy to follow t he root canal
• Similar to the shape of the root and t here fo re
less likely to perforate through to t he
pe r iodo ntal membrane
32
a b
Figure 2.4
POSt shapes .
Q Cas t gold post and core (tapered smooth shap e) .
The surface has been sand blasted to improve retention.
b A parallel-sided, serrated post system . This manufac-
turer produces five diameters rang ing from 0.9 t o
1.75 mm. This is the middle of the range, 1.25 mm
diamet e r. Fro m t he left a twist drill with a r ubbe r d isc
which can be moved up and down to set the length. a
smooth plastic impression post. a sta inless steel
serrated post which can be used in th e direct te chnique
(see Ch apter 6), an aluminium post with a sma ll head
used fo r making tempo rary post crowns and a serrated
plastic burn- out post used in the labo rato ry as part of
the pattern.
c A post syste m from a different manufacturer with th e
same five diamet er s. This is 1.5 mm diamete r. From the
left the tw ist drill has three permanent mark s to
measure the length of the post hole, two impre ssion
posts (separated befo re use), serrated burn-out po stS
and a stainless steel post for use in the direct, chair-
side technique.
d Left a parallel-threaded po st with atta ched head
which will be prepa red as the co re after the POSt hole
is thread ed and the post cemented. Righ.t a preformed
ta pe red-threaded post which is no longer reco m-
me nded (see text) .
Types of crown
c d
• Adapt able technique and therefo re can be used
wi th oval, irregular-shaped or mul ti ple -root
ca na ls
• A diaphragm may be added to cover the root
face an d exte nd e d as a be ve l aro und the
margin. T his reduces the risk of root fracture
and may also re place areas of de ntine lost
th rough ca r ies or t ra uma
• Cast posts are not as strong as wrought posts.
..,
Parall el-thr e aded (see Figure 2Ad)
• Must be pre formed and made of base metal.
A t h read is cu t into t he walls of the prepared
root canal with a n e ngineer's ta p. T he po st is
t he n ce mente d an d scr e wed in wi t h mi nimal
force (like assembling a nut and bo lt) so that
stresses are not introd uced into t he de nt ine
• T he post can be shortened
• T he most retentive post design
• Po st a nd co re are made o f diffe r e nt mat e rials.
T he post may be fitted alo ne a nd the core
added in co mposi te (see Figure 2.7b. centre) or
a pos t wi t h a metal core already attached is
fitted and the core prep ared (see Figure 2Ad.
left).
T apere d -thre aded (see Figur e 2Ad )
• Must be preformed and made of base metal
• Cu ts its own thread as it is inserte d (like a
wood screw) and t herefore introduces consid-
erable stresses into the dentine
• Ro o t s liabl e to split e it he r as t he po st is being
inserted or subsequently
• Be ca use of the diffic ulty o f inse rti ng without
root fra ctures, retention is unreliable
 Types of crown
• Not recommend ed as th e sole means of reten-
tion for a single-rooted post cro wn.
Making the choice
Many successful posts of all types have bee n
made, and although eac h dentist has his or her
own preference, and certain sets of clinical
circumstances dictate that o ne type o r anot he r is
preferable, t here is no o ne type that is uniformly
superior to t he ot hers.
However, in most cases wit h sufficiently long
roots where the coronal part of t he root canal
has not been excessively tapered, the first choice
is usually eithe r a preformed or cast para llel-
serrated post. A prefo rmed po st is preferab le for
single, uncom plicated crowns, since it avoids t he
need for a te mpo rary po st crown and also avoids
the risk of a casting failure. A re latively common
cause of such failures is porosity in the cast meta l
at the junction of t he post and t he core. As t he
metal cools, after being cast, it contracts and t he
more rapid cooling of the relatively thin post
compared with the bulkier core can prod uce
porosity at the junction between t hem . This
porosity is within th e casting and is not visible.
Cast parallel-se rrated posts and co re s are
preferred when th e core need s to be extended as
a diaphragm to cover part or all of t he roo t surface
or when a stronger core is needed. Cast posts and
cores are sometimes more convenient when
several post-retained crowns are being made and
asingle impressio n can record all of them toget her.
The next best choice is usually t he ta pe re d-
smooth (or se rrate d) cast po st and core, which
is used when the roo t canal is particularly ta pered
or oval or when th e root is very ta pered so that
there is a greater risk o f lateral perforation.
Parallel-threaded posts are used when the
available root canal is very short due to an
obstructio n or when particularly robust ret ent io n
is necessary. The technique for inse rting t hem is
rather precise and time-co nsuming. particu larly if
it is only used occasionally, and so it is not
employed as freque ntly as t he other types.
The tapered-t hreaded type sho uld not be use d
for single-rooted post-retained crowns. The post
material is relatively weak and the technique often
introduces excessive st ress into t he de ntine,
which may t hen fracture. If the self-t hreading
3J
charac te ristics of the po st are no t used in order
to avo id th ese stresses then the post is not as
retentiv e as ot her systems.
One-piece post crown
In so me cases, for example with very sho rt clini-
cal crowns o r wit h lower inciso rs, th ere is insuf-
fici ent space wit hin th e crown of th e too th to
make both a retentive core and a separate crown.
The n, a crown made of metal -ceramic materia l
with t he pos t cast as part of the crown is often
the so lution (see Figure 2.2c).
Other types of crown for root-filled
teeth
O ccasio nally the foo t canal is o bliterated by a
fractu red pos t that cannot be dislodged, or the
root cana l is completely closed w ith secondary
de ntine. A crown can still be made by building up
a core, usua lly in co mposite reta ined by pins (see
Figure 5.5, page 93): alternatively a meta l--eeramic
crown re ta ined by pins cast together with t he
base of t he cro wn can be used.
Neit her of these two tec hniques is likely to be as
retentive as a post crown, and particular attention
must be paid to avoiding excessive occlusal forces.
Anterior partial crowns
Befor e th e days of metal-ceramic crowns when
t here was no satisfactory facing mat erial for a
metal crown, partial crowns of one sort or
anothe r were commonly used to res tore individ-
ual teeth and as retainers for bridges and splints .
Tod ay, with acid-etc h reta ined co mpos ite
rest oration s and wit h met al--eeramic crowns,
parti al anteri o r crown s ar e much less com mon .
Howev er, th ere are occasions whe n t he re are
advantages in maintaining the natural buccal
surface and w he re it would be difficult to pre pare
the to oth for a full crown. Figur e 12.9, page 248
shows such a case .
The resto rat io n show n in Figur e 12.9 wou ld
no t be made today. Inst ead the fi rst choice wo uld
34
be a splint made w ith minimum-preparation
reta ine rs (see C hapter 12). Ho weve r, pat ients still
have re st o ra t io ns like th is and also individu al
anterio r partial cr own s, and so it is necessary to
recognize th e m and un derstand how t hey we re
constructed in case they nee d to be re moved or
maintained in some way .
T he traditional 'th ree-quarte r' anterior crown
was retai ned by mes ial and distal grooves and
usually a cingu lum pin. It co vered the palatal
surface and part of th e mes ial and dista l su rfaces,
but usually show ed throu gh o n th e lab iai side. Th e
incisal edge was also usua lly covered.
Posterior complete crowns
Cast-metal crowns
Although t raditio nally a go ld alloy is used for
complete meta l posterior crowns, the cost of
gold and the considerable improvements that
have been made in the alternative alloys have
resulted in a rapid increase in the number of
crowns made with alloys containing less gold , and
in some cases no ne. The term 'meta l' is therefore
used as more acc ura te t han 'gold' in most cases.
The American De nta l Associat ion (ADA) classi-
fication of dental go ld alloys is more useful than
the British Standard (BS 4425 ). The ADA classifi-
cation refers to the pr oportion of nobl e metals
(gold, platinum and palladium) in t he alloy. Th e
classification is:
High noble At least 60 % noble metals, includ-
ing at least 40% go ld.
Noble At least 25 % noble metals
Base metals Less than 2S% noble metals
However, some of th e low-gold alloys ar e
produced in a go ld colo ur, which can be confusing.
High no ble metals are still co nsidered better
th an th e others because of their great resistance
to tarnis h and corrosion and the easy way in
which they can be worked . However, they are
substa nt ially mo re e xpen sive than the other
metals and so are now used less often .
Metal crown s are used e ither w hen the patient
does not mind the app earance of metal o r wh e n
th e tooth does not show during th e normal
movements of t he pat ient's mo ut h. When a
Types of crown
com plete crown is necessary, it is the rest o rat ion
of choice since it requires the minimum reduction
of tooth tissue, the margins are uncomplicated by
the pr esence of facing material, the occlus al surfac e
is readily adjust ed and po lished, an d th e t ime ta ken
to prod uce th e restoration in th e labo ratory is less
than other types of crown so t he cost should be
less. It is the most convenient res toration for
providing re st seats, guide planes, reciproc al ledges
and und e rcuts in co njunction with partial dentures.
It can be so ldered to o t her st ruct ures to make
bri dges and splints , and so lde r can be add ed to it
to reshape its surface . T he o nly significant disad-
vantage of t he cast-metal pos terior cr own is its
appearance (see Figure 2.5).
Metal-ceramic crowns
Th e pr incipal advantage of metal--eeramic cr owns
over metal crowns is t heir appearance (see Figure
2.5). Porcelain can be used on the mo st commonly
seen bucca l and occlusal surfaces. It is often mor e
important to produce a tooth-coloured occlusal
surface than a buccal surface with lower teeth, but
usually o nly the bucca l surface shows with upper
t eet h. Any o r all of th e ot4er surface s may also
be covered with po rc elain.
The disadvantages of t he metal-ceramic crown
for posterior teeth are that more tooth tissue
needs to be removed in order to allow for the
th ickness of porcelain, and when th is is on the
occl usal surface of a tooth with a short clinical
crown, there may be difficulty with retention
because of t he red uced length of t he preparation.
Whe n this is the case, additiona l rete nt ion by
means of pins or grooves is necessary.
W ith an amalgam core retained by pins. a
preparation for a metal-ce ramic crown is more
likely to give rise to troub le than o ne for a metal
cr own, because th e greater re duction of the core
material may exp ose the pins and thus jeopardize
the retention of the core (see pages 36-38).
Ceramic crowns
Occasionally it is re aso nable to use a porcelain
jacket crown o n a posterior tooth, for exa mple in
conjunction wit h a po st and core on a single-rooted
T,.pes of crown
c A part ial crown (three-quarter crown) . The tooth is vital: the grey
colour comes from the amalgam core . A composite core would have
been better.
premolar t ooth. Car e needs to be taken in assess-
ing the occlusion, but if th is is favourable a casta ble
or high-st re ngth ceramic crown ofte n has a better
appearance tha n a metal--eeramic crown.
Posterior partial crowns
'Three-quarter' crowns
'Three-quarter' post erior crow ns act ually co ve r
fo ur-fifths of th e tooth's su rface - mes ial, dista l,
occlusal, lingual or palatal.
35
Figure 2.5
a and b Go ld crowns on the first molar teet h which,
with this patient's lip morphology. were aesthetically
acceptable. There are metal-ce ramic crown s on the
upper canine and premolar tee th and PJcs on the upper
incisor teet h.
They are retained by grooves on t he mesial.
dist al and occlusal sur fac es that effective ly
perform t he sa me function as the buccal surface
o f a complete cro w n (see C hapt er 5) . They are
always made of cast metal, and are used when
t he bucc-al surface of a tooth is intact and reduc -
ing it as part of a complete crown preparation
would either produce an unsightly and unnec-
essary disp lay of me tal or w here reducing the
bu ccal cusp wou ld weaken it. red uc ing the
stren gth of th e pr ep a rat ion. An exam ple o f a
t o o th w here a t hree-q uarter crown is ne e ded
is shown in Figure 1. IOc (page 18). Clinical
36
exa mples a re shown in Figur e 2.5 c an d 2.6e. f
and g.
T he advantages of posterior 't hree-quarte r'
crowns are tha t they are more conservative of
tooth t issue than com plete crowns, and th e
margin of the cr own does not approach th e gingi-
val margin buccally. It is still po ssible to test the
vitality of the tooth via the buccal surface. and th e
appea ra nce is pr efe rable to a com plete metal
crown, wit hou t th ere being th e need for t he
ext ra to oth dest r uction .
Some o pe rators find t he pr eparation difficult.
but they wo uld do we ll to learn the skill invo lved
since t he posterior 'three-quarter' crown is st ill
a useful part o f the de ntist's repertoire .
Other types of posterior partial
crowns
There are a var iety of alternative posterior
crowns. The 'seven-eighths' crown covers all but
the mesia l buccal cusp of an uppe r mo lar tooth.
the 'half crown covers th e me sial half and
occlusal surface of a lower posterior tooth where
t he distal wall is very short. and other variations
leaving various odd bits o f the tooth surface
ex posed ar e also made. Principles governi ng th e
design of all th ese partial restorat io ns are th e
same and are covered in Chapter S. It is fo r th e
dentist to use these pr inciples to plan t he detailed
design of each rest o ration to solve its particular
problems. It is not good pract ice to follow classic
cookery-book-type preparat ion des igns. none of
wh ich may be suita ble.
A further variation of the po ste rio r partial
crown is the o cclusal onlay . made to alter the
shape of the occlusal surface o r t he occlusal verti-
cal dime nsion but withou t nec essarily covering
any of th e axial wa lls. It is reta ined by intra -
coronal feat ures, adhesive techn iques o r pins. and
sometim es who le quadrants of o ppos ing teet h are
restored by th ese mea ns.
Cores for posterior crowns
Badly br ok en- do w n po st erior teet h are re built to
the general shape o f t he toot h using amalga m.
com posite. glass ionome r cement or cast metal
Types of crown
before prepar ing t he m for cr owns. These co res
are usually retai ned by pins o r po sts .
Cores of amalgam, glass ionomer
cement or composite
Th e co mmon est type of po steri or co re is made
of amalgam retained eit her by pins o r by po sts in
t he root canals. Th e pins are usually t hrea de d
self-tappin g pins screwed into dentine. Pin-
reta ined co res are used in vita l te et h. but it is
preferable to use po st-retained co res w he n the
to ot h has bee n ro ot-filled . T he de ntine of ro ot-
filled teeth is tho ught to be mo re brittle th an vital
teeth. and so th e stress introduced by se lf-tap ping
pins may produce a greater r isk of the tooth
fracturing. In any case it seems commonsense to
use the relatively large holes that already exist
down the root canals rather than drill yet more
holes into the tooth for pins.
When pins are use d in a vital tooth. it is
important to choose the correct numbe r of pins
and to site th em pro pe rly. In dec iding t he
number and loca tion of pins. th e final desig n of
t he pre para tio n must be ant icipat ed . Fo r
exa mple, pins sho uld nee be placed in the middle
of th e mes ial or distal surface s of a core w he n
th e tooth is go ing to be restored by means of a
partial crown. If t hey are. t he grooves in t he
mesial and distal surfaces of th e pr ep ar ation may
ex pose t he pins (see Figur e 2.6a). If a sub sta ntial
cusp remai ns. the pins sho uld be set at an angle
relative to the inne r surfa ce of this cusp so t hat
there is a retentive unde rcut between the pins
and t he cusp .
When the final restoration is to be a
metal-ceramic crown. t he pins must be kept
well clear of the bucca l shoulde r area so that
t hey are not exposed duri ng t he prep a rat io n of
t he tooth. Also whe n a metal- ceram ic crown is
pla nned . a ny rem aining buccal cusp will us ually
be seve re ly weake ned by th e pre pa ration, and
cann ot be re lied up on to ' retain t he core.
Sufficie nt pins must th erefore be placed to
retain t he core w it ho ut t his cus p. and it is
so me times good practice to re move t he cusp
completely befo re the core is placed (see Figur e
2.6b. c).
A convent ional amalgam matrix may be used to
retain the amalgam while it is being co nde nsed.
Types ofcrown
a The amalgam core for the partial crown shown in
Figure 2.5c. Pins must be site d with a view to the
eventual preparation des ign - in t his case avoiding th e
mesial and distal surfa ces. where grooves are to be
prepared. The alternative. a complete metal-ceramic
crown. wou ld have relied enti rely o n pin retention. th e
remai ning cusp having been removed during pr epa ra-
tion. Elective endodo ntic th erapy and a post-retained
crown would have been less conservative.
c The compos ite core in place. having been built up in
several increments of light -cured po sterior co mposite.
Figure 2.6
Cores for posterior crowns.
37
b To ath prepared with pins for a pin-retai ned compos -
ite co re. The enamel marg in is being et ched w ith gel.
tak ing care to avoid t he ge l making co nta ct wit h the
de ntine. Once the gel is washed off. the dee p part of
the cavity will be line d.
d An amalgam co re retai ned by a co ppe r ring. The
pat ient was unable to return for the cro wn prepara-
tion unt il e ight month s after the co re was placed .
The re is som e gingival inflammatio n distally. but apart
from th is t he gingival irritatio n has been minimal.
38 Types of crown

Figure 2.6 continued
e A large failed amalgam rest o ratio n.
f The ama lgam removed and a g The part ial (three quart e r) crown
composite core placed. retained by on the die.
two pins. The heads of the pins can
be seen . Th ey are sited with in th e
co mposite core. away from th e
periodontal membrane and pu lp
and will re sist lingual displacem ent
of the co re.

but w hen cons iderabl e tooth t issue lo ss has
occurred it is often better to use a copper or
o rtho do ntic band that can be left in situ unt il t he
crown preparat io n is sta rted. Th is sup ports the
amalgam while it is setting, and reduces t he risk
of th e amalgam co re fracturing before pr epara-
tio n (see Figure 2.6d).
Co mpo site cores can be used in th e same way
as amalgam co res, and they have t he advantage
that t hey can be prepared at th e same visits as
they are inserted (see Figur es 2.6e, I and g). T hey
shou ld be built up in increments, light -curin g each
increment to re duce t he effects of polym erization
contraction. Despite this precaution, there is
so me co ncern about the risks of microleakage
between t he co mposite core and the de ntine
su rface . In so me cases pin retention is no t neces-
sary . Glass ionomer cement may be used as a
core mate rial provided there is suffici ent de ntine
to retain it. Pin retentio n is not usually used. It
do es not contract on setting and so has an advan-
tage over compo site, alt ho ugh it is less strong.
Cermets (glass ionom er cements con taining
metal powd er sintered into the glass) are
so metimes used as core mat eri als. They have the
advantages of glass ionomer cement, the y are
easier to dist inguish fro m enamel and dentine
while pr ep aring t he toot h, and t hey are radio-
o paque. When posts are use d to retain posterior
ama lgam o r co mposi te co res, t he com monest
type is the paralle l-ser rat ed preformed metal post
(see Figures 2.4b and c and Figur e 2.7). II a
su bstantial cusp remains and th e post is placed in
one of t he root canals at an angle to t he inner
surface of the cusp, this will prod uce an under-
cut and therefore retent ion for t he core. In ot her
situations where more of the enam el and dentine
have bee n lost or will be rem oved in the crown
 Types o( crown 39

www.allislam.net
Problem

Figu r e 2.7

a A root filled tooth which is to be restored by a post- re tained

amalgam restoration and in due course by a partial crown. Two
parallel-serrated posts have been placed, one in the distal canal and
one in one of the mesial canals.

b Three threaded posts used to retain compos ite or

amalgam cores on anterior or posterior teeth. Left has
a split post that collapses towa rds itself as it is inserted
so that excess force is not applied to the walls of the .
root canal. Centre: a thread is cut into the walls of the
post hole first. and the post is then screwed in with
light pressure, together with cement. Right has a very
fine thread that CUts into the walls of the post hole
without causing undue strain.

preparation, two, or even three posts should be
used.
A cemented POSt may be sufficient for some
single-roo ted posterior teeth, but in other cases
it is not sufficiently retentive in view of the
greater occlusal force usually applied to posterior
compared with anterior teeth. A number of post
systems have therefore been designed to
overcome this problem (see Figure 2.4d and
Figure 2.7b). These are usually threaded posts.
tapered or parallel-sided posts. either self-tapping
or requiring a thread to be cut in the root canal
walls. They are very retentive, and , provided they
can be inserted w ithout putting undue strain on
the root of the tooth, they provide an excellent
way of retaining a core.
Cast posterior cores
With currently available posts and pins used to
retain amalgam and composite posterior cores,
there Is less need for cast-metal posts and cores
in multi-rooted posterior teeth than there once
was. However, cast posts and cores are still
useful for single-rooted premolars, and two-part
posts and cores are occasionally used for poste-
rior teeth with divergent roots.
- 40
Practical points
• Po rce lain jacket crowns are preferr ed for
ant erior teeth when possib le.
• Meta l-ceramic crowns are stronger but may
not give such a good cosmetic result. and
require mo re labial tooth reduction.
• Vital posterior teeth commo nly need pin-
retained cores.
• Ro ot-filled anterior teeth may need po st-
ret ained co res, and root-filled posterior te et h
need po st-retained cores.
Types of crown
• Posterior partial crow ns are less destruct ive of
tooth tissue, but ofte n show gold.
• Partial crown designs vary con siderably, but are
all based on a co mmon set of princip les.
• When making pin-reta ine d cores, t he number
and siting of the pins mus t be planned with the
final crown preparatio n in mind.
3 Designing crown
preparations
Teeth vary so much in their general shape and in
the effects upon them of caries, trauma, tooth wea r
and previous resto rations that it is less helpful to
describe classical 'idea l' preparatio n designs t han it
is to give t he principles determin ing the design and
then show how these sho uld be applied.
The principles of crown
preparation design
The following factors need to be co nside red:
• Materia ls
• Function
• Appearance
• Adjacent teeth
• Pe r iod o ntal tissues
• Pulp.
Related to materials
Metal crowns
Dental casting metal is strong in thin sections and
can be used to overlay and protect weakened
cusps against the occl usal forces. It is, however,
ductile, and can be distorted if it is too t hin or if
it is subjected to excessive forces . Normally no
metal surface should be less t han 0.5 mm th ick and
occlusal surfaces shou ld be more. This usually
means that an equivalent amount of tooth tissue
has to be removed. When distorting forces are
anticipated. the design can be modified either by
reducing the tooth mo re, and prod ucing a t hicker
metal laye r, o r by introducing grooves o r boxes
into the pr eparat ion to st iffen the meta l by
producing ridges on the fit suriace. If high noble
metals are used, their ductility allows finely
bevelled margins to be burnished against the tooth
surface. This means that the tooth preparatio n for
high-noble-metal resto rations is usually finished
wit h an o blique cavosuriace angle (see Figure 3.1).
Noble and base metals
Some of t he alternatives to high noble meta ls tha t
are increasingly being used in den tistry, particu-
larly t he nickel- c hrom ium-based alloys, are less
pron e to distortion t han the o lder co nventio nal
de ntal casting golds . It is therefore possible to
rem ove rather less tooth tissue in preparing teeth
for these materials. Howeve r, because of their
greater stiffness and reduced ductility . it is not
po ssible to burnish t he margins o f t hes e meta ls.
Porcelain
Porcelain is brittle when subjecte d to impact forces.
and must be in sufficien tly thick sections to
withstand no rmal occlusal and other forces. When
a high-alumina co re is used to strengthen the
resto rat ion, th is is opaque , and so it is necessary
to provide a sufficient thickness of more translu -
cent porcelain on the buccal surface of the crown
to simulate the appearance of a natural tooth. It
follows that the minimum redu ction for a porcelain
jacket crown (PIC). made by any of th e techniques.
is much grea ter than for a metal crown. A thick-
ness of 1.5-2 mm of po rcelain is ideal, part icularly
on the labial or buccal side.· However, with vital
teeth this can only seldom be achieved, and the
minimum is I mm of porcelain. This is acceptable
only on the lingual (occluding) suriaces of uppe r
incisor crowns, wher e the occlusal forces are
minimal. With normal occlusal forces this t hickness
is inadequate, and either the preparation sho uld be
deepened or a metal-ceramic crown used .
41
.
42
, . - - -- - - - - Suitable fo r metal - - --
a b c d
Near to 180' 130- 160'
The edge st re ngt h o f po rce lain is low, and
therefore th e comp romi se at t he cavosurface
angle between brittle enamel and brittle porcelain
is a 90 ' butt joint (see Figure 3.1e).
Metal-ceramic m aterials
Even greater re duction of tooth tissue is neces-
sary for metal-ceramic cr owns on the visible
surfaces. becau se th e metal layer w ill need to be
cove red by an o paque layer of porcelain, and th is
in tu rn w ill ne ed to be covered by translucent
po rc elain. A thickness of 2 mm is ideal , but in
many situation s, for examp le lower incisor
crowns, t his is impossible because of th e small-
ness of the tooth. Where part of the crown is all
metal. for examp le on t he lingual side . the prepa-
ratio n is as it wou ld be for a metal crown.
Th e margin of t he crown may be constructed
in po rcelain or me ta l. or the two materials may
join at the pe riphery. The cavo surface angle w ill
depend upon this decis ion (see Figures 3.1e, f).
Related to function
Occlusion"
The occl usal re lationships of t he to ot h to be
crowned will influence t he design o f the pr epa ra-
tion . Tho se areas of t he cr own subjected to
heavy o cclusal load ing in t he inte rcuspal position
(see Chapte r 4) or in on e of th e exc ursio ns of
the mand ible should be suffi cie ntly thick to
withstand t hese fo rces without dist ortion if the
cr own is metal. and with out fractu re if the cr own
is po rcelain o r meta l-ce ramic. This means that In
Designing crown preparations
SUita ble for porcela in Suitable for
- ---, or metal-ceramic metal-ceramic
e f
Approx 90 ' Appro x 90' 130- 160'
Figu re 3.1
Margin configurat ions for crown pr eparation s.
a A section of a mo lar too th
b A knife-e dge margin w ith a cavosu rlace angle
approaching 180' .
c A chamfer margin with a cavosurface angle of
130 '-1 60 ' .
d A finishing line with minimal tooth reductio n but
with a sharp ste p. prepa red wit h a squa re- ende d instru-
ment producing a cavo surface angle of approxi mately
90' .~
e A full shoulder with a 90' cavosurface angle. W hen
used for a metal-c eramic cr ow n. th e metal is e ither
bro ught to the margin or finished sho rt . leaving a
porcelain margin.
f A full sho ulde r with beve lled margin.
an Angles Cla ss I occlusion there should be
ade quate red uct ion of t he occlusal surfaces of th e
posterior teeth. th e palata l surfaces of upper
incisor te eth and the incisal edges of lower incisal
teeth. Other surfaces may also be involved in
different occlusal relati onships.
Whe n there is po ste rior group functio n. t hat is.
seve ral pairs of poste rior teeth slide against each
othe r as the jaw moves to t he working side (see
Chapter 4), t he res ult of applying this principle is
that the cusps that function against each other in
 Designing crown preparations
this way sho uld be reduced more t han other parts
of the preparation. Th is is oft en refer re d to as
'bevelli ng the functio nal cusp'. Befo re t his is don e,
the actual relationships of t he cusps in -questio n
should be stu died during the fult range of
movements. In the majority of patients t he po ste-
rior tee th are discluded in lateral excursion by the
canine teet h. Th ese 'functional' cusps therefore
only functio n in the inte rcuspal position and are
less vulnerable to wear and to lateral for ces. There
is therefore less need to bevel them excess ively.
In so me cases the crow n is being made to alter
the occlusal relationsh ip, and it may be necessary
to reduce t he occl usal surface less t han usual if
the intention is to increase th e occlu sal vert ical
dimension.
Future wear
All res torative materials wea r in use, and the rat e
is det ermined by th e occlusion. the diet and
parafunctio nal (bruxing) habits. Where t he tooth
surface is intact before crown pr ep aration is
started, care ful no te sho uld be made of any wea r
facets. and t hese are as of the tooth surface shoul d
be prepared sufficiently to allow for an adeq uate
thickness o f cr own material so that futu re we ar
will not prod uce a perfo rat io n of t he cro w n.
Related to appearance
Buccal, incisal and proximal reduction
Ade quate reductio n o f t he toot h su rface must
be car r ied o ut o n t ho se su rfaces w here t he
appearance of t he cro w n will be impo rtant.
43
Figur e 3.2
Inadequate reduction of the labial incisal area of the
pre paratio n so that the core shows t hro ugh the PJc on
the upper right ce ntral incisor.
Insuffi cien t buccal o r incisal re duction s for PJcs
resu lts in th e core mate rial showing thro ugh
(see Figure 3.2) or t he crown being to o prom i-
nen t. Pro ximal red uction is impo rtan t to achieve
t ranslucen cy at the mesia l and distal su rfaces o f
the crown. Further back in t he mouth it is more
important to reduce the preparatio n rnesio -
bucally than disto-bucally since this is the more
important surface aesthetica lly.
Occlusal reduction of posterior teeth
In mo st patients th e occlusa l surfaces of th e
lower pr em olar and mo lar teet h are mo re visible
tha n -th e buccal surfaces in normal speech and
laughte r. If meta l-ceram ic crow ns ar e made for
lowe r po sterio r teet h, it is usuall y necessary to
red uce the occl usal surface sufficiently for po rce-
lain to be carried over it.
In t he upper -jaw t he occlusal surfaces are far
less visible. the buccal surfaces being more impor-
ta nt aesthe tically. It follows t hat it may be neces -
sary only to red uce the occlusal surfaces of uppe r
poste rio r teeth sufficiently for a thickness of metal.
Crown margins
Th e pos ition of t he cr ow n margin in relatio n to
the gingival margin affects th e appearance. Sub-
gingi val margins may have a better appear ance
initially but wilt often produce a degree of gingi-
val inflammation t hat, apart from po ssibly leading
to more se rious period ontal disease, is itself
unattractive. Crow n margins at th e gingival margin
o r slightly supragingival need not be obvio us and
will be less likely to produce gingival inflammation
44
(see Figur es 2.5a and 3.3). It is also easier to ta ke
impr essions of supragingival margins, to assess t he
fit and to mai ntain them. Th e intention t o make
vis ible margi ns suprag ingival sho uld be discussed
wit h th e pat ie nt. ex plaining t he reasons, before
t he teeth are pr epared .
Related to adjacent teeth
Cl earance to avoid damage to adjacent
t eeth
If on ly o ne tooth is being prepared for a crown, it
is clearl y im portant to avoi d damage to t he adjacent
teeth. This is much easier said than do ne, and a
number of studies have shown tha t slight damage
to ad jace nt te eth during crown pre parat io n is
extre me ly com mon . In pr epari ng the approxirnal
surface of a too t h with burs. the tooth surface must
be r educed sufficie nt ly to allow the full th ickness of
the bur to pass across t he con tact area within t he
contou r of t he tooth be in ~ 9r"ll. xed. lea,,,,'!,.. ,i\\~
fragment of enamel o r amalgam core in co ntact
with the adjacent tooth. This falls away once t he
bur emerges at the other side of the tooth. This
means that extensive reducti on is often inevitable
at t he approximal surface (see Figures 3.10 and
6. IOb. pages 52 and I 12).
Designing crown preparations
Figur e 3.3
C ro wn margins.
a Six cr owns made in 196 9 wit h subgingival margins.
b The same crowns. exc ept for th e central inciso rs,
which have been re placed . photog raphed in 1978.
There has been extens ive periodontal disease and
su rgery t hrou gho ut the mouth. The crowns were
rep laced wit h slightly supragingival ma rgins. and the
gingival t issues have re mained stable.
Path of insertion
When teeth are unevenly aligned, altho ugh a crown
preparat io n can be made and an impression taken.
the fi nished crown so metimes cannot be seated
because the overlapping adjacent tee t h prevent its
insert ion. The so lution is eit her to reshape the
adjacent teeth o r to design the preparation at an
angle that permits the insert io n of t he crown.
Technical considerations
Pro ximal reductio n sho uld prefera bly be continued
to allow clearance betwee n the gingival margins
and t he adjacent tooth sufficient for a fin e saw
blade to be passed between the dies, so t hat t hey
may be separate d in the laboratory . This also facil-
itat es cleaning the margins once t he crown is fitt ed
(see Figure 3.14k. page 59). W ith convergent roots
of adjacent teeth th is may not be possible.
Related to periodontal tissues
The impo rtance of sup ra- or subgingival crown
margins to perio do ntal healt h has already been
discussed . Th e shape of th e cr ow n margin (the
cavosuriace angle) should be de signed so that the
Designing crown preporations
crown surface can co nvenie ntly be mad e in line
with the tooth surface. Insufficient re duction at
the margin can res ult in an ove rb uilt cr o wn,
which in turn pr od uces a plaque re tention area
at the margin (see Figure 3.1b).
It is not always possible to kee p crown margins
supragingival at t he proximal su rface. W here the
gingival tissues are normal and healt hy when
crown preparatio n starts. t he interdental papilla
fills the space beneath the contact point.
Therefore if the crown margin is to include the
contact point, it will usually be necessary to make
the crown margin subgingival or to remove
healthy gingival tissue surgically.
When the gingival tiss ues are inflamed. as they
often are arou nd teeth to be crowne d. becaus e
ofplaque retention around existing unsatisfacto ry
restorations. it may be necessary to mo dify t he
4S
Figure 3.4
a Gross gingival hyperplasia and enamel hypoplasia.
b The hyperplastic gingi v al tissue has been removed
surgically.
c Crowns on the upper incisor teeth for "the same
. ~
patient.
restoration and encourage better cleaning, or to
make a we ll-fitting provisio nal crown. provi de
periodontal t reatment and t hen adjust the
margins of th e pr epa ratio n.
W hen peri od ontal pock ets are present t hat are
so deep t hat they can no t be mainta ined by
impr o ved oral hygiene . pe riod ontal surgery may
be necessary. and this will usually have the effect
of moving the gingival margin apically so tha t
more of the clinical crown (and root) is visible.
This make s crown preparation with supragingival
margins easier. but the ap pearance may be poor.
with large triangular spaces betw een the necks of
t he teeth (see Figur e 7.5. page 155).
T his surgical procedure is certainly justified
w he re t he re has been alveo lar bon e lo ss t hro ugh
peri od ontal disease or in other pe rio don tal condi-
t io ns (see Figure 3.4).
·.
46
,
A similar proced ure known as 'crown lengt h.
eni ng' is also so metimes car ried o ut wh ere there
is a normal level of alveo lar bon e and healthy
gingival tissues but where t he clinical crown
height is re duced and it is perceived that t here
is a problem with retention. Cro wn lengthening
usually invo lves t he rem oval of healthy alveolar
bo ne. and is th ere fore des t ru ctive. and is qu ite
unco mfo rta ble for the patient. Alternative means
of improving retention sho uld therefore be used
whenever pos sible. and crown lengtheni ng should
be reserved for t ho se cases where part of th e
purpose is to mo ve t he gingival margi n apically
for aesthetic reaso ns o r where alternative means
Desjf!ninl! crown DreDarations
Figure 3.5
a A peg shaped late ral incisor with a low gingival
margin.
b Elect ive crown lengthening. This photog raph was
taken a week after the surgery and the suture s are
about to be removed.
c The upper late ral incisor crowned.
of retention are co nsidered to have a poor
prog nos is.
Figure 3.5 shows a patien t who has had elective
crown lengthening.
Related to the pulp
W hen a vital pulp is to be reta ined within the
crown preparation. a minimal thickness of dentine
must be preserved to protect it . The thickness of
this layer will depend upon the age of the patient.
t he condition of the dentine (i.e. the amo unt of
 Designing crown preparations
peritubular and secondary dentine) and the type of
preparation. Only an approximate estimate can be
made of the size of the pulp in a given case , even
with good radiographs. So. confusingly. t he design
of the crown preparation is partly determined by
the need to preserve the pulp undamaged without
really knowing in detail where it is within the tooth.
The size of the pulp will also be decermined by
the condition that has necessitated the crown
preparat io n. If this has been a slowly progressing
condition such as caries or toothwear then the
probability is that the pulp will have laid down a
substant ial amount of secondary dentine and will
therefore be much less vulnerab le tha n if th e
tooth has been fractured in an accident. If the
natural crown of the tooth is small (microdontia)
and the purpose of making a crown is to inc rease
the size then ve ry little tooth preparation is
necessary and the pulp is not significantly jeopar-
dized even with yo ung patients (see Figure 3.5).
This need to protect the pulp often conflicts
with the need fo r an adequate thickness of crown
material, particularly in extreme cases such as
metal--ee ramic crown preparations on lower
incisor teeth. Here the ideal thickness of cr own
material commonly has to be compromised in
favour of the need to protect the pulp.
A good way to gain experience that should help
avoid too many dead pu lps or failed crowns is to
make preparations on a variety of extracted teeth
and then section th em to se e how much dentine
is in fact remaining.
Retention
There are two principal systems used to retain
resto rat io ns in crown and bridge work. The
convent io nal method, which has been used for
many years, invo lves pr eparing the tooth to a
retentive shape and then cementing the crown or
bridge retainer with a lut ing cement, which is not
usually chemically adhesive to either the tooth
surface or the fit surface of the crown. The
crown is retained by a combination of the design
features to be discussed shortly.
The second system is to use an adhesive luting
cement that bonds either chemi cally or
mkromechanically to both the tooth surface and
the restoration. Restorations cemented in this
way therefore do not need to be mad e in t he
47
conventional manner. Examples of these restora-
tions are porcelain veneers (see Figure 1.8,
pages 13-15) and minimal pr eparation bridges
and splints (see Chapter 8) . At present th ere a re
three such adhesive luting cements:
• Glass ionomer luting cements, which adhe re
chemicall y to both e namel and dentine but not
t o cast-metal surfaces or other re storative
materials
• Chemically adhesive resin -based cements,
which adhere to a freshly sandblaste d cast-
metal surface and which lo ck micromechlni-
cally into an etched enamel surface
• C omposite luting cement consisting of a lightly
filled resin that retains restorations by physi-
cally locking into micromechanical re tenti ve
feature s o n both the tooth surface (etched
enam e l) and the restoration.
Th es e adhesive cem ents have produced signifi-
cant changes in the practice of crown and bridge
work in recent years but have not replaced
co nve nt io nal techniques in the majority of cases.
This is because with all these adhesive mat eri als
there must be sufficient sound enamel or de ntine
left for th e cement to adh ere t o . In many of the
situations described so far, this is not so, and in
ot he rs th ere is a need to remove sub stantial
amounts of tooth tissue in order to replace it
with crow n material for aesthetic reasons.
These adhesive syst e ms ar e still in the process
of development, and it is likely that they will have
an influence over th e principles of retenti on used
in conventional , crown and bridge work. Glass
ionomer and resin-based luting cements are
already commonly used with con ventional crow ns
and bridges, and time w ill tell whether this will
allow mod ifications of the co nventional prepara-
tion designs . In t he meantime it is wise to
continue to apply the general principles of reten-
tion that have been shown to be effectiv e over
many years. The following paragraphs all relate to
co nventional crowns and bridges rat he r than
those reta ined by adhesi ve cements.
Retention against vertical loss
A crow n is inserted from an occlusal or incisal
direction and can be lost in the reve rse direction .
48
a
c
b
Forca ha &Ih lll
di5lodQiog enec r
Forces unseati ng crowns in t his dir ect io n fall into
th ree catego ries. First, t here can be a dire ct pull
o n t he crown such as t hat exerted by bit ing into
a sticky toffee and t he jaw then being op ened
shar ply. Othe r direct unseating fo rces are t he
removal of partial dentures and lever age in som e
bridge designs. Second, th ere are forces arising as
a co m po nent of lat er al fo rce against an inclined
plane (see Figur e 3.6). and third. th ere are forces
exerted by t he de nt ist in a de libe rat e attempt to
remove the crown. Apart fro m t he fo rce exerted
by the den tist. th ese verti cal unseating forces are
less t han the fo rces applied in normal function.
which are in dire ct ions t hat seat the crown onto
the preparation.
The path of insertion may be incline d away
from the long axis if an an terior crown is be ing
co nstruc ted to give the appearance of procli-
nation or retrocllnarion . or if a large amount of
tooth tissue has been los t o n one or o ther side
of the to o t h due to caries or trauma so that
Designing crown p reparotlfYro
Figur e 3.6
This ex tracted mo lar tooth has been prepared with a
taper of 35·. This is more th an the recommended
figure (page 49). An occlusal force. a. will not dislodge
a crown. however unretentive the preparation . A force
directed at an inclined cusp plane. b. occurring in lateral
excu rsio ns of t he mand ible will. t houg h. have a dislodg-
ing effect if the crown pre par atio n is unre te ntive as in
this case . Lo ss of rete nt ion is unlike ly to occur as a
resu lt of a single co ntac t of this sort. It is more likely
to resu lt fro m small repeated fo rces in alte rnate direc-
tion s. b and c.
inclining the pat h of inse rt ion wou ld allow
mo re of t he remaining too th tissue to be
pres erved .
Interlocking minor undercuts
Figure 3.7 show s a sec tion th ro ugh
dentine/cem en t/c ro wn inte rface. The surface
irregularities of th e de nt ine are typical of those
pro duced by fi ne diamo nd or t ungste n car bide
burs. The irregulari ties of t he cast-metal surface
are typical of a surface that has bee n cleaned by
light sandblasting. Even without an adh esive
cement. it woul d not be possible to detac h the
crown from th e too th by sliding it away parallel
to the tooth surfac e o r at an angle from the tooth
surface. until an angle of more t han 30" were
reached. without crushing and shea ring the
cement wit hin t he mino r undercu ts on the two
surfaces.
D~igning crown preparations
t
OCCLUSAL
SEPARAT ION
NOT POSSIBLE
I
SEPARATION
POSSIBLE
"
CEME T
CROWN
100 lJm
Taper of the preparation
Depending upon the size of these minor under-
cuts and the compressive strength of the cement
used. the tape r of th e pr ep ar atio n (the angle
betwee n oppo sing walls) and its length determin e
the degree of retention against axial unseatin g
forces. A par allel prep aration is impractical, since
cement cannot be ex t ruded fro m t he cr ow n
during ceme nta t io n leaving an ex cessive th ickness
ofcement occlusally and at the margin . Once the
taper of the preparation ex ceeds 30 o r so, failure
through loss of ret entio n beco mes common.
Under 'ideal', artificial, laboratory co nditio ns and
using art ificial materials ra t her than natu ra l te eth,
a taper of 7 has been shown to be t he o pt imum
with minimum ce ment film thic knes s and
maxim um rete ntion . However, in t he mouth it is
49
Figure 3.7
A section through a typica l dentine/cement/crown
interface showi ng the irr egular ity of the two surfaces
and the angle at which separatio n must occur unless
the ceme nt is to be cr ushed.
impossible to achieve consistently a unifo rm 7
ta pe r withou t pr oducing some undercut prepara-
tions and da maging ma ny adjacent teeth . T he
human eye cann ot, in t he clinical sit uat ion, de tect
the difference betwe en a par allel pr ep ar at ion and
o ne of 10 o r so . Seve ral st udies have shown th at
. the ave rage taper for po sterior cr own pre para-
tion s that have bee n clinically succe ssful in a large
num be r of cases is ap proximat ely 20 (see Figure
3.8).
Mo st clinicians do no t have a protractor
amongst their inst ruments and so rat he r than
aiming t o achieve a taper of x - which cannot be
co nve nientl y measured and which will vary
aro und the t ooth - the o bject should be to
pr oduce a pre parat ion th at is as conse rvative of
t o ot h tissue as possibl e (inc luding adjace nt teeth),
but where an absen ce of undercut can clearly be
so
seen. In most cases t his will produce an accept-
able taper of between 10 and 20 .
Length of the preparation
The gre ater the le ngth of the preparation, t he
more retentive the crown will be. T he
minimum acceptable length wi ll depend on
other cir cumstances. includ ing the nature of t he
o cclusa l forces, the numb er of othe r teeth and
whe ther the crow n will be su bjected to
withdrawing forces from a partial denture o r
bridge.
The re lationship between length and taper is
important. The shorter the clinical crown, the
more parallel sho uld be the ta per attem pte d.
Designing crown preparatJal!
Figure J .8
Bucco-lingual se ct io ns throu gh crown preparat ions on
th re e pre molar teeth . The tape r of the pr eparations is
sho wn. The 7.5 and 12 pre parations wou ld be suffi-
ciently reten t ive in virt ually any clinical situation. The
23 preparatio n wou ld pro bably be satisfactory in most
clinical situa tio ns unless su bject ed to undue lateral or
axial with drawing forces. Note th at in the 7.S prepa-
ration both buccal and lingual enam e l is hardly reduced
at all towards t he oc clusal surface . Th is is also tr ue of
the 12 preparation . This would result in an overbu ilt.
bulbo us cro wn in th is re gion .
Designing crown preparations
When the clinical crown is assessed as being too
short for ade qua te re tentio n it must be built up
with a core (if there is suffic ient o cclusal clear-
ance), or a surg ical crown lengthening procedure
may be carried out (se e Figu re 3.5, page 46), o r
additional retention may be achieved by means of
pins or grooves.
Retention against other displacing
forces
Provided the taper of a complete crown prepa-
ration is uniform be t we en all t he o ppos ing
surfaces, the o nly way the crown can be lost is
along th e path of insertio n. However. som e
crowns cann ot be made w ith uniform taper.
Incisor teeth, for examp le. can be prepare d
with a small angle o f taper between the mesia l
and distal surfaces. but it is impos sible to
produce a narrow angle of tape r bucc a- lingua lly
- similarly with some mo lar teeth (see Figure
3.9). Part ial cro wn s must also be de signed to
prevent lo ss in directions othe r th an ax ial (se e
page 61).
51
Figure 3.9
Sectio ns thro ugh several teeth showing the difficulty of
preparing o pposing wa lls nearly parallel.
In all th ese Cases it is helpful to envisage the
crown as potentially being dislodged from t he
preparati on in o ne of five directions:
. O cclusally
• Buccally
• Lingually
• Me sially
• Dista lly
or at any angle between these direc tions. The
pr eparat io n needs features that pr event loss in all
t hese dire ct ions. These featu res also need to be
distributed aro und the preparat ion so t hat the
co mple x (and not fully understood) forces applied
to t he crown do not dislo dge it. All crown
mat erials, and ce rta inly dentine. have a degree of
fl exibility. and unles s t he cr own preparation has
52
these retentive features , this fl exibility may
eve nt ually lead to a breakdo wn in th e cemen t
lute, leakage and eith er caries o r lo ss of reten-
tion.
These additio nal retentive features are usually
e it he r gro oves o r pinho les. Both have the poten-
t ial not o nly to resist loss of t he crown in a direc-
tion ot he r t han in t he long axis, but also to
reduce t he angle of t he path of insertion . For
exa mple, a cro wn pr eparation with an excessive
me sio-dist al taper may be impr oved w ith buccal
and lingual grooves (see Figur e 3.10).
Avoiding failure from other causes
Fracture or distortion of tooth tissue
The remaining tooth t issue, o nce t he crown
prepar at ion is com plet ed, must be sufficiently
Designing crown preparations
Figure 3.10
A complete crown preparation t hat is inevitab ly over -
tapere d rnesio-distally because of the rela t ionship with
the adjace nt teeth . This overtaper has been compen-
sated by bucca l and lingual grooves .
ro bust to wit hsta nd not o nly th e fo rc es to which
it is subjected wh e n t he cr own is completed and
ce me nt ed, but also t he for ces that it will
en co unter dur ing impression tak ing, while a
temporar y cr own is in place. and du ring try-in and
ce men ta t ion of t he final crow n. This may be a
problem in preparat io n for anterior post cr owns
where a rim of t oot h t issue is left aro und th e post
ho le and wit h partial cro wns.
Fracture of porcelain jacket crowns
Stre sses are deve loped within PJcs as a result of
con t ractio n on cooling after th e firing cycle.
Thes e stresses pro duce minute cracks, some of
which o riginat e at th e fit surface an d pro pagate
to produ ce failure if the crown is subjected to
sufficient fo rc e. Th ese stresses are co ncentrat ed
arou nd sharp int ern al angles of t he fit surface, so
 Dtsigning crown preparations
" mon, this type of prep aration (With a larger distal box)
the external ang les of PJc preparations shou ld be
rounded to reduce t he m (see Chapter 6).
Rounded angle s have other ad vantages: it is
easier to lay down a platinum foil matr ix without
tearing it. sharp co r ne r s o n a r efracto ry die migh t
be damaged , and d ur ing cementation t he flow is
improved. pro duc ing a t hinne r film o f cement.
Distortion of metal
A common cause o f failur e of ante r io r partial
crowns is lea kage prod ucing discolouration and
caries behind t he incisal ti p, an d car ies starting at
the approx ima l gingival m argin. Both ty pes o f
failure re sult from inad equate atten t io n to t he
53
Figure 3.11
Rigidity in part ial crowns.
a The fit surface of a prem olar partial cro wn showing
the ridge of metal runn ing across the oc clusal surfaces.
The partial crown for the canine is re tained by th ree
pins rather than groo ves. This is reasonably rigid
except for th e prox imal surfaces, which would have
been stiffer if grooves had been used instead of pins.
Although the premo lar preparation is still used, the
canine preparation would now be uncommon, although
many patients still have successful bridges reta ined by
this type of partial cro wn.
b The fit surface of an anterior partial crown showing
mesial and cingulum pins and a distal groove. O nly the
palatal and distal surfaces of the tooth are prepared.
No te th e ridge of metal running around the periphery
of th e res to ratio n and stiffening it. Although unco m-
is still used fo r a minor re tainer for a fixed-movable
bridge (see Chapt er 8).
nee d to st iffe n the casti ng against distorting
. forces . T he inte rnal mesial and distal ridges of a
classical partial crown provide both stiffening and
rete nt ion . Th e internal o cclusal r idge . w hich
should co nnect the o ther two r idges, p roduc es a
stiff U-shap e d bar (see Figur e 3.1 Ia). In less classic
pre parat io ns the principle should be for a rid ge
o f meta l to run all the way roun d th e periphery
of t he preparati on to prevent d ist ort ion (see
Figure 3. 11b).
Casting difficulties
T he ext e rnal angles o f cro w n preparations for
met al castin gs shou ld also be ro und ed t o prevent
54
o ne of t he faults th at may o ccur in th e fo llowing
chain o f events:
• Stone die mat erial may not fl ow into t he
impressio n ade quately. trapping air bubbles in
the sharp angles of t he impression
• The shar p e dge s may be damaged at t he wax-
up stage
• Investment material may not flow adequately
into the wax pattern to produce rounded
internal angles on the casti ng. pre venting the
cast ing from seating fully
• It may be diffi cult to remove the investment
ma terial entirely from sharp internal angles
without dam aging t he casting
• C eme nt will flow less read ily around sharp
angles. incr easing the likelihood of an unneces-
sary t hick cement layer at t he margins.
Des ignin~ specific crown
preparations
T he princi ples o utline d above are co mmo n to all
prep a ratio ns. So me are more important th an
ot he rs. however. with different types of crown.
Posterior complete crown
preparations
All-metal crowns
Whethe r t he preparatio n is o n a natural toot h o r
an artificial core, application of t he princ iples will
usually res ult in preparations as show n in Figure
3. 12.
Variations include additional axial grooves or
pinholes to limit the path of insertion when a pair
of opposing walls are more ta pered than is destr-
able.
Metal-ceramic crowns
Posterior metal-ceramic crown preparations will
usually have an all-metal lingual surface and a
porcelain buccal surface. and may have a porcelain
occlusal surface. The decision where to finish the
porcelain will influence the preparatio n. The
Desif!ninl! crown OrebarotioMS
margin may we lt be a bevelled shou lder to allow,
sma ll line of me tal to show. simplifyi ng the finish-
ing of t he crown margin (see Figur es 2.Sa and 3. 1 ~.
In the po sterio r part of the mou th this appearance
is usua lly acceptable. Figur e 3. 13 shows typical
posterior metal-ceramic preparations.
Anterior crown preparations: crowns
for vital teeth
Porcelain jacket crowns (pJcs)
A series of PJC preparations is shown in Figure
3.1 4, demonstrating t he application of the princi-
ples in a variety of case s, including lower incisor
teeth. In all but Figur e s 3.14d and g. t he crowns
will be re ten tive and t here is sufficient tooth
reduction to enable a crown to be made of
ade quate t hickness for strength and appea rance.
Metal-ceramic crowns
Figur e 3.14 also shows prep arat ion s for
metal-ceramic crowns. Co mpared wit h PJ C prep a-
ration s, th e buccal reduction is gr eater and lingual
redu ction less where possible.
Post-retained crowns
Th e shapes of post hole s were described in
Chapter 2. The margin of the crown pre paration
will be similar to t hat for a vital crown of the
same mate rial, the difference be ing that in t he
case of a post crown t here is no pulp to protect.
and t herefore the shoulders can be wider and the
core th inner than for an equivalent vital to oth
preparation. Th is is poss ible not on ly because of
the absence of a pulp but also because the core
mate rial is o ften cast meta l or re inforced with a
metal po st (see Figure 3. 1Sa) and therefore
stronger than dentine. Besides, a labora tory-
produced core can be made more parallel-sided
and retentive than a clinical preparatio n.
The dentine rema ining between the post ho le
and th e shoulder, or o t he r margin, may be
retained or removed, depending upo n its th ick-
ness . With a preformed post and com posite co re,
Designing crown preparotians 55

Figure 3.1 2

Full metal crown prep arat io n o n a molar t oo th with an

amalgam core.

a Preop erat ive

b Mesial and distal preparation with a thin diamond

instrume nt with pointed tip to pr odu ce a chamfer
finishing line.

c The axial pre paration has been carried ro und the buccal
and lingual surfaces. and grooves are now being placed in
the occlusal surface to ensure uniform reducti on.

d Reduct io n of the occlusal surface.

e The axial walls of the pre par at ion finishe d with plain-
cut t ungsten car bide bu rs. Th e axia l-occlusal angle will
no w be rou nded.
56 DesiRning crow n prepara tlons

f A mes io-d ista l section of a cast of the finishe d prepa-

ration w ith t he diamo nd and tungsten carbi de burs
used [Q prepare th e tooth. The re lationsh ip between
these bur s and the adjacent teeth can be seen , and it
is d ear that this is the minimum achievable taper avoid-
ing damage to the adja cent teet h and an excessive
sho ulder preparati o n mesially and distally. The mesio-
distal tape r is 14· .

g O cclusal view of typical complete go ld cr own prepa-

ration on an upper first mo lar tooth with an am algam
core .

www.all islam .net

Problem

h Impr essio n of the pre paration in g sho wi ng the

cham fe r finishing line.
Designing crown preparations 57

Figure ] .1]

Post er io r metal-ceramic crown prepara tions.

a A t ooth prepared as a bridge abut me nt . Only a small

amalgam restoration was present. The buccal margin is
a bevelled sho ulder, the palatal margin is a chamfer
fi nishing line and th e entire margin is supragingival.

band, A typical me tal-ceramic crown pre paration o n

a ro o t-filled to oth wit h a post- ret ained amalgam core .
Note th e amo unt of oc clusal clearance . The axial wall
has been finished smooth but t he occlusal surface has
no t. This is of littl e significance, except that the mesial
and dista l co rn ers of the occlusal surfa ce should have
been rou nded .
-
58 Designing crown preparations D

Figure 3.14

. Anteri or crown prep arations .

a Sufficient sound dent ine rema ins for conventional PlC

preparation s. These prep arat io ns were made (or an all.
po rce lain br idge befo re the days of minimal-pr eparation
br idges .

band c The o bjec t ive is to redu ce the size of the

upper central incisors. Prep aratio ns in c are as exren-
stve as po ssible. allowing PJcs [0 be cons tructed that
are narrowe r and less prominent than t he natural
teeth. except at the neck.

www.alllslam.nel
Problem

d An inadeq uate PJc preparat io n. The previous crow n

had broken. The angles of the preparation are too
sharp and there is insufficient reduct io n fo r an adequate
thickness of po rcelain fo r strength and appearance.

e The preparat io n sho wn in d mod ified for a cast

ceramic (Dicor) crown. Note t he rounded ex terna l and
inter nal angles and the greater reduction .
Dtligmng CrOwn preparations 59

( r-tecal-ce ramtc crown prepa rat ions to re tain a bridge

on the lowe r incisor and lowe r canine t ee th.

g To tally inadequa te pr e parations on a number of

upper ant erior teeth. The pre parati o ns are o ve r-
cape re d, all ex cep t th e ce nt ral inciso rs are far , t oo
short. and the surface s are to o rough. All th ese
restoration s faiied wit h disastr ous consequences .

h Meta l- ce ramic crown pre paratio ns on badly worn

inciso rs that have been built up with co mposi te cores
(t he same patient as in Figure 5.5. page 93). The tem po -
rar y com pos ite restorat ions shown in Figure 5.5 are
re tained by acid etching to th e ename l. The se were
re placed by pin-ret ained pe rmanent cores, since thq
cro w n prep ar at ions removed ail th e e name l.

•
i, j and k PJc preparation o n an inco mplete ly e rupted
t ilted upper canine tooth in a patient with a repaire d
cleft palate. The final cr own will have a very differen t
alignme nt and appe ar ance to t he unprepa re d tooth.
There has been almost no e namel removed fro m t he
incisal edge and the adjacent buccal surface. A tr ial
pre paratio n o n a stu dy cast is esse ntia l with this type
of pro blem (see lat er).
60

Fig ure 3.1 5

POStS and co res,

" A prefo rm ed stain less -steel post ha s been cement

pre serving as much dent ine as pos sible. The to oth \\1l
roo t-filled at age 9, befo re the a pex wa s clos ed. 50 t
a large access cavity was nece ssary. Therefor e onIi
t hin she ll o f d e m ine remains. and this ne eds to
rei nforced by a pose.

b A u sc pose and co re W Ith a substa nt ial amount t

dent ine r emaining as part of th e pr eparation.

c A cast po s t and co r e w ith no co ro nal den tine.

 Designing crawn preparations
virtually all t he denti ne ca n be saved (se e Figure
115a). The a dvan ta ge in retaining a collar of
denti ne aro und t he post hole w he n a ca st post
and a co re is to be ma de is to gu ide the tec hn i-
cian in t he d ime ns io ns of th e co re req uired . T he
rim of de nti ne a lso s lightly lengthe ns t he post an d
improves the retention o f the wh o le res to rat ion
(see Figure 3. ISb ).
Partia l crown preparations: posterior
teeth
A typical po sterio r part ial crown is muc h like a
complete go ld crow n except t hat t he buccal wall
of the tooth is left unpre pa re d . T his mea ns t hat
the crown can be ins e r te d o r lost no t on ly from
the occlusal d irec t io n but also lingua lly. A poste-
rior partial c ro w n m ust th erefo re inco r porate
featur es t hat wil l pr eve nt lingua l loss, usua lly
Pract ica l points
• The re is no ide al c row n prep ar atio n.
• Pre paration an d design should fo llow general
principle s su itably adapt ed t o t he particular
case.
• Adequ ate re d uctio n is necessary wh e re appear-
ance is important.
61
Figure 3. t 6
A poste rior part ial crown prepa ration for an upper first
molar tooth. Mesial and distal boxes have been prepared
rather t han grooves, since there was a previous MO D
amalgam. The occ lusal groove has been prepared
through the remaining amalgam. The stained dentine is
firm, and furt her removal is unnecessary. The to oth has
been prepa red as an abutment tooth for a bridge, which
will be fixed-movable with an MO D inlay with cuspal
coverage in the premolar tooth (see Chapter 8).
mesial and d istal grooves connected by an
o cclu sal groove, the important area be ing the
lingua l wa ll of t he groo ve (see Figure 2.6, page 38
an d Fig ure 3,16 ). Wi t h other t ypes of posterio r
partial c row ns, sim ilar groo ves or pins are used.
Anterior teeth
Both the de sign an d the preparatio n of t e e th for
anterio r partial c row ns a re d ifficult. Rete ntio n is
ach ieved by at least three pinh o les or grooves,
o ne each mesia lly, d istally and in t he cing ulum.
The surfaces pre pared w ill de pe nd upon the type
of pa rti al c rown, w hich in tur n w ill depend u pon
its purpose, t he occlusion and t he impor tance of
ap peara nce. T his difficulty, and t he avai lability of
less destruct ive, adhesive restoratio ns have
contributed to the decli ne in the use of individ-
ual a nte rio r partial crowns.
• Re te nt io n still depen ds in many cases o n
convention a l methods .
• Re ma ining tooth t issue and ad jacent teeth must
be preserved.

4 Occlusal
considerations
T he re a re excel lent textb ooks o n occlus ion , an d
the reader w ho has studied these w ill be fo rgiven
for s kimmi ng this chap ter. For those wh o a rc no t
yet co nversant w ith t he pr incip les of oc clusion,
this short explanatio n togeth er w ith the practical
techniques for reco rdin g and re prod ucing o cclusal
relationships is inte nded as an int rodu cti o n to t he
subject. It w ill be suffic ient for making crow ns and
bridges for patien ts wit h no functi o nal distu r-
bances or pathological changes in t he tem poro-
mandi bular joi nt or t he oro-facial m usculature
and no major occlusal abnormalitie s, i.e. most
patients. For mo re difficult occlusal pr oblems the
reader is referre d to t he co mprehe ns ive te xts,
In recent years t he re has been co nsiderable
inte rest in normal and abno rmal occlusions and
in t he effects of ab no rmality. Th e re is a rapidly
expanding lite rature, both researc h-based and
empirical. An unfort unate side-effect of t his
enthusiasm is that the whole subject seems to be
confused in some de ntists' minds with the use of
complex articulators, reco rding devices and
ex pe nsive full mouth 'rehabilitations'. T he all or
no thi ng law see ms to apply, with som e de nt ists
apparent ly blaming mos t of th e human race 's ills,
and all of its den ta l o nes, o n t he odd aberrant
cusp, wh ile som e o thers rem ain unconvi nced,
th rowing th e baby ou t w ith t he bath wat er -
paying little or no attentio n to oc clusal relat ion -
ships ot he r t han when a fi lling or crown is 'high
in the bite'.
An understanding of a few simple pri nciples of
occ lusio n related to natu ra l tee t h and in parti cu-
lar how to examine o cclusions e nco ur ages a
middle cou rse between t hese ext remes and will
be of great value in preventing som e of the
failures that occur with resto rat ion s t hat rep lace
occl usal surfaces.
Elabo rate equipme nt is unnec essary for the
application of t hese prin ciples to th e re storatio n
of small groups of teeth; equipment sho uld be
see n simply as a mea ns to an end. In fact, the
62
0.
pr inciples determini ng t he design of articulate'i
and rec ordi ng devices ar e fairly simple, but their
conversion into t hree-dimensio nal reality lead, t:
the co mplex ity of t he equ ipme nt.
A functional approach to occlusion
The most useful way fo r a re storative dentist to
loo k at occlu sio n is from th e functio nal pont 01
view; the morpholog ical deta ils of the occlusion
ar e less important. T he fact that an occlusion i!
Angles Class I, II or III is less impo rt ant than th
way t he t eeth mo ve across each other in various
moveme nts o f t he mandible . For example. in
lateral excurs ions in som e patie nts, t he canines
are the on ly te eth in oc clusion , and in others
several of t he teeth are in occlu sion (see Figure
4. 1).
T he restorative denti st shou ld also recognire
that crowns, br idges o r any resto rations irrvob.
ing t he o cclusal surfac e will often affect the W,)
t he occlusi o n function s. This effect should be
de libe rat ely planned rath er t han be allowed to
infl uence the occlu sal mo vem ents by accident.
The functional compared with the
orthodontic approach
O rt ho dontic t re atm ent is aimed primarily ac
improving t he patie nt 's appearance and producing
a sta ble po st erior o cclusion in a single static
po sitio n. So me for ms of orthodo ntic treatment
go further and establish de liberate patterns of
co ntac t between t he teet h in various movements
of t he mandible.
Most o rt hodont ic treatm ent is carried out on
you ng peo ple w ho have no t yet developed rigid
patterns of invo luntary neu ro musc ular control of

their mandibular moveme nts. They are therefore
capable of adaptation to fairly drastic changes in
their occlusal re lationsh ips in a way that som e
older patie nts find difficult .
f rom the functiona l point o f view th ere sho uld
be no difference In th e o bjectives of the
orthodontist and res torative den tist - only differ-
ent mea ns of ac hievi ng t hem.
63
Figu re 4.1
latera l gUidance
a Can ine guidance in lat era l excursion with t he po ste-
r io r and incisor tee th co mpletely disciuding. Contact in
th is po siti o n is som etim es shared between the canine.
late ral and ce nt ral incisor teeth .
band c Group funct io n_ T he pat ient is show n, b. in
inter cuspal po sit io n, and w hen she mo ves to th e
work ing side. c. con tac t is sha re d betwe en t he poste -
rior teet h. Th e lateral and central incisors disclude .
Fixed compared with removable
prosth etic approach es
The main purpose of designing the oc clusio n fo r
complet e dentu res is to pro duc e sta bility of me
den ture bases. This is an entire ly d iffe rent co ncept
fro m me restoratio n of natural tee th with intact
roots and pe riodon tal membrane s. O cclusal

consideratio ns fo r part ial den tures fall so mewhe re
between these two po sitio ns. In com plete denture
co nst ruc tio n. conside ration of where the o cclusal
surfaces of the art ifici<ll te eth sho uld be in relation
to the ridge, the presence of balancing co ntacts
on the ncn-wcrkmg side. and the angulation o f
cusps or absence of cusp s altogether. are unpor-
tant, No ne of these applies in the same way to
th e construction of fixed restorations.
The metho ds of re co rding and reproducing
mandibular mo vement are similar whether fixed
or removable app liances are being made.
However, the principles go vern ing the de sign of
the oc clusal relationships, altho ugh similar in
some respects , are differen t in o thers.
Man d ibul ar movem ents a n d
d efin iti on o f terms
The move ments that the mand ible can make and
the names of the impo rtant pos itions within this
range of mo vem e nts are sho wn in Figure 4.2.
Inter-cuspal position (ICP)
This is the pos ition of maximum co ntac t and
maximum mtercuspario n between the t eeth. It is
therefore the most cranial pos ition that the
mandible can rea ch. Th e term 'ce ntri c o cclusio n'
has been used to describe this position , but th is
is con fuse d with 'cent ric relation' (see be low) and
may also imply centricity of the co ndyles in the ir
fossae, centric ity o f the mid line o f the mand ible
with the midline of th e face, or centricity of th e
cusps wit hin t he fossae of t he op pos ing t eet h,
no ne of which may be the case. The te rm 'cent ric
occlusion ' is there fo re bette r no t used.
Retruded contact position (Rep)
This is the mo st re truded po sitio n of the
mandible with t he tee th together. It is a clinically
reproducible pos it ion in the no rma l co nscio us
patient. Patients with conditioned patte rns of
muscle activity may no t be able to manipulate the
jaw into it. eve n with assistance by the de ntist. In
Occlusal cOMslde,ar03<I
less t han 10% of the de ntate popu latio n the RC'
coi ncides with the ICP. In the re maind e r RCP is If:
to 2 mm or mo re pos terio r to ICP. The tem:
'ce ntric re lation ' has been used to de scribe th!
pos itio n, but it has th e same disadvanta ges as thE
term 'centric occlusion' and will no t be used.
Mandibular movem ents
Those patients who have a discrepan cy between RO
and ICP usually close Str<light into ICP from the postu-
ral or res t positio n. Ho wever, co ntact occurs in die
range between ICP and RCP during empty swallow.
ing (part icularly noctu rnal swallowing), during the
masticat io n of a tough bolus and during parafunc-
tional activity. Th us t he mandible can slide from I(P
in four main direc tio ns with the teeth in co ntact, or
in an infinite number of direct ion s at angles between
these main pathways. T he four excursi ons are:
• Ret rusive
• Protr usive
• Left lateral
• Right lateral
Re tru sive m o vem ent s
Movem ents betwee n ICP and RCP are usuilily
guided by a limited number of pairs of cusps of
pos terio r teeth. Figures 4.3a. band c illust rate the
o cclusal co ntac ts pro duced in RC P and ether
ex cursio ns in a typical natural de ntit io n. The angle
o f the slide betwee n Rep and ICP. its length and
the individual pairs of teeth tha t prod uce it are
important and sho uld be exam ined. Of even
grea te r importance is any uneven ness of the
movem ent producing bu lges o r lumps in the path
of mo veme nt. T hese d isturbances to the smooth
mo vement of t he mandible are o ne form of
occlusal inte rfere nce (see page 65).
Protrusive excu rsion
In forward mo veme nt of the mandible with the
teeth tog ether it is usually the incisor teeth that
guide th e move ment. Th is will not be the case in
ante rio r o pen bite s or in Class 111 inciso r relance-
ships.

The angle and length of movements will be
determined by the inciso r r elation ship so th at. for
example, in a Class II D ivisio n II incisor r elationship
with an increased overbite and reduced ove rjet. the
roovement of the mand ible has to be almost ve rn-
cally downwards before it can move forward s.
Anterior guidance is impo rta nt when making
anterior cro wns or bridges. Sometimes, when the
teeth are a nor mal shape. it is helpful co reproduce
the patient'S existing guidance as accurat ely as
possible; on oth er occasions, for example. with
worn teeth . it is unnecessary o r undes irab le to do
so, and in fact the purpose of the treatme nt may
be partly to alter the incisor guidance.
Left and r ight lateral excursions
In lateral excursions t he side t hat the mand ible is
moving to is known as the working side and the
opposite side the non -wo r king side. The term
'balancing side' has been "used to refer to the no n-
working side, but since it implies a balanced
occlusion, b3lancing or stabilizing a complete
denture base, it sho uld no t be used in reference
to natural teeth.
The contacts on the wo rking side are either
between the canine teeth on ly (can ine-guid ed
occlusion - see Figure 4.la) or between gr oups
of teeth on th e working side (group function -
see Figures -t.l b. c). Occasionally, individua l pairs
of posterior teeth w ill guide the occlusion in
lateral excursion, but this is no t regarded as ideal.
Contact on th e non-working side in lateral
excursions sho uld no t normally occ ur . It do es
sometimes afte r extract ions and ove r-erupt ion
and occasionally following orthodontic t reatment,
particularly when th is treatment has bee n ca rried
out with re mo vable app liances that have allow ed
the posterior teet h to t ilt (see Figur e s 4.3d, e).
Contact may also occ ur in case s of posterior
crcssbite w here the lower te eth are placed
buccally to the upper teeth.
Occlusa l interfere nces a nd occl usal
harmony
An occlusal in t e rferenc e may be def ined
either- as a contac t between teeth in one o f the
6S
excurs ions of th e mandible so that the fre e sliding
movement of the mandible is inte r rupted o r
uneven, or as the guidance of the mandible bei ng
ca rried o n teeth that are unsu itable for the
purposes. In many cases oc clusa l interfer en ces
develop some time after the eruption o f th e
pennanent dentitio n and are the result of dental
treatment .
Figure 4 .4 illustrates an alteration to th e
move men t between lC P and RCP res ulting fro m the
over-erupti on o f a tooth. Th is const itutes an
occl usa l interference in this excurs ion. Figure!>
4.3d and e illustra te an interference in lateral
excursion.
T hes e inte rfe ren ce s are o ften diffi cu lt to detect
becaus e t he sensory mechanism w ithin the
periodontal me mbranes of the teeth involved
det ects th e int erferen ce and trigg ers a cond i-
t ion ed pattern of ma ndibular mo vement to avoid
it. This acco unts for the diffi cu lty many patients
have in perm itti ng their mandible to be man o e u-
vred into th e Rep and also t he d ifficulty they have
in voluntarily making lateral excursions w ith th e
teeth togethe r.
An interfere nce in t he mte rc uspal position
result ing fro m a 'high' resto ra tion involving the
occlusal surface W ill be readily detected by the
pat ient, w ho will usua lly comment on an oc clusa l
change as soon as th e rest oration is inse rted .
These instant, entir e ly arti ficial interferences are
obviously eas ier to dea l with th an occlusa l inter -
ferences in the vario us ex curs ions of th e mandible
- whic h may be artificial but ca n also develop
slowly and naturally fo llowing extractions, tooth
movements, occl usal wear and over-eruptio n.
Inte rferen ces sho uld be sus pected if the pati en t
has difficulty in making vo lunta ry protrusive and
lateral excursion s w ith the teeth in conta ct or
t here is difficulty in ma no euvring the ma ndible
into a reprc duclble R. CP. Inte rfe rences can also be
detected by the de nt ist rest ing a finger gently
under the patient's ch in while the vario us exc ur-
sions are pe rfo rme d. Irr egular mo veme nt s, wh ich
th e finge r will fee l, indicate inte rfe re nce s th at
need fuller inve stigation.
Occlusal h arm ony - the abse nce o f ccclu sa t
inte rfe re nces - allows compre hensive move-
ments of the mandible in all excursio ns with the
teeth together w ithout st rain or discomfort, the
m ove me nts not causi ng harmful effec ts to the
teeth (for example tooth mobil ity, fra ct ured
"
cusps or excessive wear) . A har monio usly
funct io ning oc clusion w ill usually also invo lve
fairly shallow angles of movement in th e
guida nce fr o m lCP in all four d irectio ns. Pat ients
wh o do not have free slid ing mo vem ents may
not have sympt o ms. They have adapted to the ir
oc clusal interferences. Howeve r. if the occlusion
is alte red to prod uce new and different occl usal
interferences (for example by unsat isfactory
cro wns o r br idges). th e pat ient's neuromuscular
mechanism may well expe rie nce difficulty in
adapting t o t hese, resulting \n damage to t he
re sto rat io ns o r te et h, o r a dysfunctio na l diso r-
der leading co t empo r omandibul ar joi nt pain.
muscle pain and spasm. o r postural and
Figu r e 4.2
Borde r movements of the man dible.
a Th e max imu m po ssible movemen t of t he ti p of a
lower centr-al incisor. The teeth ar e in oc clusion from
RCP to the fully protruded pos ition (P). In o pening from
RCP to X . the mand ible rotates in a pure arc of a circle
ar oun d an axi s (th e term inal hinge axi s, TH,o,). whi ch
passes thr ough th e co ndyles. X is t he maximum
open ing th at can be made w ithout the condyles moving
forwar ds and 0 is th e max imum open ing w ith th e
co ndyles full y protruded .
b T he view from above . showing Rep and ICP. Th e
moveme nts ar e no t pure ar cs of cir cles, because wh en
the mandible moves to the side the co ndyle o n the
w orking side shifts lat era lly (Bennett mo vement) and
th e co ndyle on t he non - working side moves forwar ds
and med ially (Benne t t angle) .
c T he border m ove ments viewe d fro m in front . Th e
mo vement fro m ICP to the cusp- eo -cusp contact (C) is
gUided either by canines. all the anterior te eth o r a
gr oup o f po sterio r tee th (see f igur e '1. I ). f r om C to
the maximum lateral posi t ion, L, the guidance is irreg-
ular and usually controlled by t he anteri or teeth or
teeth o n th e no n-wo rk ing side. Thi s is a non-function al
ra nge not usually involv ed in par-afunctioflal activ ity , and
is th er efore of hrtle en pcrtance.
d Changes in the lateral guidance wi ll either expand the
o r iginal bor der moveme nts. Y. o r encroach upon n. Z .
fun ctional problems. These disord ers ar ising
fr om o c clu sal d ishar m ony ar e fully d escribed in
specialist t extbooks.
'Premat ure co nt act '
The t erm 'p r ema tu r e contact' should not be used
in re lation to the natural dentition. With complete
dentures th ere is no natural ICP, and ICP and RCP are
m ade to coincid e. i.e. the artifi cial teeth interdigi tate
on the r etrude d pat h o f clo sure. The pat ient learns.
subconsciously. to d o se o n this r eproducible path
of closur e and closes in to jntercuspanon. When. as
Both changes con stitute occl uu l Int erfe r ences. The
change. Y, would re sult.. fo r example, from the fract ure
o r ex rra cuon of a canine tooth th at previously
gov erned latera l guidance. The change, Z. m ight r esult
fr o m ove rbuilding the cusps of a po sterior cr ow n in a
group funct ion occlusion or fr om the develo pm ent of
non -w orking-side contacts.
e This oc clusal interfer ence, an irregularity developin g
in the smooth mo vement fr o m ICP t o RCP. may also
r esult from crown s. A n exam ple of extracti on and
o ver-eecpeon causing th is change is sho wn in f igure
·H_
( An expan sion o f t he border movement is ohen an
o bje ctive of occlu sal adju stment in t he range from ICP
to RCP. for example . if the o r iginal m ovement was
fro m ICP to ReP I. Wit h lu ge vertical and ho ri zonu t
component s to the movement, an adjust m ent could be
carr ied out to pro duce a 'lo ng cent r ic'. so t hat the
movem ent w as flat from ICP to ecez. T hi s w ou ld nc r
change th e ho ri zontal component of the movement,
but w ould reduc e th e vert ical component to zer o . The
alt ern at ive of m akmg ICP and RcP co incident (RCP))
usually inv olves mu ltiple crow ns or ot her r esto rations
as w ell as o cclusal adjust m ent. Th is is because either
t he bor der movement space needs to be encr o ached
upo n (the dashed li ne) or Ol. substantial amount of
tooth t issue m ust be r emoved . Wh en t his is do ne the
process is kno wn as 'r eorganizin g' th e occ lu sion, If ICP
is left und istu rbed , t he occl usal plan is kno w n as
'confo r mative'.
 61

Bennett ang le
L Be nnett
move men t

THA
ICP
RC P I
,,
--
,,
,
,,,
,
,,
® o .: Rep
~w-
- I CP

THA P

ICP
L
\
I

© @
o
CP
,,

® CD
68

Figure 4,]
Occlusa l contacts.
o Perfcranons in a O.S-m.....-t hick sheet of soft w ax
produced by the patient closing in !CP.
d A differ ent pat ient making a r ight lateral ex cursio n. The
left (non-working) side is ShOWl1, and ther e is contact
between the lowe r second molar and the fint upper
mola r. This r.. a noo-wOl'"'king-side occlusal interle.-ence,

b The same patient co ntact ing in Re p. Ther e are of

course fewer contacts, but they are evenly distributed. e A wax oc clusal record o f th e patie nt shown in d in the
both anterio-posteriorly and between left and right. same right lat era l excursion, showi ng th is interlere n<:e to
be the only contact at this point.

c The same patie n t making contact in right la te ra l

e xcu rsion, ma inly o n the canine tee th. a lthough a
co ntact is also pr esent po steriorly.

ess. I~·
~ -
, Previously the mandible could slide smoothly back fro m
a result of inaccurate occlusal records. the ICP and
RCP of the complete de ntu res do not coincide. the
patient may d ose on the retruded path of closure,
and the n may slide into maximum intercuspation or
alternatively the den tu res may mo ve. This is know n
as prematu re con tac t and is clearly unsatisfacto ry.
Tile artificial teeth do not have a pe riod o ntal propri-
oceptive system, and so the positio n of an artificia l
ICI' cannot readily be detected. W ith a natu ral den n-
uon the ICP is well rec ognized by the neu romuscu-
lar mechanism and the mandible d o ses direc dy into
ICP in t he great majo rity o f involun ta ry closing
movements. It may not do so in t he artificial
environment of t he dental chair whe n th e mandible
IS brought under voluntary rather tha n involun ta ry
control. In these circumsta nces, even If the first
contact appea ~ to be a pre matu re contact. th is
sboold no t be assume d to be the no rm al patt e r n of
closure, but o nly th e result of t he patie nt co nce n-
trati ng o n a movem ent that is usu ally entirely
automatic.
For t he se reasons th e ter m occlusa l inte rfe r-
ence as defi ne d an d described above is pr efe r re d
10 the te r m premat ur e co nta ct for t he denta te
panem.
Occlusal stability
A stable oc cl usio n is o ne in w hich o ve r-eruptio n.
tilting and drih ing of teeth ca nnot o ccu r a nd
"
Figure 4.4
Since th ~ lowe r t hird molar has bee n extrac te d, the
uppe r t hird molar has o ver-e rupted. changing the Rep.
!CP to Rep. but it now has to make a detour to the new
Re p to circumnaviga te t he mesial surface of the upper
thIrd molar. This is an occlusal interfe rem:e, This
patient presented with pain diagnosed as mandibular
dysfunction. which disappeared once the uppe r t hird
molar- had bee n ext racte d. Caries, although prese nt in
the mesial surface of the upper third molar well below
the original contact point. was not the cause of ltle
pam.
therefore ca use new occlusal interfe re nces. For
an o ccl usion to be sta ble. t here m ust also be suffi-
cie nt poste rio r co nta cts to pre ve nt a general
coll apse of t he poste rior oc clusio n resulting in a
loss of occl usal vertica l dime nsio n. Figure 4.5
shows a diso rdered but sta ble occlusion. a disor-
de red and unstable o cclusion, and an occlus ion
t ha t has lo st poste rior support to the point
whe re colla pse a nd lo ss of oc clusa l vertical
dimens ion has o cc urred.
In a stable occlusio n all t he t ee t h s ho uld have
oc clusal contact with e it he r a no th e r tooth or a
pr o sth es is (occlu sal stops). Me sia l d rifting s ho uld
be pre ve nted by t he pre se nce of contact po ints .
eithe r with o t he r teeth o r a prosthesis. or by
adeq uate cuspal locking w ith t he o pposing te eth
in inte rcuspa l po sitio n.
N o t a ll pa r tially ede ntulous o ccl us ion s a re
unsta ble . Fo r e xa m ple. if all the molar tee t h a re
ex t r acted. th e r e ma ining teeth ma y sti ll be in
sta ble o ccl us io n. T herefore e xt rac ted t ee t h a re
no t al wa ys replace d (see C hapte r 7 ). In a ny
case. a degree of insta b ilit y is s o m etimes
ac cepta b le .
Occlusal vertical dim ension (a vo)
T he occlusa l ve rtica l dimension is the re latio n-
sh ip be t w ee n t he mandible an d the max illa wit h
t he teet h in ICP. that is. t he face height w ith the
70

Figu r e 4 .5

Occlusal stability.

o A disordered but stab le oc clusion. Several teeth are

missing and ther e have been i number of tooth
movem ents. some prcduong aesthetic problems and
poten nal occlusa l ie terferences. How eyer, the occlusion
is now stable and study u su taken five years before
this photograph sho w (hat no change has occurred in
that pe r iod. T here are no symptoms 0 1 mand ibular
dysfuncnon and no othe r co mplaints by the pauem
even of the appearance of the missing u~per teeth.
T r eatment of th is occlus ion is the r efore not justified

b T he re have been recent e x tractions in the upper

arch and u nd esirab le toot h mov ements. including over-
eru ption of th e lower teet h. can be ant icipated

c and d A 'co llapsed bite" W ith lo ss of a number 0'

posterior teeth. periodonul deease. d rifting upper

incisors. an increase in overbite a.nd a red uct ion r:
oc clusal verucat d imension.
 OcdUIOI consideratiam
teeth in occlusion . It is usual to mea su re the
difference between rest pos ition and IC P (t he
freeway space ) t o give an indication as to
whether the QVO is w it hin th e normal range.
However, rest pos ition is difficult to mea sur e
with any precisi o n, particularly in de ntate
patients, and t he no rmal freeway space may be
2-5 mm o r mo re. Q VO is t herefore judge d as
much as it is meas ur ed by the patient's gene ral
fac ial appeara nce wit h t he te et h tog ether and
apart. In most cases re qu iring cro wns or brid ges
the OVD is satisfactory. In so me it has been
reduced by t he ext raction of tee t h, by tilting,
drifting and co llapse of th e po ste rio r oc clusion
or by rapid wear o f the teeth (see Figures 4.5c,
d arid 5.5a). In t hese it is necessary to restore
the original occl usal level for bo th aesthetic and
technical reasons. In other cases gradual wear of
the dent ition has resulted in ve ry short teeth so
that making aesthetic and rete nt ive crowns is a
problem, yet th e re is no lo ss of facial height
because t he tooth wea r has been co mpe nsated
by over-eruption. In t hese cases a deci sion must
be made between:
• Artifici ally increasing t he aVD by restoring or
replacing all t he occl usal surfaces in o ne jaw
• Accepting that the crowns will have a short
appearance
• Artificially lengt heni ng th e clinical crowns by
gingival surgery and sometimes alveo lar surge ry
(crown lengthening)
• Creati ng int e r-o cclusal space between t he
teet h to be cro wned wit ho ut alte ring t he other
occlusal re latio nships
• A comb inat ion of th ese approaches .
When a change in aVD is planned, whethe r or not
it is to restore lost facial height, it is usual to
assess the to lerance o f the patient's neuro mus -
cular mechan ism to t he change . A rem ovable
acrylic plate co vering all the occl usal surfaces of
one arch and increa sing t he av o by at leas t t he
same amo unt as is pr oposed for the final resto ra-
tions may be fitte d. Alternative ly the teet h may
be tem po rar ily built up using acid-etch co mposite
restorations (whe n sufficient ena mel remains),
amalgams o r te mpo rary cro wns. The te mpo rary
adjustment to the avo shou ld be left for at least
six week s and preferably three months o r more
to ensu re t hat pr ob lem s do not arise with the
neurom uscular mechanism o r t he teeth befo re
71
t he change is made pe rmanent (see Figure 5.5,
page 93).
Creating interocclusal space for teeth
to be crowned
In certain circum stances, particularly extreme
wear of anterior teeth, it is helpful to carry ou t
mino r orthodo nt ic treatment to enab le cro wn
preparations to be carried out without furth er
preparation of the wo rn surfac es. Often the wear
has bee n sufficiently slow that o ver-eruption has
ke pt pace with it, carrying t he gingival margin
alo ng with t he over-e ruption. Conventiona l
orthodo nt ic treatmen t can be use d, but a simple,
reliable and rap id tech nique is to use eit her a
rem ovable o r fixed appliance co mmo nly known as
a 'Dahl' appliance. Dahl o r igi nally described a
rem ovable ante rior bite plane made of cast
cobalt--chrom ium but modern adhesive techno l-
ogy has e nable d a simpler fixed appliance to be
made t hat is well to lerated by mo st patients and
t hat usually achieves the requ ire d resu lt in about
t hree months . Figure 4.6 shows the appliance in
use.
Mandibular dysfunct ion
Many terms are use d to describe this condition,
for examp le te mporomandibular joint dysfunction,
myofascial pain dysfunction syndrome and muscle
hype ractivity diso rder. This illust rates the fact
t hat t he conditio n is po orl y underst ood and that
t he re are many suggested exp lanatio ns for it.
Some exp lanatio ns blame the jo int itself for the
symptoms , some t he muscles of masticat io n and
their control syst e ms, and som e the occlusion,
which in turn affects t he control system and again
in t urn t he muscles and t he joints , and some cli ni-
cians believe t hat the symptoms arise e nt ire ly
from psycho logical stress and anxiety.
The least pejo rat ive te rm is t herefore
'mand ibular dysfunction', wh ich is simply use d to
label a commo n co mbination of symptoms o ften
including tenderness, pain and tens ion in the
muscles of mastication and pain, clicking and
limitatio n of mo veme nts of th e te mporomandibu-
lar jo ints.
72 Ocdusoi COnsiderOlOO

I,
,
I r. •

Figure 4.6

a and b Palatal e rosio n affecting the upper incisor

teeth. The low er teeth have o ve r-e rupt ed and are
making co ntact with t he wo rn palatal surface.

• r

, The pos terior teeth in occlusion.

d The cast Dahl appliances. They are left se parate at

the midl ine because of th e diastema,

e The Dahl appliances in place propping the ccclus ce

open on the an te rior teeth.
Occlusal consideratians
In many cases the sympto ms resolve spo nta-
neously wit h or without treatment, The incidence
is higher in young adu lt dentate female patients
than in other groups. These two facts suggest that
the con ditio n is more com mon ly of functional and
psychogen! c origin than it is to do with
irreversibl e physical changes in the joints
themselves .
Change s do occur in the joints, and these can
be demo nstrated by conve ntion al rad iography o r
by spe cial, and sometimes invasive, tec hn iques
such as arthrograp hy, in which radio-op aque
material is injected into t he jo int space, or
arthroscopy, in which a tiny fibre-optic instr u-
ment is inserted into the joint space, w hich ca n
then be viewed directly. However, th e least
invasive investigation is by magnetic reso nanc e
imaging (MRI), which do es no t involve ion izing
radiation o r physical invasion of t he jo int . Whe n
MRI is available (it is a very ex pe nsive t ec hnique)
it is the best way to invest igate t he po ssibility of
internal jo int derangem ent s. C o nfusingly, MRI
surveys of no rmal patients with no sympto ms of
mandibular dysfun ction have shown t hat a signifi-
73
f The appliances have worked in depressing the lower
incisors and the four upper incisor teeth have been
crowned without any further reduction of their palatal
surfaces.
g Another typical Dahl appliance, this time in one piece
and with a more pronou nced shelf palatally to pro duce
axial too th movement.
cant prop ortio n of th e m have displaced discs
wit hin t he temporomandibular jo ints, w hich,
w hen such displacements were discovered by the
invasive techniques (which could on ly ethically be
used o n pat ients wit h sym pto ms) were co nsid-
e red t o be t he cause of t he sympto ms.
Undoubtedly so me of these internal joint
derange ments, o r more frank pat holo gy o f th e
jo ints, do cause symptom s similar to those ar ising
from t he purely functio nal diso rde r: mandibular
dysfunction.
T here are clearly case s in w hich t he caus e of
the symptoms is dysfunctio n, othe rs in which
th ere is so me o rganic, physical explanat ion and
many w here th e cau se is less clear. Sadly some
dent ists align th emselves with o ne or othe r of t he
rath er narrow and excl usive regimes fo r t he
management o f mandibular dysfunctio n. T his is
unfortunate and unscientific. With diffe rent
scho o ls o f t ho ught about the ae tiolo gy and
managem e nt o f mand ibular dysfunc tio n, each
supported by so me, but inco mp lete, resea rch
evidence, the sensible dentist will kee p an o pe n
mind. However, some line s of treat men t are

mo re mte rve nnve than o the rs and so it is wiser
to take a co nse rvative approach to t he manage-
ment of mandibular dysfunctio n and ass ume that.
in the abse nce of firm evidence to t he co ntrary,
most cases of mandibular dysfunction are
functional rath er than organic in natu re,
An attractiv e hypoth e sis is that occlu sal inte r-
fere nces (descri bed o n page 6S) pr od uce co ndi-
tione d patterns of muscle activity that avo id these
inte rfe rences. This increase s the basic level o f
muscle act ivity. which. when it is furth e r
incre ased by anxiety o r stress. brings the level of
muscle tension above a threshold and sympt oms
develop . T herefore tre atment aimed at removing
the o cclusal inte rfe rences is aimed at th e cause
o f the problem rath er t han the sympto ms.
Similarly, t reat ment aimed at redu cing anx iety and
stress is also aimed at the cause, but this sho uld
be limited to sympathy and explanatio n of the
cause together w it h a cari ng appro ach to t reat-
ment rathe r th an. in the hand s of the general
de ntal prac titio ner, th e use o f drugs.
O cclusal interfere nces are no t always eas y to
detect clinically because o f the se t of co nditio ned
re flexes that avo id con tact o n the oc clusal inter-
ference. A simple way to detect wheth er alt er-
at ion o f the occl usion is likely to re duce th e
sympt o ms of mandibular dysfunction is to
provide a hard acrylic biteplane covering all the
surfaces of on e (usually the upper) jaw. If the
sympto ms improv e after a few wee ks o f we aring
the appliance at nights (or all day if it is toler -
ated) then th is is a clear indication that the oc clu-
sion has something to do with the symptoms and
justifies t he expendit ure of furt he r time and
effort o n iden tifying and dealing wit h the o cclusal
interfere nces.
Th e acrylic bneplane shoul d be used in this
diagnostic way rather t han as a lo ng-term treat-
me nt of t he co nditio n. However, som e patients,
despite advice given to t hem , co nt inue to we ar
the plat e because it has re duced t he ir symptoms,
and for this reason plate s making co ntact with
on ly a limited num be r o f ante rio r o r posterio r
teeth shoul d no t be used. If the y are, the y will act
as o rtho do ntic app liance s and prod uce depression
o r over-e ruption of t eeth.
Th e t reatment of occl usal interfe rences in th e
manage ment of mandi bular dysfunction is usually
fairly simple o nce the inte rference has been lde nn-
fi ed . It usually invo lves occlusal adjustment by
grinding selected parts of the occl usal surfaces.
O<duwl Co<lstdero!1OI1\
This is no t the same as occlu sal 'equtllbranc n,
which suggests reco ntouring the entire o cclusion
to fit some preco nceived, idealized co ncept of
what the oc clusio n should be. Similarly the treat-
ment of mand ibular dysfunction o nly very seldom
indeed justifies the constructio n of multiple crowns
or bridges. C rowns and br idges may be necessary
for o ther reasons, and if the patien t has mandibu-
lar dysfunctio n then this wilt complicate the treat-
ment and definitive resto ratio ns should not be
pro vided until the sympto ms have reso lved.
The detailed manage me nt of mandibular
dysfunction is beyo nd t he sco pe o f th is &oo k, and
the remainder of th is chapter deals with practical
aspects of de aling with the o cclusio n in a patient
wit hout symptoms of mandibular dysfunction.
Exam ination and an alysis o f t he
occl us ion
In mo st cases it is sufficient to exa mine the occlu-
sio n clinically, but in mo re extensive occlusal
re co nst ructions o r where the re are co nditioned
patterns o f movement preventing clinical exam-
natio n. study casts should be art iculate d. Provided
the clinician und erstands what he is locking for,
there is no need to articulate study casts for the
majo rity o f cro wns and bridges.
Clinical exam inat ion of t he occlusion
The following points sho uld be no te d:
• Any co mplaint s t he patie nt may have of
t emporom andibular jo int pain, muscle spasm or
unexp lained chro nic den tal pain
• The ease o r diffi culty with which the various
excurs ions can be made volunta rily by the
patie nt
• Any occl usal interferences and whethe r the
proposed resto rations will influence these
• Mo bility of teeth du ring excurs ions of the
mandible with th e t eeth in co ntact
• The presence, angle and smoothness of any
slide from Rep to ICP
• The type of lateral guidance and particularly the
degree of contact in lateral excursion of any

te eth that are to be restored. or t he like ly
degree of contact fo r any teeth to be repl aced
• The pre sence o f any contact on the non-
work ing side
• The locatio n, extent an d ca use of any faceting
of the teeth to be resto r-ed
• The degree of stability of t he c cctu slon an d
whethe r the propo se d rest o rations w ill influ-
ence stabi lity
• Over-e rupted and tilted teeth . particularly if
they are the teeth to be res tored or jf they
oppo se th e teeth to be restored.
Clin ical aids
Articulating paper
Ae~rble articulating paper o r plastic foil of differ-
ent colours may be used to mark occlusal
ccotacts in different ex cu rsions. Fo r e xam ple. ICP
may be reco rded in one co lou r and ~CP in a
second (see Figure 4.7) . Articulating p<l. per is
rather difficu lt to use . having a te nde ncy to mar k
the tips of cusps wh ether or no t the y ar e in
occlusion, and often it does no t register co nta cts
_.td05.hed 2 01d and glazed porcelain.
www.all isla m.nel
Problem
Figure 4.7
o and b Occlusal coneacu marked in rwc differ ent
colours of articulatIng paper. The black marks on the
marginal ridges of the upper premolars. c. and o n the
bucca! cusp of the lower first premolar. b. were made
WIth the panent in lCP. Movemen[ (0 Re p produced [he
co ntacts marked in red.
W ax
Thin, fairly soft w ax w ith an adhesive on one side
is marketed as a material for regIster ing occlusal
co ntacts. Th is is useful but ra ther e xpensive. An
anemauvc is to use O.5. mm-thick. dark-coloured
sheet W 3X . Occlusal registrati ons in this material
Me shown in Figur e 4.3. It has the advantage mac
it can be removed from the teeth an d placed over
th e i tu dy cas u for the occlusal contacts. to be
studied mo re dosely. It can also be used in full
arch-sized pieces. Areas of contact in the mouth
may be marke d th ro ugh the perforatio ns wit h a
ch inagraph pen cil.
P lastic st r ip s
Plascic scrips ma y be used to test whether teeth
are making contact in var ious e xcursions . The
thinnest of th ese materials [shimstcck] is opaque
and silver -coloured and is o nly 8 IJm thick. The
strip is placed between opposing tee th an d pulled
aside once occl usal co nta ct has been made. O fte n
two pieces are used on opposit e sides of the jaw
to te st [he symm etry of [he occ lusion , or
betwee n the cro wned tooth and iu opponent,
and th e ad jac ent ro o m and its o pponent to tes t
th at the crow n is in contact but is no t ·h,gh'.

Less acc urate (40 urn th ick) but mo re manage-
able mylar mat rix strips, used fo r co mposite
resins, is an accep table alte rna t ive.
Stud y cas t s
Unart iculated study casts are usefu l fo r assessing
th e stability o f the oc clusion in ICP and for
e xamining wear facets, which are o ften eas ier to
see on the cast than in the mo uth . They are of
little value in assessing co ntacts in the excursions
of the mandible .
Articulated study costs
W hen sufficient information can not be o btained
by clinical exami nation o r ex amination of hand-
held st udy casts , it is unlikely th at st udy casu
mounted on a simple hinge articulato r will give
adeq uate additio nal info rmatio n; a se mi-adjusta ble
o r fully adjusta ble art iculator is nec essary .
Rgure 4.8 shows a set of study casts be ing
mo unted on a semi-adjustable articulato r. For regis-
trance of the cc closicn the following are req uired:
• A face bow record : se t to an aveT'3 ge term inal
hinge axis of 10 mm in fro nt of the supe rio r
bo rd e r of th e tragus of t he ear o n a line to the
ala of th e no se
• A record o f RCP in o ne o f t he materials
de scr ibed mo re fully in C hapte r 6
• Prot rusive ex cursio n record, usually in wa x,
but sometimes in one of the o the r mate rials
descr ibed in C hapter 6, o r
• Lat eral excurs io n reco rds take n in wax or o ne
of t he o ther mate rials.
The se mi-adjus table articulator has a number of
limitations and pr o duce s o nly an approximation
to th e too th moveme nts in t he mo ut h. For the
no rmal pur po ses o f analysis it is quite sufficien t.
Occlusal adjustments prior to tooth
preparat ion
O nce the o cclusion has bee n assessed, adjustment
prior to tooth pr eparat io n must be co nsidered.
Occluw l consideralions
Th is will be necessary in cases whe re the teeth
o pposing a pr o po sed bridge have over-erupted or
whe re t he occlusal plane is going to be altered by
mea ns of crow ns. Sometimes the incisal plane of
the lo we r inciso rs is adjusted and leve lled out
befo re making upper inciso r cro wns.
O cclusal ad justment is also indicated in many
cases of mandibu lar dysfunct io n (see page 7 1).
The re is no just ificatio n for prophylactic adjust,
men ts unless there is e vide nce o f damage or
patho logy arising fro m the oc clusio n; o ur le vel of
unde rsta nding o f oc clusal problem s iSr not yet
sufficie nt to warrant arbitT'3ry pro phylactic alter-
ation s in an established, com fortable , functio ning
oc clusio n.
Occlusal objectives in making
crowns and bridges
T here are tw o main o bjectives:
• To leave the occl usio n wit h no addit ional
occlusal inte rfe re nce s
• To leave the oc clusion stable.
In addition, t here may be seco ndary o bjectives,
for example:
• To distribute th e guidancc in o ne of the excur-
sio ns mo re e venly betwee n a number of teeth.
for example, by mo difying the ant erior guidance
so that a number o f anterio r teeth share the
occl usal for ces in protrusive excursion.
• When a canine to o th t hat pr evio usly guided the
o cclusio n is extract ed, lateral forces sho uld be
distr ibuted as evenly and as wide ly as po ssible
betwe en t he remaining po sterio r teeth.
T hese latter o bjectives may be described as
oc clusal e nginee ring, planned to pr od uce o cclusal
relatio nships that ach ieve th e fi rst two major
o bject ives of o cclusal harmo ny and o cclusal
sta bility.
Most crowns and sma ll br idges are made in
mo uths with an establishe d ICP and RCP. These
sho uld be left unaltered by t he rest orat io ns (i.e.
a 'co nfo rrnarive ' approac h) unless:
• So many o f th e oc cluding surfaces are being
resto red that ICP will inevitably be alte red

• 10' is unsatisfactory fo r so me reaso n
• OYD is being alt e red. or
• There are symptoms of man dibular dysfunctio n.
In all these cases the occl usion is usually restored
with ICP mad e t o co incide with Re p [i.e. a 'reorga-
nized' approach). This is mostly for practic al
reasons and docs not imply that Rep is preferable
to an established. comfortable , functio nal tCP,
Clinical and laboratory
management of the occlusion
Avoiding loss of occlusal relationships
When sufficient occludi ng teeth w ill r emain to
register the IC P and other occlusal re latio nships
after toorh pr eparation . there is no need to take
any preca utions to record the occl usal relation-
ships beforeh and. H ow ever , wh en th e occlusal
surfaces arc being remo ved fr o m a number o f
teeth, o r when one o r mo re of these teeth are
crucial to the guidance of mand ibular movements.
the occlusal relat ion sh ips sho uld be registered
before the tooth preparations are begun.
When large numbers of posterior teeth are
being prepared or when seve ra l tee th are missing
there is a risk of lo sing any reco rd of the o rigi.
nal ovn. A pair of oppo sing teeth on either side
may be left unpre pared. the remaining teeth
prepared and then th e o pposing teeth adjusted so
that ICP is the same as Rep. Impr essions and
occlusal records are taken with these teeth stabl-
liling the jaws during th e occl usal registration.
They are t hen prep ar ed and further impress io ns
taken. Alternatively. on e pair o f opposing crowns
can be mad e fo r each side of t he arch before the
other tee th are prepared and t hese pair s of
crowns se rve t he same purpose .
Maintoi ning occlusal relationships
with temporary restorations
Prepared teeth and their opponents will over-
erupt unless occl usio n is re-established by means
of adequa te tem porary restorations; and the
prepared tooth and t he teeth either side of it can
drift togethe r unless co ntac t po ints are
77
maintained in th is way. The lo nger th e period
between th e impression and fitting of the resto r-a-
tio ns, th e more important are temporary res to ra-
tions. Th ey are probably also mo r e important in
yo unger patien ts. whe re tooth movement may
oc cur mo re quickly. For th is reason. individually
made te mporary resto ratio ns in plast ic are
preferr ed to preformed types unless the
preformed temporary restoration happens to be
an exce llen t fi t at t he co ntact points and in the
oc clusion.
Recording and occlusion
A decis ion must be mad e on the type of articu-
lato r to use for the wo rking casts. Once th is is
do ne. the appropriate occl usal records will be
o bvious . The choice is as fo llo ws:
Hand·held m odels
Unless enormous care is taken. these are not
satisfacto ry. The most common problem is that
restorations are made high and are not detected
because it is very difficult to see th e tiny spaces
betwee n pairs o f opposing teeth ad jacent to the
restoration . It is po ssible to chec k whether these
teeth are in occl usion in lme rcuspal po sition using
shimstock or other mat erial but t his can be diffi-
cult and time consuming - it is quicker to mount
the models on an articulator in the first place.
when a high restoratio n is eas ier to see.
stmpte-htnge a rtic u la tor (see Figure 4.9)
T his is adequate when t he re are suffi cie nt unpre -
pared intercuspating teeth and the resto ratio n is
to be made occl ud ing in IC P and adjusted at th e
chair-side. For e xample. in a straightfo rw ard single
upper anterio r crown. the palata l surface can be
contoured to mat ch the adjacent palatal surfaces
so tha t the incisal guidanc e will need very little
adjustment . Similarly. fo r a single pos terior crown
when the occlusion is canine -guide d. it is nec es-
sary only to reproduce contact in ICP. The crown
will disocdude in late ral excursions. and adjust -
ment at the chalrslde for protrusive and retrusive
mo vements will be straightforward .
Adjustmen ts in lateral, protrusive and
retr usive ex cu rsio n s
The oc clusion of the restoratio n is examined for
interferences in these excursions of the mandible
and adjust ed if nec essary.
Stability
Fo llowing thes e adjustme nts . a fi nal chec k o f the
stabil ity of the o cclusion is mad e by co nfirma tion
o f the prese nce of ce ntric sto ps o n the resto ra-
tion and the adjacent te eth . T he adeq uacy of the
co ntact po ints is checked wit h de ntal fl o ss.
Practical points
• In restorative de ntistry a function al rather than
o rthodo ntic or com plete dentu re approach to
occlusio n is nec essary.
• C linical examinat io n o f t he occlusio n and
simple records are oft en sufficient fo r straight-
forwa rd cro wns and br idges.
• In cases of more com plicate d oc clusal
mo vements, a sem i or fully adjustable articula-
tor will be ne ed ed .
Adj u st m ent t ech n iq ues
ICP is adju st ed first and the ce nt ric stops
ma rke d with art icu lating pa per or wax.
Interfe re nces are mar ked with a different
colour and adjuste d.
Gold and porcelain can be ad just ed with
mo un ted sto nes or diam on d burs. Go ld ca n be
finished with finish ing burs and po lished with
mounted rub be r wh eels or points. Po r ce lain
ca n be finished with the mo unt e d po int s or
d iscs used to finish composit e and with
spec ially pr o du ced kits of instr ume nts . Wi th
th e se instr ume nts , th e finishe d surface is as
smooth as t he glazed surface , and re -gfaztng is
unnecessary.
• O cclusal ad justment sho uld be co nsidere d only
where the res toration will int erfere with a
harmonious o r stable functio n.
• The oc clusion of the rest o ration itself will have
to be checked and if necessa ry adjust ed , using
reco rding and clinical t echniq ues similar to
th o se fo r the preliminary occlusal examination.
78

Figu re 4.8

Art iculat ing casts o n a se mi-adjustab le articulator.

a T he facebow in posit io n and the upper cast selte:

in m e wax impre ssio n o f the uppe r teem. This (;1St r"
been pr epa red w ith remo vable dies. and the blobi,
red wax (oyer the ends of dowe l psns. The U~ 111
also been not ched so th at it ca n be re moved fromII
mount ing and r elocat ed (a split cut). The b eebe.
records the relationship of th e upper teeth with tht
THA or an appr o ximatio n of it .

b Quick-set. lo w-expansio n impression plaster being

used [0 mo unt th e upper can . When the upper ann
is swung int o po sition. the bite fo rk of the facebow anc
uppe r cast are suppo rted W Ith the oth er hand.

c Th e lowe r m ode l is sea ted int o the FKP reco rd. in

th is case silico ne. and plaster is app lied to t he lower
mo unting plate.
O<;ousal considerations

d T he casts arc swung o ver w it h t he upper memb er

and held in plac e with the finge rs until t he plaster se ts.
Alter nat ives are to att ach the casts together ~ h
elastic bands or wax .

e Th e mounted ca st s show ing t he upper cast removed

from its base.

rThe CaS tS in Rep. Th e condylar gu idance is now

adjusted us ing protrusi ve or lat eral e xcursion inter-
occlusal records. The reco rd is placed betwee n the
teeth and th e co ndylar gu idance angle ad justed unt il the
casts are fully seated in the record.
80
The advantage of a hinge articu lator over hand-
he ld mo dels is th at if the resto ration is made high,
all the ot he r teeth will be o ut of occl usion, an d
th is effect can be magnified by arranging the casts
so chat t he re st o ration is ne ares t to the hinge .
There is often no need fo r any occl usal r eco rd.
It is usua lly po ssible to place the mod els togethe r
ent ire ly satisfacto ril y by hand in ICP. When there
may be some do ubt abou t ICP an occl usal r ecord
is made in wax o r one of th e othe r mat e rials
discusse d in Chapte r 6.
Semi-adjustable articulator (see Figures 4.8
and 4.1 0)
T hese have t he fo llowing feat ur es:
• The maxillary cast is rel ated to an ar bit rary axis
thro ugh the condyles
Occlusal considerOlio
Figure 4.9
A simple articulator that is adequate for rn_any ,in~:
crowns and small bridges.
• C on dylar gu idanc e is var iable, but only in
st ra ight lines
• Som e adjustment of incisal guidance is usual)
pos sible .
When oc clusal relations hips are impo rtant ir
posit ions other th an ICP a sem i-adjusta ble articub
tor may be used . The maxillary cast is mounter
using the face bow , and the mandibular cast i!
related to it by hand in ICP, by an ICP reco rd. or bi
a reco rd in.the RCP. wh ichever is approp riate, n..
articulator is t hen adjusted using inrra-ccclus
re cords ta ken in either pr otrusive or later al excer-
sions . The records taken will be selected accordin!
to the circumstances. Fo r example. if crowns CII
the right side are being made in a case with group
funct ion but where th ere is no risk of non-workim
side contacts occur ring in left late ral excurs ion. on~
a reco rd of right late ral excursio n is necessary.
Fig ure 4.10
An 'arcon' type of semi-adjustable art iculator. This i\
now the most popular design of articulator for crown!
and br idges.
CWMI ,orn.'derat,on5
"
With this arra nge ment a good approximat ion
:0 groop funct ion sho uld be possible, with o nly
nloor adjustm ent be ing nece ssary at t he chat-side
eeause of the co mpromises inhe re nt with se mi-
~1S[a bl e articulators.
There arc tw o broad categorie s of semi-
~table articulator. The type shown in Figure
48 is a nc n-arcon type . That is, the balls repre-
senting the condyles are attached to the upper
member of th e - articulato r and th e condylar
guidance to th e lower. T his is. of co urse, upside
down with respect to th e anatomy of th e joint.
The articulato r sho wn in Figure 4.9 is also no n-
neon The articulato r shown in Figure 4.10 is a
semi-adjustable ar con articulator, and the fully
adjustable art iculato r shown in Figure 4.1 I is also
an arcon design.
In practical te rms the differen ce betw een t he
arccn and ocn-arcon designs is no t par ticu lar ly
relevant, providing that t he oc clusal reco rds can
be taken with the teeth in contact or nearly so .
However. if the QVO is be ing increased o r if the Figure 4. 11
occlusal records have to be ta ken at a degree of
opening of the mandible the n t his affects the o An ele ctronic man dibular movem ent rec o rding
relationship betw ee n th e co ndylar guidanc e angle device . Th e upper and lowe r mem be rs are attached to
and the upper me mber of the ar ticulator. It acrylic clutches firmly seate d o n the teeth. Mo vements
follows that in th ese cncumstanccs an arcon of the mand ible are r ec o rded by the se nso rs sited over
design sho uld be used . the condytes. and the information i~ pas sed ( 0 a control
bo x (not shown) . which produces a print oo t o f infor-
mation from w hich the fully adjustable arnculator gn
Fully adjustable articulator be set dire ct ly.

A full desc riptio n of the use of t hese articulators

is beyond the scope of t his book. Suffice it to say
that they arc used when mo re acc urate and
comprehensive reco rds of mandibular movements
are required. The reco rds used to mo unt casts
on them are the face bow set to a te rm inal hinge
axis determ ine d specifically for the pat ient, a
record of mandibular mov em ent reco rd ed by
mechanical or e lectro nic device s (pantograph s),
and usually several re co rds o f Rep that are
checked against each o ther to e nsure that the
recorded po sitio n is re pro ducible (see Figure
4.11 ).
Fully ad justable art iculato rs vary. but they
usually have so me if no t all of the fo llowing
features:

• The co ndyles are on the lo wer me mber of the

articulator and th e co ndylar guidanc e ele ment
on the upper memb ra ne. i.e . an arcon design b A fully ad justable articulator.
82
• The inte r-co ndylar distance is infinite ly variable
• The immediate side shift (Bennett mo ve ment)
and progressive side shift (Bennett angle ) are
adjustable
• The Fischer angle (the angle of th e superior
wall of th e glenoid fossa to th e horizo ntal
lateral plane) is adjustab le
• The supe rio r wall of the glenoid fossa (the
ant erior-p osterior co ndylar guidance ) is fully
adjustable and in som e cases can be co nto ured
to a curved pAth way using individu ally made
inserts
• Individually contoured ante rior gu idance tables
can also be made .
Th ese adju sunents all allow fo r fine t uning of th e
articulator so that movements of th e casts in it
more close ly represen t the physiological
mo veme nts of th e patie nt.
Even when this costly and time-co nsuming
equipmen t is used by e xpe rienced operators,
there is o ften still a nee d for some occlusal
adjustment at th e chairslde.
Laboratory stages
T ri m m in g t he casts
O ne of the common est causes of re sto ratio ns
being high when t ried in the mo uth is distortion
of the casts . particularly th e o ppo sing cas ts. which
may be made fro m an alginate imp ress io n.
Commonly, small air bubbles trapped in the
occlusal fi ssure s will prop the models apart
slightly, so t hat if th e rest oration is made to to uch
the o pposing mode l, it will be high in the mo uth .
Impressio n tec hniques for crowns and br idges
sho uld co ncent rate o n t he crown s of t he t eet h,
injecting impress ion mat erial into the occfusal
fi ssures o r rubbing algi nate into them with the
fingers. If air bubbles do occur, grea t care sho uld
be taken to trim o cclusal de fects fro m the mo dels,
and if individual tee th are suspect. they sho uld be
cut right away from the model unless they are
opposing or ad jacen t to the t eeth being re stored.
A rticu latin g the casts
As small an amount of plaster as po ssible shoul d
be used since the ex pansion of th e plaste r distorts
th e relationship of the articulator with the casu.
Ideally, imp ression plaster o r plaste r co ntaining ~
anti-expansion age nt should be used; alternatively,
the re are plaste rless designs of art iculator.
Shaping the o c cl usa l su rfaces
The te chnique o f shaping the oc clusal surface wil
depend upo n whet her the surface is to be goki
o r po rcelain;
W a x carving W ith t his techniqu e wax is built
up to excess o n t he oc clusal surface and then
carve d to th e required oc clusal co nto ur. Sman
incre ments o f wax are added when necessary to
repair ove r-carving. When co mpleted, occlusal
co nt act should be checked using shimst o ck, both
between the carved too th and its o ppon ent and
between adjacent teeth and th eir o ppo nents (see
Figure 4. 12).
The w ax -a d d ed t echnique Small increments
of molten wax are flowed from the tip of an instru-
me nt to build up cones. each o ne form ing the tip
of a cusp. The o ther featu res o f the occlusal
surface are then added, o ften with different
co lo ured waxes to ident ify each feature . Using this
techn ique, the o cclusal relatio nships in all excur-
sions can be checked from the beginning and
adjuste d as the pro cess co ntinues (see Figure 4.1 2).
O cclusal s haping wi t h porcelai n Although
ther e are cones o f high alumina available that can
be used in tech niques similar to th e wax-added
technique . there is oft en not suffi cient room for
them and they are diffic ult to use.
Usually porcelain surfaces are built up slightly to
excess and then ground to shape. stained and glazed.
Again shimstock o r similar material is useful in
checking the occlusal relation ships in the articulator.
An al t ernative a p proach: the
functi on ally generated wax record
The principle o f th is technique is that the prepared
teeth are co ate d in wax co ntained in a suitable
mat rix th:n allows free mov eme nts of the
mandible. The patie nt th en makes excursions of
the mandible with the teeth in co ntact, effectively
 Oec!",ol CDnsiderations
carving th e w ax with the opposing teeth. A cast is
made against th is occl usal reco rd and se t up against
the working cast. T his ensures tha t no occlusal
interferences are introduced as the full range of
movements of the oppos ing teeth are reco rded in
the functionally generated cast. It is, ho we ver,
sometimes difficult to ac hieve occlusal stability, and
so a normal anatom ical model of the op po sing jaw
is also set up, so that not only is the occl us ion
made stable but the appearance of the re storation
is made to harm on ize with the opposing teeth. To
allow these alternative opposi ng casts to be used
with the wo rk ing cas t, special designs of articula-
tor are available. One type has two upper ar ms:
one carrying the functio nally generated cast and
the other the anatomical cast. They can be hinged
over alte rnately to occlu de w it h t he low er cast.
Adjusting t he o c cl usi o n of
restorations in th e m outh
Occlusal marking materials
Articulating paper and O.5-mm-thick da rkly
coloured w ax have already been described. An
8J
Figure 4, 12
a and b Two crowns waxed up on the lower seco nd
premolar and first mo lar teet h. The lower seco nd
premolar has been waxed using a carving techntqire.
start ing with an excess of wax on the occlusal surface,
The fi rst molar has been carved by a wax-added
technique. cones of wax being built up to the required
contact with the oppos ing teeth and the gaps between
fi lled in with a different-colou red wax. Shimstock is
being used to check that conta ct just occ urs between
the unpre pared second molar teeth, and will be used
bet ween the wax patterns and the oppo sing teeth .
alternative techniq ue for me tal oc clusal surfaces
is to san db last them lightly w ith a mild ab rasive
wh ich gives the surface a matt appea rance.
Burnish mark s w ill then appear in areas of contact
with th e o ppo sing teeth.
Adjusting in intercuspal p o sit io n
A patient who does not have a local anaesthetic
w ill be immediately conscious of a high rcsto ra-
tion in ICP. Even w ith a local anaesthetic the
opposing teeth w ill no rmally sense a high restora-
tion. T he patient w ill not of course be aware of
a re storation that is short of t he occlus ion, and
so occlusal contact sho uld be checked w it h
s himstock or myla r matrix strip. If occlusal
contact is not present (i.e., t he restoration is not
occl usally stable) , the tooth or its opponent w ill
o ve r-eru pt and o cclusal interferences ma y be
introd uced.
High restorations should be ground. W ith
crowns short of th e o cclusion, additions may be
made, if this is possible, or the crowns cemented
an d the o cclus ion ad justed when over-eruption
has oc curred.
5 Planning and
making crowns
There is a natu ral sequence by w hich th e history
and examinati o n of t he patie nt lead to a decis ion
on the advisability o r otherwise of crowns in the
contex t of the overall treatm ent. T his ge neral
decision lead s to a fur t he r ser ies of stages in the
detailed plann ing of treatment. Th is seque nce is:
History and examination:
• Of the whole pat ient
• Of t he mouth in general
• Of t he individ ual tooth
De cisions t o be m a de:
• Kee p the tooth o r ex tract
• If the too t h is to be ke pt - c ro w n or o th er
restorat io n
• If the too th is to be crow ne d - preparatory
t reat men t necessa ry
Detailed planning of the crown:
• Appearance
• The rema ining str uctu re of th e to o th and it s
environment, includ ing any ne cessary core
• Choi ce o f type of crow n, incl uding material
• Deta iled design of the pre paration
Planning and executing the clinical and
laboratory stages:
• Appo int ment sequen ce agr eement with
patient and labo rato ry, including agreeme nts o n
fees and laboratory charge s
• First clinical stage
., Labo rato ry stage
• Seco nd clinical stage
• Mainten ance.
It would be very nice if life we re as simple as t his.
It is co nve nient to have such a sequence of events
in mind but it is not o fte n po ssible t o follo w t he
patte rn precisely. For exa mple, if en dodont ic
treatment is ne ce ssary as part of the preparat ory
treatmen t th en a temporary crown may well have
to be made at an early st age before t he pr epara-
tio n can be finally planned. This outline sequence
may have various re peat loops ar ising w ithi n it.
The de ntist mus t be prepared to re t hink the
options as new circumstance s arise an d allo w full
freedom to his or her pr ofessio nal judgem ent.
History and examination
Considering the whole patient
Patient attitude and informed consent
C o mp lex and t ime-c o nsu ming pr oce du re s such as
crow ns sh o uld not be co ntem plated unless t he
patient is enthusias tic and co o pe rative about th e
treatment. Th ere is alwa ys so me othe r way of
treating t he to o th , eve n if it mea ns extracting it.
T he patie nt' s attit ude is particu larly impo rtant
w hen cr owns are being considered fo r pu rel y
cos met ic reasons. T he dentist must be satisfied
tha t the patie nt fully understa nds the limitations
of w ha t ca n be ach ieved . Techn iques fo r de mon -
strating cos met ic change s to patients before the
teeth arc prepared ar e descr ibed lat er.
Patie nt s gene rally ap preciate having th e reaso ns
for treatment ex plained to t hem together with
some of the details of treatment. A co mmo n
source of demo-legal pro blem s is t he patient who
cla ims an inadequ ate unde rstanding of w hat was
be ing proposed and that had it been fully under-
stood, he o r she woul d not have gon e ahead w ith
th e treatme nt . Again this applies particular ly to
treatm e nt pro vided mainly fo r cosmetic reaso ns.
Age
There is no upper age limit for crowns prov ided
the pat ient is fit en ough to unde rgo the treatme nt
85
as
and is in o th er ways suitable for cro wns. The re
ar e so me practical prob lem s in e xt e ns ive treat-
ment for elde rly patients; fo r example , t he teeth
tend to beco me more brit tle wit h age and t his
affects the de sign o f crown preparations.
Neither is t he re a lo we r age limit for crowns.
It is unusu al to make crowns fo r teeth sho rtly
after they have e rupted. and crowns are
commonly delayed until the patie nt is 16 or so.
However. this decision has traditionally been
based upon th ree main factors:
• The size of th e pulp
• The degree of eruptio n of the tooth
• The coope rativene ss of the patients .
Plonnln~ arod m(l k, n~ ( 1'OW/lS
Figure 5.1
C rown s and bridges fo r young patients.
o Bridge preparaucos for a I)3.tient aged 1) w ith
oligodontia. The tee th prepared are the caoees and
seco-c pre mola rs: the dimi nutive and ulUtt n ctr.e
canines are in the position of the missing latera l irocison.
At this stage, minim,1I pre para tions are carried out and
meta l-a crylic provisional res to rauons placed for a period
o f sill; months to a year. This encou rages secondary
dentine for mation so that the definitive preoa raecns can
be made wit h less risk to the pulp (see the text lor an
exp lanation of the poo r gingival co nditiOn). ~
b Threaded-pin ret e ntio n fo r com pos ite co res in a
pat ient aged 12 wit h de ntinogenes is lmperfecta. !n this
condition t he pulps rece de rapidly, and this pro cedure
was carried o ut withou t the need fo r lo cal analgesia.
c These are the crowns made for the patient in b
eighteen years after they wer e fitted . The porc e lain at
the incisal edge of the lower left central inciso r tin
chipped and the re has been some gingival recess ion and
repairs with glass ionomer cement. otherwise the pin
re ta ined composite cores have been successful and
none o f t he crowns have been lost.
Th e s e will vary conside ra bly amo ng patients. For
exam ple , a n u ppe r inciso r t o oth that is frac tu red
at t he age o f 7 o r 8 and re sto red wi t h compos-
it e, will usua lly de ve lo p e xte nsive secondary
de nt ine so th at t he pu lp w ill be s ma ller by t he age
of J 0 th an t he p ulp of an u nda maged tooth at t he
age o f 16. In pa t ie nts w ith good o ral hygiene, the
po sit ion of the gingival ma rgin of th e inc isor does
no t a lter m uch after this age, and tcday's ch ildren
a re far le ss a n xious about d ental treatmen t than
the y we re a ge nerat io n ago. In a case like this.
therefore, t here may be no contraind ication to
p roviding a permane nt crown at the age of 10.
Sim ilarly, when a succ essful root canal trea t-
ment has been carried out so that there is no

""""""t orld mol,,"g crowns
need to worry abo ut the pulp. po st- crowns can
be made fo r children in their early teens and e ven
younger.
Even when the pulp has not been damaged or
affecte d by secondary de nt ine. the re is no w
evidence that the size of the pulp does no t vary
significantly with age in the great majority of
young patie nts . The ratio of the size o f the pulp
to the size of the tooth is very varied. and
certainly t he pulp does not sudde nly shr ive l to a
significant ly sma ller size o n the patient' s 16t h
birthday o r at any o ther age. It is much more
importa nt to asse ss pulp size fro m a good , clear
periapical radiograph than it is to ado pt an
arbitrary ru le abo ut the age at which teeth can
be prepared for crowns.
Of co urs e, there are far fewer indication s fo r
anterior crowns in young patients than there
were a few years ago . with the introd uctio n of a
variety of new ways to re store anterior teeth and
make bridges. as described e lsewhe re in th is
book.
Figure 5.\ shows bri dges being made for a 13-
year-old bo y and a set of full mouth crowns for
a gi rl of 12 with seve re de ntinoge ne sis Imperfccta .
Both patie nt s were part icular ly cooperative and
enthusiastic abo ut treatme nt. Figure 5. le shows
the crowns for th e second pat ient still in place at
age 30.
It is argued that bo isterous children and spo rts
players who suffe r damage to their teeth sho uld
not have the teeth permanently re stored until
they are o ve r this energetic pe riod. However.
many of them continue to play vigorous co ntact
sports well into their twenties o r th irt ies or later.
and. if crowns are indicated, it is q uit e unacce pt-
able that patie nts should be deprived of the m
until they have become docile and sedentary. It is
very much better to provide t he crown s. and
with them a mo ut h pr o tector, not on ly for the
crowns but also more impo rtantly for th e re main-
ing natural teeth .
Many male patients are just as co nce rned with
their appearance <IS female s. They may. ho weve r,
be less willing to admit to th is. It is mo re impor-
tant to determine patie nts' real arntudes to their
appearance than to make assu mptions based upo n
their gender.
87
S ocial history
The patient's oc cupatio n may be important. W ind
instrument players. for example. are particularly
anx ious to retain their incisor teeth in order to
support t heir embouchu re (the particular
co nt racti on o f the lips needed to form the
co ntact with th e mo ut hpiece).
Habi ts such <IS pipe smo king. whe re the stem
of the pipe is cle nched between the teeth. may
affect the de sign o r type of cro wn se lect ed.
When extensive treatment is planned , it is
impo rtant to establish that the patie nt will be
available for appointm ents of suffi cie nt lengt h and
freq uen cy to co mplete the treatme nt. Crowns
sho uld not be start ed just be fore a patient is due
to sit important examinatio ns; and people who
plan to marry usually like to have their crowns
completed in t ime fo r th e wedding photographs.
C ost
The re is no satisfactory way of mass producing
crowns. and so they will always be labour-inten-
sive and t herefore cos tly. W hicheve r way t he
co st is bo rne - by the patient. or by a privat e or
public insurance scheme - the cost is important
and must be take n into accou nt in any treat ment
plan. Because cro wns are expensive, they sho uld
no t be made unless they will re ally co nt ribute
significantly to the patient's well-being and can be
expected to last for a reasonable pe riod o f time .
Considering the whole mouth
Oral hy gie n e
There is ob vio usly no po int in e mbarking upo n a
complex course of treatm en t invo lving crowns
(or br idges) in a mouth with rapid ly progressing
caries or perio dontal disease re sulting from poor
o ral hygie ne. T he first prio rity must be to ar rest
the disease process and impro ve the o ral hygie ne.
Tha t be ing said. ho wever. it is impo ssible fo r
any mou th to be kept absolutely plaque -free. It is
almost always po ssible to fi nd some in the mo ut h
o f even th e most meticulo us patient. Most.
despite good inte ntions. achieve o nly a moder-
ately good level of plaque control. T he problem
fo r t he dentist is therefore o ne of degree. He o r
as
Figu r e S.2
a and b The same pat ient before and after a six-momh
co urse of extensive denta l tre atment invol ving
perio dontal t reatment and the co nst ru ct io n of upper
anterior crown s. D uring th is period, the patien t' s
de ntal awareness and motivat io n impr oved co nside r-
ably and his ora l hygiene became markedly bett er once
he had more attra ctive teeth.
she mu st decide wheth er t he pati ent, after
instru ctio n in o ral hygiene. can achieve a level o r
oral cleanliness t hat war rants treatment which is
time co nsuming and cost ly. It is also necessary to
decide how to treat those patie nts who are
assessed as having a level o f oral hygiene falling
below th is sta nda rd but who nevertheless have
teet h t hat can only be treated sat isfactori ly by
means of crowns.
There is no simple guidance on these d ifficult
deci sions. Perhaps th e best advice is to assess no t
on ly th e leve l o f o ral hygie ne. but the e ffect that
th is is having on pe riodonta l diseas e and caries.
Yet there is no single direct re latio nship between
oral hygiene and diseas e - many other factors
influence the disease processes. The decision
whether to cro wn a tooth o r not sho uld there-
fo re be made o n an assessment o f t he prognosis
of the to oth without t he cro wn o r with it. If, in
an o the rw ise-intact arch. a single badly br o ken-
do wn anterior too th is ugly. does not functio n
we ll and is difficu lt to restore by any means ot her
tha n a cro wn t hen. pr o vided that the prognosis
of the alveo lar support is such that t he to oth is
not likely t o be lost for at least a few years. it is
almost ce rta inly bette r to make a crown tha n to
ex tract it and provid e a partial de nture. even if
th e oral hygiene is poor and cannot be improved.
It wo uld be qu ite wrong no t to offer any fo rm of
treatment. and morally dub ious to attempt to
~annjng and making crown,
blackmai l the patie nt to maintain a better
standard of oral hygien e by refusing t he cro w n
unless the o ral hygiene improv es. In any case, t his
{rude psychological approach seldo m produces a
permanent improveme nt in o ral hygie ne.
Although every effort should be made by both
dentist and patie nt to improve oral hygiene w he n
it is poo r, th ere are t hose w ho are simply not
able to impr ove, but wh o are nevert heless fo rtu-
nate in having a slow rate of progress of
periodonta l dise ase and a low caries incidence,
and for these pati ents crow ns are often justified .
Figure 5. 1a sho ws a typical 13-yea r-old boy
who has entere d puberty . Th is ho rm o nal change
affe cts t he gingival response to plaque, but it also
- as many pare nts of teenage rs know
sometimes lea ds to express ions o f independence
and even rebellio n. This may sho w as lapses in
cleanli ness, includ ing oral hygiene. Fortu nat ely
most recover. Th is pat ient had seve ral missing or
misshapen teet h th ro ugh no fault of his o w n. He
had cooperated wit h a co urs e of fixed orthodon-
tic treatme nt. Ho w crue l no w to prescri be a
removable den ture, whi ch he despe rate ly wished
to avoid, at thi s difficult stage in his life, just
because. fo r t he time being, his st andard of oral
hygiene has lapse d.
Wh en crowns o r oth e r co m plex fo rm s of
treatme nt t hat improve t he patie nt' s ap pearance
are provided. t his and th e ge neral incre ase in
dental aw ar en ess t hat comes w ith exte nded
courses of de nta l treat me nt th emse lves ofte n
improve the pat ien t's motivat ion and, in tu rn, oral
hygiene (see Figure 5.2 ).
Condit io n of t he remaining t e eth
The state of hea lth and repair of t he w ho le mouth
must be ta ken int o account. W hen the re have
been no previous ex t ract io ns and t he prognosis
of the remaining t eeth is good, it is usually worth
the patient and den t ist put ting a co nsidera ble
amount of effort int o saving an ind ividual toot h.
Conversely, w hen t he patient has already lost a
number of t eeth and is wearing a par tia l de ntu re
that w ill need replacing fairly so o n, it wo uld be
foolish to struggle to save an individual tooth
unless it is a crucial ab utment fo r t he de nt ure, or
of particular im po rta nce to t he pat ient's appear-
ance. It is usually better to e xtract t he tooth and
remake th e de ntur e.
89
Th e periodontal conditio n of the remaining
te eth is on e o f the fact o rs in assessing their
prognosis, but it is mo re important to determine
w heth e r any period o ntal disease is pr ogressing or
wh eth e r treatment of it has produce d a sta ble
sta te. T he effects of periodontal disease, particu-
larly w he n t here has been gingival recession, can
affect t he cho ice and design of the cro wns. An
exam ple is give n in Figure 12.9, whe re partial
cro w ns are se lect ed in preference to complete
crowns partly beca use of t he length of th e clim-
cal crowns.
Asse ss ment of the o cclusio n is impo rtant (see
C hapte r 4). In pa rticular , t he adequacy of poste-
rior support shou ld be co nsidered w he n
ant e rio r cro w ns ar e planne d. Insufficie nt occlud-
ing natural poste rior teeth us ually means that
ant erior cro wn s sho uld be metal- ce ramic
rat her t han porce lain, and in so me cases w he re
th e re has also been periodon t al disease and
d rift ing of th e incisor t eeth , crowns jo ined
toge t her may be nece ssary (sp lintin g is
desc ri bed in C hapter 12).
Considering t he individual tooth
Th e value of the t ooth
Not all teeth are of equ al value. T hird molars are
commonly extracted w ith no harmful effects on
ap pearance or functio n. To crow n t hird molar s in
an intact dentition w o uld probably be no more
tha n a display of clinical virtuosity. How eve r, if a
num ber of o th er t eeth are missing, a broken-
do w n t hird mo lar tooth t hat ca n be cro wne d may
provide an invaluable abutment toot h fo r a
de nt ure o r a bridge . Th ere is a similar range of
po ssibilitie s for mo st other teeth .
Appearan ce
T he prese nce of failed rest o ratio ns may suggest
t hat crow ns are advisable, but since anterior filli ng
mat e rials ar e continually im prov ing, t he posslbil-
ity o f replacing t he restoration ra ther than
cro wn ing the teeth should no rmal ly be consid-
e red first . Whethe r the pro blem is one of failed
re sto rations, intrinsic sta ining or t he shape or
angulation of the teeth, a rea listic app ra isal of the
90
co smetic advantages of crowns must be made.
So meti mes patie nts expect mo re of crowns than
can be achieved, and are disappointed with the
end result. Th is should be avoid ed by exp laining
t he problems, complications and co mprom ises
assoc iated with crowns (see Chapter I).
Condition of the crown of the t ooth, the
pulp a n d periodontium
T he presence o f ca r ies, pre vious res to rations o r
pulp pathology are not co nt raind icatio ns to
mak ing crowns, but t hey may well de te rm ine t he
type of cr ow n and t he des ign of the pre paration.
Car ies or fractu res ex te nd ing deep below the
gingival mar gin w ill make cro wn preparatio n
difficult, and it may sometimes be better to
extract the t ooth. Alterna tively, periodonta l
surgery may be used [ 0 e xpo se the marg in of
the fracture.
Unless the tooth has been root-t reated, t he
vitality of t he pulp must always be teste d and
whe n necessary endodon tic treatm e nt carr ied
o ut . The pr ogno sis and acce pta bility of crowning
a r ecently root-filled to o th will de pe nd on the
absence of signs or symptoms and its radiographic
appearance.
If t he re is any anxiety abo ut t he success o f a
root fil ling then a cho ice must be made between
a numbe r of o pt ions:
Leave the tooth te mpo rarily re sto red until the
symptoms settle and a good pr ogno sis can be
given
2 Repeat the root filling. with eith er an ortho-
grade o r a retrogra.de appro ach
3 Pro ceed with the am algam co re (fo r a po ste-
r ior tooth) o r the post and co re (fo r an
ante rio r toot h), but delay the final cro wn unt il
the symptoms have settled or t he radiographic
appe arance has improved. or the toot h has
been apicecte d.
In many cases the third option is best. If a tooth
is left with a temporary restoration for too long.
there is a risk of further caries and periodonta l
disease. W ith anterio r teeth . if th e post and co re
are inserte d immediately, there will be no r isk o f
distu rb ing t he root filling lat er. and with mo st
well-condensed anterior root fill ings. the treat-
men t for furt he r en dodontic proble ms is often
an apicectomy. It is better to ce ment t he post
and core before th e aplce ctc my rather than
afterwards. to avo id th e r isk o f disturbing the
apical seal.
A more liberal attitu de sho uld be taken to
minor radiog raphic defects in the ro ot fi ll ing when
it has bee n present fo r some years and is
sympto mless. Further de ta ils of the crite ria for
asse ssing root canal fi llings are left to me
endo do ntic te xtbook s.
Any lo cal pe riodonta l pr ob lems sho uld be
assessed and treated .
Occlusion
The occlusal co nta cts o n the surface of the toom
may be important in dete rm ining t he type of
cro wn to be used. For exa mple. an upper canine
tooth that is the on ly tooth in co ntact in lateral
ex cursio n (canine guidance , see C hapte r 4) will
usually need a metal-ceram ic cro wn rather than
a PJc. However. if th e tooth is on ly o ne of a
number that mak e co ntact in lateral exc ursion
(group functio n). it may be po ssible to res to re the
canine with a p]C.
The point o f contact between the tooth to
be crow ned and the opposing to oth is also
import int in det ermining the po sition of the
cro wn ma rgin. It is wise to design th e prepara ·
t ion so that t he opposing too th co ntacts e ither
t o oth tissue or th e crown but no t t he jun ction
betwee n the tw o . In th e case o f partial crowns.
when oc clusal pr otect ion is required. the occlud-
ing surfaces o f the tooth to be crowne d shou ld
be determined . The se are not always the same
as the occlusal su rface. Occlusal is an anatomical
term. and an extracte d to oth still has an
occlusal su rface . Th e occluding surfa ce s are
th o se that really do ma ke contact wit h o ppos-
ing t eeth in one o r o t her excursio n o f the
mandible.
Root length
The length of th e root shou ld be assessed from
radio graphs in two ways. Fir st. th is sho uld be
done from th e point of view of per iodonta l
support. i.e. th e ratio of th e length of the root
supported by alveo lar bo ne to th e lengt h o f the
remainde r of th e tooth. Second. th e length o f the
l'Iannjng and maKing crowns
"

Figure 5.3
b A simila r case , but w ith den tu r e te e th se t on t he
Trial or diagnos t ic wax -up s.
mo del. Th is technique is less acc ur a te and give s unre al-
a Missing upper lateral incisors and a midline diastem a. isti c res ults.
Centre: closi ng the diastema orthodontically a nd provid-
ing bridges to re place the lateral inciso rs. Lower: the alte r-
native is to make four ove rs ized cr owns or veneers o n
the central inciso rs and ca nines to rese m ble fo ur incisors.
Neither so lutio n will pr oduce an idea l appearance.

c A be tt e r diagnostic wa x-up for a
similar case. T he lat e ral mcrsor
te et h w ill be r e plac ed by two 3-unit
co nven tional bridges (see Part 2)
inc reasing the size of the cent ral
inciso r c rowns and reduc ing the
size of t he can ines.
d Th is patie nt has exte nsive palata l
erosion as a resu lt of an ea ti ng
diso rd er. The tee t h a re alrea dy
short and so diagnostic prep a ra -
t ions have been m ade o n t hree of
the m to see wh e th e r s ufficient
de nt ine r e mains for re t e nt ive
pre pa ra t io ns or wh e t he r some
othe r solutio n is nec essary.
e Th e prepa rati o ns are judged as
be ing sufficie nt ly re te nt ive an d this
figure also shows how sho rt t he
unpre pared incisor teeth have be-
co me. T he diagno st ic w ax-up shows
t he app ea ra nce of the planned
re sto rati o ns an d also prov ides a
starting po int for mo re detailed
plann ing of the preparatio ns and fo r
mak ing temporary crowns .
sz
r oot is importa nt in providi ng re tentio n for a
post crown. A w orking ru le for t he length of
smooth ta pered posts is for the length of the
POSt to be not less t han th e length of t he artifi-
cial crown. Variations are pos sible: for exam ple.
a sho rter pos t is acce pta ble in the case of
reduced occlu sal forces (such as incisor teeth
with an ante r ior open bit e); and a lo nge r post is
necessary whe re there ar e excessive fo rce s
appl ied to the tooth, for exa mple w hen the tooth
is used as a partial denture abutment . W he n this
le ngth is no t available, a post with improved
retention, suc h as 3. t hreaded parallel POst,
shoul d be used . An alte rnat ive is to include a full
d iaphragm of gold ove r th e root face together
with a co llar arou nd t he pe r iphe ry. Th is
im proves r etention a nd also reduces th e hkeh-
hood of root fracture.
Decisions to b e made
Is the tooth to be kept or extracted?
Us ually the resu lt o f the hiStory and examination
will deter mine th is question. Sometimes,
Figure S.4
Tr ial wall-up 'cheatmg'. The upper cast shows a patient
with ugly prom inent canine teeth and missing lateral
incisors with no residual space . The lower cast shows
two tria l wall-ups; left, with the conto ur of the gingival
margin carefully marked in pencil befor e the prepar.l-
tion and wall-UP are made: right. the position of me
gingival margin has been lost and a more na tu~
look ing wall-up made. However , it will not be possible
to achieve th is result in the mouth and a dectsion
whether to pro ceed with cro wns must be made on the
appearance of the 'ho nest" trial wax-up.
howe ver, it is necessary to proceed to further
stages-and then retu rn to a deci sion to ex tract
the tooth if further endodontic . periodontal or
ot her treat me nt is no t suc cessful.
If the tooth ;s to be kept, Is ;t to be
restored by a crown or a filling?
In C hapter I t he alte rnat ives t o crowns a re listed,
a nd the findings o f the hist ory a nd rrc n-imerven-
nve exam ination will so me t imes se ttle t his
question , Howe ve r, it is o ft e n necessary to
proceed to a further stage, ac tually star t ing the
treatme nt by removing previo us rest o ration s and
caries, be fore a properly informed decision can
be ma de (see Figur e 1.10. page 18).
If the tooth is to be crowned, is any
preparatory treatment necessary?
Pr eparatory o rthodontic treatme nt may be neces-
sary to move th e tooth int o a suitable position
Plan""" and mol<ing crowm;
for crow ning. Combinations of o rthodo ntic treat-
ment and crowns can often p roduce re sulu that
canno t be achieved by e it he r fo rm o f tre a t men t
alo ne . Pe rio d o nta l a nd end odontic treatme nt may
also be necessary.
"
Figu re 5.5
Te mpora ry and permanent changes to occlusal vert ical
dime nsion .
o G ross e ros ion of the uppe r incisor teeth following a
period o f chrOflic vomiting. The patien t had a peptic
ulcer dla t had been successfully treated surgically two
years before this photograph. The QVO is redu ced
because of this wear and because the lower poste rior
teet h are rep laced only by a tissue-suppo rted partial
de nt ure . The gingival co ndition at this early stage of
treat ment is poo r.
band c Increasing the length of the uppe r inciso rs
tem porari ly by mea ns of light-cured co mposite placed
in a vacuum-formed PVC marnx . Acrylic was added to
the lower part ial dentu re to increase its occlusal height
tempo ra rily.
d After a perio d during which the patient became
accusto med to the new QVD. the upper inciso rs we re
crowned and a toot h-suppo rted partial to we r denture
fitted. The gingiva! condition has improved. No te the
supragingival crow n margins, whit h he lp t he pat ient to
maintain good o ral hygiene. The left lateral inciso r has
been extracted and replaced by a bridge.
D etailed plannin g o f th e crown
Appearance
W hen a significant c ha nge in a ppe a rance is
proposed. it is most im porta nt t hat the pa tient is

fully informed o f w hat ca n be achieved and wha t
can not. Th is ca n bes t be do ne by a mo dificat io n
of th e pa tie nt's o w n study casts, usually in wa x.
Figure 5.3 shows e xa mp les o f m iss ing uppe r
late ral incisors that co uld be treated by moving
th e central incisors mesially dosing the dias tema
an d replacing th e late ra l inciso rs by mea ns of
bridges. If t his we re do ne. all th e tee th wo uld be
rathe r s ma ll; The alte rn a tive o f ne t moving th e
teeth and e nla rging t he central inciso rs by means
Plann"' g and makmg crowns
Figure 5.6
Trial preparations on st udy casts,
Q The patient is unhappy abo ut t he appearan ce of the
ro tated latera l incisors and would like them crowned,
b Righi: me maximum labial reductio n. while preserv-
ing the vitality of the pulp wo uld result in this prepa-
ratio n. allowing some reduction in the pro mine nce of
this tooth. Left: how ever , initial preparation quickly
shows that devitalization would be necessary if a crown
is to be made.
c The uppe r right centr al and latera l incisors were
almon ide ntic.al to the unprepared wor n teeth left-
Trial preparatio ns sho w that it will be possible to
achieve a ret entive cro wn pre paration for the central
incisor but not fo r the lateral inciso r.
of c ro wns a nd cro w ning the canines to resem ble
late ral inciso rs is also shown. Figures 5.3c. d and
e sho w satisfacto ry tri al wax-up s demonstrating
re te ntive prepa rations and aesthetically pleas ing
c ro wns and bridges.
Trial or planning wa x-u ps ar e extremely
valua ble in pr ed ictin g th e final a ppea ra nce, and
sho uld be used routi nel y.
Beca use t he tee th and so ft t iss ues a re all rep ro-
d uced in plas te r o r a rtificial stone in t he cast, it
1'Ian"' ''1' and rna"",! crowns
is pos sible to 'cheat' by ma king the tr ial wax-up
in a way that would be im po ssible in th e mouth
by reshaping th e gingival margin or by changing
the dime nsio ns o f the root as it em erges from
the gum . W hen the teeth <I re not to be moved
cr tho do nuc ally, it is useful to draw <I pencil line
around the gingival cr evice o n t he stu dy cast and
to ensure th at th is is still visible after th e wax -up
has been completed. W hen t he tooth is to be
moved o rrh o do nncally. the mesio -d ista l w idth at
the gingiv3.1 margin should be measu re d and th is
width reproduced in th e new po sition of the
too th on the stu dy cast. Figure 5."1 sho ws an
example o f stud y cast 'cheating', Th e plan is to
crown the upper cani ne s to res emble uppe r
late ra l inciso rs. This is always difficult and ofte n
disappo int ing. O ne of th e distincti ve feat ures of
an upper ca nine is t he sharply cu rving gingival
margin. Th is will be retai ned once the crown is
in place, an d will det ract from the impression that
the tooth is a late ra l inciso r.
These tri al wa x-ups se rve a num ber o f o t he r
purpo se s as we ll as info rming the patien t o f
d The same pat ient as sho wn in Figure SA. Half the
pre parat io n has been co mple ted o n m e uppe r canine
to oth. showing the amo unt of tissue that cou ld be
rem oved with o ut damaging the pulp. Th is is not e nough
to achieve a successful aes thet ic r esult, and devrtahza-
t ion will be necessary .
e Tr ial preparati ons for a bridge (see Part 2). These
sho w that th is de sign (fixed-movable) wo uld no t work
in th is case .
w hat can be achi eved . Ho we ver e xperie nced
the clinician, eac h case is different and m o dified
stud y casts w ill help in planning details o f the
e ventual appearance. Th e t ec hnician w ill kno w
w hat is wa nte d and w ill have m ode ls to copy
rathe r tha n have t o des ign th e patie nt's new
appearance in porcela in.
Th e modified study cas t, agreed by th e pat ient,
forms part o f the co ntract betwe en t he de ntist
and patient. If th e final o utc ome is an ap peara nce
similar to that of t he stu dy cast, it can be used
as evide nce that the co nt ract has been fulfilled,
and so den to -legal problems can be avo ided. The
modifie d stu dy cas t may also be used to produce
temporary crowns (see Chapter 6).
Shade
It is w ise to select the shade at this ea rly stage ,
since so me shades are more d ifficult to mat ch
th an others . It is better to know about an y diffi-
culty before the teet h are prepared, both fro m
#
"
the point of view of wa rning the patient and
because it may be helpful to mo dify the pr epara -
tio n. Fo r exa mple, if t he re is an extensive amo unt
of incisal translucency, the preparation may need
to be shorter to allo w additional incisal porcelain
t han if the tooth we re more opaque.
Clinical modifi cations
In some cases it may be helpful to adjust the
shape of teeth in th e mouth by adding co mpos-
ite mat er ial - particu larly w hen alte ration s in
oc clusal verti cal dimen sions ar e planned . Figur e
5.5 shows a patie nt with gross e rosion tr eated by
uppe r anterior crowns and a new partia l lower
denture with an increase in occlusal vertical
dimension . The pati ent's tolerance o f an increa se
in avo is assessed by mean s of the tempo rary
additions of acryliC to the occlusal surfaces of th e
old partial lower de nt ure and of com pos ite
material to the upper incisor teeth. Te mpo ra rily
reshaping incisor teeth with composite to close
diastemas and produce other changes are further
ex amples.
Assessing the remaining tooth
structure and its environment
Existing restorat ions and caries, esp ecially in badly
broken -down pos terior teeth. should be re-
move d. togeth er with any completely unsupported
e name l. so that th e shape of th e remaining tooth
structure is ncr guesswork. Only at th is point
shou ld the final resto ratio n be planned. This
preliminary clean ing away was nece ssary in all the
examples shown in Chapte r I (see Figure 1.10.
page 18) fo r a pro per ly info rmed decision to be
made. .
At this stage it may also be necessary to return
to a decision on further preparatory treatment.
Fo r exam ple. altho ugh the pulp may be vital in an
ante rio r toot h. it may be de cided that becau se of
the weaknes s o f t he remai ning co ro nal tissue, an
elec tive root canal treat ment and po st cro wn is
the pre fer red restoration. Similarly. whe re caries
extends below the gingival margin. it may be
decided to carry out a gingivoplasty or apically
repositioned nap procedure to alte r the gingival
co nto ur.
Th e need (or a core
At t his stage. whe n the full extent of the damage
to a broken-down tooth is known. a decision is
made on whe ther sufficient tooth substance
remains fo r a cr own preparatio n or whe the r it
need s to be built up by means of a pin-re tained
or post-retained co re. and. if so , whet her the
core sho uld be of amalgam. com pos ite or cast
meta l.
At the same time. the position of the crown
marg in sho uld be sented. Usually the crown will
e xt e nd be yo nd the co re and com plete ly cover
it . How eve r. whe n part of an amalgam cor e is
subgingival but is well condens ed and polished.
it is ofte n bette r to make the cr o wn margtn
supragingival. leaving part of th e core exposed.
The choice of the type of crown and
th e mat erial
At this stage too the decision is taken between
making a complete o r partial crown. and what tile
mate rial for the crown will be.
Detail e d d esign of the p reparatio n
Chapter 3 desc ribed the principles of crown
prepara tion design. This is the point whe re they
are applied to the particular tooth . In cases of
do ubt. fo r exa mple where there are quest ions on
the likely retentive qualities of th e final prepara-
tion o r on the like lihood of exposing the pulp in
removing sufficient tooth tissue for a crown thar
is planned to change the shape of a tooth . a trial
preparat ion on the stu dy cast is of con siderable
value (see Figure s S.3d and e and 5.6).
Planning and exe c uti ng the clinical
a n d laboratory stage s
Appointments
The tr eatm ent plan and fee having been agreed
with the patient. a series of appointments is made
and agreement reached with th e laborato ry tim
t he tech nical work can be unde rta ken in the time,
Very few dentist s now carry o ut their own
Planning and making crow ns
technical work and mo st labo ratories appreciate
being no tified in advance wh e n t he ir se rvices will
be requi red, as least fo r exte nsive cases. This
avoids the pro blem of pro mising th e patient deliv-
ery of the crown by a specified date o nly to find
when the impr essio n is taken th at yo ur favou rite
technician is on holiday.
Clinical and laboratory stages
Details of clinical techniques are given in C hapter
6;at this point on ly the sequenc e of events is listed
(see pages 98- 99). De pending o n t he number of
crowns invo lved, the experience and speed of the
Pract ica l points
• The logical sequence of histo ry-ta king, exami-
nation and de cision-making, planning and
executio n in p ractice ofte n has to be altere d
or adap ted to particular circu mstances.
• In planning always fi rst con sider th e pat ient as
a whole , th e mouth next and t he t oo th last.
• The co o pe ration of the patient is essen t ial from
the sta rt.
o perator and ot her facto rs, each clinical stage may
be accompl ished in a single appo intment o r in
se veral. The pat ient shou ld be advised o n oral
hygiene tec hniques appropriate to t he new crown,
and he or she will need to be seen at regular int er-
vals for the crown to be inspected and, if neces -
sary, maintenance car ried out.
It may be necessar y to abort the procedu re
shown o n pages 98-99 and return to an earlier
stag e, eith e r in the co nst ruct ion sequence o r even
t he planning stages. Fo r exam ple, a damag ed
working mo del in t he laborato ry stage me ans
return ing to the fi rst clinical stage for a new
impression , o r a cusp fracturing after a t oot h has
been prepared fo r a par tial cro wn means ret urn -
ing to t he planning stage.
• T he value of the tooth wh e n crowned is an
impo rtant ce ntral con side ration.
• Even wit h imperfect o ral hygie ne, a crown can
be th e ba se so lutio n, provide d t he prognosis
for th e tooth is adeq uate.
• O nly afte r initial preparation of t he to o th can
a fi rm de cision o n the type of restoration be
made.
Clinical and lab o ratory stage s o f making crowns
Fin t clin ica l st age

All crowns (afte r making any ne ce ssa ry core)

• Select temporary crown technique and prep-re for tempo rary crown
• Rechec:k shade
• Pre~re me tooth 10 be crowned
• Make temponry crown (which helps to detect faulu In the prep-ntion)
• Impression of the prepared tooth and other teeth in the same arch With extremely accurate material (the worl"ng impression)
• Impression of the opposing arch. usually in alginate (unless the study cast is adequa te for the opposing arch)
• Occlusal record (if necessary)
• Cement tem po rary crown
• Advise patient On mainte nance of t empor ary n ow n

Firit labo ratory stage

A ll crowns
• ~ke wor\cing cut and articu late w,th opposing cast
• The laboratory procedure win then be d,fferent. depend,ng upon the type of crown being made

Me t al crown Po r ce lai n jacket cr own (PjC) H e t a k erami c (He) C a st post and core
• Prepare wax pattern • Adapt platinum foil • Prepare wax pattern • Prepare wax patt ern (or combmation of wax
• Case • Apply high_alum ina core and plastic or metal)
• CUt
• Polish • Apply dentine and enamel po rcelain • Eithe r add porcelain or return to cliniC fo r • Cast
• Glaze try-in of the meta l • Either make f'jc or Me crown or ret urn to
0' t he clink for try -in or post and core o nly
• Make refractol")' die
• Apply core. dentine and enamel poI"celain
• Remove d,e by sandblasting
~

• Follow instructions in making a crown in

one of me alternative g!a.ss--ceramic
materials_ Note: These materWs should
only be used by peopl e who have been
specifically instructed in their use.
S..co nd clinical stag ..

MeU.I-c .. ram ic crow n Cast post and co re

M .. tal crown ",C If porcelain is a d de d If porcel ai n is no t ad de d If c ro wn is made If cr o wn is not made

• Try-in crown • Try-in crown • Try-in crown • Try-in cro wn • Try.in post and cor e • Try.in post and co re
• Adjust. including • Adjust and add stain or • Adjust and refire if • Adjust metal wo rk and crown • Either cement post and
adp sstment to contact reglaze if necessary nec es... ry • Reco nfirm shade • Adjust and refore if cor e and take new
POintS and occlusion • Remove platinum fo~ (if • CEMENT • Ret urn to labo"'tory nece ssary impression for I'jC or
• Repo lish oc add solder pres ent) • Remove platinum foil if Me crown or return
,f ne<essary • CEMENT cro wn IS PIC post and co re to
• CEME NT • CEMENT both pos t and Iabo"'tOl')'
coco' and cro wn

Se co nda ry la bo ra tory stage

• Add por celain • If new impressio n.

proceed as for Pjc o r
MC crown
• If no new impr ession
make I'JC o r Me crown
on the post and core

Th ird clinical suge

• Try-in crown • Try. in post and cor e and

• Adjust crown
• CEMENT • Adjust
• C EMENT both pOSt and
cor e and crown
 6 Cl inica l techniques
www.alli slam.net
for crown
Problem construction
Planning stages before preparing
the to oth
Emphasis has bee n placed in ea rlie r chapters o n
the gene ral appr oach to planning. Here th e
pr ocess is taken to the final, practical stages . The
follow ing factors sho uld be considered before
clinical tooth preparati o n is started:
• Study casts
• Photographs
• Trial preparati ons
• Appearance
• The final impressio n
• The te mpo rary cro wn
Study casts and opposing cast
Full arc h study casts are useful in a variety of
planning procedures described earlier (Chapte r 5)
and below. In addition, th e o pposing cast may be
art iculated with the working cast, provide d th at
it has no t bee n damaged duri ng the planning
stages and there has been no oc clusal adjustm e nt
or o ther restorations since the impressions fo r
the stu dy casts we re taken.
Alginate is usually sat isfactory as an impressio n
mate r ial for study casts. but oc casionally a mo re
accura te material is required (or th e opposing
case if the opposing cast cannot be po ured
straightaway, a more stabl e material than alginate
shou ld be used. Alginate material shou ld be
rubbed into th e fissures with the finger to o btain
good impressions of the occlusal surfaces of the
teeth . If a rubber mate rial is used , it should be
syringed int o th e oc clusal fissures .
If there is any doubt about the o pposing study
cast, a new impressio n shou ld be taken at the
100
t ime of tooth preparatio n to prod uce an accurate
op po sing cast.
Photographs
W he n the main indication fo r cro wning anterior
te eth is to change their appea rance in some way.
photographs of th e teeth before pr eparatio n are
a valuable record. It is easy for both dentist and
patient to forge t th e exa ct appearance of teeth
when they have been pr epared.
Patients so me times have o ld photographs of
the mselves showing th eir teeth before they
suffered. These can be helpful in reproducing the
patien t's o riginal appearance.
Planning the tooth preparation
A trial pr eparation o n the study cast can be
invaluable in predicting difficulties that may De
enco untered with prepa ring the tooth. For
examp le, with short clinical crowns in posterior
te et h. whe re t he int ent ion is to provide a porce-
lain occlusal surface o n a rnetat-cerarmc crown. a
tr ial preparatio n o n the stu dy cast will indicate
whether th ere will be sufficient axial lengt h of the
re maining preparation for adeq uate rete ntio n or
wheth er additional devices are necessary to
achieve retention. W ith thin upper anterior teeth,
tria l preparations will sho w wheth er it is possible
to re move sufficie nt palatal toot h tissue to allow
a PJc preparation to be made o r whether a
metal-cera mic crown will be necessary. In some
cases it will become clear th at additional steps,
such as increasing the vert ical space between the
incisal e dges of t he upper and lowe r teeth. or
 Clino:;alle(nniques for crown comlruClio n
removing gingival tissue s to 'crown-lengthe n' the
teeth will beco me nece ssary (see page 000).
There are so many similar problems that can
beassessed with trial preparations that an inex pe-
rienced operator is rec o mme nded to always
spend a few minut es making a trial preparation
before emba rking on th e natural tooth.
When the inte ntion is to alter the shape, size
or angulat ion of incisor teeth, eve n th e more
experienced operator is well advised to make t rial
preparations first. Th is will show whethe r the
pulp is likely to be e ndangered and whe ther
problems with the appe ara nce will arise.
Trial pre para tions o n plaster o r art ifi cial stone
study casts are be st sta rted with a steel bur in a
slow handpiece and fi nished wit h a scalpel blade
or chisels. The au-c t or is difficult to contro l when
cutting relatively soft materials like thi s.
It is helpful to do the prep aratio n in stages,
particularly if there is any quest ion of the pulp
being exposed. Figure 5.6d (page 95) shows an
example with half a pre paration co mplete so that
the remaining half indicate s th e o riginal shape of
the tooth. The tooth co uld no t be pr epared any
more than this without serious r isk to the pulp.
Plonning t he ap pearance
Trial wa x -ups
Chapter 5 gave ex amples o f trial wax- ups with
alternative t reatm e nt plans fo r th e same clinical
situation.
Ivo ry wax is prefe rably to o th er waxes since it
is easy to car ve and gives a re asonably realistic
ap pearance. However, pink wax, inlay wax o r
other mate rial may also be used .
Shade
One reaso n for matching the shade befo re sta rt -
ing tooth pr epar atio n was described in C hapter
5. A second, very basic reason is t hat whe n shade
matching (one of the mo st crucial part s o f the
procedure ) is left to the end o f a lo ng appoint-
ment. the operator and patie nt ar e tired and the
operator's vision is not at its best. so the process
may be hurried and mistake s made. Be sides, t ee th
may change shade slightly duri ng a long operative
101
Figure 6. 1
The lower central incisors are bridge panties for a
minimum preparation bridge (see part 2). They are a
good shade match to the natural upper incisor teeth
but the lower lateral incisors and canines have become
temporarily whiter because they have been isolated
under rubber dam for some time while the minim um
preparation bridge was bonded. This has resulted in
the m drying out and the shade lightening. They will
revert to the normal shade an hour or so after the
rubber dam has been removed. This phenomenon m.ily
occur to some degree during impression ukin g and
m.lking temporary crowns. Hence the advice to take
the shade prior to st.lrting tooth prcoara nc n.
appointment . It is well known t hat tee th change
co lour d ramatically after a peri od of time unde r
ru bbe r dam (Figure 6.1). Altho ugh ru bber dam is
no t no rmally used fo r crown prep aratio ns, it is
poss ible th at afte r an ho ur or so o f wetting and
drying and the n several minute s in co ntact wit h a
rubber impression mater ial, the shade of the
tooth to be matche d may be alte red.
Technique for' shade se lection The lighting
co nditions are very impo rtant. Tra dition ally shades
are se lected in natural daylight rathe r t han art ifi-
cial light. However, there are practical probl ems
with th is. Daylight is very variable in its intensity;
and it is no t always po ssible to make appointments
du ring the hou rs of daylight. It is .lnyway equa lly
important that the crown appears to be the
co rrect shade in bo th artificial light and daylight.
Many people spe nd a large part of their wo rking
and social lives in artificially lit surroundi ngs.
102
Dentists ofte n now match th e shade both in
daylight and in different fo rms of artificial light
(tu ngsten fila ment and fluo rescent).
Altc rn;uively. a standardiz ed artificial light
source des igned to be a close appro ximat io n to
natural dayhght may be used . It is of course
importa nt t hat th e te chn ician has a simi lar light
so urce.
Mo dem denta l un it lights arc designed to
provide a re ason able co lo ur balance, and if thi s is
adequate then using t he unit fight has the advan -
t ages of co nsiste ncy and co nvenien ce.
Colour is said to have th ree dimensions: hue,
chroma and value . Hue is the colour itself (e.g.
red compa red w ith green). Chro ma is the amo unt
of co lo ur (e.g. red co m pare d w it h pink) and value
is th e darkness or lightness of the co lo ur (th e
shad e of grey that the co lou r w ould appear if
seen on a black and wh ite photograph) . Many
sbade guid e s for denta l porc elain ar e arra nged in
groups rcpresenung different hue~ , with a grada-
tio n of chroma w ithin ea ch hue. Figure 6.2 shows
a typical shade guide with fo ur hues (light brown.
yellow, blue/grey and a pinkish hue) designated A,
B. C and D. W ith in each group, differe nces in
ch ro ma are ind icated by a number. For exam ple.
B2 is a fairly light yellow shade, whereas C4 is a
much darker blue/grey.
In add itio n. shade guides have different neck.
body and incisal edge shades on th em. The incisal
edge is also made more translucent.
Shade se lection may follow thes e lines:
Choose the approp r iate lighting conditions o r
take th e shade in a vanery of d iffere nt light ing
conditions
2 Look at t he whole mo uth and mak e a ge neral
assessmen t of the appro priate hue - w hether
th e teeth are ge nerally brown. yellow or grey
Figure 6.2
Using a shade guide to select the basic hue. The upper
left central incisor ts in fact a PJC made fro m a combi-
nation of the two shades immediately below it-
3 Look more close ly at t he tooth to be crow ned
the adjace nt teeth and th e contralateral tood\.
and decide th e hue or m ixture o f hues (the
letter o n the shade guide)
4 Select the chroma (the numbe r)
5 Choo se th e blend of neck, body and Incisal
shad es . It is not necessa ry to select the neck.
body and incisal edge sh ades from the sarre
shade button. and it is po ssible t o m ix por ce-
lain powders so th at shades betwe en th o se on
the shade guide ar e produced .
6 Decide whether an y o the r characre rrstlcs such
as crack lines . ar eas o f opacity o r incr-eased
transluce ncy are required.
It is helpfu l to dra w a shiJe ma p of the tooth ,
Figure 6.3 shows a tooth w ith its shad e map.
Some dent ists and tech nicians prefer a shade
guide consisting o f 'shades' made by fusing a smaj
butto n from each of th e single po rce lain powders.
Others find the co mb inatio n of shades on the
co mme rc ial shade guides co nfusing, and grind off
t he neck (w hich often has surface stai n added)
and incisal portions. leaving a single body shade.
Planning the impression
The impression tech nique should be decided
befo re preparing th e tooth. So me impression
materials are be tter used in a special tray, and this
is made o n t he stu dy cast . Other techniq ues
invo lve ta king an impressio n in a material with a
ve ry stiff put~ consisten cy. putting it on one side
while the tooth is prepar ed and then relining the
initial impressio n w ith a low -viscosity wash
material. Other impression materials can be used
in stock tra ys.
Cljnical l e<:hmque~ (or crown construction
'2 / 5'/
I S} 150
01.£'1 7R1rf/5
/..08£5 WI TIIIN'
Ma.king a special tray (Figure 6.4)
Wh~n a special tray is to be used it can be made
from self-curing acrylic or light-curing acrylic.
Shellac and vacuum-formed mat erials are no t suffi -
ciently rigid or stable and so chey should no t be
used. A spacer of wax or asbesto s substitute tape
approximately 3 mm thick is laid down o ver t he
lrudy cast. This is pe rfora ted thro ugh to the
occlusal surface of three or four teet h t hat are not
to be prepared for crowns, The purpose o f these
pedo rations is to allow t ray materi al to fo rm stops
on the occlusal surfaces of the teeth . T his will
klnlize the tray in t he mo uth and prevent it
making contact with t he prepared teeth. The t ray
103
Figure 6.3
a and b A shade map of this patient's upper right
centra l incisor.
is then form ed by mou lding acry lic doug h or a
sheet of light-curing acrylic over t he stu dy cast ,
Figure 6.4 shows the st ages in making special trays
in the tw o materials. Self-cur ing acrylic is corwc -
nient and inexpensive and does not require special
eq uipment. Self-curing acrylic special t rays can be
made in the dental surge ry. ligh t-curing acrylic
special t rays are qu icker and easier to prod uce and
give more consistent resu lt s. However, it is neces-
sary to have a light-curing box in which to cure
the t ray. and the co st of th is woul d not normally
be justifi ed for surgery use, The t rays are there-
fore made in the labo rato ry. Th ere is usually little
diffe rence in co st between the two types of tra y if
t hey are labo rato ry-produced.
,0<
--
o.OIcal fl'(llniqu~~ for crown cons!J'tKlJOo1
C!inieo

Figur e 6.4

a and b Making a self-curing acrylic special tray.

c shoW!> a study ca st w ith a wax spac er w It h hole!
made in it . Th e holes have been filled with self cunog
acrylic. Self curing acrylic bas been rolled OUl ViOl
shap ed tog ether wi th a handle .

b Th e tray has be en mou lded ove r the study cast ~

spac e r and the ha nd le attached. T he Sto ps. located
over teeth which are not to be prepa red prevent !he
tn y from seating ( 00 close ly o nto the prepared reec.

c-g The co nstr uction of iI light -cu red acrylic specal

tray .

c The study cast and wax spacer toget her with

pre fo r me d blank of light cur ing acry lic mat er ial.

d T he bl ank is roughly shaped. produc ing a handle.

ilrlical l«hnoqu~ for crown comlruetion 10 5

e It is mo ulded o ver the s tu dy ca st a nd tr immed w ith

a sc alpel.

•
;'; .'1J 100

f The ligtu c uring boll WIth the brigh t blue ligh t turn ed
0".

g The finishe d (ra y WIth stops .

106
Planning t he temporary crown
Temporary cro wns may be e ither purc hase d as
prefo rmed units o r m ade at th e chair-side in a
suitable mould.
Pre fo rme d t emporary crowns
The fo llowi ng t ypes of preformed temporary
crown arc available:
Polycarbonate, tooth-coloured tempo rary
crown s for anterior and some posterior teeth
2 Stainless-steel posterior temporary cro wns
3 Alumi nium posterior temporary crow ns.
When o ne of these is to be used t he appropri-
ate size can be selected before the tooth is
prepared using the study cast as a guide.
Chairside t emporary crowns
T empo ra ry cr ow ns can be made in the mo uth .
pre ferably using one of th e higher acrylics. usually
consist ing o f a m ixtu re o f poly(ethyl methacry-
late) and poly(isobutyl methacrylate). so me times
w ith a nylo n fibre fill er. Alte rn atively ac rylic---po ly-
(methyl methacrylate), e pimine resin or amalgam
may be use d . T he mould that is use d to fo rm the
tem po rary crow n may be one of t he fo llowing:
• A prefo rmed ce lluloid crown form
• A vacuu m-fo rmed PVC crow n form mad e o n a
study cast or a mod ified st udy cast of th e
patien t's mo ut h
• A silicone putty impression of the st udy ca st
• An alginate impression o f th e mo uth ta ke n
before t he tooth is prepared
• A copper band o r ma trix band .
The use of t hese mat erials and mou lds is
described on page 122.
B uil d ing u p the core
As described in C hapter 2, cores may be made
of cast me ta l retained by a post. o r o f amalgam
o r compo site retained by pins o r posts o r by glass
(ljnicol ll'<hmques (or crown comrruaioo
io no me r ce me nt w hen pins are no t usu ally used.
Techniques fo r constructing pin- and post-
retai ne d am algam cores are illustrated in Figure
6.5. O ther pin-retained co res are shown in Figure
2.6 (pages 37-8 ). W ith a composit e o r glass
io no me r co re the to oth ca n be prepa red at the
same visit. T he site and angulatio n o f pins is
crucial (see C hapte r 2). The detailed desig n of the
preparation m ust be decided before th e pins are
placed; o the rwise, if the pins are in th e w rong
place , t hey may be cu t o ff d ur ing t he prep ara tion
of the core for the crow n.
Mana g in g w o rn, s h o rt t e eth
figure 6.63. shows so me very wo rn and short
upper anterior teeth. They have co ntinued to
erupt as they have w o rn. and so remain in
contact with the lo wer incisor teeth. The gingival
margins have migra ted incisally. fo llowing the
further e ruption o f the teeth. The uppe r and
lower posterior teeth rema in in co nta ct. The
upper incisor teeth are to be crowned to
improve t he ir appearance and preve nt further
wear (o ther preventive measures having been
uns uccessful), but the le ngt h o f the crowns is not
sufficie nt to produce sa tisfactory preparatio ns and
crow ns w ith a good appea rance. T here are a
numbe r of w ays to overcome th is problem :
• Increase the w ho le o cclusal vertical dimen sion
by crowning all the teeth in the upp er arc h. This
is so me tim es necessary if th e o cclusal vertical
dimen sion (a vo) is reduced and if th e po ste rior
te eth need crow ning in any case. Howeve r, it is
unjustifiably destructive if t he po sterior tee th
do no t need crow ning and is like ly to fail if a
normal a vo is enc roac hed upo n artificially.
• Crown-lengt hen t he tee th by means of a
pe riodo ntal surgical proced ure to re mo ve gingi.
val tissue and us ually bo ne. T his is destructive
if t he gingival t issues are healthy and is usualiy
quite painful for th e pat ient . It can prod uce suffi -
cient lengt h fo r re te ntive crow n pr epa rations.
but th e w o rn incisal surface has to be prepared
and so there is a risk to the pulp. The neck of
the prepa ratio n is placed part wa y up the taper-
ing root, and so is of a sma ller d iameter than if
it were at th e cement-enamel junction . This
mea ns that th e interdenta l spaces are usually
greater, and this can spoil the appearance.
 (li"i<:al rechniques (or crown consrroetion
Figure 6.S
Post- and pin-r eta ined cores.
Q A copper band t rimmed to shape and the margins
smoothed.
b Coo per band in place rea dy to re ce ive am algam.
Retent ion in t his root -filled to o th is provided by a
preformed post (see Figure 2.7. page 39).
c The amalg am co re placed. No t e tha t th e palatal gap
betw een th e cusp and co pper ring has bee n filled w ith
107
amalgam. Th is will fall away when th e co pper r ing is
removed at t he nex t visit. As t he co pper band w ill be
left in place. th e ama lgam can be left in oc clusion -
not e the marks from ar-ticulating paper.
d Pins, lining, matr ix and wedges plac ed. Pins arc used
wh en th e pu lp remai ns vita l.
e Amalgam placed .
r Matrix removed and ama lgam roughly ca rved. The
amalgam is left o ut of occlusion t o avo id undu e st re sses
before the crown is place d
108
/ \
• The incisal teeth may be dep ressed and/or the
posterio r te eth allowed to over-erupt by
co nvent io nal orthodontic treatment. T he int er -
incisal sp ace created means that th e w orn
incisal surfaces do not need to be prepared.
and the gingival margins migrate upwards as the
inciso r teeth arc intruded. This is the techniq ue
o f cho ice in so me cases. but th e disadvantage
is that the pat ient needs to wear an orthodon-
tic appliance. w hich is usually visible.
Oinicol tl"Clmoqut s (or (Town conwtKtior
Figure &.6
o A patien t who has suffered fr om bu limi a nerv csa
prod ucing extens ive palatal and incisal e ro sion of ell!
uppe r im;isor teeth. C ontinuing e ru ption has kept pace
with th e e rosion and so th e upper and lo w er incisor
teeth are st ill in c o ntact.
b A similar case, again caused by an eating disorder,
but this time predominandy affect ing th e incisal edgel
of the uppe r ce nt ral inciso r t ee th ,
c The central inciso rs have been bu ilt up with compos-
ite wh ich improves th e ir appearanc e for t he time be lllg
but also acts as a fo r m o f Dah l app liance which wiR
depress both upper and lower incisor teet h. Note that
me co mpo site re storation s are in contac t with the
lower Inciso rs and yet th e canine and posterior teem
are o ut o f o cclusio n.
• A fixed anterio r bite p lan e . (a fixe d D ahl appli-
ance). ca n be ceme n ted to t he uppe r incisor
tee t h. This is design e d t o ho ld th e ant erior
tee th apa rt by t he a m ount t hat is ne e ded for
t ooth p reparatio n. Once cemented. t he peste-
ri or teeth d o n o t occlud e . b ut patients cope
with this very well. In three to six months the
anterior tee t h a r e intruded an d/or t he poste-
rio r teet h o ve r -e ru pt so that t hey come into
occlusa l contact. At this stage the fixed Dahl
 s
appliance can be remo ved and t he teeth
prepare d for crowns w ith o ut remo ving any
more dentine fro m the worn incisal edge s (sec
Figures 4.63 to g). The original D ahl appliance
was a remo vable ca st -me ta l ante rio r bnepla ne
retained by clasps o n posterio r te e th.
However. th is has now been largely supe rseded
by the fixe d app liance .
• The upper ante rio r teeth may be prepared for
crowns, w ithou t remov ing any dentine fro m the
worn incisal ed ges, and then provisio nal cro wns
made to th e length and shape th at is req uired fo r
the permanent crowns. These wi ll act in a similar
way to the fixed Da hl appl iance. H owever, t he
disadvantage is that the teeth arc prepared befo re
the tooth movement has been established.
• Restoring the worn s urfaces wit h co mposite to
act in th e sa me way as a Dahl appliance (see
Figures 6.6b an d c).
Of these technique s. th e fixed Da hl appliance is
preferred whenever poss ible. Pr o visional cro w ns
or convention al o rthodo nt ic treatme nt are the
next bes t, and cro w n-lengt he ning and increasing
the O VD o ve rall sho uld be preserved fo r those
cases w here th ere are specific indicacio ns for
these tech niques.
Tooth pr epa r atio n
Choice o f instr uments
The ma jo r pan of the prepa ra tion is ca rr ied o ut
with the au-cto r. Diamond burs are prefer red for
res
Figure 6.7
A selection of burs and the surfaces prepared by them,
In all cases the bur was used entirely within the contour
of the too th and wou ld not have damaged the adjacent
too th. From the left: a square-end tapered diamond bur,
a square -end tungsten carbide bur. both producing
narrow shoulders; a parallel-sided but pomred diamond
bur, with the matching tungsten carbide finishing bur: a
round-ended parallel-sided plain cur tungsten carbide
bur, these last three prod ucing chamfers.
prepa ring ena mel, and eit her d iamond o r t ungste n
carbide bu rs fo r amalga m and denti ne .
Th e shap e o f t he bur o r stone sho uld be
chosen to match t he co ntour o f t he su rface that
is be ing prepa red . Th is includes the shape of th e
margin, so th at if a sho ulder is be ing prepare d, a
squ are-e nde d s traight o r tape red bu r should be
use d. Alte rn at ively, if a chamfe r finis hing line is
being prepared the n an appr opriately sha ped bu r
should be cho se n. Figu re 6.7 sho w s a sele ct ion o f
burs se t agains t the too th surfac es th ey have
prepared.
It is ea sie r to control the preparation of the
co nc ave palatal s urfa ce o f uppe r incisor teeth if a
large-d iameter d iamo nd bur, match ing the
conto ur of the too th, is used.
Th e finis hing is an important stage and can ta ke
rathe r lo nge r th an the main bulk red uct ion. The
pu rpose is to fina lize the shape of the pre para -
tio n, ro un din g-off angles w here necessary, ensur-
ing th at the margin is property loca ted in relatio n
to t he gingival margin an d is t he correct co nt o ur
and dimension. In addit io n, the sm all und ercuts
res ulting fro m diamo nd sco re marks sho uld be
re move d an d th e s urface of th e pre pa ration left
reasonab ly sm oot h. O the rwise th ere w ill be d iffi-
culty wi th remo ving a wax pattern fro m t he d ie
and w ith ce mentatio n. There is, ho wever, no
need to polish prepa ratio ns: a very slight ro ugh-
ness he lps rete nt ion (se e Figure 3.7, page 49).
Slow -spe ed hand piec es w ith st ee l finishi ng burs,
fine st o ne s o r flexib le d iscs can be used fo r finish -
ing; however, it is more com monly do ne at
medium to high speed wi th plain tungsten carbide
bu rs , fine-grain diamonds o r tu ngsten carbide
stones .
' 10
Stages in the preparation
It is usua l t o prepare eac h su rface in turn so th at
t he amou nt of tooth re du ction ca n be controlled .
Esta blis hing how much tooth has been removed
can be done in a num ber o f ways. At th e margin
t he w idth of t he shoulder or other fin ishing line
can be se en directl y. W here t he tooth being
prepared occludes wit h op posing te eth, and other
adiacent te eth also occlude. t he amou nt of t ooth
tis su e remo ve d from the occl uding s urface is
assessed by dire ct o bser vat ion o r by the pati e nt
biting thro ugh so ft wax ; th e thick ness of the
remaining wax sho ws ho w much to oth has be en
removed (see Figure 6.8). O n other surface s, half
ma y be prepa red first , leaving a ste p betwee n t he
pr epared and unpre pared areas so indicat ing t hat
amo unt of tooth tissue removed (similar to Figure
5.6). Alternat ive ly, a groove may be prepared
across the s urface to t he inte nded depth of t he
preparat ion and th e remaind er of the s urface t he n
prepared to t he de pth of the groo ve (se e Figure
6. 10).
The o rder in which the tooth surfaces are
prepared will de pend upon th e circu mstances; but
some basic guide lines ma y be usefu l. Surfaces tha t
are eas y to prepare and th at will improve access
to mo re d ifficult s ur faces sho uld be prepa red firs t.
For ex amp le, wi th inciso r tee th some o pe ra tors
prepa re the incisal edge first in order to remov e
part of the app roxi mal surface and impro ve
access to the re mainder of it. Similarly, t he mo st
difficult surface s ho uld be left until last.
Sometime s wit h a difficult pat h o f ins ert io n, the
directi o n of one surface is cr it ical. In t his ca se it
sho uld be prep ared firs t and t he oth er surfaces
prepa red relative to it . W he n pins o r grooves ar e
to be used as pa rt of t he preparat ion , t hey are
Clinical technjques (or crown WIlS!rlKl;1
Figure 6.8
An occlusal record taken in 2 mm-thrck soft wax. whk
docs not require warm ing. The occlusal co ntacts ofth
unpre pare d first and third molar teeth can be see
to gether with the imprint of the second molar prep;
ration. It is clear that there is near ly 2 mm clea ranc
and th is is sufficient for a met al- cera mic eccles
surface.
left until last and aligned w ith ot her prepare,
s ur faces to form part of th e ove rall reteow
design.
Preparing teeth for complete
posterior crowns
Figur e 3.12 (pages 55- 6) shows a typical sequentl
in th e preparation fo r a complete gold crown 0
a po st erior tooth t hat ha s be en built up with :
pinn ed am algam core. Figu re 6.9 sho ws a premo-
lar with a composite core prepa red for,
metal-ceramic crow n.
Occlusal reduction
The sha pe of th e pre pare d occl usa l su rface should
fo llow t he gen eral contours of the original tooth
s urfac e . In some cases, w ith he avily worn teeth,
th is w ill be flat, bu t in o thers the general shape
of the cus ps should be repro du ced. This allows
th e crow n to be o f reasonably un iform thickness
w ith min imum preparat ion of to oth tissue.
A co nve nie nt inst rume nt to pr ep are the
o cclusal surface is a dome-ended para llel-sided
diam o nd bur held on it s side. W it h t his instru-
ment it is po ssible to form t he cuspal lndines
togethe r w ith a ro unde d shape to the fiss ure
patte rn.
T he o cclusal relationsh ips of t he to ot h being
pre pa red sh ou ld be st udied in function. For
exam ple. in prepa r ing a poste rior tooth, if the
guidance in late ral exc ursio n is carried by the
tooth bei ng prepa red, the cus p, o r cusps, that
carry th is gu idance should be prepared rather
 III

Figure 6.9

Cro wn preparation for a rnetal-ce rarruc crown.

a The pin-retained co mpos ite core has been present for severa l
mo nth s. T he appeara nce is be tte r than an am algam core,

band c The finished pre parat io n.

"'
I r
mo re, so that there is a greater thickness of
cr own material co vering th em. Th is will produce
grea ter strength in this stressed are a and will also
allow fo r future wear. In t hese circum stances t he
cusp in quest io n is known as t he 'funct io nal cusp'.
However, in most nat ural dentitions the poste-
rior tee th d isclude in lateral exc ursion and so
non e o f the cu sps can be described as 'functi o nal
cusps' in th e sa me sens e. T he refo re t he y do no t
nee d to be reduced any mo re th an th e re main-
de r of the occlusal surface .
Fig ur e 6.10
Stages in the pre parat ion of uppe r in CISO r!; for 1')(.$ . ITt
ind ica tio n fo r crowns wa s progressive ero sion of tht
buccal surfaces and unsightly re storations that rapidly
disco lou red afte r rep lacemen t. The first t hree stages
we re carr ied ou t wit h a long-tape red diamond bur.
Finishing was with plain-cut tungsten carbide burs in ~
1:4 ra tio speed incr easing co ntra -angle handpiec e. The
stages in the preparanon for metal-ceramic cro wns
wou ld be very similar ex ce pt that t he palatal surfaces
wo uld be prepa red with a suita bly shaped bur ,
o Reference grooves are cu t in the buccal and incisal
surfaces to e sta blish the dep th of the pre paraeo n
b Dista l surfa ces being pre pared. Note th at a sliver o!
ename l has been pre serv ed at the contact point of ee
late ral inciso r to protect the canine fro m damage. Thls
w ill fall away as the prepa rat ion is car ried further
gingivally.
c Th e incisal reductio n of the ce nt ral inciso r has been
comple te d together wit h half the incisal reduc t ion of
the lateral inciso r.
O ne advantage o f m inim izing the red uctio n
t he occlusal s urface is t o ma intain the ax ial wall
o f th e prepara t ion as lo ng as poss ible. rhe rebj
im p rovi ng re tent io n.
A x ia l r e du c ti on
Buc c al and ling u al surfaces Th e se may be
pr e pa red w ith paralle l-sided o r tapered diamonds
•
(Jncli 1e<:#1n1ques (Of' cro wn COnSt!lK t;" n
of appropriate length and wit h the end sha ped to
produce the req uired shape of margin. It may be
possible to use a diamond of kno wn taper held
at a constant angle o n th e buccal and lingual sides .
so that the taper o f th e preparation ca n be
controlled. How ever, th is c hen has to be
modified because of m e curvature of the t ooth's
surface. previous restoratio ns or the presence of
a co re . A fairly large- diame ter instrument is
convenient and r edu ces the likelihood of vertical
ridges in the preparation .
"'
d Palata l red uction with a round-edged wheel bu r in
an atro ror.
e C hecking. w it h the tee th in occlusio n, t hat there is
sllfficient clearance fo r po rcela in.
r The finished preparancns . The r ight lat era l iocisor
has lost a mesial composite. This defect will be made
good with g1.1SS ioncmer cement before the impreSSIon
;s taken . The finished crowns are shown in Figure 2.1.1
[page 26).
Me sial and di st al su rfaces These are t he
mo st diffi cult surfaces to prepare if there is an
adjace nt tooth in con tact; with o ut o ne . th ey arc
prepared .like the buccal and lingual surfaces .
So me times both adjacent po steri or teeth are to
be crowne d. and the n the surfaces in con tac t
sho uld be pr e pared simultaneo usly, th e red uction
of eac h being minimized.
Unfo rtu nately. d3mage to adjacent teeth is
com mon. with some studies sho wing over 90% of
adpcent teeth damaged even by careful operators
114
w ho knew the ir work would be inspect ed. W hen
the preparatio n is fin ished t he adjacent tooth surface
sho uld always be checked for damage, and if neces-
sary smoothed, polished and fluo ride app lied.
It is almost impo ssible to pre pare t he app ro x-
imal surfaces of a poste rior to oth whe n there are
teeth in contact on e ither s ide w it ho ut either
c ve rtape rtng the preparatio n, re mo ving more
tooth tiss ue t han is de sirable o r da maging the
adjacent teeth (se c Figur es 3.1 2 and 6.7 ).
Ver y thin long tapered diamond burs are passed
through th e approximal surface in an attempt t o
lea ve a slive r of enamel (or core) between the bur
and t he adjacent tooth. ControlJing the ang le,
position and dep th of this bur w itho ut waveri ng
o r go ing off course is one of the mo st skilful
procedures in o pe rat ive dentist ry and dese rves
many hou rs of practice on extracted teeth in
models before it is attempted in t he mouth.
A mat rix band may be ap plied to the ad jacen t
tooth to protect it, but t his inte rfe res w it h vision
and access, and is in any case cut th ro ugh ve ry
eas ily. A wooden w edge at the gingiva! margin to
se parate t he t eeth slightly may help .
Margins
The shape of the margin w ill be determined by
t he shape of the end of the bur used fo r t he axial
reduction. This may be flat, producing a sho ulde r,
or chamfered. A knife-edge finishing line is
produced by t he side of the bur o nly be ing used,
t he tip not cutting t he tooth. It is mo re efficient
to produce the required shape of margins du ring
the bulk preparation sta ge rather than as a
seco ndary proced ure.
Fini shing
Suitable finish ing instruments are used as
described o n page I IS.
lt is important that the angles between the axia l
and occlusal surfaces arc rou nded for reasons
described in Chapte r 3.
Preparing teeth for co mplete anterior
crowns
Figure 6. 10 shows stages in prepar ing an upper
incisor tooth for a PJc. The st ages of preparatio n
Clinicol techniques (or crown com!,",I,
for a toot h fo r a metal-ceram ic cro w n are similar
alth o ugh the e nd re sult is rathe r differen
com plying w ith t he princip les de scribed i
Chapte r S. If a ta pered o r parallel-s ided dtamc«
bur of appropriate lengt h and diameter !
selected, t he first t hree st age s o f th e prepar-anc
can all be ca rried out w ith the same inst rument
wit h only the incisal-palatal re duct io n and finisf
ing left to be done w ith differen t inst ru ments.
Incisal and proxi m al red uction
When o nly one t oo t h is be ing prepared th e incise
su rface ca n be reduced w ith th e shank end of th€
tape re d diamo nd bur and th e adjacent t eet h U\e~
as a guide to the amo unt of re duction necessaq
W hen a series of teet h is being prepared eithe-
alternate teeth are reduced first w ith the unpr€-
pared teeth used as a guide , or half the incisa
edge is reduced fo llowed by the second half «
the sa me depth.
In patients with a Class I incisor relationshif
the uppe r inciso r teeth have t heir incisal edge!
inclined lingually and the lowe r incisals buccally.
T he same inclinati ons are pre se rved in t~e
pr epared teeth.
Ap proxi mal reductio n may be conti nued witf
t he sam e bur. Because so m uch mo re tooth ~
be ing remo ved than is necessary for a posteric
gold crown and since inciso r teeth are a more
favou rab le sha pe and the buccal/lingual dimensicr
at the co ntact poi nt is smalle r, it is much easier
to prepare t he approximal surfaces withou
damaging the adjace nt teeth th an in the case of
posterior crowns. Passing t he bur th rough the
mesial and dista l appr-oxlma l surface s (leaving a
sliver of ena me l) establishes t he tape r of these
surfaces as w e ll as the location and widt h of t~e
app ro ximal shoulde rs.
Bucc al reduction
The contour and depth of the bucca l shoulder s
es tablishe d w ith the tip of t he diamo nd bur. A
commo n m istake in preparing uppe r incisor reed
for cro w ns is to re move insufficient material from
the buccal/ incisal th ird o f the preparation. This
results eit he r in a crown that is too t hin, so that
the opaque core material sh ows th rough (see
Figure 3.2, page 43), or in a bulbo us crown. The
• I I!

Fig ure 6.1 1

Three bu r~ used to finish a s ho ulder p re pa ra tio n. left : a steel slow-speed

bur c u tti ng boch on the sid e an d at th e end. Centre: a n end (u tting bu r
that has produced a ledge; It wou ld be diffrcult to era dic ate th IS wIthout
IifcHlg the bur fr o m th e shoulder. RIght: a plain-<ut tungsten car bide
tapere d side and end cutting bur, which is bes t use d in a frictio n grip
1:4 speed inc rcasing handpiece . T he tungsten car bide bur pr o du ces the
best finis h mo st co nvenie nt ly.

amount of too th r educt ion in th is are a can be
fixed by a bucca l depth indicato r gr oove be ing cut
down the buccal su rface and the re mainde r o f the
surface reduced to t he same depth. With la rge
teeth o r wh ere t he alignment o f the buccal
surface is being altered. more tha n o ne groove
may be needed. In reducing th e rem ainder of t he
surface. the bur shou ld be used at a shght ang le
to the depth gr oove to pr eve nt it dropping into
the groove and dee pe ning it uninte ntionally.
Gingival-palatal red uct io n
The same bu r is continued ro und the palata l
surface. pr oducing the palata l shoulder and a
short gingival palatal wall nearly parallel to th e
buccal-gi ngival surface.
The se thr ee stages, using the same bur, ca n all
be carried out very quic kly provided the o pera-
tor has planned the design properly and has
thought t hro ugh the se quence.
Incisal-palatal reduction
This surface is usually co ncave and is bes t
prepared w ith a large-diame te r inst ru ment. for
example a lar ge w heel bur in the air turbine (see
Figure 6.IOd). Small instru me nts produce an
undulating su rface . w hich is difficult to finish
smooth ly. The occl usion between this su rface and
t he o pposing teeth sho uld be checked before t he
preparation starts, and co nsta ntly rechecked
du ring pre para tio n until suffici en t space has been
pro duced for the cro w n mate rial.
Finishing
T he prepared individua l su rfaces should be
blended into each o the r to produce a ro und ed
shape during the gro ss reduction. The axial
su rfaces are finished and th e ang les around the
incisal edge rounded. using a su itab le finishing
inst ru ment. An e xcelle nt finish can be produced
by using a plain-c ut tungst en ca rbide fr ict ion grip
bur In a 1-4 speed increasing co ntra-angle
handp iece. T he sho ulder can be finished using the
same inst ru ment o r steel burs. So me dentists use
end cutt ing burs to good effect, but th ese arc
difficult t o mast er (see Figure 6. 1I).
Preparing teeth for partial crowns
Occlusal and ax ia l r eduction
The majority of the preparation is carr ied o ut as
for a co m plete crown. exc ept that care is ta ken
to produce suna btc finish ing lines at the junction
of the buccal and o the r surfa ces. In particular. the
reduc t ion shou ld no t be carried too far round o n
the mesi al su rface or excessive metal w ill show.
"'
Groove s, boxes a n d p in holes
Grooves and boxes are pre pared w ith e ithe r
high+spced or slo w -speed burs, depending upon
the difficulty of acce ss and the operator's co nfi-
dence. They are usually prepare d with th in
ta pered plain-cut burs. If the preparation is a
co nve ntio nal three-quarter crow n, thc lingual
surface of the axi al grooves sho uld be well
defined . since this is t he rete ntive surface .
Parallel-sided pinho les arc pr epared wi th a
tw ist dr ill o f suitable diameter for th e im pression
technique used. usually 0.7 mm . If po ssible. the
pinho le sho uld be d r illed on ce o nly and no t in
seve ra l attempts. w hich deepe ns it a little each
time. but also wide ns and ta pers it so that it
becomes less re tentive.
Parallel pinho les arc pr eferable to ta pere d: they
arc mo re retentive, can be prepared with paral-
leling jigs, and even freehand are easier to prepare
paralle l to each o ther than tapered ho les. W hen
it co mes to th e impression there are even more
impo rtant advantages (sec page 135).
Preparing anterior t eeth for post
crowns
The re are three stages:
• The shou lde r or o ther margin is pre pared
• The po st ho le is prepared
• Any remaining tissue between the two is
red uced as necessary.
W hen a large part of the natural cro w n o f th e
to oth re mains, it may be conven ient to cut this
acro ss ho rizontally between t he midpo int and the
incisal edge and remove th e incisal part before
t hese t hree stages are und ertaken. T he margin is
prepared as for a PJC o r metal-ceramic cro w n,
but wit h more red uctio n so t hat the shou lde rs
are wider than for an equivalent vital tooth .
P o st-hol e preparation
Removing t he root canal filling W he n the
root canal fill ing co nsists of gutta percha (GP) and
sealer, th e co ro nal part may be removed with
Gates- Glidden o r ro und burs (sec Figure 1.6b) o r
by softening it with hea ted metal instruments.
Pro vided the root filli ng is we ll co ndensed , a
co nven ie nt method is to cut out the GP po int with
a slowly rotating rou nd bur o r twist dr ill slightly
large r in diameter than th e root canal. If too small
an inst rument is used , or too fast a speed so that
the GP me lt s, it becomes attached to t he bur and
the w hole of th e root fill ing may be pu lle d out
w hen the bur is removed . Us ing a bur o r drill
slightly large r than the root canal e nables the roo t
filling to be cut away from its e nd with o ut the
sides o f the GP point becoming e nta ngled in the
bu r. Ext ra-lo ng-shank cc mra-ang!e burs are useful
in lo ng t eet h. With normal-length burs the head
o f t he handpiec e clashes with t he adjacent teeth
(se e Figure 6. 12).
G utta percha and most sealers are so fter than
dentin e, and so the bur will tend to fo llo w t he
ro o t filling rat her than cut into t he side of the
root canal, but neverthele ss gre at care must be
tak en to e nsur e that the bur sta ys o n co urse.
Regular inspe ctio n o f the root canal using both
the mouth mirror and direct vision is essential
(see Figure 6.13). Tr ansilluminatio n o f the root
canal may also he lp.
Some ceme nt fillings are mo re d iffi cult to
re move th an GP beca use they set to a co nsistency
harder th an dent ine so t hat th e bur tends to slip
awa y fro m the ro ot filli ng into the de ntine. In this
case the coronal e nd o f the ro ot filling can be
rem oved with a lo ng ta pered bu r in the airotor ,
but great care is nee de d to avoid late ral perfcra-
t io n o f th e root.
It is almost impossible to cut down full.length
silver poin t ro o t fillings, and these shou ld be
remo ve d, if possible, and re placed by GP root
fillings. W hen t he silver poi nt canno t be rem oved,
an alte rna t ive fo rm of co re should be used.
Shaping the p ost hole The pos t hole needs
to be shaped to match t he po st selected (the
diffe ren t types of po st were de scribed in Chapter
2). When the po St is to be paralle l-sided . a twist
d rill may be used fro m t he o utset, and the root
filling is removed and th e po st hole shaped in a
single o pera tio n. In some case s. on ce the root
fill ing is removed . it may be decided that a larger-
diame ter po st is needed, and so the next size of
twi st drill is th en used to shape the post hole (see
Figure 6.14).
For a tapered pOSt hole for a cast -meta l post.
an inst rument such as that sho wn in Figure 6. 12c
is used. This no t on ly pro duces the taper but may
 ",

b c
Figure 6. 12

Po st -ho le pre para tion .

a Lon g-shank ro und burs (left) an d G ate s- Glidden burs fo r rem o ving
gut ta perc ha from root canals.

b an d c Ext ra-long-shank co ntra -angle bu rs allo w access without th e

head of the hand pece clashing w ith adiacent teem . They also improve
visibility.

Figure 6.1]

l o o king up th e post hol e w ith dir ect visio n. Note the ov al sh ap e of th is

po st ho le w ill r esis t rotation o f t he po st wit hin th e ho le. N o t e too tha t
the crown margin has bee n exp osed using e lect ro surgery. T his was
necessary here because o f car ies ben eath th e pr evio us crown.
"' C~nK/l1 t<"Chmques (or crow n COrll l",etlOll

Fi gur e 6 .14

a A handpiece- d r iven twi st drill to prepare a para llel-

sided pos t hole.

b The prepared post hole and a preformed sUinless·

steel po st be ing tried in.
 "'

mm c T he po stho le is '3 mm lo ng.

d The post is shortened from «s apical end co preserve

th e re te ntiv e tag fo r the core. a nd is t ried in aga in.

e Glass io nomer luting cement is spun down the

posthole w ith a rotary paste fille r .
120

f The POSt cemented w ith glass io nom er ce ment,

g Light-cured composite is bulle up freehand .

h The completed core.

 '"

, b c d e

Figu re 6.15

o A sect ioned. e xt ract ed tcorf sho wing me prepara t ion fOf' a paratle l sided post hole . The system being used is
d1e same as that sho wn in Figure 2.4b. This is a 1.75 mm diameter drill. It is ra the r tOO big fo r th is size of tooth
and is veering towards the side . Ideally th e post hole sho uld be longe r but. if co nt inued in this direction, there
would be a risk of lateral perforation of t he root.
b This to oth is th inner a nd th e d rill is 1.25 mm diam e te r. Howeve r jt is progre ssing do wn the ce nt re o f the toot h
w,m less r isk o f lateral perfora tion.

( A sectioned. extracte d to oth w ith a stainless ste el POSt and composite co re in place. The co mposite co re is
about half the prepara tion . (The scalnjess steel post is parallel and lo nge r but part of it and me ro c r fi lling have
been lost in th e sec t ioning proc ess.]
rJ A radiograph of a post in a roo t filled upper lateral inciso r too th. The too th is an abutment fo r a br idge and
the bridge had bee n present fo r many years. The le ngt h and diameter of the post are suitable fo r t his size and
shape of root.
t A taper ed POSt hole CUtt er with good side t utt ing ability. It has bee n tilted back and forth to prod uce a tape red
POst which is larger at the neck than the diamete r o f the bur. This is o ften nece ssary when caries has progressed
down the root canal or when a previous post was prese nt. An impressio n and cast pos t will be necessary. As this
preparatio n inevitably weakens t he toot h. the root face has been prep are d with an external beve l so that a comp lete
diaphragm can be cast toget he r with the post and co re ,

also be move d side to side to p rod uc e an oval- Finishing the preparation

shaped canal, following the sh ap e of the too th .
This inc re ases the strength o f t he post w hile
leaving a u nifo r m t hick ne ss o f root (se e Figur e
6.13). A select io n o f instrume nts . a nd sections o f
the teeth pr epared us ing them. are illustrated in
Figure 6.1S.
O nce t he ma rgin. t he re mai ning a xial wall s a nd
th e post hole have been p repa red. the re ma y
re ma in a su bsta n tial co llar o f dentine, so me spu rs
o r none at all. Sub stant ial a mou nts o f denti ne
sho uld be le ft. since th e y lengthe n t he post ho le
122
and define t he margins. Fragile fragment s.
howe ve r, sho uld be re mo ved .
Comple ted po st crown prepara tio ns with posts
and co res in place are shown in Figure J. r5 (page
60).
Temporary crowns
Fo r a descript io n of th e difference between
't empo rary' and 'pro visio nal' crowns and bridges.
se e page 128. Te mporary cro wns are de scr ibed
at this stage because in a no rmal clinical seq ue nce.
once a crown preparation has been sta rt ed. it
must be co mpleted at least in terms of gross
red uction at the sarne visit and a te mporary
crown fi tt e d. O fte n it w ill be possible to proceed
to impress ions and o t her stages at the same visit.
but these can be defer re d if necessary. The
te mporary crown. ho wever, cannot be deferred.
Preformed temporary crowns
P ol yc arbona t e t empora ry crowns
The appr op riate size of a te mpo ra ry cro wn has
already bee n selected during t he planning stage,
and Figu re 6. 16 shows the sta ges in pre paring and
mo difying a po lycarbonate cro wn for an uppe r
incisor tooth. Here th e crown is relined wit h a
highe r acrylic produced speci ally fo r t emporary
crowns by acry lic resin - po ly(methyl meth acry-
late) - may also be used.
O nce t he po lycarbo nate crown has bee n
relined, it can be adjuste d for incisal le ngth. oc clu-
sion and marginal fit. It docs no t matter if the
polycarbonate is gr o und r ight t hrough, as long as
a layer of t he lining material remains.
Sta in le s s-ste el t e m porary cro w ns
The se are difficult to adapt and often do no r
pro duce good co ntact po ints o r occl usal contact.
They are, howeve r, hard and durable and can be
left in place fo r so me time . The margins are
tri mmed with st on es and co nto ured with pliers,
and the tem porary cro wn is the n ce me nted,
usually wit h a rigid cement such as zinc phosphate
o r a rei nfor ced zinc ox ide eugenol ce ment.
Alumini um cro w n for-ms
Being softe r, t hese are more readily adapted to
fi t contact points and oc clusal contacts, but the
margins are ir rita nt to the soft tissu es unless
ex treme care is taken in contouri ng them, and
some patie nt s co mplain of a me tallic taste.
Altho ugh th ey are quick to make, they are gener·
ally less satisfactory than acrylic te mpo rary posre-
r io r crowns.
Chairside techniques
P ouring tec h n iq u es
The higher acrylics go thro ugh a stage dur ing
setting whe n t hey can be po ured o r injected into
a suitable mou ld that is placed over t he pre pared
teeth. Only a very th in flash of excess material
remains at t he periphe ry. Conventio nal self-curing
acry lic resin (poly(methyl met hacrylate» should
no t be used wit h these techniques because,
co mpared with the othe r materials, it has a more
exo the rmic se tting re actio n and is therefore
more likely to pro duce pu lp damage. It is also
more chemically irritant to gingival tissues and
docs no t go t hro ugh this po uring stage, so that a
thick fl ash is prod uced and more adjustment is
necessary.
The mou ld used may be a preform ed celluloid
crown form, a thin PVC slip vacuum fanned on the
patient's st udy cast (o r a mod ified stu dy cast), or
a silico ne putty or alginate impressio n. Figure 6.17
illust rates typical t echniques using an alginate
impression and a PVC slip with two different higher
acrylics. Figure 6.18 shows a similar technique with
a puny impress ion of a modified st udy cast and a
th ird highe r acrylic in an autormx gun.
Moulding t ech n iq u e s
Som e of the higher acrylics go through a dough
stage when the y can be mou lded rather like putty.
In this consiste ncy t hey can be fo rmed into
te mporary cro wns simply by mou lding over the
pr epare d to o th with the fingers and the patient
biti ng into it to establish the occl usion. Gross
e xcesses will be pre sent, but t hese can be
removed by rou gh carving in th e mou th and then
with an acrylic bur in a st raight handp iece o nce
OmPc"i 1«lmoq""1 (or {rOw n £ OnS!nK1Km

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Problem

Figure 6 . 16

Polycarbonare tempo rary crowns .

a Temporary crown being t r ied -in.

b Tr immed and relined With " tempora ry crow n and br idge highe r
acrylic.

( The temporary crown two weeks later.

www.allislam.net
Problem
'"
Figure 6.17

C han-side te mporary crowns: pou r ing t echmques.

• •
a The patient shown in Figur e 6.10; the buccal surfaces
of the cen t ral iociso rs are r eshaped with ~)( in the
mou th .

b A te mpo ra ry crown and bridge higher acrylic

r einfo r ced w ith nylon fibr es being injected into an
alginarc impress io n of the mo dified te e th .

( The t emporary crown s befo re being remo ved from

t he mouth. N o te me ( hill flash.

d Flex ible PVC slip vacuum-formed to the stu dy cast fo r a different

pa tient.

the crown has been remo ved and has become
hard (see Figure 6. 19). This is a useful technique,
particularly for pos terior teet h whe re the shap e
of the tooth to be prepar ed (ofte n a co re) is to
he changed and so is no t suitable for the po uri ng
rechmque .
A te mporary crown made by this mo uld ing
technique will have better co ntact points, occl usal
contact and marg inal adapta tio n than an
aluminium cro wn fo rm . There is no need to
modify the study mo del o r ma ke a vacuum -
formed pvc sli p and so it is an effect ive and
effic ient t echn ique .
Tem porary-post c r o w n t echn ique s
Some manufact ure rs supply temporary po sts with
their kits. An e xample of an aluminium te mporary
post is shown in Figure 6.1 S. Otherwise, te mpo-
rary posts may be made from wire modified w ith
a co nvent io nal or highe r acrylic before the
temporary cro wn is add ed to the wire by o ne o f
the techniques describe d in th e previous section
(see Figure 6.20) .
e The partly set material (in this case a drtterent higher
acrylic) is removed 'rom the mouth still in the mould.
( The completed temporary crowns fo r the second
patient.
O t h er t echnique s
B uil d- u p techn iq ues Temporary partial
crowns, particularly pin-retained partial cro wns,
are ve ry weak and tend to break up and become
lost. It is also difficult to form pins by any o f the
techniques de scri bed so far . Tempo rary partial
crowns can be made by plaCing plastic pins into
the pinho le s and building up a te mporary cro wn
in self-curi ng co nventional or higher acrylic, using
a paint brush.
C oppe r ring and a m a lgam A ro bust pes te-
nor te mpo ra ry cro wn that can be left in situ fo r
some time may be made by ada pting a copper
ring to th e mar gins of th e pr epar atio n. cutti ng it
sho rt o f th e oc clusion and fill ing it with amalgam
carve d to form o cclusal contacts. If an amalgam
co re is prescnt, th e pr epa rat io n should be lubri-
cated with petroleum jelly to avoid any risk of
new amalgam beco ming attached to t he pr epara-
tio n. These te mporary cro wns are easily re moved
by slitting the coppe r ring.
126 O""col Ied>nroues for uown constnICtoO/I

Figure 6.18

a-<i A similar techn ique to Figure 6. 17 but this t ime

using a mould pr oduced in a labo r ato ry silicone putty
materia l and a newer type of higher acry lic temporary
crown and br idge mate rial mixed in an automix gun and
injecte d dire<:tly into the im pr es sio n.

a Th e silico ne mould made on a study cast mod ified

w ith wax.

b The autom ix gun with a very fine n o zzle.

(Jill ( il

c Inser ting the material.

d Ready to be p laced in the mouth.

 121

Figure 6.19

Ch air-side tempor ary crowns: moulding technique.

a A temporary cro wn and br idge higher ;lcrylic mixed

to a do ugh co nsist ency is mou lded over the prepared
tooth and the patien t is a ske d t o occl ude into it.

b When ne arly set it 15 eased o ff the prepa ra tion and

o ut of th e undercut s be tween adjacen t teeth. In t his
case the fit surface was satisfacto ry; in others it may
need to be r elined w ith a further mix of material after
the exte rior surface has been tr immed.

c The temporary cro wn tr immed to a good fit at the

margins_ Arti culat ing pape r is being used to adluse the
occlusion.
128

Figure 6.20

Tem pora ry-post crowns.

o The same preparatio n as show n in Figure 6.' 3 after iootial gIngival

healing .

b Th e thic ke st possible le ngt h of serrated Ge rma n silver wire is t r ie d in the root canal,
coated with a higher acrylic and inserted int o t he POSt hole . When nearly set it is
withdrawn and r eseared a number of t imes to prevent the possibi hty of the post
jamming and not co ming ou t. Afte r ex cess material has been t rimmed . the co ronal part
of th e te mporary cro wn is added uSing one of the techniques de scr ibed earlier. In chis
case th e polycarbooat e te mpora ry crown is illustrat ed in Figure 6.16 .

Difference s between temporary over-eruption o f the prepared tooth by mainta in-

and provi sional crowns
It is useful to make a dist inctio n bet ween 'tempo-
rary' and 'pro visio nal' crowns (and bridges).
Te mporary restorations are made to last for a
short while to protect the prepared dentine. to
mainta in th e appearance , and to prevent tilting o r
ing co ntact po ints and o cclusio n. Because they are
te mporary, they are usually made by o ne of the
rel atively simple chairs ldc tec hniques des cribed
above and are ce ment ed with a temporary crown
and bridge ce ment.
Provisiona l res to ratio ns also have all these
functions, but are made to last for a lo nger pe riod

while other treatment is bei ng provided be fore
the permanent restorations can be made or when
a period of asse ssme nt is necessary. Fo r example,
if the patient has periodontal disease associated
with poor margins on ex isting restora tion'>, provi-
sional restorat ions may be made wit h well-
adapted margins and left fo r som e t ime until the
treatment of the pe riod on tal diseas e is completed.
Similarly . w hen th e occl usion is being mo dified. for
example by incre asing t he OVD, pr ov ision al
restorations will be left in place for som e months
to assess the pati ent 's tolerance of this change
before th e new occlusion is finally estab lished by
permanent restorations. Du r ing th is time. the
occlusion can be modified by occlusal ad iustrnent
or by additio ns to the res torations .
l aboratory-made provision ol
restoratio ns
Some of the newer temporary crown and bridge
acrylics are capable of lasting in the mo uth lo ng
enough to functio n as provisio nal re st o ration s.
They can therefore be made at th e chairside by
the same techn iques as have been described for
temporary restoratio ns.
Alternatively. the teeth are pr epared. an
accurate impressio n ta ken and temporary
restorations made at the chair-side. The impres-
sion is then used to make heat -cured acry lic
restorations in the labo ratory, or sometime s a
simple casting is made to which acrylic or
composite is added (see Figure 11.9). The se will
!:an fo r six mo nth s or a year without serious
deterio ratio n. although they should be chec ked
periodically. particu larly for marginal leakage and
occlusal wear. wh ich will allow the prep ar ed
toot h to o ve r-erupt .
Cement ation of t emporary and
provisio nal crowns
The retentio n of the te mporary or provisional
restoratio n and the likely dislodging for ce s shou ld
be assessed and a cement of approp riate strength
selected. The follow ing list o f temporary ceme nts
and their appropriate use is arranged in ascend-
ing orde r of st rength:
129
• A non-setting mixtu re of petroleum jelly and zinc
oxide po wder - used for short periods between
appointments. for example. for cementing
temporary crowns when teeth are prepa red and
impre ssions taken in the mo ming and labo rato ry-
processed acry lic prov isional crowns fitted with
a st ronger cem ent in the afternoon
• T emporary cro wn and bridge cem ent with a
high pro portion of mo d ifier to red uce the
strength - used whe n several te mporary
crowns are jo ined together. giving co nsiderable
overall retention; this may be do ne even
thou gh the pe rman ent crowns will be separate
(see Figure 6.17)
• Unmod ified temporary cro wn and bridge
ce ment - used for individual complete crowns
t hat will have to stay in place for periods of up
to tw O to th ree wee ks
• Reinforced zinc o xide eugenol cement - used
when a stro nger cement is re quired. for
example. with partial cro wns o r when
co mplete crowns have to last for periods
longer than about t hree wee ks
• Po lycarboxylate and zinc phosphate cem ents -
used with poorly fi tting te mporary crowns. fo r
ex ample aluminium te mpo rary cro wns. o r
where the temporary crown has to last fo r an
extended period. for example labo ratory-made
provisional crowns fitted during perio ds of
orthodontic or periodonta l treatment.
After tem porary crowns have been ce me nted. it is
impo rtant that surplus cemen t is remo ved. o ther-
wise irritation of the gingival margin and plaque
retentio n will produce gingival inRammation.
Th e working impression
The working impression is the very accura t e
impression from which a cast with removable dies
is made . The cro wn is made on the rem ovable
die o f the prepared tooth. The imp ressio n should
include no t o nly an accurate impre ssio n of the
prepared tooth but also the ad jacent tee th so that
the contact points and occlusal surface s of the
crown may be contoured . It should also include
the remaining teeth in the arch so that the
working cast can be articulated against the oppos-
ing cast. Th is usually means that it sho uld be a futl
arch impressio n.
1]0
Impression materials (Figure 6.21 )
The re are two grou ps of ma te rials use d for
crown and br idge impressions: elast om eric
mate rials (sil ico ne. pclyet hcr Of polysulphidc (sec
Figure s 6.2 Ia,b and e» and reve rsible hydroco l-
loid (see Figure 6.2 1d). The elasto me nc materials
set by a che mical reaction when two mate rials.
usually two pastes, are mixe d to gether. The
reve rsible hydrocolloid is based o n agar agar. It is
me lted in a water bath and sets on cooling. The
teeth must be dry for elastc meric impressio ns.
but may be w et with r ever sible hydr oco llo id.
Silico ne impre ssion material s
The se ma.y be divided into tw o gro ups. The early
type of silicone material set by a condensat ion
rea ctio n. leaving a residual alco ho l by-pr oduct.
which evapo rate d fro m the imp ressio n, causing
shrinkage. The se earlie r co nde nsat io n silicones
sho uld not now be use d.
The seco nd grou p of silicone mate rials was
deve loped much later, and they set by an addition
react io n, leaving no vo latile end-pro duct. They
are very sta ble and can be kept fo r e xtended
periods before casting. It is safe to send th em
th ro ugh the po st.
Mo st manu facturers supply addmcn-cunng
silicones in a range o f five visco sities : putty, he avy-
body, regular, light-bod y and wash. This means
that a who le range of techniques is pos sible using
co mbinatio ns o f th ese mate rials with o r witho ut
special trays . light body mate rial is usua.lly
inserted into the mo uth fro m an aurcrmx gun (sec
Figure 6.2 If and g) and the medium or heavy body
either mixe d in a. second gun or o n a. pad. Putty
is kneeded by hand.
Th e material does not wet tooth pre par-atio ns
well. In co mpensation, it is ve ry clean to usc. Tox ic
and allerg ic reactio ns have not bee n reported.
The automix gun used with an e xtra fine no zzle
has several advantages in placing the light-body
materi al direct ly around the pre paration s (se c
Figure 6.21g). The mat erial is thoroughly mixed
without air bubb les. and t he mix is very fresh
when it is applied to th e tooth preparauo ns. W ith
light- and heavy-body mat erials mixed o n pads,
t he dental nur se usually mixes o ne material and
th e dent ist t he othe r. Timing of th e tw o mixes.
loading the syringe and then drying and iso lating
the preparatio ns requ ires very go o d timing, and
t he mixed, light- bod y material may start to set
befo re it is prop e rly in place. W ith the automix
system the de ntist matntams the prepared teeth
in a dry and isolate d state and starts to inject the
light-bo dy mater ial at the po int where t he nurse
is lo ading the tray.
P olyethe r impre ssion m ateria l
Polyether is conven ient since t he same materia l
may be used in the syringe and the tray. o nly o ne
mix being req uired, altho ugh light and heavy
viscosities ar e also available. It is also best used
in thick sections, and so should be use d in stoc k
trays: o r if a special tray is used. it sho uld be
made with extra t hick space be tween o ne st udy
cast and the tray.
An automatic mixing machine is available for
po lyethe r (see Figures 6.2 1h and i).
P olysulphid e impression material
This is rare ly used now. It is supplied in two
visco sities: light- and heavy-body . The hght-bod y
ma te rial is used in the syr inge and the heavy-bod y-,
material in the impression tray. The more visco us
heavy-body he lps to dr ive th e light-bod y material
into the details of the prepared tooth and into
the gingival crev ice. It sho uld be used in an unpe r-
forared rigid special t ray to achieve the maximum
pressure on the unset light- bo dy material.
Po lysulphide material has the advantage of a
lo nge r wo rking time than the o ther elastome ric
materia ls. but it also has a lo nger setting time . It
is a sticky material that wets the tooth prepara-
tion well and so adapts to it. but this stickiness
is a nuisance in ine xpe rie nced hands. The patient.
assistant. o pe rato r and surge ry can all end up in
a mes sy co ndit io n after attempt s at taking po lysul-
phide impressio ns. So me patients co mplain of t he
tast e and smell o f the ma terial; it is usually an
unappealing brown co lo ur .
Reversible hydrocollo id
This was available lo ng befo re the elasrom e nc
mate rials we re developed, and it largely fell into
disuse wit h the ir int rodu ctio n. Ho weve r. t here
has now be en a revival of int erest in the material.
It has the advan tage of be ing usable in a wet

enviro nment. The mate rial is relatively inexpen-
sive. alth ough the conditioning bath (a hea ted
water bath with t hree chambers) is cost ly and is
a necessary part of th e equipme nt. It is used in
special wat er-cooled tr ays.
The hydroc o llo id co ntains water th at evapo-
rates wh en the imp ressio n is stored. and so it has
to be cast almost immediately after it is taken.
There is also a reactio n with the artificial stone
used to make the w o rk ing cas t, and so the surface
of the hydroc o llo id impressio n must be condi-
tioned w ith potassi um su lphate before the cast is
made .
Impression techniques
Sin gle-stage t echnique (e.g. po lyether)
When a single-viscosity mate r ial is used. the
materi al is mixed, and part of it placed in an
impressio n syr inge and t he re mainde r in t he
impressio n tra y. usually a sto ck tray. Th e mat erial
is syringe d over th e d ry to o th prepa ra tion and
the tra y immedi ately sea ted in place . W ith a stock
tn.y that has no occlusal stops. it is important to
localize the tra y carefully and avoid sea ting it [00
far so that it does no t co ntact th e prepared
tooth.
Two-stage t echnique light- and he avy-b od y
mate rials (e.g. light- and heavy-body silico ne o r
hydr oco llo id)
Two sets of mat erial are mixed: a low-viscos-
ity material that is syringed around the prepara-
tions. and a hea vier -visco sity material used in the
impressio n tray and sea ted in the mo uth befo re
the hght-body mat erial has se t. The light-bo dy
material is th us for ced into intimate contact w ith
the preparation and gingival crevice.
A special tray with occlusal stops is usually
used with the etastomcnc mate rials. and occl usa l
stops arc sct into t he wat er-cooled t rays used for
hydrocolloid .
Putty and wash (e.g. silico ne)
This is a mod ification of th e tw o -stage t echn ique.
but in th is case a low- o r me dium- visco sity
material is used in the syr inge and a putty material
in the tray. Because of the viscosity of th e putty
III
mate rial. a stock tray is usu ally used. This
tech nique is the refo re popular be cause the co st
of a special tray is save d. T he ve ry th in wash
material does not w ork w e ll w ith thi s tech nique
since it t ends to dro p off the prepared teeth
befo re th e putty material can be seated.
Polymer materials
One disadvan tage of putty materials is that some
of the gloves w orn by de ntists react with th e
material and preve nt it se t ting. It is the refore
ofte n nece ssary for t he de ntist or nurs e w ho will
be mixing the putty mate rial to rem o ve their
gloves and was h their hands before mixing it. The
most convenient method is to use one o f the
polymer ma terials available in an auto mix gun.
An alternative technique is to tak e a put ty
impressio n before the to o th is prepared. Th is is
t hen trimme d to remo ve unde rcut areas and
es cap e channels are cu t in t he sides of the
impressio ns of all t he teeth . The impr ession is set
on o ne side while th e tooth is prepared. and it is
the n relined wit h a very light-bo died wash
material. which can also be syringed ro und the
tooth preparati on. The putty im pre ssio n is then
researcd in the mouth and in effect fo rm s a very
acc urate clo se -fitt ing special tray. T he co nsider-
able differen ce in the visco sities of the tw o
mate rials reduces t he r isk o f t he primary impr e s-
sion becoming d isto rted th ro ugh press ur es gen e r-
ated in t he resea nng.
Th is technique should no t be used wh e n t he
viscos ity of the two materials is close. In partic-
ular. an imp ression ta ken in any ru bber material
sho uld not be re lined with th e same material
once set witho ut exten sive mo dification to
re mov e all t he undercuts (sec Figure 6.22).
A var iatio n o n t his tech nique is to take a putty
impression with a spacer of flexible mate rial. For
exam ple. po lythene sh eet may be placed over the
unset putty mat erial before it is seated in the
mouth. This reduces the amo unt of modification
of the putty im pre ssio n.
Gingival retraction
The idea l is to start with gingival health and
supragingival crow n margins. G ingival ret ractio n is
no t the n needed. impression taki ng is easier and
more re liable. but most important ly. gingival
III

'.

Fi gure 6.2 1

Impre ssions for cro wns and bri dges in vario us materials.

c The imp ress ion of t he patient sho wn in Fig ur e 6.20

in ad dit ion _curing silico ne : light - an d heavy-body
techniqu e. F()l" me im pre ssion of th e post. th e light-
body materia l ;s spun do wn th e pos t ho le w ith a spiral
root canal paste fi ller. This is ro tated dun ng removal.
A thin reinfo rcing w ir e is ins erted to st iffe n th e tmpre s-
sion and pre ve nt it be nding wh e n t he die is cast .

b A differe nt brand of addi tion-cu r ing silico ne showing

t he impressio ns for tb e pa tient m Figure 6. I0,

c A n impr essio n in po lyethe r in a stock tray.

d Revers ib le hyd roc ollo id in a wat er cooled tray.

 e Para llel plastic impr essio n pins in place . Th ese will be
inco r po ra ted in a rubbe r impr ess io n. (Th is is t he
patie nt sho wn in Figure 12.9)

f An automix gun wit h a sta ndard no zzle adapted w ith

a fine curved tip for direct use in the mouth.

g The au[omix gu n be ing used in the mouth .

h A mixing machine fo r polyethc r impressio n ma te rial.

13<
health is easy for the pat ient to maintai n.
However, it is o fte n necessary to ret ract th e
gingival t issue s in order to o btain an im p re ss io n
of t he tooth surface beneat h t he gingival margin.
This will always be necessary if th e pr epa ratio n
i Material being de live red directly into a stock tn y.
Figure 6.22
Elasto meri c im pressions shou ld not be reli ned with a
furthe r mix of materia l once they are set unless all the
undercut areas are cut away.
o A preliminary im pressio n ukcn w ithout a spa cer .
b If t his impress ion is relined with a seco nd mi ~ of
material, disto rtio n will occur: the second layer of
mater ial in t he unde rcut areas of the unprepared teeth
w ill disto rt the o riginal mater ia! whil e it is in t he mouth.
When th e impression is removed th is will re turn to its
o r iginal shape. dist o rti ng the imprcs sioo of the
prepared tooth. For a tw o-stage te chn ique. a spacer of
polythene o r similar material sho uld be used.
Alter native ly the pr imary impressio n shou ld be Cut
back with a scalpe l o r bur s, and in parti cular all the
int erd enta l are as and impressio n of any undercut
surfaces rem oved.
ma rgi n is su bgingiva l. It will als o be desira ble if it
is dose to Dr at t he gingival m a rg in. This is
becau se th e crown co nto u r a t the periphery
sh o uld b e in lin e with t he tooth surface t o avoid
a p laque r e t e nti ve crevice at the m argi n. This can
Clinical tech niques for crown con5(rua jon
only be achieved if an imp res sion of th e tooth
surface is obtained for som e distance beyond t he
preparatio n margin.
There are fou r ways of retracting th e gingival
margins (in ascend ing o rd er o f destruct iveness ):
• Blowing the impress ion material into t he gingi-
val crevice with vigorou s blasts of air
• Tempo ra rily retracting the gingival margin with
co rd
• Using cords impregnated wit h chem icals
• Electrosurge ry.
Compre ssed a ir (see Figure 6.2 3a,b) W ith a
healthy gingival marg in undamag ed by th e prepa-
ration it is usually suffic ient to blow t he impres-
sion material int o t he crevice w ith air. Th is
tec hnique wor ks best w ith polysulphide impres-
sion mat erials and with so me silicones. Th e
viscosit y and wetti ng ability o f the material are
critical.
Cord and impregnated co rd (see Figure 6.23c)
If cord is to be used, it is usually impregnated
eithe r wit h adrenaline, which acts as a vasocon -
strictor assist ing in gingival retraction and in
arresting any minor gingival hae morrhage, or with
an astringent material such as aluminium trichlo-
ride, which func tions in a similar way. Ho wever,
some operators prefe r plain unim pregnated cord.
Cords are available in var io us t hicknesses, both
twisted and br aided. Braided co rds are prefer red
since they do no t unr avel wh ile t hey are bei ng
inse rt ed.
A cord of app rop riate d iameter is pressed lightly
into the gingival crevice wit h a suitable instr ument,
for exam ple a flat plast ic type or one of the spec ial
instrume nts designed for the purpose (see Figure
6.23d and e). It may not be necessary to retract
the gum all t he way ro und t he to o th if part of the
prep aration margin is sufficiently sup ragingival. The
cord is left in place fo r two o r t hree minutes and
the n removed before the impression is taken. If it
is left for too short a time, gingival retraction is
inadequa te; if it is left for too long, the chem icals
diffuse and becom e inactive. Too much force
shou ld not be used, or permanent damage to t he
gingival t issues may result .
It is po ssible to use a very th in cord pres sed
into th e base o f the gingival cre vice and a thicker
cord placed on top of it. On ly the th ick cord is
re moved before t he impression is taken. This
13'
techniqu e is not rec om me nded, since it can be
unnecessarily destruct ive. The cord, be ing inelas-
tic, often beco mes attached to t he rubber impres-
sio n, and may cause a distorted die to be made.
If t he re is e nough ro o m for two layers of cord in
the poc ket, pe rhaps the pat ient sho uld have
periodontal t reatment befo re permanent crow ns
are made!
Electrosurgery (see Figures 6.13 and 6.20a)
Electrosurge ry can be used to ar rest gingival
haem orrhage befor e impr ess ion taking and to
establish a distinct gingival cre vice, exposing ar
subgingival preparat ion margin. This technique
sho uld be rese rved for unus ual situations, for
example where a to oth has been fractu red with
t he fractu re line ex tending subgingivally and an
imp ression is re qu ired in order to ma ke a post
co re and diaphragm. Further gingival recontour-
ing may be carried out surgically once the crown
is fitte d if necessary.
Impress ion of pin holes
Tapered plastic pins are available that match the
size of standard tapered burs. These are inserted
into t he pinhole and become inco rpo rat ed into
the c1asto meric impression. T he problem is they
sometimes do n't - they eit her wedge in the
tapered pinho le and ar e left behind, or t hey fl o at
o ut during t he syri nging procedure and are lost
in t he bulk of t he impressio n. T hese tapered
plastic pins we re in fact produced to be inco rpo -
rated in direct wax patt erns made in the mouth.
They were no t int ende d orig inally fo r the indirect
technique, and so it is not surprising t hat these
problems arise. Th ey should no lo nge r be used.
Paralle l-side d pinho les avoid these problems.
Th e impre ssion pins are longer and it is eas ier to
syr inge impression material arou nd t hem witho ut
dislodging them. Plastic para llel pins have heads
t hat lock them into the impressio n material (see
Figu re 6.21e). Either a plastic pin 0. 1 mm smalle r
t han the ho le is used in t he wax patterns o r, if
t hese are not available, pinho les in the die may
be slightly enlarged by gently tu rn ing the twist
dr ill in t he ho le wit h t he fi ngers. The n pins t he
sam e size as t he impression pins can be used.
These burn o ut with t he wax so t hat the pin is
cast together with t he re st o f th e casti ng (see
Figure 6.24).
136 Clinical fechnlqun (or crown COllSfruaj"n

Figure 6.23

G ingival re tracti o n.

a A crown preparacon wit h th e mesial ITf.lIrgm level

with the gingival margin.

b The mesial-ging,val margin be ing retrac ted solely by

blowing air into th e gingiv:al crevice. With light-bodied
elasromenc imp ressiOfl mater ials dns is often all the
re t ract io n that is neede d.

c Gingival ret raction w ith adr enaline-impregnated

braided co rd. These are t he preparat ions shown in
Figure 6.9f. The palata l margins are supr agingival. and
gingival r et r action is on ly necessary o n th e buccal and
pr-oximal surfaces,

d An inst rume nt designe d to insert gingival re t ract io n

co rd.
 "7

e The inst ru ment in use.

IT
Figure 6.24

a A 0,7 mm diameter tw ist drill w ith tw o headed. burnout plastic pins.

These Ire also 0.7 mm diameter bu t w ill go into the d rilled pin holes
beca use . prepared freehand. the pin holes are always slightly larger than
th e dnll .

b The wo rk ing cast has been pou red and the impression pins remo ved
from the pin hol es. The y cannot. ho we ver , be reinserted as they are too
tight a fit. The pin ho le can be slightly enlarged by turning me d rill in the
pin ho le w Ith th e fingers so th at th e same size pl aSlic pinS can be used
as pa rt of th e pattern.
;us
138 Clinicol technique s (or crown construction

Figu re 6.25

Oc clusal rec or ds.

a A full arch w a lC oc clusal rec o rd mod ified by the

addit io n of a rapidly se tling teenpo ra ry crown and
br idge cement to the up pe r and lo wer surfaces. Note
that th e wax exte nds across the palate. suppo rting the
tw o sides .

b Excess cement is trimmed aw.l.y with a scalpe l so th at

when the usu are seated. very precise loc atio n of
the m with in the record can be see n. Note tha t this
pat ient has an anter ior open bote. mak ing loc ation of
the cas u Without an occl usal rec o rd difficult .

c Hard-setting li ne; ox ide occ lusal registra tion paste used on a

specially designed adju stable plast ic fra me with gauze mesh.

/
Occlus al record s
An occlusal re co rd is no t always necessary (see
Chapte r 4). In some cases an mter cuspal position
(lCP) reco rd is all that is require d. In ot he rs a
com binatio n of retruded contact positio n (Rep)
and left. right and protrusive excu rsion records,
toget he r with a facebow, may be needed.
The mcra-occfusal records may be tak en in a
polymer ma terial, in wax, o r a zinc oxide eugeno l
past e o n a suitab le frame.
In most cases the mo de rn po lymer mate rials,
delivered by means of an automix gun, are the
Il,
d and e W hen many or all o f the teeth are to be
pre pared . an acrylic re sin index rn.ay be used to record
t he OVO. In th is case th e teeth we re prepare d and 'C¥'g-
te rm pro visional resrc r-atro ns placed at a new increased
OVD, When t he patient ha d becom e accusto me d to
th is, the ante rior pr o visio nal re storatio ns were
re mo ved and an acrylic index made lO the height e sta b-
lished by the posterior prov isio nal r esto ratio ns. Then
these were removed and th e occlus al r elat ionships
reco rde d for the who le arch with zinc o xide eugeno l.
with t he acrylic index sti ll prese nt (e).
(A n elasrom e nc po lyme r occlusal record. This is
placed in the mouth by an aut omix gun as a wide strip
of mate rial laid o ver the lo we r tee th . The jaw is d o sed
into wh ichever positi on is being registered (eg ICP o r
RO' or a lat era l excu rsion r eco rd). The mat erial sets
qUickly to a firm but still elast ic co nsistency. It should
be t rimmed with a scalpel fo r the same reason
described in b abo ve .
mater ials of choi ce . So me of these guns have a
sha ped nozzle so tha t a flat. broa d band of
mat e rial can be laid directl y from th e gun ov e r
th e oc clusal su rfaces o f th e lo we r teeth.
If the aurormx mater ial is no t available . any of
th e elastorne ric impression mate rials ca n be used
to pr o duce o cclu sal reco rds. and there are fast-
setting rubb er mate rials spe cially pr oduced fo r
the purpose .
T he disadvantages of some of th e ol der
o cclusa l re gist ration polymers is that. being
rub ber. th e casts tend to spring out of it and have
to be held firm ly in place while be ing articulated .
140
Because of it s elasticity. t his o lder mat er ial is not
suitab le when all t he post er io r tee t h on on e side
have been prepa red o r are missing,
Wax occlusal records
Pink wax is softened in a nam e o r in ho t wa ter
and shaped to the approximate size of the study
cast. It is laid o n the lo we r teeth and th e jaw
d osed into th e requ ired position . The wa x is
allowed to cool or is chilled w ith wa ter and th en
removed .
Wax records are liable to distort and may need
to be readapte d. This may be done by th orough
cooling ou tsi de t he mouth and re lining w ith a
tem porary crown and bridge ceme nt (see Figure
6.25).
The pro blem with the wax re co rd is that f inn
pressur e is needed to seat the wo rking and
opposing ca sts int o it, and this can d ist o rt it.
particu larly if all t he teeth have been prepared or
are m issing o n o ne side of th e ar ch. Conve rsely,
knowing of th is risk , the technician may not press
the cas ts into th e reco rd firm ly enough, an d so
they are left sligh tly unsea ted. T hese problems
ca n be avoided if th e bucca l part o f the record is
cut away so that the fit o f the casts into the
record can be clearly seen (see Figure 6.25) .
Zinc oxide eugenol paste record
A special hard setting zinc o xide e ugenol o cclusa l
registration paste avoids some of the pr oblems of
w ax reco rds. It is spread o n to a gau ze mes h in
a plastic frame (see Figure 6.25). Th is do es no t
dist o rt, ca n be trimme d wit h a sca lpel o ut of the
mouth and resists firm pr essure in sea ting th e
casts . It is. howeve r, a rath e r t ime -co nsuming,
messy and expensive tech nique.
Trying-in the crown
Safety precautions
Small slippery objects like crowns t en d to slip o ut
o f the gloved finge rs. especially w hen wet. T hey
Clini<:al trc nniq"e s (or crown constru<:tion
are eve n mo re prone to slip o ut of tweez ers.
wh ich should ne ve r be used.
T he dangers of dropping a crow n down the
pat ient's thro at are o bvious. If it is inhaled , this is
a se rio us med ical emergency and the patient
should be rap idly inverted an d encouraged to
co ugh. If t his is no t successful, the patient should
be im me diately ta ke n to ho spita l for the crown
to be re mo ve d.
If th e crow n is swallowed, this is le ss danger-
o us - and also less dangerous than swallowing a
sharp instrume nt suc h as an e ndodontic file.
Howe ver , rad iographs sho uld usually be liken and
if possible th e cro wn recovered by the patie nt
w he n it is pass ed to reass ure the pa tie nt it has
passed safely. The patient should be advised to
use a sieve and ru nning water to find the crown
in the faeces. Figure 6.26 sho ws an abdominal
radiograph w ith a crown in the colon.
Various precautions are poss ible:
• W ith practice and exper ience it is possible to
contro l ev en sma ll inlays and crowns by
keep ing t he glove s dry and the tooth well
isolated and dry . One finger sho uld be kept
be hind t he crown at all t ime . A competent
denta l nurse w ith a w ide-bore high-vo lume
aspirator should be at th e ready.
• Ga uze o r sponge packs may be place d beh ind
the area where the crown is being tried in.
These are theore tica lly a go od idea, but with
so me patients the irr ita tio n at th e back of the
mouth make s them co nscio usly suppress the
cough reflex so that if a fore ign object dr ops
behind the pack . the risk o f it be ing inhaled
rath er than swallowed may be increased.
• The pat ient may have treatment in an upright
pos itio n and be told to lean forwa rd, if the
crow n dro ps. an d cough it o ut.
• In some cas es it is advisable to try-in crowns
under ru bber dam , but it is difficult to assess
t he margins if clamps arc used, and impo ssible
to judge the gingival relatio nship or occlusion.
The checking procedure
As pointed o ut in C hapter 5. a gold crown is t ried
in. adjusted if necessary and the n ce mented.
A conve nt ional PJC is tried-in w ith its platinum
foil in place. ad just ed, sta ined and reglazed if
Cltn>col Ier:hm(jlle$ (or crown conSlrlletion
CROW N
J
•
.,.
necessary. and t he n t he foi l is re mo ved be fore t he
crown is ce me nted.
The metal part o f a metal-ceram ic c ro w n may
be tr ied-in before th e porcelain is added a nd then
returned to the labora tory an d re tried w ith t he
por-celain before being finally ce mented.
At the try-in sta ge the following c hecks sho uld
be made . together w ith a ny ne ce ssa ry adjust-
menu.
141
figure 6.26
A cro wn t hat has bee n swallowed at the try ·in stage.
It is now at t he top of the descending colon. and was
passed 24 hou rs after this radiograph was taken. It "Yas
recovered. sterilized and cement ed.
figure 6.2 7
o A cro wn with a large positive ledge or overhang.
This shou ld not be cemente d in this condition. The
distal margin is a bet ter fit. but the surface is bulbous
and overcontoured. encroa ching on the embrasure
space. Co mpare the contour of the dista l surface of the
cro wn with the mesial surface of the tooth behind.
b A negative ledge or sho rt crown margin. There is no
gap. All the oth er r estcra tlo n margins on this radio-
graph are also overhang ing or defect ive in some way.
Checking an d ad jus t ing the fit
The ma rginal fit is chec ked by eye and w ith a
sharp probe. Ga ps . overha nging margi ns (positive
ledges) and de ficie nc ies (negativ e led ges) ma y be
present (see Fi&\Jre 6.27) .
A unifo rm ga p al! th e w ay round indic at es t hat
t he crown is no t fully se ated . Having c he cked fo r
r etained tem po ra ry ceme nt o r t ra ppe d gingival
,<2
Im p re s si on
t issue, a firmer seating force should be applied.
and jf the gap persists. the contac t points should
be ch ecke d. If, aft e r any necessary ad jus tment to
th e se. th e crown still do e s not se at, it sh o uld be
remo ved and the fit surface ins pected. If it is
metal, burnish marks on the ax ial walls may
show whe re the crown is binding. These are
ground tightly w ith a bur o r stone and t he cro wn
retried.
If there is some im pro ve me nt but not complete
se ating . the fit surface sho uld be lightly sand-
blasted and resca led. If no burnish marks appear,
it is likely that the margins or occlusal surface are
preventing co mplete seati ng. A common cause is
a slightly o vertrim med die (see Rgure 6.28). If the
occlusal surface is s uspected. disclosing wax (a
ve ry soft w ax) is melted into the crown, wh ich is
sea ted before the wa x se ts. W he n the crown is
removed. high Spots will show as perforations of
th e o paq ue wall.
Fine powder suspens ion s in ae roso l sprays o r
painted colloida l graphite are also used t o show
wh ere t ight crowns ar e bind ing. but they a re very
unt idy ma te ria ls.
If th e re is a gap a ro un d only one part of th e
crow n, it ma y be seat ing une ve nly because of a
tight contact point; otherwi se the impression or
die may have been distorted.
A positive ledge s hould be adjusted until th e
probe passes smoo th ly fro m tooth to crow n
w it hou t a catch. A negat ive ledge is a bigger
problem an d o fte n means th at th e cro w n has to
be re mad e.
A e re made for a ve ry parallel-sided pre pa ra-
tio n may no t seat fully with o ut forc es bei ng
ClmK:al !«hni<lu ~5 far crown COnllruClion
O ve rt rim med
Tooth
Appears to lit
Figure 6.28
A common cause of crowns not seating. The impres-
sion clearly shows the margin of the prepara tion but
doe s not extend very far beyond it. It is often more
difficult to distinguish the margin on the sto ne die than
on the impre ssion . particularly when dust from the
trimming o bscures vision. This leads to an overtri mmed
die. To be on the 'safe side', the technician extends the
cro wn beyond the margin. produc ing a bevel. This fits
the die well. but when tr ied in the mou th the tiny bevel
perches on to p of the prepared margin. preventing the
crown from fully seating. It may appear to fi t in the
overtrimmed are a. but a gap will be presen t elsewhere
applied that w ould risk th e c rown being fract ured .
If the shade and o the r aspects of the crown are
satisfactory, t he platinum fo il sho uld be removed.
and th e c row n will usually the n se at co mpletely.
Checking retention
A c ro wn should not feel tight. A c ro wn for a long
preparat io n w ith o ptimum taper. w hich w ill have
ex cellent rete ntio n when cemented. may simply
dro p off the preparation w hen tried in. A feeling
ClifUc;ol t~dlniqu ~1 (or crown construction
of tightn ess is th e result of unnecessary rough-
ness of the preparation or a cast ing that has bee n
distorted. Tight ness o f fit is no t a re liable test o f
retent io n. and t ight cro wns may be more difficult
to cement. result ing in an o pen margin.
The crow n sho uld be tested fo r a tende ncy to
tilt o r pivot w hen rocked fro m side to side .
Tilting o f t he preparation clearly reveals an
uoretenuve des ign. Small pivoting movem en ts
show th at the crown is not fully seated and is
rocking abo ut th e co ntact points o r on high spots
on the fit surface - in wh ich case the margins
should be chec ked again. Alternatively. there is
too much spa ce betw een the crow n and the
tooth. This may be due to the ex ce ssive use of
die re lief (a varnish spacer painted o n to the die.
avolding t he margi ns). a po orly adapted plat inum
foil. an over-e xpanded casti ng o r o ne that has had
its fit surface ground.
Che<king and adjustin g contact poin ts and
axial co n tou rs
Dental fl oss sho uld be used to check t hat the
contact points are neither too tight no r too slack.
Tight co ntacts can be lightly ground a littl e at a
time and polished; any deficiency in porcelain
should have more porce lain added.
Buccal and lingual contours should no t be too
bulbous, the marginal area sho uld be in line with
the toot h suffic e to red uce plaqu e retenti on an d
the surface sho uld lo o k natural. Again. adjust-
-
Figure 6.29
A pair of callipers which magnify 1;1 0 being used [ 0 ·
measure [he thickness of me occlusal surface of a metal
cera mic crown. h: is about I mm mick at this point.
mems may be mad e by removing o r adding
materials and repolishing or glazing.
Che cking and adjusting the shade
Shades that are slightly to o tight (th e chroma too
low) can be dar kened by adding sta in of appro-
pr iate colo ur and refiring. Stain can also be used
to add missing characte rist ics such as crack lines
o r mottled areas . However. if [he basic hue is
wrong or the chroma too dark. o r the fault lies
in the co lo ur o f the opaque co re material o r t he
'dentine' porcelain, it is o ften no t po ssible to
chang e the shade sufficiently . The crown has to
be remade if it is a PJC o r the porcelain re moved
and repl aced if it is a metat-cerarmc cro wn.
Checking and adjusting the occl usi o n
See Ch apter -4 fo r details o f occl usal adjustments.
If reduction is nec essary, t he thicknes s of the
o cclusal surface should be checked with magnify-
ing callipe rs (see Figure 6.29 ).
C ementation
When all the chec ks and adjust me nts are
complete . the cro wn is permanently cement ed .
144
Choice of cements
Th e ra nge o f ceme nts used for permanent cemen-
tatio n include:
• G lass ia nomer ceme nt
• Z inc phosphate ce ment
• Resin-based adhes ive ce ments
• Pclycarbcxylaee cement.
G la ss ionomer ce m ents
Glass tonomer luting cements have now been
available for lo ng enough for on e t o be able to
say t hat they are a go o d cho ice for many crow ns.
Glass ian om er cem en t adh eres to dent ine and
enamel, it has a Jow sol ubility, it leaches fluo ride
an d is relatively non-irr itan t to the pulp.
Z inc phosphate ce ment
Zinc phosphate has bee n in use as a luting cem ent
fo r much longer than all t he others. Although its
acidity must be irrita nt to t he pulp. literally millions
of cro w ns have been cemented with it, wit h a very
low pro portion of clinically detectable ill-effects.
Patients som etimes com plain of transi en t discom -
fo rt w he n the ce ment is setting if a lo cal anaestheti c
is no t used, but mo st patients nee d a local anaes-
thetic fo r cro w n ce me ntatio n anyway and so t his is
not a major problem. However, the irritant nature
of t he ce me nt remains an anxiety. The pulps of
some teeth fitted w ith crowns do become inflamed
and eventually necrotic. This also happen s occasion-
ally w ith oth er ceme nts, and it is difficult to ident ify
t he ca use of pulp deat h. Was it the ceme nt, the
effects of prepar ing th e tooth, o r th e o riginal condi-
tio n for wh ich a crow n w as necessary? .
Z inc phosphate has tw o majo r advanta ges
which probab ly account for its cont inued popular-
ity . It has a long, co ntro llable working time and it
prod uces the thinnest ceme nt fil m, whi ch can be
as little as 10 IJ m. Of cours e, this is still te n times
the diameter of t he micro- organisms th at lodge at
the pe riph ery o f t he ce me nt film to fo rm plaque.
Res in-based and ad he sive cements
A variety of resin-based luting materials are now
available. T hey are still not commo nly used with
co nventio nal cro wns fo r a number of reason s. First
the truly adhesive cemen ts co ntaining either 4-
META o r a phospho nate derivative are inhibited
Clinical tech niques (or crown constrllClioll
from setting by the presence of oxygen. The marg ins
of th e restoration therefore have to be coated with
an aqueous jelly material until th e ce ment sets, and
th en cleaning up the surplus cement is difficult. A
second rea son is that, although they are initially
more adhesive tha n the established luting cements,
they have not been used for long enough fo r one
to be sure of their long-term success .
Therefore the resin-based and adhesive
ceme nts ar e used for luting porcelain veneers and
m inimu m-prepar at io n bridges (see C hapte r 8),
but are not yet recomm ended for cementing
co nventio nal crow ns, alt hough t his advice may
change in th e future.
Polycarboxylate cement
This has a re latively low co mpressive strength and
high ce me nt-film th ickness. It also absorbs water
to a greater extent .
De spite a lo w pH w hen set, it is less irritant
t ha n zinc phosphate ce men t and adh eres to
enam el and to a lesse r extent to dentine.
However, its disadvantages probably o utw eigh its
advantages , and it is not use d by t he majority of
dentists .
Cementation technique
Preparing t he crown
T he cro wn should be completely cleane d of all
t races of polish, disclo sing wax, saliva and so o n.
Th is is best done in an ultrasonic clean ing bath,
o r if th is is not available by scrubbing with a
toothbrush and deterge nt. The crow n shoul d be
tho ro ughly d ried with tissues and blasts of air.
Preparing the too t h
The toot h should be thoroughly washed with
wa ter spray and gently dried with air; it should
not be overd rie d, since thi s may damage the pulp
by desiccation. The wash ing an d drying shou ld be
left until t he last m inute to avoid conta minat ion
of th e surface by saliva o r gingival exudate.
Mixing and applying the cement
The ce ment shoul d be mixed according to the
manufactu rer's inst ructio ns. Glass ionom er
Gnlcal redloiques for crown constrocvon
cement is mixed by incorporating powder into
waler o n a glass slab o r paper pad, o r enca psu·
bled vers ions are mixed mec hanically. In th e case
of zinc phosphate ce me nt, slow mixing of small
increment s of powder on a cool glass slab, over
a wide area, will increa se t he wo rking and sett ing
time. This will also allow the pH to rise a little
before the ce me nt is applied to the tooth.
The cem ent is applied t o the hollow part. W ith
a com plete crown this is the fit surface of the
cro wn, while with a pin it is the pinhole in the
tooth. When the opposite member is inserted
into the hollow, the cement coa ts it and is
extruded from th e margins. If the o t he r surface
is coate d wi th ce me nt, for exam ple th e tooth
preparatio n for a co mplete crown, it may be
scraped off t he surface when the crown is seate d,
and part of t he surface left bar e of ce ment .
The walls of a post hole may be coa ted using
a rotary paste fi ller o r re amer.
Nothing is gained by coating both surfaces.
Time is lost. so that the cement becomes mo re
viscous by the time the crown is seated, result-
iog in a thicke r cement layer. Only if both parts
have hollow features, such as in a complete
crown prepa ration with add itional pin retention,
should both surfaces be co ate d.
The entire surface should be coated quickly with
plenty of surplus cement. Any benefit t hat might
be gained by applying a th in, even coot of cement
is lost th rough the extra time taken to achieve this.
Inserting the cro w n
The crown should be sea ted quickly and pressed
home with finn , co ntinuous forc e to extrude all
the excess ce ment from the margins. ' The
pressure may be applied by t he operator o r by
the patient biting o n a suitable prop. such as a
cotto n wool roll. Press ure should be maintained
and t he are a kept dry with cotton rolls o r
absorbe nt pads and aspirat ion until the cement
has set. Excess ce ment is also left unt il the set is
complete and it is then re mo ved.
Burnishing crown margins
finely beve lled gold crown margins may be
burnishe d and so distorted to provide a close fit
at the margin. The value of this procedure is
doubtful for a number of reasons: the dist o rtion
t-
may prod uce a plaque re t entive gr oove at the
margin: the sites where burnish ing may be most
valuable since they are the least accessible for
oral hygiene procedures ar e also the least acces-
sible for burn ishing (fo r exampl e inte rproximal
areas): th e harde r mode rn cast ing alloys. includ-
ing many metal-ceramic alloys, canno t be
burnished successfully: and finally, moder n
impres sio n and cast ing te chniques are very
accu rate. so that the benefits of burnishing are
less than they were at one time.
If margins are burnished nevertheless, this
should be done while the cement is setting. If
do ne beforehand, t he tighdy adapted margins
wo uld prevent the escape of ce ment unless a vent
(o r hole) were prepar ed in th e occlusa l surface
of th e crown. If burnishing we re to be done after
the ce me nt had set, t he ce ment at the margin
would be cr ushed and leakage would follow.
Ora l hy gien e in struction a nd
m aint en ance by t he pa t ien t
A fi nal and impo rta nt stage is to teac h th e patie nt
how to clean and maintain the crown, and in
parti cular how to clean the marginal area. Dental
floss and an appropri ate toothbru sh technique
shou ld be advised.
Some patients already have exce llent o ral
hygie ne. and too much emphasis o n the impor-
ta nce of cleaning around the crowned tooth may
result in ove r-enthusiastic cleaning. causing
damage to the gingival tissues o r to the tooth.
Recall , a sse ss ment, maintenance
an d r epair
Asses sment
A systema tic assessme nt of all crowns shoul d be
made at each recall examinatio n. This should
include evaluation of the following:
Ora l hygiene
Plaque leve ls and gingival inflammation around the
cr ow n should be compa re d with similar te eth
 l~
'" a no::01 (or Clown consUUetron

elsewhere in the mo uth . If the crowned tooth is A ppea rance

worse. th e reaso n should be investigated and
The appearance o f the crown or th e adjacent
dealt w ith. In any case, when it is present
teeth may have alte red since it was fitted. Any
pe riodonta l disease should be treated.
change should be asses sed as acceptable or
unacceptable. In the latt er case the crown will
usually have to be rep lace d: apart fro m grinding.
Margins litt le ca n be done to alter the cr ow n's appearance
o nce it is cemented.
The crown margins shou ld be exam ined for
po sitive and negative ledges and gaps. and prepa-
rati on margins should be examined for seco ndary
carie s and signs o f abrasive w ea r.
Adjustments and repairs to crowns in
situ
Structure of the crown
These are dealt with in C hap te r 13, together with
This should be exa mined for fractures and wear, br idges .
including occl usal perforati on s.

Practical points • The wo rk ing im pre ssio n sho uld include an

accurate impression of both the contact poi nts
• Good records in the form of st udy casts an d and occlusa l surfaces o f the ad jace nt teeth as
photographs before prepar at io n are useful for w ell as th e prepared too th itself and the
plan ning and later referen ce. rem aining t eeth in the arch.

• Examine the whole mouth and use differe nt • Good te mpo ra ry cro w ns are necessa ry to
lighting conditions when selecting t he shade for pro tect th e pre pared to oth and to prevent
the crown. to oth movem ent.

• Prepare each tooth surface in tum so th at the • Special care is need ed w he n tryi ng in the
a.mount of red uction can be controlled; the cro w n to avo id the risk of losing it do w n the
order depends on individual circum stances. patient'S th roat.

• G ross re duction, at least, m ust be completed • After cemen tation, car eful instruction to the
in on e visit and a t emporary cro w n fitted. patient on o ra l hygiene and maintenance is of
paramount impo rta nce.
Pa r t 2 Bridges
 7 Indications for
bridges compared
with partial
dentures and
implant-retained
prostheses
Although the number of cr owns made in the UK
Natio nal Health Service mo re tha n doubled in the
decade between 1980 and 1990 (see Chapter I).
the number of bridges increa sed nea rly twenty-
Iold in the same period. Figur es for bridges made
under private contract arc not available. but it
seems almost certain that the increase Ius been
of similar magnitude. Large increases ar e also
report ed in many o the r co untries.
It can be assumed that this dramatic change is
the res ult of a numbe r of factors: a general
growth in de ntal awareness and expectation.
changes in unde rgr adu ate an d postgraduate de nta l
educatio n, and the intro duct io n o f new. simpler
techniques and mate rials. Many patients reject the
idea of wearin g partia l den tu res. and the demand
for bridges. des pite t he high cos t, is likely t o rise.
Gener a l t erminology
The termino logy used in bridgewo rk is sometimes
rather loosely applied, and in differen t parts of t he
world the same terms are used to desc ribe differ-
ent th ings. The wo rd 'bridge ' itse lf is use d in the
UK to desc ribe a fixed appliance o nly, whereas in
parts of the wo rld it also includes ce rtain tooth-
borne removable appliances .
The follo.....ing names will be used for the
vario us appliances . The terms in parentheses ar e
those co mmonly used in th e USA. although
American terminology is rath er variable.
• A bridge (fixed partial denture ) is an appliance
replacing one or more teeth that cannot be
re mo ved by the patient (see Figure 7.la). The
general term 'fixed bridge' is avo ided since it
implies o ne of the specific designs of bridge
(see Chapter 8). Substantial tooth preparation
is nec essary for a conventiona l bridge . The
br idge usually occupies no mo re space than the
original de nt ition.
• A m inimal-preparation bridge (resin-
bonded bridge, adhesive br idge, Maryland
br idge) is attached to the surface of minimally
prepared (o r unpre pare d) nat ura l teet h and
therefo re occ upies more space t han the origi-
nal de ntitio n (see Figure 7.1b).
• A removable bridge is ver y much th e same
as a br idge in t hat It is reta ined by cro wns, is
enti re ly tooth-suppo rted, does not replace soft
tissue, and, unless it is examined closely,
appears to be the same as a bridge. Howeve r,
it can be re moved by the patient (see Figure
7.2).
• A precision-attachment partial d enture is
re ta ined by proprietary attachme nts and is
removable by the patient. Soft-tissue elements
are replaced and the appliance usually has
structures that pass across the o ral tissues, for
ISO

Figure 7.1
Bridges.
o A c.o rweouonal bridge repla cing the upper righ t
late ral incisor wit h a single ar tificial premolar tooth
filling the space be tween the canine and first mo lar
teem . The bridge has just been cemented. T he gingival
con dit ion aro und the mo lar abutme nt is good. but
arou nd the canine it is inflamed buccally as a resu lt of
irr it at io n fr om a bro ke n t e m po rary bridge in this area,

b A minimal-prepara t ion br idge atta ched to the surface

of the la te ra l inciso r and second premo lar , with a single
a~lr,cia' t ooth filling the space be tween rhrs . This filled-
fixed des ign is new less popula r (see page 175).

Figure 7.2

A re m ovable bridge.

a Ca St copings permanent ly cemented to the remai n-

il'lg teeth. T he external surfaces of these arc milled
para llel t o each other in th e labora tory.

b The remova ble bridg e. w hic h the pat ient can take
out himse lf.

example ac ross the palate o r around the lingual
alveolus. N atura l teet h ha ve to be prepared
and cro wns or o the r restoratio ns made fo r
them. inco rp orating part of the pr ecision
attachm e nt (see Figure 7.3 a).
• A partial denture may be rested entirely on
teeth, o r be support ed by the soft tissues. o r
by a co mbination of these two . Rest seats are
commo nly used, but otherwise it is usu ally no r
necessary to prepare the natural teeth ex te n-
sively. Part ial dentures arc re taine d by clasps.
by adhesion to t he soft tissues. or by dental o r
soft tissue unde rc uts (sec Figure 7.J b).
• An implant-retain e d p rosthesis is o ne
reta ined by osscointegra tcd imp lants (see
Figure 7.4a). A single implant may support a
single to oth prosthes is (see Figure 7Ab,t and
'"
Fig u r e 7.3
Part ial de ntures.
o A precision -attac hme nt retamed partial dent ure. III
this case the t wo premolar te eth on the right of the
picture are splinted togethe r and an intra-coronal
precision at tachme nt is inco rpo rated into the distal
surface of the second pre molar. The fir-it molar on the
left is an art ,f,cial tooth - part of a bridge - and it too
co ntains a precmoo attachment . The partial demure
retained by e-cse two atta chments can be remo ved by
the patie nt.
b A con vc ntronal cc bah-cbrcrmum partial uppe r
dentur e t hat is tooth-supported with rests, clasps and
a majo r palatal co nnector. No ne of the metal work is
visible fro m the front of the mout h.
d ) o r a series of imp lants may support a
prosthes is replacing a nu mber of teeth. T his is
usu ally known as an im plant-suppo rt e d bridge .
Th e patient ca nnot re move it, but in som e
ca ses the de nt ist ca n, by un doi ng t he sc re ws
ho lding the prosth es is to the implants (see
Figure 7.4e,f an d g). Implant s upported bridges
may be small, replacing o nly one or two teeth.
o r ma y be la rge r. includ ing replacing a ll th e
teet h mone a rch . Implants may also be used
to s upport a bar (or o t he r attach men ts) on to
whlch a remo vab le complete o ve rde nrure can
be dipped. Overdentures are beyond the scope
of t his book.
T he term 'fo c rure' is some times used to
des cribe t he osseointegrated part of t he implant ,
 p

'"

Figure 7.4

(I A cross section th rough 01. typical implant- Systems vary and so this
one wi ll not be described in deu.it but it is typ ial in h.lving tOW'
e leme nts: from the top down t he coa rs ely threade d screw is tilt
fixture which is screwed into a tapped ho le in the bone and then
( o vered to o ssecm tegrate: the e-a nsmuco sat abutment is smooth sided
and retai ned into the oss eointegrated fixture by t he middle sized
screw; the small screw at the bo ttom holds the prosthetic ele ments
to the fixtu re . T he re are now a wid e range o f pro sthet ic elements
wh ich will no t be desc ribed here.

b. c and d A single tooth en plant re placing the upper

right lat eral inciso r.
b Shows the stage aee- the second surgical procedure
to ex pos e the l'ixture and to place the hea.ling abutment
The hea ling abutmen t is in place and the incision line
mesial and distal to it can still be see n.

c The healing abutment has been rep laced by the trows-

mucosal abutment (TMA).
 IS)

d A crown has been fitt ed to the TNA.

e Fo ur fixtures in t he lo wer jaw.

( A three unit 'bri dge' has been attached to the th r ee

implants on th e left and on the right. a th r ee unit
can tilever bridg e retaine d by th e nat ural canine tooth
and the implant has been extended w ith a canti leve r
premolar pontic.

g A t h, "e unit bridge re tained by two fixtures showing

the sc rews wh ich can be undon e if necessary by t he
de ntist. Th e se are cove re d wit h co mposite unt il it is
necessary to gain access to t he screws.
'5' Indi<:otiom (or brPdg<'s r om por l"d woth pamo! d.... r"'es and impJanl-,..lOjnW Jlflnll>eses
but is also so metimes used to descri be the w hol e
im plant assem bly. It is helpful to usc the follow -
ing terms:
• F ixture to describe th e part that osseoinre-
grates and tha t is buried beneath the gingival
tissues (in mo st syst ems) fo r a perio d of
months before e xposing it dod inserting the
• Transmu co sa l ab u t ment (TMA), which is
the part o f the implant that at taches to the
fixtu re and passes th ro ugh th e gingival tissues
t o the mou th. To this. is attached the
• P rosthe si s, whi ch replace s the m issing too th
o r teeth.
G eneral a d van t a ge s and
disadvant age s of replacing missing
teet h
It is not always nec essary to replace miss ing
teeth, and in some cases there are positive disad-
vantages in doing so. At one tim e there was a
rat he r naive, simplistic view tha t the mouth was
a 'function ing mac hine ' and that if part of it was
missing, it was rather like a tooth or t eeth missing
fro m a cogwheel in a piece of mach inery such as
a ca r gea rbox. Th is is no t t he case beca use the
human body is much more adaptable and flexib le
than mac hinery engineere d by man . In fact there
is reaso nably good evidence that, with a modern
diet. it is perfectly possible to function with no
mo lar teeth at all provided the fi rst and second
premola r teeth and inciso rs are all present in the
uppe r and lower jaws and are in good occl usa l
contact. Despite this eviden ce, many patie nts
would prefer to have at least some of th e ir
missing t ee th replaced . It is the dent ist's role, as
a professio nal adv ise r, to adv ise t he pat ient
w het her o r no t it is re ally in thei r bes t inte res t
to have a tooth o r teet h rep laced. In som e cases
it is wise for a de nt ist to refuse to repl ace missing
teet h, particularly by means t hat are likely to give
rise to problems elsewhere in the mouth, o r if
the prosthesis has a poor prognosis, e ven if the
patient attempts to insist that a re placement
sho uld be made. This is primarily for the patient's
be nefit but also fo r me dentist's. There have been
a num be r of de nto-legal cases in which dentists
have been success fully sued (or mak Ing pro sthe-
se s. particularly bridges and implant -retained
prostheses . wh en it was against th e de ntist's
better judgement and the prosthes is has subse-
quently failed.
The first big decision that th erefo re m ust be
made jo intly by the dentist and patient is 'should
the missing toothlt eeth be repl aced o r no r"
It is necessary for both th e dentist and the
patient - and in so me cases a third party f man-
cially involved with the transactio n - to be
co nvinced that the replacement will pro duce
significantly more ben efit tha n harm. The follow-
ing questions mu st be asked:
How will the patient's ge ne ral o r de ntal well-
being be impro ved by the re placeme nt!
- W hat disadvantages will the replacement
bri ng with it?
- What is the rauo of these advantages and
d isadvantages?
2 If the balance is st ro ngly in favo ur of replace-
ment. should the re placement be by means ot
A br idge
A remo vable bridge
A precisio n-attac hmen t partial de nt ure
A partial de nt ure
An implant-retained prosthesis
(O f t hese, a bridge o r a partial denture arc by
far t he most common.)
Advant ages o f re placing m issing teeth
A ppearance
For ma ny pati ents with t eeth missing in the
anterio r part o f the mouth , appearance is an
overriding consideration , For th em a replacement
is ce rta inly necessary. Just as with cro w ns, it is
also necessary to judge t he appeara nce of gaps
further back in the mo uth , taking account of the
anato my and mo vement o f the pat ient's mou th.
Occlusal s t a b ilit y
This was discussed in Chapter 4: and it was also
made clear that in many cases. although occlusal
sta bility is lost initially when teeth are ext racted.
tilting and over-e rupno n usually event ually lead to
art occlusal relatio nsh ip that. although It may not be
.<.atisfacto ry and may co ntain o cclcsat interferenc es,
 Jnd"arjons (or brjdges compared with puniol dentures ond impla"t-retojned prostlieses
is nevertheless stable. If the missing te eth can be
replace d before t he toot h mo ve me nts o ccur and
when tooth mo ve me nts are like ly, th is may well be
suffi cie nt justification fo r t he replacement. In many
cases, however, t he patient is fi rst see n some years
after t he extract io n and has a new stable relation-
ship. A re placeme nt for t he miss ing teeth would
not improve t he stability a nd so is not justified (see
Figure 7. 15). Spec ial occlusa l co nside ra tions are
discusse d unde r o rthodo ntic re te ntio n and alte r-
atio ns to th e a VD.
Ability t o eat
Many pati e nt s ma nage to eat q uite successfully
wit h large numbe rs of teeth m issing. Pat ients with
no lo we r mo lar teeth who are fitted w it h well-
des igned a nd well-constr ucted pa rtia l lo w e r
dent ures freq uentl y leave th em o ut be cau se the y
cla im th at it is easier to ea t w it hout them. So me
patie nts, t ho ugh, have a ge nuine and pe rs iste nt
fee ling of aw kwa rdness if t hey are de prived of
eve n o ne po s te rio r to o t h. As wi t h appearance,
the patient 's co nce pt of t he pro ble m is as imp or-
tant in deciding o n a replacement as t he probie m
itse lf. Gc ne raily th o ugh, th e more tee t h t hat ar e
missing, t he mo re importa nt is a rep lacement.
ISS
Figure 7.5
Q A 12-unit bridge supported by 6 teeth with cons id-
erably reduced periodontal support. Several teeth were
uncomfortably mobile before the prov isional bridge
was fitted . The patient was able to maintain good or al
hygiene following per iodontal therapy, and t he provi-
sio nal br idge was re placed after a year by th is pe rma-
nent bridge. which has now been in place fo r 12 years.
The patient understood the reasons for the visible
supragingival margins and accepted them .
b Radiographs of the th ree abut me nt teet h on t he left-
hand side fo r the pat ient sho wn in Q .
Other advantages
T he three ad va ntages listed abo ve are by far the
mo st co mmo n indicatio ns fo r re placing missing
teeth . T he following, though less commo n, can be
e xt re me ly impo rta nt fo r individ ua l pat ien ts ;
S p e e c h Pat ie nts conce rn e d about t he qu alit y of
t hei r spe ech a rc us uaily also co nce rned about
t he ir appe a ra nce . The uppe r incisor teeth a re th e
mo st imp o rtant in modifying s peech, a nd so wh e n
t he y arc missing th ey wi ll usually be replaced to
impro ve bo t h speech a nd appe a rance .
Per io d o n t a l s p lin t in g Fo llo w ing t he suc cess-
ful t re atme nt of ad vanced pe riodontal diseas e, it
may be necessa r y to splint un co mfortabl y mobile
tee t h. In o rder to produ ce a cross-a rch splinting
effe ct it is ne cessa ry to bridge a ny ga ps to pr o vide
a continuo us spl int - w he t he r or not t he re arc
a ny other indicatio ns fo r rep lac ing t he missing
t ee t h (see figu re 7.5 ).
A fe el in g o f ' co m pl e te n e ss ' So m e pa tients
be lie ve, or have been told, that there is a major
disad va ntage to having tee t h m issing, even w he n
t he y have no pro ble ms of appearance, o ccl usal
sta bilit y or w ith eating. T hese patients app ear to
156
receive considerable comfort from a bridge - less
from a re movable app liance. T his fee ling should
no t be disco unted if it is held with co nvict io n.
eve n thou gh the de ntist may no t be equally
co nvince d of the bene fits of a bridge. However,
such atti tudes should no t be enco uraged.
O r thodont ic retention Most ort ho do ntic
treatm ent is sta ble. but it is occasionally neces-
sary to provide a bridge partly to maintain an
o rthodontic result. A co mmon exa mple is in
cases where the lat era l inciso rs are congenita lly
missing and the upper canines have been
retracted to recreate space for them. The main
reason fo r replacing the missing lateral incisors is,
of course, appearance, but a second reason is to
prevent the canine teeth re lapsing forwards again.
and so the bridges must be designed to serve th is
purpose . T he resulting appearance .is usually
be tter than atte mpts at co nverting the appe ar-
ance o f t he canines to lateral inciso rs.
Another exam ple is in pat ien ts with cleft
palates who have been treated ortho do ntically as
well as surgically (see Figure 7,6).
O rt ho do ntic retentio n is a specia l example o f
an indicatio n for tooth re placem e nt for reason s
of occlusal stabi lity. In almo st all patients who
have taken the trouble to have orthodontic treat-
ment, appearance will also be important.
Re s co ring occlusal verti cal d imensio n
Occl usal collapse with exc ess ive wea r o r drifting
o f the inciso r teeth some times follo ws the lo ss of
a num ber o f pos te rio r tee th. This is a difficult
Figure 7.6
A sorgically repaired cleft lip and palate with missing
lateral incisor. The palatal gingival inflammation ii
exacerbated by the temporary denture - an addltlonll
indication for a bridge. Oth er indications. as well as
improving the appearance by replacing the Iacenl
incisor, are to change the shape of the central incisor
and stabilize the relationship of the abutment teeth
either side of the cleft.
problem to creal. but in some cases the peste-
rior teeth are replaced by bri dges or re movable
de ntures th at no t o nly replace the missing teeth
but resto re the lost occlusal ve rt ical dimension,
creating space for the upper inciso rs to be
ret racted o r crowned as necessary.
Wind-instr u ment p la yers Playe rs o f bras s or
r eed instrume nt s co ntract the oral musculature
to form what is kno wn as the embouchure . This
allows for th e pro pe r supply of air to the instru-
me nt . Eve n minor variations in the shape o f the
teeth can affect the embouchure , and missing
teeth can have a disastrous effect on the music
produced by some players.
With some instruments the mouthpiece is
supported ind irec tly by the teeth, via pr essure on
the lip. Clearly with these patie nts not o nly is the
replacement of any missing teeth esse ntial but a
br idge will usually be necessary. This must be
designed very car efully to rep roduce as much of
th e o riginal conto ur s o f the missing teeth as
po ssible.
Disadvantages of replacing missing
teeth
Dama g e to t ooth a n d pulp
In preparing teeth for conventional bridges or
precision-attachment parti al dentures. it is often
nec essary to re mo ve substan tial amounts of

healthy tooth t issue. This damage . alth o ugh it may
be justifi ed if the indications are pow erful enough ,
should not be unde rtaken tightl y. T he pr o blem is
leu serious if the teeth to be used to support the
bridge are already heavily restored o r crowned .
Whe never a tooth is prepa red. there is a
d~ nge r [ 0 th e pulp, even if proper pre cautio ns
such as cooling th e bur are follo wed. The re is
sometimes an add it ional th reat to the pulp whe n
teeth are prep ared for bridges. With so me
designs. preparat io ns fo r two o r more teeth have
to be made parall el t o eac h ot he r, and if the teet h
are slightly o ut of alignme nt, t he at t empt t o make
the pr eparat io ns para llel may invol ve more r educ-
tion in o ne part of t he tooth tha n no r mal and so
endange r t he pulp.
With the fall ing inc idence of caries in many
countri e s. and a more conservative approa ch to
restorative dentistry, situations arise more and
more co mmo nly in which the lo gical ab utm e nt
teeth for a br idge are sound and unre stored o r
have minimal rest orations. To pr epare t hese
teeth wou ld be very destructive, and t his is o ne
reaso n why the minimal-preparati o n brid ge and
implant- retained pr o sth eses are becom ing so
popular.
Seco nda ry caries
As with a.1I restorations. bridges carry t he r isk of
micro leakage and caries. T his risk is more signif.
ca nt (part icularly denro-tegauy) if th e r esto ratio n
is an elective on e rather than the re sult o f caries .
Failures
Chapte r 13 co nta ins a black mus eum o f failures
among cro wns. br idges and implant- reta ined
pro st heses. Provided t he br idge is well planned
and execute d and the patient is taug ht pro per
mainten ance and is conscie ntio us. the chances o f
failure are small. Ho we ver, there is always an
eleme nt of risk, and th is must be e xplained to the
patient .
Patients ofte n ask how lo ng the bridge will last.
This is an impossi ble question to answer, since
most bridges do not wear o ut, neither do the
supporti ng teeth. Failure is the result of an iso lated
incident, a prog ressive disease pr ocess, o r bad
planning o r execut io n in the fi rst place . Isolated
'"
incide nts such as a blow can not be pr edicte d and
may occur o n th e day th e bridge is fi tted, in 40
years' time o r never. The prevention of car ies and
periodontal disease is largely under the control of
the patient. as explained abo ve, assisted and
mo nitore d by the de ntist and hygien ist. C hanges
affecting cartes and pe riodontal disease likewise
canno t be predicted. Th ese ind ude dietary
changes. drugs pro ducing a dry mo uth and
ge riat ric changes t hat ma ke cleaning difficult.
A numbe r of long-t erm surveys of bridge
success and failure have pro duce d results varying
from very lo w to high rates o f failure . It is possi-
ble to calculate from the published figures an
average life expectancy o f a br idge. but th is is not
the pro pe r statist ic to use, and it should no t be
quoted to patie nts unless the statistical signifi -
cance is th oroughly underst ood by both dentist
and patient . So me bridges arc failures fro m the
day they are inserted and som e last for over 40
years. To quo te an 'average ' of 20 years is
meanmgtess.
In the more re cen t surveys more so phisticated
st at ist ical metho ds have bee n used to describe
survival rates of bridge s. In add itio n. a numb e r of
factors affect ing t he surv ival rate have also been
analysed . including the design of the bridge. th e
number of teeth be ing re placed, the peri o do ntal
support fo r the abutm ent teeth. th e vitality of the
abutment teeth. and fact o rs to do with the
patient suc h as age and gen de r. Some of the
surveys sho w a survival rate that remains high for
the first ten years or so with mo re tha n 90% o f
the bridge s still in place at rhat time. After this,
th e survival ..ate decl ines. with 60-70% o f bridges
still in place at 15 years. There are no t sufficient
stu dies to establish th e num be r o f years at which
the survival rate is 50%. in othe r words when
there is an eve n chance t hat t he bri dge will st ill
be in place . However. loo king at t he published
survival curves and ext rapolati ng t hem. the figure
is like ly to be betwee n 30 and 40 years survival
for small. we ll-made co nve ntion al bridges.
O ne of the difficult ies in inte rpr eting t hese
surveys is t he fact that many o f the bridges we re
mad e a lo ng time ago using t ech niques, materials
and concepts that ar e now regarded as o ut of
date .
The re is therefore no re liable, co nsistent figure
which can be given to a patient when they ask:
'Ho w many years will the br idge laser . It is often
necessary to give the patie nt a fairly deta iled
lndicaDoilS (or br!dee-; com par{'d WIfh partial dentur{'s ond impla m-retained prostllese-;
patient is particularly anxious to have a brid ge o r
implant-retaine d pr o st he sis and fully understa nds
the implicat io ns. it is often better. particularly
when a num ber of t ee th are missing. to make a
partial denture first to see how the patient
responds . It may be that th e denture is sat isfac-
tol)'. both aesthetically and funct io nally. If so, the
destructive and irreversible to oth preparations
that may be necessary for a br idge o r su rgical
procedures fo r implants can be avoided. or at
least de ferre d .
Alternat ively. if the patie nt is unhappy with the
partial de ntu re , he o r she will en ter into the
arrangements fo r making a bridge o r imp lant-
retained prostheses with greater e nthus iasm and
commitm ent. Patie nt s should never be persuaded
to have bridge s o r implants against t heir wishes,
and t hey must give fully info rmed co nse nt. includ-
ing, in mos t case s. t ime to reflect.
Age and sex
Similar argu ments apply to brid ge s as to crow ns
(see C hapter 3). However, wh ereas there may be
no satisfactory alternat ive to a crown for an o ld
or young patient. a partial dentu re may make a
very satis factory alternative to a br idge o r
implant-r eta ined prostheses. This is particularly
true for very young patie nts . w ho may not fully
appreciate the lifelong implicatio ns o f bridges or
implants . It is ofte n better to make a minimal-
prepara tion bridge or partial denture unt il the
patient is mature enough to asse ss the relat ive
merits o f the alte rna tive s. But a teenager with a
missing inciso r wh o cannot be fitted with a
minimal-preparation bridge may be des pe ra tely
unhappy abo ut wearing a partial den ture . In this
case, the pr ovision of a co nven tion al br idge o r
single to oth implant as ea rly as pos sible may make
a re mar kable psycho logical difference (see Figures
7Ab.c and d and 7.7).
At the other e nd of t he age scale, no patient.
howeve r old, sho uld be writte n off as be ing past
bridgework. Figure 9.4d sho ws a bri dge made for
a sprite ly 76 -year-old w ho wo uld have been
appalled at the idea of wear ing a partial den tu re .
Many patients 10 years o lder t han th is would have
the sam e attitude. Figure 9Ad wa s published in
the first ed ition of thi s te xtbook, and t ile pat ie nt
is still we ll and is still happi ly wearing th e perma-
nent bridge made when the two lower inciso r
'"
sockets had fully healed . The br idge has so far
lasted fo r more than 12 yea rs and . like the
patie nt. is still go ing st ro ng.
Confidence
Many pat ients fee l more co nfide nt with a bridge
than with any fo rm of re mova ble appliance .
Howeve r rete ntive a partial de ntu re , some
patients ne ver lo se the anxiety that it will become
dislodged d ur ing speaking o r cating. Others are
no t prepared to re mov e partial dent ures at night.
Many patien ts do to lerate partial de ntures ve ry
well, howe ve r. and it is ofte n difficult to te ll
beforehand wh at the re spo nse w ill be to eit her
form of treatm ent . Th e majori ty of patie nts w ho
have had both part ial de ntures and bri dges pr efe r
the latter.
Occupation
Spo rts players and wind-instrume nt playe rs have
bee n refe rred to earlier (see C hapte r 3). Althou gh
sports players sho uld be provided with crowns
when necessary. it may be better to defer mak ing
an anterior bridge o r implant-reta ine d pr ostheses
until the pat ient gives up the mo re vio lent spo rts.
and meanwhile to prov ide a partial denture.
Alth o ugh wmd -instru rnenr players usually need
a bri dge re placement fo r their missing anterior
teeth, the re are so me w ho fi nd t hat air escapes
beneath and between the teeth of a br idge. They
are bette r able to maintain a seal with a partial
de ntu re carrying a buccal flange.
Public spe akers and singe rs w ho make mo re
extreme movem ents of th e mo uth ofte n need the
co nfide nce th at co mes from wearing a br idge.
General h e al th
Both bridges and partial dentures are e lective
forms o f treatment. and need no t be provided for
people w ho are ill. W he n tooth replacement is
necessary for someone w ho will have difficu lty
to lerating it because of poor healt h. o r w hen
there are medical co mplications such as with
patients who require antibiotic co ve r for every
appo intme nt. it is better to co nsid er the simple r.
less time-consuming fo rm of treatm ent first.
' 60 IndicO lions for bridg~s compared wilh pan ia! denf,ues and jmplrmt·rewined pnl11heles

Figure 7 .7

o O riginal study cast and d,agno sti<; wax-ups lor l

patie nt wh o lost the upper r ight central incisor in u
acciden t in his ear ly teen s. Rat he r than maintain the
space, the latera l inciso r was mo ve d into the position
o f the central inci sor and the canine tooth into the
pos ition o f th e latera l inciso r . O n the patient's left the
tint premolar was e xtracted since the teeth were
crowded, and so th e m idline was maintained. This study
CUt wa s made when th e pat ien t was 16 and w:n
becoming very concerned about hiS ap pe arance. The
shape of the lu era! inciso r had been modi fied will-
composite. but this and the canine tooth we re Iii
unattractive. The appearance of simp ly crownin g the
lateral incisor to make It resemble a cent ra l incisor 15
sho wn in the fIrst diagllOstic wax-up . This is also not
satisfactory. and so the second diagno u ic w.I.:o:..q:>
sho ws the effe<u o f extracting the uppe r right first
pr emolar . ret racting t he can ine tooth and th e lateral
inciso r o rthodcnncally and making a bridge t o re place
the ce ntral inciso r t ooth. However , th e patient was not
prep ared to have further o r thodontic t reat ment to
achieve th is idea l res ult. and so t he bo t tom diagnostic
wax-up sho ws t he appe arance t hat would be achieved
by extracting th e late ral mc.sc r and making a conven-
t iona l t hr ee -unit fixed-fixed bridge . This is a very
destructive appro ach, but was justified in th is case in
view o f t he patien t 'S co nsider able anxiety over his
appea rance .

b The bridge in place. Th e pat ient is hap py wit h this

appearance and co nsiders the treatment to be
s uccessful
Indtall'(I<11 (or bridges comporl"d .....tll portr<ll d~IIl""S ond implont..r doiMd prostheses
, a and b A bridge with separate acrylic buccal pros-
Having missing anterio r teeth replac ed. t houg h.
ca n bo ost th e mora le of patie nts reco ve ring from
lo ng illnesses or facial trau ma.
A p p e a n.nce
W he n a tooth is lo st. alv eo lar bone a nd gingi-
val co ntour are also lost. a nd it is ne ve r pcssr-
06'
Figu re 7.. 8
thes is.
a The lateral inciso r and canine were lost in a road
accident toge ther W i th a substa ntial amou nt of alvec -
lar bon e. The teet h have been re placed by means of a
bridge, and a horizontal pr ecisio n attac hme nt has bee n
set into the neck of the later al incisor .
b The unilate ral gingival prost hesis in place. retained by
the prec ision anachment, In this case t he main purpose
is to pad oot the lip contour rather than change the
appea rance of the gingival margins. The lip. when nee
retracted. conceals the necks of the teeth .
c and d A fi xed partial cro wn splint (see Chapter 12
and Figure 12.9)
c The unsightly appearance follOWing gingival recessio n
and surgery.
d A rem ovable acrylic gingival prosthesis in place.
ble to di sg Uise t his fact entirel y (se e Figu res 7. 1a
an d 9.. 9a). Thus no a r t ificial r e placeme nts e ver
lo ok e xactly like t he na t ural te e t h. altho ugh
so m e may be s ufficien tly realistic t o deceive all
e xce pt the de nti st wi th h is bright ligh t and
mouth mirror.. In some cases de ntu res w it h
flange s ac hieve th is o b ject better tha n b ridge s;
in others bridge s have th e better appe a ran ce.
W he n a subs ta ntial a mou nt o f alveolar bone is
162 Indicm",,,,, (0'
lo st in on e ar ea. the combination o f a bridge
with a sepa rat e rem o vable bucca l flange
sometimes gives t he best ap pe ar ance (se e
Figu re 7.B).
W hen the lo ss of alveolar bone is sign ificant
and t he lipline is such t hat it sho ws and is ditfl-
cult to disguise easily, the ridge may be
b<jdg~ comp<J'ed ...,th partial demlJre~ and implonl_relained p rOSll>esn
Fig u re 7.9
a A m inimum prep ara u c n bridge w ith OJ very unsightly
an d unsatisfactory flange in pin k porcela in w hich does
nOI matc h [he panen t's gingival pig me nta t ion_ It is atsc
unhygieniC.
b After rom ovmg t he bridge t he thin re ceded r idge can
be seen.
( T he alveolar ridge is expos ed.
augme nted surgically and t he tooth or teeth
re placed by a bridge o r implant . The preferred
material is autogeno us bo ne usually taken fr om
somew here within the patient's mo uth, often th e
ch in o r t he max illar y tube rosity, but free ze- dried
bo ne or other artificial materials are available (see
Figures 7.9 and 7. IO).
 IMlCal>Ons for bridfCS compared with partiol denl,,,es and implant-relained prostheses
General dental considerations
Q uestion s o f oral hygiene and pe riod o ntal health
were dealt with in re lation t o crow ns in Chapter
3 and similar co nside ratio ns apply to bridges.
However. w hen there are st ro ng ind icat io ns for
replacing missing teeth in a case where there has
163
d Afte r augmentation and suturing.
e The ridge healed.
rA new mmimum-prepa ra non br idge with an
improved appearance of [he po ncks and (he augmented
ridge. It is also mo re cleansable.
been peri od o nta l disease and alveo lar bo ne lo ss.
pro vided the peri o don ta l diseas e is under contro l
it is preferable to pr o vide a br idge w hene ver
possible rather tha n a partial denture. This is
beca use a number of abu unent teeth splinted
togeth er as part of a bridge have a better pr ogno-
sis than ind ividual teeth with red uced alveo lar
164 Indications for brjdf'es comDared wifh Do rtial dentu res and imDtam- retained Drostheses

Fig u re 7. 10
Localiz ed alveolar bo ne lo ss treated by ridge augmen-
tat ion and implants.
(J Th e upper cen t ral incisor teeth have been crowned
but in t aking the imp ressio n, electrocautery had been
used and had damaged th e alveola r bone. A sequestrum
of bon e had subseq uentl y be en exfoliated. This photo-
graph was ta ken th ree years later at which time the
gingival recessio n had become aesthetically unaccept-
able and t he central inciso r t eeth were beginning (0
d rift fo rw ards.

b Radiographs of t he fi xt ures in place helping to

support an alveo lar bone graft ta ken from the chin.

c T he healing abutments.

wwW.allls lam.net
Problem

d The healing abutments in place after second stage

surgery.
 16'

e Afte r healing and remov al o f t he healing abutments.

f Th e impression.

g The w o r king model w ith a silicone ridge and the TMA

analogue s.

h The Tt1A and prosthetic co re .

168 IndKOliol'l,
Local dental c onsiderations
The condi tio n of t he te e th adjacent to and o ppos-
ing the missing tee th may help to determine
wheth er a fi xed o r rem ovable prost hesis is
indicated. W he n the prognosis of teeth adjace nt
to th e space is do ubtful it may be better to
provide a partia l dentur e - at least in the short
te rm until the prog nosis is cleare r. The doubtful
tooth could the n either be use d as a suppo rt fo r
a bridge o r ext ra cted and a larger bridge o r
den tu re co nstruct e d. If th e ang ula tion o r size of
the tee th adlacent to th e space make the m
uns uitable to su pport a bridge. it m ay be bette r
for t>J'Jdges ,ompo,ed Wllh poniol denlures and ".,plon Helmmd ptost'ltsfl
Figure 7.11
Indicat io ns for partial de ntu res .
a A heavily w orn denti ti on w ith sho rt clini cal cro wns
and no poste rio r t eeth on o ne side. A part ial denture
is t he o bvio us choice here .
b Several teeth missing as a result of hypodontia in a
19-year-old patient. In view of the rec ent extrac tion of
the decid uo us teeth together With the appare ntly high
carie s incidence judged fro m the number and size of
amalgam resto ra uoos, and the small size of the ante riof
abutm ent tee th. a partia l dentu re was provided. Art
addit io nal problem in providing a bridge wo uld have
been the lingual inclination of the first lowe r molar
teeth. making para llel pre paration difficult. Eventuall,
tho ugh. t he pat ient found the de m ure into ler able. and
a bridge was made. O ne stage in its const ruction is
sho wn in Figure I LlI [page 232). Implants would have
been a pos sibility. pro bably with ridge augment ation.
but at the time funding was not available for this
pat ien t.
In bo th a and b the indications fo r re placing the
missing tee th are bot h ae sthetic and functio nal.
to p rovide a partial d e nture rathe r th an d e s ign an
unn e ce ssarily e laborat e and c o m ple x bri dge .
Examples of specific indication s for
bridges, d entures a n d implant
brid ge s
Figure 7. 12 shows th ree cases in w h ich b r idge s
we re p referable. and Figure 7. 13 one w here a
partia l d e nture w as t he chose n t reatment a nd o ne
w he re it might have bee n. Figure 7. 14 shews
pat ients for w ho m im plant -r e ta ine d b r idges are
2

Indil:otions (or bridges com pared with partial demu~s and implom·retoJned pr051heses ' 69

Fi gu r e 7.1 4

Indications for implant s,

a and b The upper left late ral inciso r and canine tee t h
have been lo st t hrou gh t rauma. The mouth is ve rv
clean and well care d fo r with no caries or re storat ion s.
The r idge is substantial (confirm e d by appr o pr iate
imaging) ,

( The occlusion of the patie nt show n in a and b. It is

unfavourable fo r a mi mmum preparation bridge.
Therefore all the indicAtions in th is care arc fo r an
implant re tamed pro sth esis_

d In thi s case onl y o ne cent r al inciso r toot h is mi ssing

b ut the gap is mu ch greater th an the other ce nt ral
inciso r. T he patient had previous ly had a mid line
diastema w ith whi ch he was content. T he mo uth is
we ll cared for w ith few r estorations and a single tee th
implant is indicate d.
170 IndiC{mons (or bridges com pared w.!h partial denllues and impla nt-reta ined prostheses

-.,;; --

e. (. g and h A patient who was severe ly injured in an

accident in w hich, amongst other iniuries, she lo st six
upper and six lower teeth tog ethe r w ith a significant
amount o f alveola r bone.

(and g A Scancra (3 three d,mensiona l im.lging systcm wh ich invol ves

less radiation than computerized tomography - CT) profile of the
upper left latera l incisor reg ion.

f The radiograph.

g A tracing o f the ou t line of the r idge. The original magnificat ion is

1: 1.7. Imaging either by Seano ra, CT or a similar imaging syst em is
usually necessary to determine th e quality and amount of bone avail-
able fo r placing implants . In th is case ridge augme ntat ion would have
been preferable but the pat ient had had so many ope raucns fo llow-
ing her accident that she refused to have fur th er o perauo ns for ridge
augmenta tion.

indicated. f igu re 7. 15 shows a case where it
would be better to leave th e pat ient w ith no
pro sth esis.
Scope of this book
Th is chapte r has dealt w ith t he de cisions to be
made abo ut whet he r t he tooth or teeth s hou ld
171
h The implants in place. some at a compromised
position. How ever they have all s.atisfaetorily o sseo-
im egnted a nd the patient has been we ar ing the
prostheses fo r five years and has recove red fro m her
ot her inrur ies_
Figure 7. 15
T his pa t ient ha d had th ese spa ces for ma ny yea rs, and,
des pit e so me me sial drift of t he low e r mo lar to o th an d
con side rab le mes ial mo ve ment of t he up pe r mol ar
tee th - so th a t spa ce for bo t h premo lar tee th w as now
less than half a unit - she was not co ncerned about
t he appearance. had no difficulty eat ing. and even these
extensive tooth movements had no t produced occlusa l
mrerfe rences. There therefore se emed ins ufficie nt justi-
Bcarion to re place any of th e miSSing teeth.
be r eplaced, and, if so, wh et he r th e r ep lac e -
me nt should be by a parti al de nt ur e , b ridge o r
im plant-retained prost hesis. All t hese alte rna-
tive s ne ed to be co nside r ed equ ally at the
plan ning stage and so arc inclu de d here in
some de ta il. H owever , t he r e main de r o f thi s
bo ok is [ 0 do w ith br idge s o nly, and the
se ction o n furt he r r eadi ng guid es th e r eade r
to w ards t e xts o n partial de nt ures and implant
pro st he se s.
172
Practical points
• When teeth are missing. t he first decisio n is
w hethe r re placing them will do mo re good
than harm .
• If the decis io n is for re placeme nt. the second
co nsideratio n is wh ether the pro sthes is sho uld
be a partial de nt ur e, a br idge o r an implant-
retained prosth esis.
• If t he decisio n is for a bridge . it is ne cessary to
con sider w hat de sign sho uld be used.
• T he patient 's attitu de. general healt h. occupa-
tion and age sho uld all be ta ken into consider -
atio n.
• The sta t e o f the teeth and the wh o le mo uth
will affect the final decisio n as to w het her a
bridge will be successful.
8 Types of bridge
The appliances used to replace missing teeth
were defined in Chapter 7. Some of the terms
used in bridgework are also use d in re latio n to
partial de ntures.
• An a b ut m e nt is a tooth to which a br idge
(o r pa rtial de nture) is attached.
• A retainer is a crow n or other resto rat ion
t hat is cemented to the abutment. T he terms
'retainer' and 'abutment' should no t be
confused or used interchangeably.
• A pontic is an a rtificial tooth as part of a
bridge.
• A sp a n is t he space bet wee n natu ral teeth t hat
is to be filled by the bridge.
• A pi e r is an abutme nt tooth standing between
and supporting two panties, each pontic being
attached to a further abutment tooth.
• A un it, w hen applied to bri dgew ork, means
either a retai ner o r a pontic. A bridge w it h two
retainers and one po nt ic wo uld t herefore be a
three-u nit bridge.
• A conn ect o r (o r jo int) con nects a po ntic to
a re taine r, or two retainers to each other.
Connecto rs may e ither be fixed o r allow so me
movement between the components t hat they
join .
Conventional and m inimal-
p rep a rat io n bridges
Conventional br idges invo lve re mov ing tooth
tissue, or a previous restoratio n, and repl acing it
with a retaine r. Th is may be destructive of to oth
tissue and wi ll certain ly be t ime -consu ming an d
expe nsive. T he alte rn at ive, m inimal-preparation
bridge invo lves attachi ng po ntics via a metal plate
to the unprepa red (or minimally prepared) lingual
surfaces of ad jacent teeth. The attach ment is
made by a composite resin material, retained by
the acid-etch tech niq ue to the enamel. Obviously
these bridge s can be used only wh en t he
abutment t eeth have s ufficient intact enamel.
Basic designs, comb inations and
variations
There a re fou r basic desig ns of bridge, the differ-
ence be ing the typ e of support prov ided at each
ends of the po ntic. The same name is given fa
the design, however man y ponncs there are in
the spa n an d ab utme nt teet h sp linted at one end
of t he s pan (see Figu re 8. 1).
The fo ur bas ic designs are the same w hether
the bridge is a co nven t ion al or a minimal-prepa-
ration type . It is po ss ible to co mb ine two or
mo re o f t he fou r basic designs and to combine
conventional and minimal-preparation retainers in
the same bridge (the hyb rid bridge - see page
179).
Of the four basic designs, t he first three may
be e ither co nve ntio nal or minima l-preparation
types. It wo uld be un usu al to have a minimal-
preparatio n versio n of t he spring cantilever
bridge.
The four basic designs (see Figure 8. 1)
Fixed-fixed bridge
A fixed-fixed bridge has a rigid connector at both.
e nds of t he pontic. The abu tment teeth a re the re-
fore rigidly splint ed together, a nd for a conven-
t ion al bridge must be prepared parallel to each
other so t hat t he bridge, wh ich is a minimum of
three unit s, can be cemented in one piece. The
re tain e rs should have appro ximately the same
ret e nt io n as ea ch other to reduce the risk that
forces a pp lied to t he bri dge w ill d islodge one
re ta iner fro m its ab utme nt, leaving the ' bridge
s uspended from t he other abutment.
To minimize th is r isk, it is also important for
the entire occluding surface of all the abutment
teeth for a co nve ntio na l br idge to be covered by
the retainers. The oppos ing teeth cannot then
contact t he surface of an abutme nt tooth, depress
it in its socket and break the cement lute. If t his
17]
,7<

Fig ure 8.1

Four basic bridge designs o f conventiona l bridges.
o Fixcd-fixed d e sign Both uppe r and lo wer bridges
will be fixed-fix ed, the low er re tained by full cro wns
all th e canin e to o th and centr al incisor (see Figures
7. 12c, page 167 and 3.141, page 59 for t he pre-opera-
t ive co ndition and the preparation s). The uppe r bridge
will be reta ined by the canine tee th only (see page 209
(o r th e rationa le fo r this de sign). The bridge was made
before implants w ere genera lly available.

b Fi xed-rn o v abl e d esign w ith DO inlay in the low er

sec ond prem olar and full crown on the mdlar tooth.
This br idge has been pr esent for 20 years - in fact so
rong tha t t he oc clusal surface o f the crow n has wo rn
th ro ugh (see Ch apter 13). The mo vable jo int can be
see n bet wee n t he po nt ic and t he minor reta iner . It
would not norm ally be as obviou s as t his.

c C antilever desig n Bot h lat eral incisors are peo nes

suppo rt ed by cr owns on me canine te e th. Both bridges
ar e conventio nal all-porc elain, and th e right one had
been pr ese nt for 14 years at th e time th is photograph
wa s ta ke n. The left on e fractu red afte r 7 years and was
rep laced w ith anomer all-po rce lain bridge.

d Spring can t ileve r d e s ign with the first mo lar

tooth as abut me nt. The re is a midline diaste ma. and a
diast ema be tw ee n m e lat era l inciso r and canine on the
side of th e missiT1g cen tral incisor. Any other bridge
design wou ld have invo lved c1o siT1g o ne o r both of
thes e spaces . Tod ay a single-tooth implant wo uld be
the preferred so lutio n to the pro blem.

Oc c lu sa l fo rc e
Figure 8 .2
Ceme n t lu te fa ils An unsatisfactory design for a fixed-fixed br idge.
-, A conventio nal fixed-fixed bridge sho uld have all the
J J occlud ing surfaces o f the abutm en t tee th protect ed by

( - the re tainers. Otherwise an oc clusal force directed at

the unpro tec ted area will dep ress me abutment t ooth
in its soc ket while me reta ine r is he ld by t he bridge

vrJ To ot h dep re ss ed in soc k e t

and th e ot her abutment tooth. This will break dow n
th e ceme nt lut e. causing leakage. The retainer is he ld
in place by t he br idge , and so seco ndary caries devel-
o ps rap idly (sec Figure 13.5. page 26 1).
Tr/le5 of bndge
- #
sho uld happe n, t he retainer will no t ap pea r lo o se
since it w ill sti ll be held in place by t he res t o f
t he bridge . Ho weve r, 0 1<1.1 fluids w ill e nter t he
space be tween the reta ine r a nd t he ab utment
prepa ration, a nd caries w ill I<I.pidly develop (see
Figure 8.2).
T his rule does no t app ly to minimal-pre pa ra-
tion br idges in w hic h t he bond between the
re ta me r and the abu tment tooth is much
175
Figure 8,]
Fixed-mo vable bridges.
a A conventional bridge with an MO D gold mlay as the
minor retaine r and a futl gold crown as the major
retainer.
b Acrylic burn o ut patte rns fo r moveable connecto rs.
The blue is ve ry tapered , t he red mo re parallel-sided.
c and d A minimum-pre paration fi xed-mo vable bridge.
c Sho ws the mino r re tainer in place with a depresston.
rather than a SIOL in the distal rest, The prepa ration
for the minor retainer is With in enamel.
d Shows the finger from the ponnc reSWlg o n the
minor retainer. This will resist axial forces on the
pontic which wou ld tend to tilt the molar abutment
tooth fowards. It does not resist lateral for ces but
these can be made insignificant by contou ring the
occlusion of the pont ic
st ronger. Howe ver, it is so me time s no t strong
e nough, and debonding someti mes occurs as a
result of a mecha nism similar to th a t show n in
Figu re 8. 2. T his proba bly pa rtly acco unts for the
highe r incide nce of retent io n failure w ith mimm al-
prepa ration br idges than w ith co nve ntional
bridges, particu lar ly w ith t he fixed-fixed design.
Initia lly, the most popular design of m inimal -
pr e paration bridge was fixed-fi xed. T his was
'"
because in the early days of the minimal-prepara-
tion de sign. it was th o ught that as m uch reten-
tion as po ssib le should be obtained by using at
leas t tw o abut men t teeth. Since t hen, a number
of success-and-failure surveys have shown that
t he cant ilever design of m inimu m-pr eparation
bridge w ith one abutment tooth is more success-
ful, particularly with anterio r bridges.
At one time it was thought that the support
for the abutment te eth at each end of a
fixed-fi xe d conven tional bridge sho uld be similar.
In o the r words, th e root surface ar ea of the
abutm ents sho uld be ap proximately t he same.
Today th is is not consi dered nece ssary (sec
Ch apte r 10).
Fix ed-movable bridge
A fixed-movable bri dge has a rigid connector.
usually at th e d ista l en d o f the pon tic, an d a
mov ab le con nect or tha t allows som e vertical
mo veme nt of t he mesial abut me nt tooth . T he
movab le connector sho uld resist bo t h se paration
of t he pontic from the retainer and late ra l
mo ve ment o f the po ntic (see Figu re S.3a an d b).
Occasionally the fixed and movable connectors
are reversed. but this has a numb er of disadvan -
tages. The retainer with the movable connector
(the mino r retainer) is smaller and less visible and
so is better in th e mo re ant erio r abutment tooth.
Po ste rio r teeth co m mo nly t ilt mes ially, and t his
tends to unseat distal movab le connectors. but is
resisted by mesial ones.
The movable connector can be se parated
before the bridge is cemented. and so th e two
parts of t he br idge ca n be cemented separately.
Th e ab uunent te eth do no t th erefo re have to be
prepared parallel to ea ch o the r and the re tentio n
for the mino r retainer does not need to be as
ex ten sive as for t he major retainer. Ne ither docs
it nee d full o cclusal pro tection. O cclu sal fo rces
ap plie d to th e to oth surface no t covered by the
re ta ine r will depress the tooth in its socket. and
the re will be movement at th e movable joint
rather than ru pturing of the cement lute (see
Figure 8.2).
A fixe d--movabl e minimal-preparati o n bridge
ca nnot have t he mo vable joint wit hin th e co nto ur
of t he o riginal abutme nt tooth unless th is is
prepared sufficie nt ly fo r t he movable connecto r.
o r the re is sufficient occlusal cleara nce. w hich is
sometimes the case fo llowing t ilting of the minor
abu tme nt tooth. The fixed-movable design for
minimal-preparatio n bridg es has bec o m e po pular
in rec e nt times, and ea r ly results suggest that it
is mo re successful than fixed-fixed. This is
pres umably becau se it can accommodate individ-
ual movement of the abu tment teeth and the risk
o f de bond ing is therefore reduced (see Figure
S.3c and d).
C antilever b r idge
A can tilever bridge pr ovides suppo rt for the
po ntic at on e e nd o nly. The pontic may be
attached to a single re ta iner or to twO o r more
retainer-s splinted together. but has no connection
at the other end of the pontic. The abutment
toot h or teeth for a ca nt ileve r bridg e may be
eith e r mesia l o r dista l to the span. but fo r small
bridges th ey are usu ally distal.
Tw o co nventio nal cant ilever bridges are shown
in Figure 8. 1c. These we re made befor e t he
minimal-preparation des ign of bridge was in use and
wo uld now be co nside red unnecessarily destruc-
tive. However. they are sometimes still used (see
Figure 8Aa). Figures BAb.c and d also sho w
minimal-preparation cantilever bridges which are
less des tructive and have a good record of success.
Spring can t ile ve r b r id ge
Spring can tilever bridge s are restricted to the
repl acement of upper inciso r teeth. Only one
pont ic can be supported by a spri ng cantilever
brid ge. This is attached to the end of a long metal
arm running high into the palate and th en sweep-
ing down to a r igid con necto r on the palatal side
of a single retai ner o r a pair of sp linted reta iners.
The arm is mad e long an d fairly thin so th at it is
springy. but no t so thin that it w ill defo rm perma-
nen dy w ith no rmal occl usa l forces (f.e. exceed the
elastic limit). Forces applied to the po ntic are
absorbed by th e springi ness of the arm and by
displacement of the soft tissues of the palate so
that excessive leverage fo rce s do no t d istu rb the
abutment teeth. Th e abutments ar e us ually t he
tw o premo lar t eeth splint ed tog eth er, or a single
premolar o r mo lar to oth.
Spring cantileve r bridges are seldom made
th ese days and have been re placed either by
 '"
Figu r e 8.4

a All porcelain cantilever bridges similar to Figure S.1e

but made more recently of a strooger ceramic mate rial
[lnceram] . In this case the late ral incisor teeth were
congenitally missing and the deciduo us canine teeth
remaine d with good lo ng roots. They we re t herefore
used as abu tments fo r t he se cantileve r bridges until
such t ime as the deciduo us canine tee t h are lost. The
patient is in her early twen t ie s and t his may not be fo r
a dec ade or t wo when implan ts will pro bably be the
tre atm e nt of c ho ice but w ill have to last fo r less time.
assuming the pat ient has a normal lifespan.

band ( A mmimum-prepa ra non ca ntile ve r bridge

r eplacing the lateral incisor retained by the canine
tooth.

d A sim ilar cantil ever bridge but this time re tai ned by
the centra l inc iso r tooth .
178 TV~5 of brime

Fig u re 8.5

A large s plint/br idge w ith cant ileve red pon tk s.

a Th e w o rking dies.

b The me tal frame wo rk. sho wing two cantilevered

pon tic s o n t he r ight of t he picture.

c The completed restoration in the mouth

(pho tographed in a m ir ror so th at the cantilevered
pcnncs are show n o n the left ).

m inimal-pre paratio n bridges o r by single-tooth de sign s are preferable to th e spring canti leve r
im plants T he t w o co mmonest reasons for making bridge. which is diffic ult to d ean and ma inta in.
spr ing cantileve r bridges used to be to preserve
inta ct anterior teeth wh en po sterio r teeth
needed crowning in any case and also to pre serve
diast ernas between the anterior teeth . The Combination d esigns
min imal-preparation bridge now allo w s t he firs t o f
th ese objectives to be met and the single-too th The four basic designs ca n be co mbined in a
implant solves the second pr o blem. Both these varie ty o f ways. In partic ular, th e fixed- fixed and
Types of bridge
'"

Figure 8.6

A hybr id bri dge wi t h a co nventio nal r etainer (an inlay in the premo-
lar to o th carrying a mov able connector for a fix ed-movable bridge).
T he ot her r etainer on the canine is of the minimal-p re parat ion type.
Hybr id bridges shou ld o nly be made filled-movable and w ith the
m ovable jo int in m e co nventional retainer.

cantilever designs ar e ofte n co mb ined (see Figur e
7. la ). In large r br idges addit io nal cantileve r
po ntics may be suspended from th e end of a large
fi xed-fixed sect io n (see Figure 8.5 ). Simi larl y, it is
po ssible to co m bine fixed -fixed and
fixed -mo vable designs.
It is po ssible t o co mbine a br idge w ith a r emov-
able buccal flange t hat re places lost alveo lar tissue
(see Figure 7.8).
Hybrid d e si gn
T his t er m r efer s to a br idge w it h a co mbinati o n
of co nventio nal and rr nnimal-pre parauo n re tain -
ers. Th er e are t hr ee differ ent hybr id designs:
• 'Fixed-fi xed w ith one co nventio nal and o ne
rmnlmal-preparau on r etain er .
• Fix ed-movable w ith a minimal-p re paratio n
r etainer carryi ng t he mo vable con nector.
• Fixed -movable w ith the conventio nal retainer
carrying th e mo vable co nnector.
The fir st design should not be used and th e
second on ly rar ely. In eit her case, if t he minimal-
pre par at io n retai ner beco mes debond ed the n it
will not be po ssible to r e-ceme nr it wi th out
rem ovi ng th e co nvent io nal r et ainer . w hich may
we ll invol ve destroying the br idge.
The t hir d design is accepta bl e and may w ell
be t he o ne o f cho ic e given circu msta nces in
w hic h o ne o f the abut m ent te eth (usually t he
m esial o ne) alr eady has a r estor at io n that co uld
be r eplace d by m eans o f an in lay o r o t her
co nventio nal r etainer and the o t he r abut me nt
tooth is unrest c r ed o r th e r est o r ati o n does
no t invol ve t he sur faces to be co vered by 3.
minim al-p reparatio n retaine r (see Figu r e 8 .6) .
T hese circum stan ces oc cur sur pr isingly o fte n,
and so t his de sign of bri dge is incr easingly bei ng
used .
180
Variations
Re movable bridg e s
All the designs descri bed so far are permanently
ceme nted in the pat ient's mo ut h. W it h large
br idges t he re are disadvantages in permanent
cementation in that the ma intenance and further
endodont ic or periodontal treatment of abutme nt
teeth is difficult, and if so mething goes wro ng wit h
one part of the bridge or w ith o ne of the
abutment teeth, usually the w ho le bridge has to
be sacrificed. For th is reason, large r br idges,
including full arch br idges. are so meti mes made
so that t hey can be removed by t he patient. The
adva ntage o f t his is that clean ing aro und the
abutment teet h and under the po nties is muc h
easier. The br idge has to w ithstand handl ing by
the pati ent . and so it is usually made with acrylic
facings (see Figure 7.2, page 150). T he acryliC
facings are less liable to chip if the bridge is
dropped . They can also be replaced w itho ut t he
risk o f d istorting t he framework as w o uld be t he
case w it h porcelain.
Advantages and disadvantages of th e
four basic designs
A compariso n of co nve ntional fixed -fi xed, fixed-
movable and ca ntileve r br idges is sho w n on page
182. Spring cant ileve r br idges are no t included,
because th ey are now se ldom made and should
not be attempted by ine xpe rie nced de ntis ts .
A comparison of minima l-preparatio n fixed-
fixed, fixed-movable and ca ntilever designs is
shown on page 183.
Ch oice o f m ate rials
Metal only
Many posterior bridges, both con ventiona l and
minimal-preparation can be made entire ly of cast
metal, whether they are fixed-fixed,
fixed -movab le or ca nt ileve r. If the retai ners or
po mics do not show w hen th e patient smiles and
speaks the n an all-metal bridge is the best choi ce
w ith conventional br idges - the material necessi-
Types or bridge
tates the least destruction of tooth tissue and,
depe nding o n the choice of metal, may be the
least costly. The margins are also eas ier to adapt
to the preparations.
M etal-ceramic
W hen the st rength of m eta l is requ ired together
with a to ot h-co lo ured retainer or pontic,
metal-ceramic is the best material. T his has now
re placed all othe r crow n and pontic facirfg materi-
als, including acry lic, except in special circum-
st ance s, such as patient -removable bridges.
Proprietary ceramic po ntic facings have also been
supe rseded by meral-ceranuc po ntics.
A range of composite crown and bridge facing
material s is now available, but it is too ea rly to
say wh ether t hese have no advantage over
meral-cerarruc materials for permanent bridges.
Ceramic only
The all-ceram ic bridge is limit ed by it s re latively
poor st rength to two-un it cant ilever bridges or
three-unit fixed-fixed bridges. All-porc elain
bridges made from co nve ntio nal feldspat hic
porce lain can have a very satisfactory appeara nce
(see Figure 8.1c , page 174). Howeve r, w ith
improveme nts in metal-ceramic materials, these
all-porcelain bridges have no w fallen into disuse.
The ne we r cast- ce ra mic and reinforced porcelain
materials (see Figure 8.4 page 177) have produced
a new ge neration of all-ceramic bridges.
One adva ntage of the all-ceramic br idge is the
'fuse -box' principle (see Chapter 2). All-ceramic
bridges, if properly des igned and constr ucted,
have sufficient strength to survive no rma l
functional fo rces, but w ill break if sub jected to
ex cessive forces . T his potential for fracture may
save the ro ot s of the ab utment teeth from
fract uring if the bridge receives a blow. It is not
uncommon for patients who lose a to ot h as a
result of an accident t o have a further acc iden t,
e ither because of their occu pation o r sport or
because, w ith a Class II Division I inciso r relat ion-
ship , their upper inciso rs are vulnerable to
trau ma. A broken bridge is bette r for the pat ie nt
than br oken roots.
Types of bridge 181

12 0 0 Bo n di ng alloy ca sting temp 1200'

_ Bond ing a llo y me lt ing temp 1 15 0

1 10 0 f1-,P re-c e ra m ic solde ring tem p

U' 10 7 5 "- 1 12 0

10 0 0
Degass in g 970 '
Po rc e la in firin g 9 4 0 -97 0
o Po st-c e ramic s olderinq 01
.::'900 me tal- c e ra m ic u n its m ax te m p 92 0
v" Yell ow g o ld c ast ing temp 9 2 0
o
"o Ye llow gold melt ing t e m p 850
~800
r»
o•
D- Pos t-c e ra mic sold e ring t o y e llow
g o ld un its 7 5 0 -800

700

100 Figure 8. 7

Typical temperature ranges for (he metal-c er-amic

process . These vary accord ing to the metal, porcelain
and solder used, and with the type of furnace, in part ic-
ular its rate of temperature rise.

Combinations of materials improv ed materials and tec hniques, ho w ever, t his

Many co mbinatio ns are possible, but three
deserve special mention. The first two are
common.
• A metal-ceramic retainer and pontic w it h a
movable connector to a gold inlay or other
m inor retai ner.
• An all -metal re tainer (a full o r partial crown)
towa rds the posterior end of the bridge wit h
anterior metal-ceramic units.
So ldering standard cas ting alloys to metal-ceramic
alloys after t he porcelain had been added w as
difficult at first, and failures we re common. With
is no longe r th e sam e problem. The solder joint
is made in a low -fusing so lder after the po rc elain
has been added, and th e bridge cannot be
retu rned to t he furnace fo r fur the r adjus tments
to the porcelai n afte r it has been made . Figure 8.7
sho ws the range of tem pe ratures of the various
components in the m etal- ce ram ic system.
• A frame work of standard casting alloy and
separately constructed porcelain crowns
cemented to t hem; th is type of co nst ruction is
now unco m mo n, but they are st ill seen in a
nu mber of pat ients and need to be mainta ined,
sometimes by the replacement o f fractured
crow ns (see Figu re 13.1 1h, i, page 269).
18'
CO MPARISON O F CO NVENT IO N AL BRIDG E D ESIGN
ADVANTAGES
Fi xed-fix ed
- Ro bus t de sign wit h max imum rete ntio n
and strength
- Abutm ent t eeth are splinted togeth er; th is
may be an advantage. particularly when
te eth are unco mfo rtably mo bile fo llo wi ng
bo ne los s th ro ugh per iodo ntal disease
The design is the most pract ical for larger
bridges. part icularly when there has bee n
per iodo ntal disease
The construction is relat ively st raightfo r-
war d in the labo rato ry because the re are
no movable jo int s t o make
- Can be used for long spans
Fi xed-movable
Preparat io ns do no t need to be paralle l t o
eac h o th er, so diverge nt ab utme nt te eth
can be used
Becau se preparations do no t need to be
paralle l, each preparaoon can be designed
to be re tentive independe ntly o f the other
preparation(s)
More conservative o f tooth tissue
because pr eparations for minor retaine rs
are less destructive tha n preparatio ns for
major retai ners
Allows mino r m oveme nts of teeth
- Parts can be cemente d se parately, so
ce mentatio n is easy
C anti leve r
- The mos t co nse rvative de sign when only
o ne abutme nt to o th is ne eded
- If o ne abutm ent tooth is used, there is no
need to make preparat ions parallel to each
o ther; if two or mo re abutme nt teeth are
used. they are ad jacent to each o ther, so it
is eas ier to make the preparatio ns parallel
Const ruction in the laborato ry is
re lative ly straightforward
Mo st suitable in repla Cing ante rio r teeth
where. if the occlusion is favourable. there
is little risk of the abutment tooth tilting.
Types ofbtidgt
D ISADVANTAGES
Fixed-fixed
- Requ ires preparations to be parallel. and
this may mean mo re to oth reduct io n than
normal. endange ring the pu lp and reduc-
ing reten tion ; t he strength of the
prep ared tooth may also be re duced
Preparatio ns are difficult to carry b ut,
particularly if seve ral widely se para ted
teeth are invo lved; th e preparatio n is slow
and t he parallelism has to be constantly
chec ke d, or alte rnat ive ly (and w rongly)
the preparat io ns are over-ta pered to
ens ur e t hat th ere are no unde rcut s and
so re te ntio n is lo st
- All the re tainers are major re taine rs and
requ ire exte nsive, destructive pre para-
tions of the abut ment teeth
- Has to be cemented in o ne piece, so
cementation is difficult
Fixed-mov a ble
Length of span limited , parti cularly with
mobi le abutment t eeth
Mo re co mplicate d to co nstruct in the
laboratory than fixed-fixed
Difficult to make te mpo ra ry bridges
C anti lever
W ith small bridge s the le ngth of span is
limited to o ne po ntic because of the
leverage force s on the abutme nt teeth; if
more teet h are to be replace d with a
cantilever bridge, a large numbe r of
abutments Widely spaced rou nd th e arch
must be used
- The co nst ruct io n of t he bridge must be
r igid to avoid distortio n
- Occlusal forces on th e po ntic of small
posterior bridges encourage tilting of the
abutme nt to oth. particularly if the
abutment tooth is distal to th e ponti c and
is already predisposed to t ilting mes ially.
Tjpes or bridge
CO MPARISO N Of MINIMAL-PREPARATION BRI D G E DESIGNS
ADVANTAGES
Fixed-fixed
A large retentive surface area
A singlc casting and so re lat ively simple in
the labo ratory
Fixed-movable
Independen t tooth mo ve ment is possi ble,
pa rt icularly for th e minor abutment tooth
(w ith t he mo vable jo int). The major
re tainer ca n be designed fo r optimum
reten tion, sometimes incorpo rating int ra-
co ro nal as w e ll as extra-coronal elements
replaci ng res to rations
- The retention of the minor reta iner need
not be subs tantial, particularly if the mo vable
jo int consists o nly of a rest seated in a seat
on the minor re ta iner. In this case there are
few displacing fo rces on the minor retainer
- The retent ion of the two retaine rs can be
very differen t, usually with the major retainer
distally and the smaller, minor retain er
attached to a prem o lar tooth. The retainer
can be made very small, and its appearance
is similar to a small amalgam resto rat ion
Pre vents a po sterior abutment tooth
tilting as is sometimes th e case w ith a
ca ntilever bridge . The mo vable joint
merely acts to prevent t his rat he r t han to
provide an y rete nt io n for the bridge
Cantilever
The mos t conse rvat ive of all de signs,
usua lly on ly invo lving a single minimal-
preparation retainer
Ideal for replacing upper lateral inciso rs,
using the canine tooth as the abut ment,
provided the occlusion is favo urable
Suita ble posteriorly w hen the span is short
Easy for the patient t o clea n with flo ss
passed t hrough the co ntact poin t between
the po ntic and t he unrestored ad jacent
tooth
No need to align preparations
Easy labo ra to ry constructio n
183
DISADVANTAGES
Fixed-fixed
- Because part of the occl usa l surfaces of
both ab utment teeth are usually oppos ed
by teeth in the o ppo sing jaw, there is a
tendency for the m to be d islo dged fro m
the re ta iner, th us deb o nding the bridge
W ith tilted abut ments it is somet imes diffi-
cult to ac hieve an adequate rete ntive sur-
face w ith ou t substantial tooth preparation
The rete nt io n of both retai ne rs sho uld be
app roximately eq ual. This is difficult to
ac hieve wh en one retainer is a molar
toot h and the other a premo lar
Fixed-movable
N o t su itab le for ante rior bridge s
More difficult to make in the labo rato ry,
requ iring tw o separa te casti ngs
N ot suitable for longer-span bridges,
wh ere a con ventional fixe d-movable
bridge w ou ld be satisfacto ry. This is
because the mo vable joint is se ldom large
enough to resist late ral fo rces on the
pontic, but will only resist axia l forces by
means of the rest on the m inor retainer
Cantilever
Relative ly small ret en t ive ar ea, an d vulner-
ab le to dcbo nding t hro ugh to rqu ing forces
.
,
M IN IMAL PREPARA n O N BR.IDGES
I
I I
D IRECT IN D IRECT

Macr o Me c~nlUl
I
Medi\lm H cd u.nical MICro M"", ha",iu l
I
Chemiao .y
Ret em iOll - Ret ention - Ret ent io n - Ad hO!'S ,ve -
e .g. Roc hett e e.g. Virginia S3.lt Mesh e,g. Mary land e.g, Pa ~yQ -ex
(sec f ig 8. 10) Crystal Bond (sec F;g B 12) (see f ig_ 8.11)
(sec Fig 81 1)

Figu re 8.8

A simple classification of minimal-pre paration bridges.

Fi gu r e 8. 9

Min imal-p re pa ration d ir e<t brid ge.

a This paner u pre sented W I th periodon tal disease and

gro ss ca lcu lus. As an initia l pha se in his t re atme nt
follo wing re mo va l o f t he c alculus. th e mo b ile lower
inc isor was sp linte d to t he adpac e nt tee t h w it h acid-
e tch re tai n e d composite . Howe ve r :

b It wa s decid ed la te r th a t th e p ro gn o s is of th is tooth
w a s ho pe le ss. and the roo t wa s resecte d an d re moved.

Type s of minlmal-preparation bridge to oth lost through injury (which canno t be

re implanted) o r w hich has to be e xt racted
Figure 8.8 shows a simple classificatio n o f ur ge ntly. Some t imes metal me sh o r wire is
m inimal-p re paration bridges: var iati o ns of th is added to t he li ngual surface to increase
technique arc sho w n in Figur es 8.9- 8.13. strength, but this is no t always nec essar y. If the
nat ural crown of the to oth is no t available or
• D irect bridges may be made using th e crown is no t suita ble, an acry lic de ntur e tooth can be
of the patie nt's o wn tooth . This can o ften be used in the sam e way (see Figure 8.9).
do ne as a simp le and rap id wa y of rep lacing a • Macro -mec hanically re te ntive bridges (Rochett e.
T"pes of bridge 18'
Figure 8 . 10

A Roc he tt e (macro- mec hanically rete nt ive) bridge

replacing o ne ce nt ral inciso r. The porce lain is yet to be
added. and the palatal spur o n the pontic will act as a
hand le unt il the bridge is finished. whe n it will be
removed. Th is design is st ill used whe n the br idge (or
splint ) is like ly to be removed in the future . The
co mpo site is dolled ou t of the ho les. and th e bndge
can be rem oved with leSS" trauma to th e abutment
te e th than with o ther me tho ds.

Figure 8 . 1 1

Four type s of med ium-mechanically ret entive sc rtaces .

All ar e bulky and with poor retention. They ar e now
seldom used .

(J A scann ing electron micrograph (SEN) of the re ten -

tive meta l surface produced by the Virginia salt
technique . Salt is applied to an adhes ive o n t he die and
the n a pattern is built up in eit he r wax o r acr ylic. This
is remove d fro m th e d ie and the salt dissolved in wate r.
The pattern is then cast , leaving depress io ns whe re the
salt crysta ls were. Field width equa ls 900 u rn.

b A Cast- mesh br idge. It is diffi cult to achieve good

adaptatio n o f the mes h e ver the entire re taine r surface.
and neith er of th ese re ta iners has retentrve featu res
right up to the per iphery, The added th ickness of t he
retamer can also be seen .
...--
186 1Y~5 of bridg<

c SEM of <I casr-mesh surface. Note that t he undercu ts

fo rm o nly a small pr oport ion of the sur face and that
t here are t hick , no n-under cut eleme nts. Field width
equals 900 u rn

d SEM of a cast -meta l surfa ce re sulting from a pr opri-

etary mixtu re of acr-ylic bea ds and sa lt. pro ducing both
sphe res (from the acrylic be:ids) and depressio ns (from
th e salt) . Again th is has large un retenti ve ele ments.
Fic ld width equals 900 urn-
ry~l o( bridg~
'"
Figure 8 . 12

a A minimum-prepa ra tion bridge : me des ign is unsat-

isfactory in mat the extension distally o nto th e thi rd
mo lar t ooth t o incr ease retent ion wo uld give rise t o
an impossible cleaning problem bet ween the scccod
and th ird mo lars . This is a t echmque bod ge. no t made
for a patient. It is sho wn to illust ra te a co mmon design
er ror.

b SEM of a cast nickel-ch ro mium metal surface e tched

in th e labo rato ry . The very reten tive but delicate etc h
pattern IS much smaller in scale tha n th e re tention
syst em s sho wn in f igure 8. IOa. c and d. Field width
equa ls 90 Jim. i.e .• the magnification is 10 times greater
tha n f .gure s 8. lOa. c and d

( SEM of a surface chem ically etched at the charrstde .

Field width eq uals 90 Jim.
188
see Figure 8.10) have large undercut pe rfora-
tions through t he cast-metal plate. through
which the co mposite flows. T hese ho les are cut
in the wax or acry lic pattern wit h a bur and
are th en co untersunk.
• Med ium-me chanical retentive systems all
invo lve re te nt ive featu res cast as part of the
met a) framewo rk (see Figure 8. 11). They all add
Significantly to the cem e nt-film thicknes s in
some areas, at least. o f the reta iner and they
all pr od uce large. no n-undercut lumps o f m etal
o n th e fi t surface that do not con t ribut e to
retent ion but necessita te a relatively th ick
retainer. Th ey are therefo re no longer used.
but pat ients w ith th is type of bridge may
pr esent with the bridge debon ded . It is usually
not worth t rying to re-a tta ch it .
The size of the re tentive features is inter-
med iate between those of macro - and micro -
mecha nical rete ntive syste ms.
• Micro -m echanical re tent ion is p ro duce d by
casting the metal retainer and then etching
th e fit surface by o ne of tw e. met hods:
Figure 8. 11
SEM of a cast nickel-ch romium metal surface blasted
with SO-lA-m aluminium oxide part icles. The surface bas
no physical undercuu but is irregular. This is the
recommended metal finis h for the chemically adhesive
cementing resins Field width equals 90 urn-
ele ct rolyt ic etching in acid in t he labo rat o ry
or chem ical et ching wit h a hydrofluoric ac id
gel e ith e r in the labo rato ry o r at the chair-
side . Although these two systems pro duce
d ifferen t etch pa tterns, t hey are all very
re te nt ive (see Figure 8 .12). The size of t he
rete nt ive fe at ure s is approx imate ly o ne- tent h
that o f th e mediu m-mechanical retentive
sys tems. and th e re tent ive feat ur es are under-
cut from the surface. The smaller size of
th ese et ch pit s and th e abs e nce o f any unne c-
essary no n-retentive feat ures (as in th e
me d ium-mechanical re tentive systems) allow
thi nner metal retainers and a thinner ce me nt-
film thic kness.
• Ch emically re te ntive resins are no w available.
Several have be en ma rketed, and some (e.g.
Panavia 21) have performed well in laboratory
and sho rt -term clinical trials. T hey adhe re
chem ically to recently sandblast ed metal
surfaces and are retained o n the tooth by
conventiona l acid-e tching of the ename l (se e
Figure 8. 13).
Type5 of bridge
Comparison of indirect minimat-
preparation retention systems
A numbe r of laboratory studies an d clinical trials
have sho wn that m icr o- mechanical and chem ical
ad hes ive syst ems are th e mos t retentive. The
chemica l ad hes ive systems have been available fo r
a num be r of years and are pro ving t he mos t
successful of the systems. Howeve r, lo nger-term
clinical t rials are st ill necessary. T he mo re
recent ly introduced materials are claimed to have
better rete nti ve pro pertie s than earlier ma terials,
but time w ill tel l. An advantage of using the
chemical adhes ive ma terials is that the laboratory
o nly ne eds a sandb laste r rat he r t han etching
eq uipment, an d the health and safety hazards of
etching in an acid sol ut ion or us ing hydrofluoric
ac id gel ar e avoided. The ad hesive cement is easy
to m ix an d use and has a good w orking t ime, so
t hat the bridge ca n be fully seated w ith o ut too
much hur ry. Rubbe r da m should always be used
and t he margins of th e resto rati o n coated wit h a
ge l mat er ia! to prevent air co ntact ing t he setting
cement, since its setting is inhib ited by oxygen .
A disad vantage of the m icro- mec ha nical reten-
tion system is that the metal framework should
189
Figure 8.1 4
(Iand b The upper conventional bridges and the lower
Rochette bridge were all made five years before these
photo graphs we re taken. Not e that the patient has
managed to maintain good ora l hygiene and per iodon-
tal health round the conventional bridges. but has had
much more difficulty arou nd the lower Rochette
bridge.
not be tried in the mo uth after the surface has
been etched. This is be cause the ve ry delicate
etch patte rn may welJ be da maged or clogged by
deposits from sa liva (sec Figure 8. 12). T his mea ns
that the ideal is to try-in th e unetc hed framew ork
and then either re tu rn it to th e labo rato ry for
etching or etch it at the chai rside. T his takes time
and the refore adds t o the cost.
The macro-mechanical rete nt ive desig n
(Rochette) o vercomes th is problem but is less
retent ive in mos t cases, and , because it is
ceme nted w ith a co nve nt io nal composite (rather
t han o ne spec ifically designed for cement ing
m inimal-preparation retainers, see page 233) and
the composite comes through the perforatio ns t o
the mo uth, it is prone to deg rad ation over a
period of years. How ever, t he main advantage of
the Rochette bridge is that it can be re moved
from the mo uth fair ly easily. The composite is
dr illed out fro m t he ho les, an d th e bridge can
usuall y be removed witho ut to o m uch force . For
th is rea son, the Roc hette br idge is st ill use d whe n
t he abu tmen t teeth have a poor prognosis and
whe n furthe r mo dification s are likely to be nec es -
sary - for example wh en one lower incisor is
bei ng re placed for periodontal reasons and the
190
o the r tee th arc sti ll re ceiving periodontal treat-
ment. The Rochet te des ign is also use d for
immediate inse rt ion br idges so th at the br idge can
be re moved when t he tissu es have healed and the
pontic adapte d to t he ridge or the bridge rem ade.
Histo rically, the me dium-mec hanical ret entive
systems we re deve loped afte r th e Ro che tt e and
Maryland designs in an attem pt to overcome th e
deadvaneages o f these de scribe d above. However,
they have disadvantages of the ir o wn in being le ss
retentive than the micro-mec hanical system and
yet having thicker metal retainers and a th icke r
cement film. O ne advanta ge. however, is that they
can be made in any metal. including precious
metals. whe reas the etched systems can only be
made in base metal alloys th at are etcha bte.
How eve r. despite this. they are no longer used.
Practical p o in t s
• The four basic br idge designs differ in th e
support provide d at each e nd of (he pontic.
• The basic des igns can be co mbincd ( 0 give. for
ex ample, a fi xed -fixed/cantileve r dcsign.
• Minimal-pre parat io n br idges are uscful, partic u-
larly in yo unger patient s. and - where practica l
- arc ofte n t he de sign of choi ce.
r ees of bridpe
Disadvantages of minimal.
preparation bridges in general
As the metal plate is added to the surface of the
rocth or o nly rep laces part of it. the th ickness of
(he too th is increased. and may (for example in
a no r mal Class I inciso r relatio nship) interfere
with t he occlusio n unless space is crea ted
o rt hodontically o r by grinding the op posing teeth
(see Ch apte r I I).
The margin of (he retainer ine vitably produces
a led ge whe re plaque can co llect. "ihis is a
pr o blem. espe<.ially in (he replacemen t of lo wer
incisors . Her e plaque and calculus de posits are
common on the lingual surface towards the gingi-
val margin. and (he presence of such a ledge can
only make it more difficult for the patient (0 clean
in t his area (see Figure 8.14) Another exampl e of
a design that would prevent good oral hygien e is
sho wn in Figure 8.12a.
• W ith co nventio nal bridges. (he fixed-movable
design is preferred to fi xed-fixed where possible.
• W ith rmmmal-prepa ranon bridges. the
prefe rred des ign is cantilever. followed by
fi xed-movable rat her (han fix ed -fixed,
• Bridges that are made to be rem ovable by the
patient make furt her e ndodontic o r periodon-
tal treatment possible and also make cleaning
easier.
9 Components of
bridges: retainers,
ponties and
connectors
Each part o f t he br idge sho uld be designed
individually, but w ithin t he con t ext o f the o ver all
design. T his chapt er sho uld th er efo re be read in
con junction w it h t he next , since in practi ce t he
t w o pro cesses - designing th e bri dge and it s
co mponen ts - are do ne t og ether, altho ugh it is
clearer to de scribe th em separately.
Retainers
Major or minor
As descr ibed in Chapter 8, all fixed-fixed ,
cantilever and spring cantilever bridges have o nly
major retainer-s. Fixed-movable bridges have a
major r eta iner at o ne end of th e po ntic and a
mino r reta iner (carrying th e mov able joint) ar the
other.
Majo r retaine r prepara tions must be reten tive
and. with co nvention al bridges. must cove r t he
wh o le occluding su rfac e o f t he too th. It Is impo r-
tan t to recognize th e difference between the
occluding and the oc clusal sur face.
A major r etainer fo r a con ventio nal po st eri or
bridge should no t be le ss t han an MO D inlay w ith
full occlusal protection . Fo r inciso r teeth it is
usually a complete cro wn . altho ugh pa rtial crowns
are sti ll sometimes use d.
Minor r e t ainers do no t need full oc clusal
protection: a m ino r re ta ine r may be a complete
o r partial cro w n. or a two - or three-surfa ce inlay
w itho ut full oc clusal prot ection (se e Figures 8.1 b
and 8.3 pages 174 and 175). Minimal-preparation
m ino r retainer-s are also used for mtnima t-pr epa-
rat io n bridge s w here t he occl us ion is favo ur ab le
(see Figure 8.3c and d) .
C o m p le t e crown, partial crown, intra-
coronal or minimal-preparation r etain ers?
The choice be tween co mplete o r parti al crow n
retai ne rs in the past was gov e rned by the
techniques and mat erials availab le. Befo re t he air
roto r and meta l-ce ramic techniqu es were avail-
ab le. three-quarter cro w ns were popular as
bridge retainers, partly because less enamel had
to be removed and partly because it was not
necessary to provide a toot h-coloured faCing.
W ith the air rotor, complete crown preparatio ns
became ea sie r , and the re was a swing to wards
complete cro wn retainers. Once metal-ceramic
and elastome rtc im pressio n ma terials became
ge nerally availab le. the sw ing wa s accelerated.
T he cho ice between complete and partial crown
reta iners for pos te rior con vent io nal bridges sho uld
depend upo n a pro per con siderat ion of all the
circum sta nces of the case. and sho uld not be made
fro m habit. It will be found th at even after a full
assessment, 80-90 % of co nventiona l bridge retain-
ers will be full crow ns, but for the remaining
10-20% the re are so und reasons fo r choosing a
partial crow n. (Sec C hapter 2 for a comparison of
complete and partial crowns.]
Int ra -coronal retainers are used only as m inor
reta ine rs except fo r very rete ntive MO D protected
cusp inlays.
W ith t he reported re ducti o n in car ies and with
a mo re co nservative approach to cavity prepara-
t ion. an increasing number of potent ial abutment
teeth have suffi cient e namel availab le for minimal-
preparation retainers to be considered. W hen
'"
19'
th is is so. th ey are usually the retainers of choice.
pr ov ided that t he o th er co ndul c ns for thei r use
are met (see late r). This is because th ey arc t he
most conse rvative reta iners. and it is wise to
preserve as much natural t ooth t issue as possible.
even at the cost of a slightly increased risk of
reten t io n failur e.
Part ial cro wns are now seldom used for
anterior br idge retaine rs. W hen the to oth is intact
a mmimal-prepa raricn reta iner is mo re co nse rva-
tive o f tooth tissue than a co mplete cro w n. and
so is the preferred cho ice whe neve r possible.
Ma t eri al s
Minimal-pre paration re taine rs are usually made in
base meta l alloys so that th ey can be etc hed and
also because the se alle ys are st ro ng in t hin
sect ions. Of the co nvent io nal retainers, an all-
me ta l re ta iner is the mo st conservat ive of tooth
t issue, and th e simples t and usually the least
expe nsive to pro duce . W hen appearance pe rmits,
t his s ho uld be used in the pos te rior pa rt of th e
mouth. In the anterior part o f the mouth
mccal-ccrarnic is the mo st suitab le mate rial.
Criteria for choosing a suitable
retaine r
In some cases the type of re ta iner w ill be obvious.
Fo r ex ample . if a roo t-filled tooth that already has
a post crow n is to be used as a bridge abutment.
CompOilems of bridges: retoiners, ponties ond connectorJ
Figure 9. 1
Non-parallel abutment teeth. It would not be possible
to make a Irxed-fix ed bridge with com plete cro wns on
the central incisor and canine. Even If one of the teeth
we re devitalized to align an artificial core with the
other abutment, this would not wo rk. If the canine
were devitalized, the core would have to be so promi-
nent to be parallel With the central incisor that it would
interfere gross ly With the occlusion. If the ceoe-al
incisor were devuahzed. the reta iner wou ld tilt lingually
and would be both uncomfortable and unaesthe tic. The
deSign chosen was a simple cantilever. The preparat ion
of the canine too th and finished bridge is sho wn in
Figure 10.3.
there is litd e choice but to use anoth er post-
retai ned crow n. whethe r as a majo r o r m inor
reta ine r. In ot he r cases, the fuU range o f choic e
is available. and the dec ision o n t he typ e of
reta iner canno t be d ivo rced from th e decisions
o n th e overall design and w hich ab utme nt teeth
to use . These th ree sets o f consid era tio ns are
dea lt w ith se parately (in C hap ters 8, 10 and here),
but in reality the decis ion-making proc es s is not
so clea r-cut. and thoughts o n po ssible abut ment
teeth , reta iners an d the o ve rall des ign intermin-
gle in th e o pe rator 's m ind and influence ea ch
o th er until a final deci sio n o n all three eme rges.
Th e criter ia fo r selec t ing a particular retaine r
will inclu de:
• Alignmem of abutme nt t ee th and reten tio n
• Ap pearan ce
• Condition of abut ment tee th
• Conse rvatio n o f too t h t iss ue
• O cclu sion
• Cost
A lignment o f a but ment teet h a n d
retention
Whe n t he abutme nt teeth are mo re o r le ss paral-
lel to each o the r and a filled- fixed co nve nt ional
bridge is bei ng cons ide red, e ithe r co mp lete o r
parti al crown retainers can be made. If the
ab ut ment teeth ar e not paralle l (see e.g. Figure
9. 1), complete cro wn retainers w ith a comm o n
Components of bridges: reta iners. ponks and connectors
pa t h of ins ert io n are no t feasible. T he y co uld no t
be made independently re tentive w it ho ut on e or
o t her of t he teeth be ing dev ita lized . T his is
so me t im es ne ce ssa ry, but it is a ve ry destr uct ive
approac h.
The solution w ill us ually be to employ a
m inimal prepa ration bridge o r a de s ign other t han
fixe d- fixe d so t hat t he teeth do no t have t o be
pre pared parallel to ea ch other.
It is im po ss ible to give in a bsolute t e rm s t he
amo unt of retention nece ssary for a nyo ne
retainer. It is reaso na ble to ass ume t hat t he
rete nt ion for a bridge reta ine r sh ou ld be at lea st
as great as fo r a similar resto ration made as a
single unit . W he n it is ne ce ssary to redu ce a
193
Figure 9.2
T he appearan ce of retainers.
a The canine to ot h has a par-tial crown reta iner that is
barely visible fro m t he fro nt. The bridge has been
prese nt fo r many years.
b T he upper canine tooth has an extens ive incisal wear
facet and pro nounced buccal st riae. The buccal surface
wo uld be diffi cult to re pro duce in po rce lain if a
complete crown retainer we re used. and a large
amount of gold wo uld show if the wear facet were
protecte d by a part ial crown retainer . The design of
the bridge in t his case was therefore fixed-movable
with a distal palatal gold inlay in t he canine toot h,
c The upper centr al incisor s both have minimal-prepa-
rat ion retaine rs. The blue ' meta l shine-t hro ugh' can be
seen , The incisal e dge of t he uppe r left central incisor
has bee n resto red with com pos ite, which is beginning
to lose its po lish. 'Metal shine-th rough' can be reduce d
by fi nishing the retainer shor-t of t he incisal edge. but
t his also re duces its rete ntion. The problem can be
minimized using o paque luting cements .
rete ntive feature, for examp le to ov er-taper a
pre paration to provide a single path of inse rtio n
w ith anothe r pr ep ara tio n, it is advisab le t o add
some further re tentive featu re such as groov es o r
a pin.
Appearance
In some cas es a co m plete crow n w ill ha ve a
better ap pe a rance, in some a pa rtia l crown, and
in o th ers a minimal-prepa ra tion re taine r.
Sometim es no ne of these types w ill be completely
satisfactory, Figure 9.2 shows exam ples of partial
c row n, infay. and minimal-preparatio n retai ners

'"
where the appeara nce of the buccal surface is
better than would be expected with a full crown.
Figure 9.2c also sho ws an example of 'metal
shine-t hrough', wh ich so metime s occurs with
minimal-pre parat ion retaine rs.
Whe n several teeth are to be cro wned o r
replaced as pa nt ies. t he re is an aest hetic advan-
tage to th e bridge retainers and pon tics being
made in the same materi al (usually metal-
ce ramic). at least giving co nsiste ncy o f appear-
ance.
T h e condition o f tile abutment tooth
Freq ue ntly a minimal-pre para tion or partial cro wn
r eta iner cannot be used bec ause of the presence
of caries or large restorations involving the buccal
surface, o r because of the los s of th e buccal
surface fro m tra uma or other cause . In th es e
cases a co mplete crown reta ine r is chosen.
Conservation of tooth ti ssue
The re is a natural re lucta nce to remo ve so und
buccal ename l and de ntine fro m a healt hy intact
to oth. This weake ns th e tooth, destroys its
natural appe arance and endangers th e pulp.
The refo re minimal-pr e paration re tainers sho uld
be used whenever po ssible. However, if the re are
sou nd ind ications fo r a complete cro wn, th e
o pe rator sho uld no t allow his o r he r clinical
judge ment to be infl uenced by an overpro tective
attitude to dental e namel.
Occlusion
In so me cases t he ab ut me nt teeth are sound but
t here is insufficient space for a minimal-prepa-
rati on retainer. The cho ice therefore is
be tw een creating space by re ducing th e o ppo s-
ing teeth, pr epari ng part way thro ugh the
ename l o f the ab ut men t te eth, mov ing the
abu t me nt t ee th o r tho do m ically o r a co mbina-
tion o f th e se ap pr o aches . Often th e be st way to
achieve a sma ll amount of axial tooth move men t
is to use a fixed Dahl app liance (se e Figure 4.6.
page s 72-3). If non e o f these met hods arc
acceptable then a co nve ntional re ta ine r will be
ne ce ssary.
Comp on~ n ts bndg~ s :
or rNajncrs, ponlics and W'ln eetors
Cost
Part ial crowns and complete metal cro wns may
be less expensive th an metal-cerarruc cro wns
(see C hapte r 2), and minimal-preparat io n retain-
ers ar e the least expe nsive. When t here are no
o ther overrid ing factors affecti ng the cho ice. t his
is o bvious ly o f co nsiderable importance .
Panties
Principles of des ign
Pa nties ar e de signed to serve th e thr ee main
functions of a bridge:
• T o imp r ove appearance
• To sta bilize me occl usion
• T o impro ve masticatory function.
In differe nt areas of the mou t h th e relative impor-
tance o f th ese will alter. T he princ iples guiding the
design of t he po nt ic are :
• C leansability
• Appe ara nce
• Stren gth.
The co mp ro mise o fte n necessary betwee n cleans-
ability and appearance will also vary in different
parts o f the mouth.
Cl e a n sa b ilit y
All surfaces of t he po ntic. espec ially the surface
adjace nt to the saddle, sho uld be made as cleans-
able as po ssible . Th is mea ns t hat t hey must be
smooth and highly po lished o r glazed. and sho uld
not co ntain any junction s between different
materi als. In a metal-ce ramic pon tic the junction
between t he two materi als sho uld be well away
from th e ridge surface of the ponti c.
It is important too that the embrasure spaces
and co nnecto rs sho uld be smooth and cleansable.
T hey should also be as easy to clean as po ssible.
Acce ss to t hem and the patie nt's dexter ity shou ld
be taken into accou nt in de signing po ntics.
W he n a co nflict e xists between c1eansab ility
and appearance, priority sho uld be given to
c1eansability.
Compon~n(~ of bridf" "Iorn~rs, peones a nd cO/'1 nc<Iors ,,,

Fig u re 9.3

The stre ngth of mecat-cerarmc panties.

a The centra l incisor panties in this case have no m etal

visible on the palatal surface.

b W hen the palatal reduction of the abutment teeth is

only sufficient for a layer of metal. this is often carried
along the peone s as well. leaVing an occluding sulfate
entirely in metal. The porcelain. however, is carried right
under the peones '>0 that 0f11y porcelain con tacts the ridge.

c Preformed wall: patt erns for me tal-c eramic peones .

The porcelain is con densed through the holes.

Appe arance st rengt h with a minimum of me ta l are availab le

(the reinforced porcelain system - RPS) (Figures
Where the full le ngth o f the pontic is visible. it
9.3c and 8.Sb. page 178).
m ust lo o k as toothlike as possible. Ho w eve r. in
the premo lar and first molar regio n it is often
possi ble to strike a happy compromise between
a reasonable appe aran ce for those parts of the The surfaces of a pontic
pontic th at are visible and go o d acc ess for clean-
ing towards the r idge . A pontic has five surfaces:

S trength • The ridge

• The o ccl usal
All panties should be des igned to withstand • T he appro xirnal
occlusal fo rces; but porcelain panties in the • Th e buccal
anterior part of the mouth may not of course be • Th e lingual.
expecte d to withst and accidenta l trau matic
forces. So me o f the se will be similar to the nat ur al too th
The lo nge r t he span, the greate r the occl usal being replac ed : o the rs will be very differe nt.
gingival t hick ness of th e pontic should be .
t-teta l-cerarmc ponncs are stiffer and withsta nd
occlusal forc es better if th ey arc made fairly thick The r idge su rface
and if the porcela in is carried right round th e m
fro m th e o cclusal to the r idge surface. leaving This surface o f th e pontic is the most difficult to
o nly a line of metal visible on th e lingual surface clean. and yet it also has a considera ble influence
or no ne at all (sec Figu re 9 .3.1, b). Preformed wax o n ap pearance . Th ere are fo ur bas ic designs o f
patterns fo r pantie s de signed to give max imum r idge surface (see Figures 9.4 and 9.5) .
196

F igure 9.4

T he fo ur designs o f po nnc r idge surface.

a A wash. th rough po nt ic w ith a concave mesio- dista l

co ntour.

b Wash-th rough pontic. co nvex me sio- disu.lly.

c and d Dome-shaped pe r-tics. c A molar dome-s haped

ponti c w ith the male par t of a movab le co nnecto r and
a lingual handle to localize th e po ntic wh ile solderi ng
to the go ld crown. This hand le w ill be rem oved after
the br idge is tri ed in.
 197

d An acrylic provmonal bridge frtted as an immediate

r eplacem ent fo r th e lower left ce ntral and la t~ral
inci sors. sho w ing an applic ation of th e dome-shaped
pontic.

e and ( Ridge-lap ponncs. e This bridge has been satis-

factory. but th e pat ient complains of food impact io n
under the single lat era l incisor pont ic. She can sweep
th e o ther side clean wit h her to ngue since the span is
lon ger.

www.allisla m.nel
Problem

f A mod ified r idge-lap po nt ic with co ntact over the buccal half of

the ridge but cut away lingually. Th e bridge has failed because of a
fract ured so lder joint (sec Chapte r I ]j ,
198
Wash-through O the r terms used for this type
of po ntic are hygienic and sanitary, but the te rm
wash-through is more descriptive and less sugges-
t ive of vitreo us china bath r o o m fittings. T he
w ash-t hro ugh po ntic makes no co nta ct w ith the
so ft tissues a nd so is the easiest to dea n. It is
used w her e a po ntic is r equired for funct io nal
purposes rat her (han appearance and is most
ComPonentl of b"d~es.- relainers. tJomics (Jlld ccooecrcrs
g T ypical ridge -lap peo nes o n ano th er {;ailed bridge.
Th is t ime t he failu re W ;ll due to lo ss of reten tion.
D es pite (he deSIgn an d the smooth porcelain surface.
m e ridge beneath these peones w as mode rately
inflamed.
n Saddle-sh ape d ponncs wit h w ell-co nto ur ed, clea ns-
able co nnecto rs.
useful in t he lower mo lar region. Of the tw o
des igns sho w n in Figure 9.4a and b. the concave
mesiodi sta l des ign is prefe rred. It is sufficient ly
strong, use s less me ta l and leaves a large space
fo r access for the too th brush or o the r clea ning
aid. The othe r design derives hist o r ically from an
early type of pro prie tary 's anita ry' po ntic. wh ich
is now o bsolete.
Components o( bridges: retainers. pomics ond connectors 199

Figure 9.5
Fo ur sectioned casts o f t he same pat ien t , show ing th e
profi le of the m idpo int of a lower m ola r ede nt ulo us
area wh ere a br idge is to be made. The profi les of fou r
pontics are show n;

Q A wash -thro ugh po nt ic with no contact w ith the

ridge.
b A dom e po ntic making poin t co nt act o n the t ip of
th e ridge.
c A partly modified ridge-la p po ntic w ith a bu cca l
surface resembling a natural tooth but w ith m inimal
ridge contact. Th e difficulty of cleani ng t he lingual
aspect ne ar th e r idge is o bvious.
d A fu ll-sad dle po nt ic that, if well pol ished on the gingi_
val s urface. wo uld be c1eansa ble with su pe rflo ss.
200
Dome-shaped (see Figure 9.4( , d) This is the
next eas iest to clean and is used where the
oc clusal two-th irds or so of the buccal su rface of
th e pontic show, but not the gingival th ird. It is
co mmo nly used in th e lower inciso r and premol ar
regio ns and so meti mes in the upper molar r egion .
This has also been described as torpedo -shaped
or bullet-shape d. but th e less aggressive term.
dome-shaped. is preferred.
Ridge-lap a n d mod ified ridge -lap (see Figure
9.4e, f g) T he principles o f this des ign arc t hat
the buccal surface should lo o k as much like a
tooth as po ssible right up to the r idge. but th e
lingual su rface sho uld be cut away to pr o vide
access for cleaning.
Ideally the pontic shou ld have a co mpletely
co nvex lingual surfa ce. mak ing onl y a line con tact
along the buccal side of the r idge. But t his is often
impractica l beca use of th e shape of th e ridge . and
so the modified r idge-lap pontic. which has
minimal co ntact with the ridge fro m the po int of
co ntact on the bucca l side up the crest, is o fte n
used (see Figure 9.4).
Th ese designs, particularly if the pon tic is fairly
narr ow meslo -distalty, as in t he case of an inciso r
or premo lar po nt ic, are sometim es unpo pular
with patie nts because they find that food impacts
into t he space o n t he lingual side and canno t be
readily re mo ved with t he to ngue (see Figure
9 .4e ). Besides. considera ble manual de xterity is
need ed to mano euvre denta l floss, ta pe o r o ther
cleaning aid. hold ing it first against the po ntic and
then in a secondary cleaning mo vemen t against
th e r idge (see Figure 9.5).
T hese po nuc s were designed at a t ime w hen
there was a lo t of concern abo ut the effect of
po ntics on the soft tiss ues but befo re the signifi -
cance and nat ure of plaque we re as well und er-
sto od as th ey are today. T hey are st ill co mmo nly
used, perhaps t hro ugh habit and co nvent io n.
Other design s sho uld also be co nside re d.
Saddle T he saddle po nt ic is so name d because
of its sha pe . It has by the far t he largest area o f
su rface co nta ct with soft tiss ue . and so. although
it wa s popular in the early days o f bridgewo rk. it
became much tess so as den tists became more
conce rned about th e effects o f pontics o n ridges.
Now that it is rec ognized th at plaque can cause
inflammatio n ho wever sm all th e surface area o f
contac t and must be remo ved in all cas es, the
em phasis in po m ic de sign has shifted . Accessibility
fo r cleaning and patient comfo rt and convenience
are th e important criteria. rather tha n the size of
area of co nta ct. Many pat ie nts pr efe r th e saddle-
shaped po ntic since t he lingual surface feels mo re
like a tooth than any o the r de sign. W ith modern
cleaning aids. such as supe rfloss. the ridge surface
o f properly de signed and const ru cted saddle
po nncs is relatively easy to clean. This also
req uires less manual de xterity by the patie nt than
ridge-lap po ntics (see Figure 9.Sd).
A saddle po ntic sho uld clo se ly fo llow the
co nto ur of the ridge but sho uld be smo o th on
the unde r surface. It sho uld not displace the soft
tissues o r cause blanching whe n it is inse rted. but
sho uld make snug contact.
The effects o f pontics o n the ridge
Sometimes w he n bridges ar e re moved the area
o f t he ridge th at wa s in contact with t he po ntic
has a red appea rance. Bio psy st udies have sho wn
t hat there are always some chr o nic inflam mato ry
cells in this regio n, but the main expla natio n for
t he re dnes s is probably t he red uction in
kerat inizatio n. Th e surface doe s not have t he
norma l stimula tion fro m foo d and th e tongue that
st imu late s ke ratinization elsewh ere . Unless clearly
inflamed o r ulce rated. the redness is of little clini-
cal co nsequen ce (see Fig ure 9.6).
The occlusal s u rfa ce
The occlusal surface of the pontic should rese mble
the occlusal surface of the tooth it replaces.
O therw ise it will no t serve the same occlusal
function s and may not provide sufficie nt co ntacts to
stabilize the o cclusal relation ships of its o ppo nents.
In some case s. w hen oc clusal stabi lity is less
importa nt (for e xample whe n t he po ntic is
o pposed by ano t her br idge), the po ntic may be
mad e narro we r bucco -Iingually t o impr ove access
for clean ing. Othe r argu men ts for nar ro wing
po nrics are less co nvincing (see C hapte r 10).
The approximal su rfa ces
The shape o f th e me sial and dista l surfaces o f th e
pon tic will depe nd upon th e design. W ith
fixed-fixed br idges the appro x imal surface will
consist partly of a fixed co nnector. It is impor-
ta nt that the em brasure spa ce between th e
con necto r and the gingival t issue be as o pe n as
 201

Figure 9.6

a Mucous-membn ne reactio ns under pon ncs. This area

of red uced ke ratiniutioo unde r a pontic pr od uced no
symptoms. Ther e was no ukeraoco or bleed ing on floss-
ing under the pontic. AJthotJgh inflammation requiring
trea tm e nt at the gingival margin o f the abutment t(!oCth
is present, it is do ubtfu l whe th er- the changes in the
remainder of the ridge have had an y real significance.

b A much mo re se rio us case, with ulce rat io n and a

very inflame d ma ss o f gra nu lat io n t iss ue. T his mu st
clearly be treated in the first place by removal of the
br idge. In fact no furth er t reatment was nece ssary. The
inflammation re so lved o ve r a three -wee k per iod .

Fi gu re 9.7

Well-con toured o pe n e mbras ur e space s.

Figure 9.8

Sectio ns th rough bo th t he late ral incisor areas o f the

same patie nt . l eft: the la te ra l inciso r is pr esent. RIght:
it is missing and t he .alveo lus has re so rbed . The pr ofIle
of th e r eso rbed side has been superimposed on the
oth e r to sho w the ex ten t of me re sorptio n and th ree
ways in wh ich a pontic might be modified to ove rcome
mis problem.
202
, contoured in line with th e adjacent teeth so that all the
pos sible to ensure that there is good access fo r
cleani ng. particularly if the pontic is a ridge -lap or
saddle pontic (see Figure 9.7). T he gingival side of
a movable joint is more d ifficult to leave ent irely
smo o th. and so it is again impo rta nt t hat there
sho uld be good ac ce ss for cleani ng.
The approximal surface o f a cantilever bridge o n
its free side will simply make normal contact with
the adjacent tooth. o r in some cases there may be
a diastema w ith no contac t. Occasionally. where th e
span is very short, a cant ilever pon t ic may be mad e
to overlap the adjacent tooth to improve its appear-
ance. In th is case t he ponti c surface in co nta ct w ith
t he natu ral tooth sho uld be as smooth as possible,
although it may be slight ly concave. If th e pati ent is
taught to d ean with dental floss, the natural tooth
surface shoul d not be any mo re susceptible to caries
than with a no rmal contact point.
The buccal and lingual surfaces
The bu ccal surfa ce o f a wash- through or dome-
sha pe d pontic does no t rese mb le the shape of a
Compon~n ts of bridg"l"' rr toin" rf, pan!/(s and conn"ctOfI
Figu re 9.9
Buccal pOntic-ridge re lationships.
a A pontic replacing an upper canine, where the neck
of the poouc has been curved inwards to meet the
resorbed alveolar ridge at the corr ect vertical po sition.
The incisal two-th irds of the buctal surface have been
compen sOl.tion for the missing alveo lar bone is in the
gingival buccal third. (Note the excessive amount of
gold shown by these two partial crowns. in contrast
wilh those in Figure 9.7.)
b The same compromise has not been made with this
lower premolar pontic, which instead looks too long.
This would also rr-eaee difficulty in cleaning under the
pontic.
natu ral buccal surface, particularly gingivally. With
ridge-lap an d saddle ponties th e buccal surface is
inte nded t o look as m uch like a tooth as possi-
ble for its entire le ngth . The problem is th at when
a tooth is m issing. so also is some o f the alveo-
lar bone t hat supported it. Th is means tha t the
alveo lar conto ur w he re the pontic touches the
ridge never looks e ntirely natura l, and the pontic
must also be sha ped unnaturally to meet the
resorbed ridge. Figure 9.8 show s. by means of
sections t hrough a study cast, how the ridge
co nto ur in a resorbed sadd le area necessitat es a
compromise pontic app ear ance. Figure 9.9a
sho ws an o bvio us ex ample of th is wh e re an upper
canine is missing. Figu re 9.9b also sho ws an
example of a case in wh ich this co mpromise has
not been made. T he aesthe tic result is no t good
and the re is greater difficulty than necessary in
cleaning.
No ridge-pontic r elat ionsh ip can ever appear
entirely natural, even wh en the ridge has no t
resorbed significantly. But at th e normal distan ce
fro m wh ich teeth are seen, the illusion that the
tooth emerges from t he gum can be sufficien t ly
Component\ of brjdges: retainers. pontics and connectors
I
convincing: wh ich are the po ntics and wh ich ar e
t he retai ners in Figur e 9 .101
The lingual surface of a po nt ic w ill be design ed
as a res ult of deciding t he ridge surface. W ith
ridge-lap po ntics, the lingual surface should be
s moo th and co nve x.
Materials
The cho ice fo r po m ics is the sam e as fo r retain-
ers. At o ne t ime there w as also the choice of a
numbe r of proprietary pontic facings.
Propri etary p ontic facings
W ell after the introd uction of me ta l- ce ra mic
mat e rials, until de ntists and tec hnicians became
203
Figure 9.10
An acceptable appearance for a bridge - or is there
more than one bridge!
Figure 9. 11
A long-pin porcelain pontic facing. The two pins
protrude from the palatal surface. The neck (above) and
the incisal edge are ground to shape before the backing
is waxed up to the pontic facing. W hen the backing is
cast. the facing is cemented and the pins cut slightly
long and riveted ove r into two small countersinks o n
the lingual 5.!Jrface.
mo re confident w ith t hem, man y panties w e re
made w it h proprieta ry ce ram ic po ntic facings.
N owadays. howe ve r, t hese facings are not used,
an d so wi ll not be described in detail. It is on ly
necessary for the practising de ntist t o recognize
the common types and have so me ide a about
maint e na nce and repai r (sec Chapter 13).
The commo nes t type of fac ing in rece nt use
was the ceram ic lo ng-pin facing (see Figu re 9. 11).
Other old er types includ e Steele's flat-back
facings in porcela in o r ac rylic, Trup ontics an d
tube pontics.
The s pecia l ca se of the s pring cantil ever
bridge ponti c
Again the br idges a re now se ldom made, but
many patients still have the m and they may need
mainten an ce or re pair.
,0<
Spring cantilever bridge ponrics may be
metal-ceramic. Th is means e ither making the
w hole spri ng arm of a metal suitable fo r bonding
t o porcelain. o r soldering a meta l-ce ramic pontic
to a standard gold bar. w he n local ization is a
problem. The bar settles into the tissues for the
firs t two to th ree w eeks after it has been
ce mented. and so it is better not to complete the
ponti c unti l th is has happened.
For the se reaso ns the spri ng cantileve r br idge
po ntic o ften co nsists of a separa te cro wn
cemented to a core o n t he end of th e bar. The
core s ho uld have a diaph ragm $ 0 th at t he ce me nt
junct ion is no t dee p unde r the po ntic an d difficult
to clean.
C onnecto rs
Fixed conn ectors
The re are three types o f fixed connector:
• Cast
• Soldered
• Porce lain.
Cast connectors are made by wax patterns of
the re tainers and peones connected by wax being
produced so that the br idge is cast in a single
piece. This has the advantage that a second
so ldering operatio n is no t requ ire d. But the mo re
units there are in th e bridge. t he more accurate
t he casting must be. Mino r discr epanci es in the
co mpensation for the co ntraction of mo lten
metal t hat may be acceptable for single-unit
casti ng beco me unacce ptable when magnified
seve ral t imes.
Cast co nnecto rs are stro nge r than soldered
co nnecto rs, and also it is sometimes possible to
disguise t heir appearance more effecti vely. For
t hese reaso ns, mult iple-un it bridge s are often
cas t in se ve ral sections o f thr ee o f four un its
d ivide d t hro ugh the middle o f a pontic. The sp lit
pon t ics are th en so ldered with high-fusing
so ld e r befo re the po r ce lain is added. so tha t all
th e co nnecto rs are cast. The so lde r joi nt
produce d in th is way is Strong both be cause it
ha s a large r surface area than if it we re at the
conn ecto r and bec ause it is covered by porce-
lain. stiffening it.
Soldered c onnectors are used if the po ntics
and retaine rs have to be made separa refy . This is
nec essary when th ey are made of differ ent
mate rials. for exa mple a complete go ld crown
retainer with a meta l-ce ramic pontic.
Porce lain con nectors are used o nly in con junc-
tion with all-porcelain bridges . The detai ls of their
co nstruction are beyo nd the scope of this book.
but the same princ iples o f access ibility and cleans-
ability n il! apply.
Movable connectors
Movable co nnecto rs are always designed so t hat
t he pon tic canno t be de pressed by o cclusal
forces. T his means that th e gro ove or depression
in the minor retainer must always have a goo d
base <Ig<linst which the male part o f the attach-
men t can seat. So me times. with small po ntics and
short spans. th is is the on ly force tha t need s to
be resisted. and therefo re the female part of the
attachment, in t he minor retai ne r, need o nly be
a shallow depression (see Figur e 8.3c. page 175).
This ir the co mmonest des ign for fixed-m ovable
minimal-preparatio n br idges.
However. with longer-span bridges the
mo vable joint must also resist lateral forc es
app lied to the pontic and (assuming the movab le
joint is mesial) distal forces o n the pontic. which
wou ld separate the co mponents of the mo vable
con nector. In these circumstan ces the co nne cto r
is des igned as a tape red keyho le-shaped slot so
that t he pin can move up and down a little and
yet seat fi rmly against the base of the slot, but it
cannot move laterally and th e co nne cto r cannot
separate. Examples of this typ e of co nnecto r are
shown in Figure 8.3.
The re are different ways of pr o ducing movable
co nnec tors. In the free hand method a wax
pattern is produ ced for the minor reta iner with
a shallow dep ression o r tapered groove prepared
in the W3X . the retain e r is cast and with a groove.
the shape is refined with a tapered bur. T he
pontic is t hen waxed up wit h a finger o r ridge to
fit into the depression or groove. Th is is cast and
the twO parts of th e movable joint fitted together
before the bridge is taken to the chair-side for
try ing in (see Figure 8.Ja).
Comp or>ents of bridges: rct"ir>e~. pool ics ami (o nnKtars 205

Figure 9.12

Creati ng a fixed-fixed des ign W I th ncn -paraltel

1 a bu tme n ts.

a The cen cralmctscr could not be retracted suffiC iently

to be par allel to the o ther abutm e nt teeth eve n if

/ devitalized and wit h a post and co re fin ed. I[ would

interfe re w ith the occl usio n.

b and c The bridge is made in two parts wit h separate

pat hs of inse rtion, and t he divided ponti c con nected in
the mou t h by ceme nt and a screw attachm ent.

In so me cases a de pression o r groov e may be
prep ared in an ex isting cas t re storat io n in the
mo uth and an impre ssion taken o f it toget he r
wit h t he other prepared abutm ent to oth or
teeth.
Acrylic. burn -o ut. pattern s arc available that
may be inco rpora ted into the pontic and mino r
reta iner so that t he whole br idge can be waxed
up in o ne o pe ration and th e mino r retainer and
re mainder of the bri dge invested and cast
se parate ly (see Figure 8.3b. page 175).
Pro prie tary groove-and -ridge precision attach-
me nu in me tal may also be used as movable
con necto rs. but are generally too retentive and
206 Componeflrs of bridge,: '''lomers. pontICS a nd cooeectors

there is the r isk that t hey w ill no t permit
suffici ent mo vemen t. When precision attachments
are used. the m ino r r eta iner sho uld have more
retention to its ab uunent dun would be neces-
sary if a less retentive co nnecto r were used.
Scre w precisio n attachment co nnectors may be
used to produce a fixed-fixed bridge by connect -
ing two retai ners that canno t be prepa red paral-
lei to each oth er (see Rgure 9. 12).

Practical points
• Components need to be designed wit hin the • W ith ponti es it is often necessary to compro-
context of the wh ol e bri dge . mise be tween the best results for cleanse bility
and appearance .
• The crit eria for selecting reta iners depe nd o n
t he co nd ition of th e ab ut ment teeth, appea r-
ance, oc clusio n, co nser vat io n of t ooth tissue
and cost .
 10 Designing and
planning bridges
Criteria for selecting a bridge
d esign
N o firm rule s can be given for selecting any
parti cular design. Bridge design is co mplex. poorl y
r esearc hed and do minated by per sonal o pinion
de rived from clinical expe rie nce, o r lack of it.
Many o f th e ground rules of bridge des ign were
laid do w n in the first three decades of t his
ce nt ury by teac hers w ho were trying to re scue
t he subjec t from th e purely emp ir ical appr o ach
used until that t ime. Alt ho ugh t hey w er e a majo r
advance o n what had go ne before, th ese ground
ru les we re not scie ntifically invest igated. Yet they
became accepted as irrefutable and rema ined
relatively unaltered for over SO years, despite a
growing understa nd ing in that time o f related
subjects such as the · supporting structures of
teet h in healt h and disea se. and o f occl usio n and
jaw funct ion. In this period. great 'deve lo pments
have been made in resto rative mater ials and
techniques. so t hat bridges now fit better', lo ok
better and are stronger.
This Increased unde rstanding and tech nical
de velopment sho uld affe ct tradition al ideas of
des ign to a conside rable de gree.
In re cent years, clinical evidence has been
accu mulat ing suggest ing t hat many o f the earl y
rules of bridge design should no lo nger be applied.
However. th is evide nce is not yet suffici e ntly
clear -c ut for new , firm rule s to be establishe d.
leaving today's dentists. including th e au thor. in a
state o f confusio n. A num be r of crit eria may
nevertheless be used in cho osing a design.
although the we ight gi....en to ea ch w ill vary w ith
the circumstances and the o pinions held by the
o pe ra to r. It is to be hoped tha t with further clini-
cal re search (w hich is urgently needed) the
relative importance of these criteria will become
clearer.
Su pport
O ne o f th e best kno w n rules for bridge de sign
was devised by Ante and de scribed by him in
1926. He suggested that eac h pontic sho uld be
su pported by th e equivalent of an abutme nt tooth
w ith at least the same ro ot surface area covere d
by bo ne as w o uld have su pported the miss ing
tooth; that is. a gi....en area of periodo nta l
me mbrane co uld suppo rt up to tw ice its no rm al
occl usal load . T he root surface area of an
ab utment tooth co ve re d by bo ne is o f co urse
redu ced following destructive periodo nta l disease .
T his has been '" guiding principle fo r many yea rs.
and o ther worke rs have calculated the average
root surface ar-ea of all teeth and suggested typical
bridge designs based upon these calcul ations.
This arbitrary. mec hanical rule is similar to the
engineering principles used fo r designing bridges
acro ss ri ....e rs. There ar e many reports in the liter.
at ure of e xperiments (Uloually carried out in the
labo rat o ry o n models o r in computer simulations)
rela ting ccckrsa! fo rce s to reactions in the suppo rt-
ing structures o f teeth . T he results of th ese expe r-
iments have tended to re info rce thes e me chanical
ideas of how bridges sho uld be desi~n e d .
The evide nce now accum ulati ng suggests that
th ese principles are w ro ng, o r at least do not tell
the wh o le sto ry. Provided that any pe rio dontal
dise ase is treated and per io do ntal heal th
ma intai ned . and pro vided th e oc clusal fo rces are
eve nly d istributed. b rj~ge s can be successful with
as little as o ne-q uarter o f the support ad voca ted
by Ante. Such bridges have been successful for
many yea rs .
The ass umptions mad e ' by the enginee ring
school of though t ignore the fact that the occlusal
load o n' a bridge is determined no t by extrane-
ous influences. su ch as lorries driving across road
bridg es . but by the muscl es of masti cati on. These
20'
208
x x x x
~ ~ ~ ~
a b
t t t
X X X
t
1,SX
Figure 10.1
Occlusal loading of abutme nt recch.
a In an intact dentition an occlusal fo rce. X, is res isted
by an eq ual and opposite fo rce ge nerated with in the
s upporting stru ctures of the toot h.
b W hen a tooth is ext racte d and rep laced by means
of a bridge. engineeri ng pri nciples suggest that the same
force. X, deliv ered (0 each of the three occlusa l
surfaces wo u ld require the gene ranon of I.5X in the
su pportmg structure s of the two re ma in ing t ee t h. T his
princIple is no doubt true fo r inanimate objects bu t
assum es mat the occlusal fo rce is constant..
c The occlusal force is of co urse generated by muscles
of masncaoon, wh ich are und er phySIological co ntrol
and do not function independently. The refo re. if the
supporting str uctur es of the two remaining tee t h are
are unde r the cont rol of the neu ro muscular
mec ha nism, itself influen ced by propr ioception
fro m receptors in th e per io dontal membrane o f
th e teeth su pporting th e br idge . Compa riso ns
w ith road bri dges a re th e refo re meaningless .
Th ere is plenty of ev ide nce t hat oc clusa l
lo ad ing is modified by th e prese nce o r absence of
natural teeth and by their co ndit ion. For e xam ple.
pati e nts can generate 10 times as much force
between upp er a nd lower natural tee th as they
x x rorarz x _ M usc le s of
~ ~
~ mashct on
~ ~ 0
e
a
•
~
a
t
- I
Pcu odonlal
se n so ry
t
1,SX
tX
t
X
receptors
only capable of gene rating a res isting fo rce of X. and if
the y retain a full periodontal senso ry mechanism. once
force X is exceeded. the pro prioceptive mechanism will
suppress the contr actio ns of the muscles of masuca-
con so that t he force delivered to the three occlusal
surfaces totals 2X.
This is an oversimplified version of what happens in
rea l life. Sometimes the sensory mechanism is not
intact OWing to penodomal disease and alveolar bone
loss. The proprioceptive mecharusm may be overrjd-
den by "sumulae from higher centres. producing
brUXIsm o r other- parafunetiof1:ar actiVIty. The descrip-
tio n also igno res the effect of late ral forces which are
more complex. Howeve r, the illust ratio n serves to
show that bridges should not be designed simply using
eng,neenng prmctples. the biological implications must
be taken into account.
ca n between upper a nd lo w e r co mple te dentures,
whe re t he fo rce is re sisted by m ucous membrane.
It is false log ic to ass ume th at inc reasing the
occlusal area o f a tooth by adding a pontic to it
w ill lne vuably increase t he occlusal loa ding o n tha t
tooth. Howeve r, fo rce s in an 'unna t ura l' dire c-
t ion, for e xample ro tational or leve rage forc es,
ma y not be res isted so well. T he re is not the
same inb uilt mechanis m to pe rcei ve a nd control
t he se forces (see Fig ure 10.1).

These conside rations are ofte n less impo rta nt
in designing small bridges than they are w ith large
bridges. Figure 10.2a sho ws a case whe re the span
is so small that any o f the available abutment
te eth w ou ld me et all the trad itio nal criteria fo r
suppo rt; w hile in th e case o f Figur e I O.lb a br idge
co uld no t be pr ov ided if A nt e's law w ere to be
o bse rved.
Figure ID.2e sho ws th e bridge for th e same
patient. It has been successful fo r man y years.
209
Figure 10.2
Abutmen t su ppo rt and length of span .
a A tiny pontic is needed he re. a nd any o f the avail-
able ab utme nt tee th . whi ch have no alveol ar bone lo ss.
w o uld prov ide m o re tha n e nough s upport .
b Radiograph s o f t he six abut me nt tee th suppo rting the
IO-unit bridge in c. A ll th e abutment tee t h have less
th an half th~ ir original bone support. For the rem ain-
ing lowe r t ee th th is is also much reduced, but th e
pe r io do nta l treatmen t has been success ful and th ere
has been no increase in bo ne loss or further mobility.
c The br idge has been sat isfacto ry, with no further
bo ne loss. but the te rminal abutment o n the left o f the
picture has had t o be ro o t-t reated th rough th e
retamcr. The bridge. wh ,ch wa s 9 years old w hen this
photograph was ta ken. is rather bulbous.
An examp le o f a bridge de sign that is
sometimes unnecess;l.r ify destructive becau se it
relie s in part o n Ante's law fo r its justificat io n is
the replacement o f fo ur uppe r incisor tee th w hen
t he ca nines and first prem o lar teeth on both sides
are used as abut ments. Not on ly is t his dest ruc-
t ive. it also cr eates e mbrasure spac es between
the splinted ab utme nt teeth , wh ich are diffi cult to
clean. T he premolars arc less satisfactory
abutments than th e ca nines. and add little to th is
210
design. It has been sa id th at occlusal pressure on
the pcrmcs. which are in fro nt o f a straight line
between canine abutme nts, wo uld produce a
t ilt ing force o n the canines. However, in a canine-
guided o cclu sio n th ese same tee th w ill w iths ta nd
the e ntire forc e of lateral excursions and yet
often remain the firmest te eth in the ar ch. Figures
8.la (page 174) and I l.3a (page 225) show two
cases w he re the can ines alone have been used
very satisfactorily as abutment s. This de sign. using
the two canine tee th as the only abutm ents, can
now be regar ded as the no rmal design for a
br idge to re place th e four inciso r t eeth in eit her
the upper o r lower jaw. It is no t necessary and
may be counterproductive to include the flrst
premolar teeth.
The bes t guidance tha t ca n be given for th e
present is that ab utment teeth with healt hy
perio dontal tissu es are well able to suppo rt a
(theoretical) increase in load ing in an ax ial direc-
tio n by an amount that is virtually unlim ited.
Ho wever. they are not so w ell able to withstand
twisting or lever ing forces. T his means that large
bridges o f fixed-fixed design can be made with
very limited num bers o f abut me nt teeth . The
curvatu re of the brid ge aro und the arch reduces
t he leverage and tw isting fo rces so that all fo rces
are in th e long ax is of th e ab utment teeth (see
Figure IO.2c). Th is is the principle of 'cro ss-arc h
splinting', and it may be extended 50 that in ideal
circumsta nces lo ng cantilever ex tensions of several
units may be carried by such bridges (see Figur e
8.5, page I78). Ho w ever, these long cantilevers
cannot be suppo rted by individual abutme nt te eth,
They wo uld produce a leverage o r tw isting fo rce
o n the abutment tooth causing mov eme nt of the
tooth in the same way as an orthodontic appliance ,
or they would loosen the tooth.
The ap plica tio n of th ese principles of su pport
is illust rated in a serie s of exam ple s at the end o f
this chapte r, an d more prac tical advice on se lect-
ing abutme nt teet h is also given lat e r in t he
chap te r.
Conservatio n of tooth tissue
C learly t he most co nse rvative design is a minimal-
preparatio n bridg e. This is th erefo re t he design of
cho ice wh ene ve r possible, but in many cases it is
not.
All co nve ntio nal br idges are potentially
destructive , and so me are immediat e ly so. Figures
9. 1 (page 192) and 10.3 show a case in wh ich a
bridg e was mad e before the int roduction of
m inimal-p rep ara tio n bridge s. Th e bridge has
remained sta ble and satisfactory. A conve ntional
bridge nec essitated exte nsive destruction of
sound toot h tiss ue. Although t his is unfortunate.
th e alte rnative s of leaving the space o r of pro-
viding a parti al denture we re even more
unacce pta ble.
It was reaso nab le to usc a bridge design as
co nservative of tooth tissue as po ssib le, at the
same time being compatible w ith othe r principles.
In this example a simp le cantilever bridge was
used with only o ne abutme nt too th rath e r th an
fixed- fixed o r fixed-movable designs th at would
have invo lved mo re abutme nt teeth.
Cleansability
Figure 9.2b (page 193) sho ws an examp le in which
an upper first premo lar is missing. If it is decided
th at a simple cant ileve r de sign using e ithe r the
uppe r ca nine o r the upper se co nd premola r will
no t giv~ sufficient suppo rt. the cho ice w ill be
between a fixed-fi xed or fixed-movable design,
o r a cantilev e r bridge using the premo lar and first
mo lar splint ed toget her as th e ab utments. This
latter design will be more difficult fo r the patient
to clea n than t he othe rs becaus e of the fixed
co nne ctor betw een th e premolar and mo lar
tooth. This conside ration may determine t he
choice of design.
Abutment teeth towa rds the front o f the
mout h are eas ier fo r patients to clea n than those
further back, partly because o f access and partly
be cause the bucco -lingual widt h of t he co nta ct
areas is gr eate r w ith po ste rio r teeth ,
Appearance
The example sho w n in Figure 9.2b may again be
used to ill ustrate t he way in whi ch the app ear-
ance of the brid ge may be o ne of t he facto rs in
de termin ing it s design. If a fixed-fi xed design is
used. in this case it w ill be necessary to make
either a complete crown o r a partial crown
 Designmg and p lanning brKige~
I (which will have gold showing o n the incisal edge)
for the upper can ine . Neithe r of t hese is likely to
I
be as attractive as the nat ura l toot h. W it h a
co mplete crown it w ill be difficult to produce the
distinctive characte ristics of the buccal surfac e of
the natura l too th . A fixed-movable de sign. o n th e
o ther hand. can have a mino r retain e r that
co nsists on ly o f a dista l- palata l inlay in the canine
carrying a slo t for the mo vable connecto r. This
means that the appearance o f the bucca l surface
o f the ca nine will be le ft undisturb ed .
Thus conside ration o f suppo rt. a conservat ive
approach to tooth preparation, clea nsab.hty and
appearance lead to a decision in t he case illus-
trated in Figure 9 .2b to ma ke t he bridge fixed-
movab le rather than fixed-fixed or cantilever.
Plannin g bridge s
Collecting information about th e
patient
Ch apte r 5 includes a de ta iled review of the
history and e xamination of a pat ient for w hom
crow ns are being considered . T he same ap proach
sho uld be taken w ith a patient for a bridge . T here
are. ho wever. a num be r of add it ional considera-
tio ns relating to br idges. The se are list ed below
21'
Figur e 10.3
a and b A cantilever bridge with a single lower canine
abutment too th and two incisor pormcs (only one
tooth is missing). One reason for this design was to
conserve tooth tissue. in particular the lower incisors.
There would additionally be dIffIculty WIth preparing
parallel abutmen ts as IUustrawd ,n FIgure 9.1 (page
192). This bridge was made befor e the l:bys of minimal.
pre paration bridges or implants. which wOl.lld now
solve this problem. It has. however. been successful for
several years. with no rotation, mobit,ty or booe loss.
and should be read in conjunct ion w ith the
relevan t paragraphs in C hapter S.
C ons id e r a t ion o f the whole p atie nt
,
W ith crowns. the cho ice may be betw een crown-
ing a tooth o r ex tracti ng it. and the dec ision may
wel l be to make a cro w n even tho ugh many
facto rs. fo r e xample . the pat ient's age. arruude to
treatm ent o r oral hygiene are less than ideal. W ith
bridges. the re is often the alternative of a partia l
den t ure. a minimal-prepa ration bridge o r a co nven-
t io nal bridge. and so it may not be necessary to
make so many compromises. If the re is any doubt,
it is bet ter to make a partial de nture first .
Clin ic al exam inatio n
A sse ssin g ab utment teeth Any tooth t hat
ca n be crow ned can also be co nside red as an
ab utment tooth. but the abutment too th may
have to wit hstand fo rce s fro m differe nt directions
th an one crowned as an individual to o th (see
Figure 3.6 page 48),
Te eth wit h act ive period o nta l d isease sho uld
not be used as abutme nt teeth. although many
w ith reduce d alveolar support fo llo wing success-
ful treatm ent of pe riodontal disease ca n be used.
212
T hey arc co mm o nly splinted to o the r ab utment
teeth to give m utual suppOrt.
So me de ntis ts prefer to avo id root-filled teeth
o r te eth needing pan cr ow ns because of the
ch ances o f fracture of th e roots. Howeve r, th is
risk exists whether or not the tooth is used as
an abutment tooth. It may even be reduce d if the
tooth is used as o ne o f a num ber of abutment
teeth in a large r bridge. so that the fo rce o f a
blow to the tooth is s hared by th e o the r
ab utments. G iven t he choice between a tooth
with a post crown as an abutment and a perfectly
sound tooth. it is mo re co nservative of tooth
tiss ue to use the former. Alt ho ugh some surv eys
have sho wn a higher incide nce o f failur e with pos t
crow ns than o ther forms of reta iner, the se figures
are similar to the failur e rate fo r individ ual pos t-
retained crow ns.
T here may be no suitable alte rn at ive abutment
to a ro o t-fille d toot h, and the choi ce is t hen
between using the tooth o r no t making a br idge.
l ength of span Any design of br idge may be
used for sho n spans of one premolar or inciso r
width. Simple cantileve r bridges may be used to
replace o ne or eve n two anterio r teeth with o nly
o ne strong abutment too th. provided the occl u-
sion avo ids excessive lateral forces on the pontics
(see Figure 10.3). Spri ng cantilever bridges sho uld
not be used for mo re than one upper inciso r
pont ic. U nilate ral posterior cantilever bridges
should be limite d to one pont ic an d o nly used
w he n th e o cclusion is favourable. T he difference
between amerior and po sterior ca ntilever bridges
is that w it h ante rio r brid ges th e forces o n th e
ab utment teeth are more ho r izo nta l than
o cclusal, and an teri o r teeth ar e bette r able to
withsta nd add itio nal late ral forces tha n are poste-
r io r teet h. In particula r. pos terior teeth te nd to
tilt mesially in any cas e, and a ca ntilever pa ntie
attached to the me sial surface of the abutment
too th increases th is tenden cy as a res ult of
o cclus al force s o n t he po ntic. Small po st erio r
ca ntileve r bridges should t he refore be designed
cautiously. and preference given to th e
fixed-movable desig n w he re po ssible. Molar teeth
are better- abut ments fo r ca ntilever bridges th an
premolars. l o nge r spans of ca ntilever po nncs may
be use d in conjunction with large cross-arch
sp linted brid ges.
Fixed-movable bridges are usually lim ited to
spa ns of two or th ree premola r size units . Beyo nd
Des'gmn/I and planmng bridge!
th is. mo vement at th e mo vable jo int may bec o me
excessive. alth o ugh m uch lo nge r spans have been
successful.
Fixed-fixed bridge s may be used for any size of
span . It is commo n to find all fo ur inciso r teeth
miss ing. an d the design of bridge used to replace
these is almost always fixe d- fixed w ith th e ca nine
teeth as t he only abutm e nts.
O cclus io n Not o nly sho uld th e occlus io n of
th e remaining teeth be assessed. as described in
C hap ter 4. but th e po tential occl usio n of th e
po nt ic w ith the o ppo sing teeth should also be
assessed. In so me case s the occl usal relations hips
o f th e po tential ab utment teeth will help deter-
mine wh ich sho uld be used and wh ich design of
brid ge is suitable. Figure 10.4 sho ws tw o cases:
o ne suita ble and one unsuitable fo r a simple
cant ileve r bridge repl ac ing the upper lateral
inciso r, w ith the canin e as the o nly ab utm ent
to o th. Th e difference betw een t hem is th e way
the lo w er incisors relate to the space when th e
mandible is moved in t he pro tru sive late ral direc -
tio n. In the second case two abutment teeth w ill
be necessary: either the ca nine and th e first
premolar w ith a cantilever de sign. o r the canine
an d central incisor w ith a fixed-fixed or
fixe<J--..t:tlovable des ign.
Sha p e of ridg e T he contour of the saddle area
w ill be ta ke n into account in determining wheth er
a bridge w ith a movable buc cal veneer o r a partial
demure sho uld be mad e (see C hapters 7 and 8).
or whethe r surgical ridge augmenta tio n should be
conside red (see Figure 7.9. pages 162- 3).
When a bridge is to be made. t he sha pe o f the
ridge w ill affect the appearance o f th e po ntic , and
if t his is like ly to be a critica l factor. in oth er
w ords if t he neck of th e po ntic show s and the
patient is very concerned about the ir appearance,
t he n o ne of t he procedures de scribed below
shou ld be followed to ensure an acce pta ble final
re sult.
Predicting the (inal result
The final appearance of the bridge can be
pred icted using the study casts. by var ious intra -
oral trials o r by mea ns of a pro visio nal bridge.
Sometimes combinations o f t hese methods are
Designing and p lanning bridges
necessa r y. In straig htforwa rd ca ses the den t ist
and tec hnician w ill have a go od idea of wh at t he
fina l bridge w ill lo o k like, but t he pat ient w ill be
less clear. T he pred ictio n is th erefo re for th e
pat ie nt 's benefit . In o th er cases w here t he re a rc
unusu a l fea tures, t he dentist and tec hnician may
no t re alize t he full aest hetic implicatio ns of
atte mpting to ma ke a br idge, o r their unde r-
stand ing may be differen t. In t hes e cases t he
patient is like ly to be even mo re co nfuse d.
Many pat ie nts w ho complain abo ut bridges
after t he y a re fitted a rc unh appy wit h t heir
Figure 10.4
Occl usal assessment.
(l A missing lateral inciso r with deep overbite. The
lower canine tooth to uches t he palate. The re wou ld be
insufficien t space for a minimal-preparat ion bridge
without orthodontic treatme nt or extens ive re ductio n
of uppe r o r lower teeth.
b The same patient in a right late ral excurs ion. The
occlusio n is canine-guided and the lowe r teet h are clear
of the uppe r late ral incisor space, so that a simple
cantileve r bridge with t he canine as th e sole abutme nt
wo uld be satisfactor y. The occlusion of the patient
shown in Figure S.1e (page 174) is similar.
c In t his case th e lo wer inciso r passes thro ugh the
upper latera l inciso r space in right lateral excurs ion,
such that group anterior guidance will be inevirabte,
with presSUre on the palatal surface of the ponti c
unless it is shortened o r procl ined to an aesthetically
unacceptab le degree. A cantilever bridge with o ne
abutment to ot h wou ld carry the risk of acting as an
orthodontic appliance and ro tating the abutment too t h.
appea ra nce. N ot o nly is it go od pla nn ing to
pred ict the final a ppeara nce of t he bridge and
seek t he patient 's acceptance before starting, but
a record of the predicted ap pe ar a nce may also be
useful fro m a de nt o-legal po int of view sho uld the
pa tie nt eventuall y co mp lain.
As w ell as t he ap pe a ra nce ' of t he fina l bridge,
po ten tial difficu lt ies in prepa ring t he teeth shou ld
be predicted wh en po ss ible. T hes e includ e
prob lems wit h re tention a nd path of insertio n,
and the possibilit y of e ndangeri ng t he pu lps of t he
a but me nt tee th.

'"
Study cast s
A sec ond study cast should be po ured of the arc h
in wh ich t he bridge is to be made. It is sufficie nt
simply to cast t he a lginate impression a second
time. if it can be removed fro m the initial cast
intact. Alternatively. two impr essio ns should be
tak en or the study cast duplicated in the labora-
tory.
The second Study cast may be used for trial
prepa ration s to predict the pro blem s o utlined
abo ve as well as pro blem s of the individual
abutment preparation (see Figure 5.3c, d and c.
page 9 1). T he prepared study cast may be used to
make a trial o r diagno stic wax-up of the bridge to
show to t he patie nt. T his is particularly useful when
the shape of the abutment teet h will be altered by
the retainer cro w ns or w here o rthodo ntic tre at-
ment is planned pr io r to bridge const ructio n.
Th ere are often altern at ive m ea ns of replacing
missing t eeth, and th ese change appearance s in
differe nt wa ys: Figu re 5,] shows mo dified study
casts illust rati ng tw o wa ys of ch anging th e appear-
ance that wo uld be d iffi cult to de scr ibe to the
pat ient. N e ith er is ideal, and so the patient must
be warned th at compromise is necessary. The
work sho uld not be started unti l the patient
understands and accepts this .
If the patient is to be sho w n the study cast. it
is best to produce the w ax-up in ivo ry -coloured
•
Figure 10.5
An intra-oral trial.
o A partial dentu re replacing four incisor teeth, which
is to be replaced by a bridge. Ther e is a buccal fl:ange
and a midline diastema.
b Demure teeth set on a wax baseplate b<'lng tr ied-in
to ensure that the patient is happy about the appear-
ance of peones without a buccal Ilange or the midline
diastema. Periodon tal trea tmen t will be provided
before a bridge is made. The bridge witt be six units.
with the upper canines as the two abutment teet h.
wa x, o r to dup licate the waxed-up cast. The
patient ca n th us lo o k at a cast w itho ut the
distra ct ion of the co ntra st be tween the artific ial
st one and co lo ured wax. Most find it eas ier to
compare the second. modified study cast with the
first. rathe r than w ith themselves, partly because
Study casts look so artificial to them that they are
better comparing two similar ly artificial objects,
but also of course because they have difficulty in
relating a study cast. wh ich is ho w o the rs see
them, to a rev ersed, mirror image o f themselves.
Other preca ut ions are deta iled in C hapter S.
Intra-oral trials
Partial d entures Many patient s wh o are to
have ante rio r bridges already have a partial
denture. If the appeara nce of the artificial tooth
o n the dentu re is satisfa cto ry and ca n be dup li-
ca ted in a bridge . no furth er tri al is nec essary.
Ho wever. if the denture ca rries a bu ccal flange, it
is wise to try a de ntu re to oth in the mouth
w itho ut a buccal flange. usua lly attached to a
sim ple wax or shellac base, to sho w the patient
the effect (see Figur e 10.5). The change can be
dramatic. T his form of int ra -oral trial is s uitab le
o nly when the shape of abutment teeth is no t to
be changed.
Designing and planning bridges
Other reversible intra-oral modifications
The size of potential abu tme nt teeth can be
increased by the add ition of wax or compo site
attached by the acid-etch techniqu e. In so me cases
a po ntic can also be tempo rarily attac hed to
adjacent teeth by means of composite. These
mod ifications may be useful wh en predicting the fi nal
result, but are limited in t hat it is o nly possible to
increase and not decrease the size of the teet h.
Temporary and provisional bridges
Once the preparations fo r a conventio nal br idge
have been made in t he mo uth, it is poss ible to make
a provisional bridge in the laboratory with acrylic,
preferably inco rpo rating acrylic denture teeth , or
specially made facings. T hese provisional bridges are
rather more permanent than te mporary bridges
(usually made at the chatrsroe). which are o nly
intended to last for tw o o r three weeks wh ile the
permanent bridge is being made. O ne of the
purpo ses of a provisional bridge is to allow furt he r
modificatio ns to the shape of the bridge for
aest hetic reaso ns or as mo dificatio ns to the occlu-
sion until both the de ntist and pat ient are sat isfi ed
with the resu lt. These mod ifications are then incor-
porated into the permanent bridge. The provisional
bridge can also be re mo ved and adjusted to allow
periodontal or endod on tic treatment as necessary.
An example of the value of a provisional bridge
is in a patie nt w ho has had o rthodontic t rea tment
retracting t he upper canines to make room for
lateral incisors. The canines may re lapse mesially,
but this is not inevita ble, and so it is unnecessarily
destructive to make t hree-unit bridges as a matter
of cou rse, to prevent relapse: a two-unit cantilever
bridge may be sufficient. The problem is to make
t he right prediction. Provisional two-unit cant ilever
bridges using the canines as abutments may be
made in acrylic if the abutment teeth are to be
prepared for a conventional bridge; alternatively a
Rochette provisio nal may be made. T he pat ient is
then reviewed frequently wit h the aid of st udy
casts taken w he n t he bridges are fi rst inserted to
chec k fo r early signs of rela pse. If relapse has not
occu rred with in six mo nt hs, t he provisional bridges
can be replaced wit h permanent o nes. At the fi rst
sign of re lapse, the provisio nal bridges are replaced
by three- unit bridges.
Ano ther example of t he use of a provisio nal
bridge is as an immedi ate inse rt io n replace ment
of a to oth to be extracted. If the permanent
21!
bridge is to be a convention al de sign, t he
abutm ent t eet h ar e prepared and t he bridge made
befo re the tooth is ext racted - t he pr eparat io n
being protected by separate temporary cro w ns. If
th e permane nt br idge is to be a minimal-p repa-
ratio n design, a Rochett e type sho uld be used to
facilitate re mova l and mo dificatio n as the extrac-
t ion sock et heals.
Practical steps in choosing a bridge
design
So far, all the discussio n of bridge des ign has been
rather theoretical and somewhat inco nclusive.
This is inevitable, since des igning bridges is still
rath er more of an art than a scie nce. It is based
par t ly on t he clinical experience of the dentist,
wh ich will vary from person to person, and o n
the clinical condition of the patient, wh ich again
will vary. However, the design process has to
sta rt somewhere. Examples at the e nd of this
chapter illust rat e the logical steps in this process.
General approach
A list should be made of all the likely designs for
a bridge in th e case being considered. This should
include the potential abut ment teeth and their
re tainers, toget her with the basic design of bridge
(fixed-fi xed, fi xed-movable, co nventional,
minimal-pr eparation and so o n). In a simple case
w hen the de ntist is experi enced , the list can be
made me nt ally. For t he le ss experienced and fo r
more complex cases, it is helpful to w rite it do wn.
Every des ign is conside red in tu rn and advan-
tages and d isadvantages liste d.
In so me cas es, t he opti mum de sign will be
o bviou s fr om t his procedure. In others, further
investigations with mo dified study casts, intra-o ral
trials o r provisional br idges may be requ ired.
Details of stage s in the design
process: Selecting abutment teeth
After the gene ral examination of t he patient
and whol e mouth, individual potential abutment
te eth should be exam ined and a no te made of
216
the pr esence o f caries o r re storations and the
ext ent and quality of any restoration present.
2 The peri odontal state should be examined.
including the presence of plaque and other
deposits. gingival bleed ing and periodontal
pockets.
3 Tile vitality and mobility of th e too t h sho uld be
tested and a periapica l radiogra ph obtained.
4 U sually any major problems wi th th e individual
tooth should be dealt with first by appropriate
treatment, but sometimes t he mo re sensible
solution is to ext ract the tooth an d replace it
as an additio nal pontic o n th e bridge, rathe r
chan retain a dubious tooth as an abu tme nt
w hen it s presence may we ll jeopardize the
future of th e whole bridge. An example of this
is w he re th ree lower inciso r teeth are already
missing an d th e fo urth has very little bone
support. The lo we r ca nines are so und and will
mak e good abutment teeth. T hey w ill have to
be used in any case to support th e bridge.
Including th e remaining inciso r w ill not add
significan tly to the s upport o f the bridge and
may detract from it s lon g-ter m prognosis.
5 A judge me nt mu st be made as to th e prog no-
sis of all th e te eth in the vicinity of th e bridge
to reduce th e risk of anoth er tooth having to
be extracted sho rtly att e r th e bridge is made
Selecting the ret ainers
T he list of po tent ial alternative reta iners may
include complete and partial crowns and m inimal-
preparation retain ers. The cho ice of a co m plete
Figure 10.6
The upper first molar has over-erupted. It should be
ground level to the occlusal plane prior to a lower
bridge being made. in order to avoid occlusal interfer-
ences in lateral excursions. In some cases the toot h
should be intr uded to me on glnal occlusal plane
o rthodo nnca jly.
crown is inev itable w he n t he tooth is alre ady
heavily restored o r the appeara nce of a partial
crown would be unacceptable .
Th e choice between a cro w n and a minimal-
preparation retainer w ill depend upon w heth e r
the abu tme nt teeth have restoration s in th e m, the
occlusa l clearance and the appearance of the
abutment teeth. If the only difficu lty w ith minimal-
pre paratio n reta iners is the lack o f o cclusal clear-
ance. it may be possible to create sufficient
clearance by reduci ng t he o pposing teeth. partly
pr e pa ring the e nam el of th e ab utment teeth o r
moving the m o rtho do ntically. Someti mes a
combina tion of these ap proach es is possibl e .
Selecting th e po nties and con nectors
The design of pontics an d con nec tors is the
responsibility of the dentist an d no t the techni-
cian. D etai led instru ctio ns sho uld be given to the
technicia n. particularly on the contour of the
ridge s urface of the po nt ic (see Chapter 9). When
the tech nician is unfam iliar with the den tist 's usual
req uire ments . the details of the design should be
drawn and sent to t he technician as part of the
prescription for the brid ge. Where a
metal -ceram ic pontic is to be made. t he dentist
should indicate wh ere the porcelain sho uld be
finished. In some cases an all-porcelain o cclusal
surfac e is required; in others t he' porcelain covers
only t he buccal surface and buccal cus p. leaving
t he remainder of the occlusal surface in metal.
Again. this sho uld be specifi ed .
Des jgning and plannlng bridg es 21

Figure 10 .1
Bridge des ig'" fo r single miu ing inciso rs.
a A mi»ing uppe r Iacen.1 incisor wit h rotated canine and f,nc
premolar teeth. There is a CI:lSs 2 D ivision II ir\(isor rel~tion·
....ip with a deep ove rbite an d minimal overjet. This muns tha c
no space is ~vail~ble for a minimal-preparation bridge, alth ough
onhodonti<; U"",tment might crea[l! some space. A flxed-fl xed
bfidge usIng !he centnl incIso r and unine wou ld be even more
destrUCtive of sound cooth I..Sue !han usual. sInce they are no!
para llel. There would ako be a risk of th e cen tnl IIlClson nOl
"",!Ching elGletly. Splinting !he ro u ted canine and fi~t premo-
b r logether for a until......... bridge would be possible. but wou ld
produce an awl<ward embrasure space tha i would be difficull: ~
dean. Fortunately the occlusion is satlsfa«ary lor a 'iimple
cantilever bridge using just ee C.1.1\Ir>e rooth :IS the abutment.
and iu roution C.1.n be ccerected WIth a fun crown. The first
~mol.1.l" has a fa,led amalgam restoraOOf\, which wi. be
replaced separately with a poruIa... inb y Of" cO"'IJ" O'll[l! r"'t<:ln-
tion to imp<"ove the appearance.
b Anoth .... missing latet"31 inciso<", th ,. time with one
dtscoloured. non-viu~ root-filled Central inc.isor and a brge
mesial carious Ie'iion in the other. The cl!ntnl incison are also
misalIgned. The can,ne " .ound s,roce the occlu.ion i. not
bvou""b1e fo r a umllever bridge u"ng only on e abutment
loolh, both ce nl"" l incilon will be cr owned and connected 10
....ch oth...-. .. nd 10 a a.nti'e~ ......d Iacet"31 inCisor pontic, on<e
caoes ..nd peliodonul ese..se el. ewhere hu been con trolled.
c A minIng upper unine tooth. The l-e are dIfficult to r epl..ce
by bridges wh en th e occlus ion WIll be guide d by the ponuc In
late ral exc ursion s. and in t he:r.e cues seve.....1 ..butment teelh
may be nece ....ry. By glind,ng th e lower canine .lightly and
lea ving the poo uc . lrghtly shon, it was po u ible to ma'nU ln
group functio n In th IS patient ra th er than produce canlOe
guidance by the ponlic. The two pre mo lar teeth were
con nected u abutment 'i for a three -unit canutever bridge .
This de~ign wu cho sen in prderenc e to a fixed - fixed bridge
so tha t pre paring the soun d, matelling and well-aligned incisor
teet h coul d be a~o id e d .
A fixed--mo vable de.ign WIth an 'nlay in the dlSt31 .urface
of t he lateral lnciaor would not have been pr act icab le. because
th e ~t'!gula c i o n of t he larer al inci'ior wou ld pr e~cnc a com mon
path o f insertio n bet ween t he first premolar and a groo~e in
an inlay in t he inci. o r. Thi. de. ign wo uld have beet'! poss ible
{although not desir able) if th e lat er al inci'or had been mo re
pro clined .
A rnmrrnal-pr eparadcn br idge co uld be cons idere d. but
th e re is a greater ri. k of Io n of retention with th is o cclusal
rela tionsh ip.
d A compl icated cu e. If th e o nly tooth missing was the upper
laceral incisor the " th e ideal bridge de.ign wo uld prob ably be
to can{jle~er .. minimum_prepar<l tion bridge from th e canine
tootil. How ever th is tooth i. needed to help reni " a bridge
rep lacing the IWO premolar teeth. Therefo re tl>e d",'g" to
rep lace the laceral iociso r con sisted 01 a mInImum_prepar ation
bfidge a ntllevered from the cl!ncr<ll iocisor. The two premo-
lar 'P"ce . were both r",tored by mlnlmum-pr eparatloo, fixed-
bed bfidges with me canine and first molar teeth u abutmenu .
•
DeSignmg end plannjng bridges
'"
Figu re 10.8
Replacing mo re than one tooth.
a Wi th an anterior o pen bite and no rmal lateral inciso rs.
a fou r -unit fixed-fix ed minimal-prepar ation br idge w ith
the lateral inciso rs as the abutment teeth wou ld be sans-
f.lClo ry. There is 00 need to include the canine teeth.
This des ign is also acceptable in so me cases whe re
there is no rma l o cclusion between the anterior teet h,
but the le ft an d r Igh t la te ral e xcursio ns are canine-
guided. In such cases th e design may be rnirtimal-pr epa-
ratio n or co nventional.

b Even w ith three incisors missing, w ith the occlusio n

being protected in r ight latera l excursion by a so und
canine (sho wn here ). the latera l incisor m.ty be used as
the onl y abutment on the r ight side fo r a Irv e-unrt
fixed-fixed con ventional br idge. The bridge could be
extended t o include the r ighc canine. giving additional
support and a more symmctrical appearance. but th is
would make the embrasure space be tw een the late ral
inciso r and canine dlff'cult to clean and would be
unnecenarily dest ructive.

c and d The central inciso r space is now reduced to

approximat elr on e-quarter of In prope r w idth,
although th is is so mewh at difficult to judge since th e
left centra l inciso r has an acrylic jacket crown. The
rigtu canine also has an unsatisfactory acrylic crown.
Trial wax -ups sho wed t hat a satisfactory appeara nce
co uld be ob ta ined by c J(t raccing the no n-vital lateral
inciso r and making a fou r -unit fixed-fixed bridge . Both
cen tra l inciso rs and the latera l inciso r pontic wou ld be
small, but wo uld give a better appe ar ance chan l:WO
large central inciso rs with the midline offset even
furth er. The alt ernative of o rtho dontic t reatment prior
to br idgework was offere d to the pat ient and decl ined.
This is a similar problem to that of another pat ient.
sho wn in Figure 7.7, page 160.

d The uppe r lateral incisor has been e xtracted and the

cwo abutment teeth pr epared. \t is now clear that
the r-e will be sufficient space fo r the planned trea tment.
A prov isional br idge will be fitted and perio do nta l
tr eat ment provided befo re impressions are taken for
the pc rman ent br idge.

...
J totally unsatisfactory premolar po nnc wo uld be damag-
Planning the occlusion
De ta ils of this stage we re given in Ch apter 4. Th e
first decision to be made is w hether to articulate
st udy cas ts and, if so. whethe r it is ne cessary to
use a simple-hi nge . semi-ad justa ble o r fully
ad juuable articulator. With sma ll bridges it is
helpful t o mou nt casts o n a semi-adj ust able artic-
ulato r. W ith most large bridges a se mi-adjusta ble
or fully adjust able articulat o r should be used.
T he sec o nd dec ision is wh ether any occlusal
adjustment is necessary prior to tooth prepara-
tions fo r the br idge . W ith po ste rior bri dgework
it is o ften necessary to adjust an o ver -erupted
o pposing tooth (see Figure 10.6). The anticipat ed
o ccl usal r elati o nship of the po nti c with the o ppos -
ing te eth may influence the bas ic design of t he
bridge as welt as the details of the occlusal surface
of the pontic, and so, although th is step is listed
as t he final o ne in the se quence, and it is usually
considered last, if th e bridge design is innuenced
by it. it w ill be necessa ry to introd uce feed bac k
loo ps to earli e r sta ges.
'"
e Existing crowns and bridges follOWing extensive.
successful periodontal tr-eatment and the extraction of
the lateral incisors_ None of the remaining teeth is a
satisfactory abutment for a simple small bridge. and a
partia l denture rep lacing the late ral incisor s and the
ing to the per iod onta l tissues. A sphnt/ br sdge incor po-
rat ing the principle of cro ss-arch splinting is indicated
her e.
f Sound restored abutment teeth and a span t hat y,'ill
acco mmodate o ne pre mo lar and one molar po ntic. t he
buccal surface of t he premolar is sound and of good
appearance. and so o ne des ign could be a
frx ed-roovable conventional bridge Wi th a full crown on
the mo lar tooth and an MOO Inlay (without cuspal
prc recnom in the premolar. The movable joint will be
accommodated in the distal box of the inlay. A hybrid
bridge wo uld not be suitable. since the resto ration in
the molar tooth is too large for this tooth to have a
minimal-prepa ration retainer .
Exampl e s o f the br-id ge -d esign
process
See Figu res 10.7 a nd 10.8 for practical ex amples.
and t he reasons for t he choice: some alternative
desig ns. and t he reasons for rejec ting t he m. are
give n.
Dent ists w ill ine vitably become biased in th e ir
sel ectio n of bri dge designs by their o w n e xpe ri-
en ce of clinical suc cess a nd failure. Indeed, t he
aut ho r's o w n bias may be de tect ed, fo r example.
in t he section o n spring ca nt ileve r bridges and in
Figures 10.7 a nd 10.8. Ca re should be ta ken to
pre ve nt th is bias ov e rriding mo re substa ntial clini-
cal criteria.
As an additional e xam ple . t he a ble on page 220
se ts out ove r 30 diffe rent designs fo r th e re place-
ment of o ne upper late r-al inciso r. Some of the
sugg esnens on t his list are a little bizarre and
wo uld only be us ed under unusual circumstances.
Fo r example. it would not be common to sp lint
toge t her t he central incisors as o ne of t he
abutme nt s (No. 6 o n t he list). since in mo st cases
220 Desip",np cnd olannmv brid~..

Alt ernative de sign s for a bridg e t o repl ace 12

Basic design Aoofm enl fee1h Reill/flers

", Fix ed-lix "'d ~and !l II sc
f1K
Il ",
13K
J If Fe 13K
"
• f1K
f1~
13",
rr MP
6 I II and 13 11i Fe 13",
7 T1i'" ." If MP
13",
10
8
9
Fixe<f-..movable II and 13
" '" f1K
f1",
f1",
13K
13K
13K
"
12 110_ 13",
,,.Il unt>le'-er u
Tr o .
Il",
13K
15 13K
'16 13~
13 and Il",
17
18 " 13K
13",
"'"
"K
"K
" 13K
20

"
'22 !!.
13~
II ",
"'rr "
MP

2J f1K
' J< f1 ~
zs ill i'Tl Fe
,,,
26 TlTl'C
TTl,...
28 Spr ing u n olever 1<4 and ~ 1 <4~ IS",
"K 'sK
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JJ
16

17
"'""'" 16K
17 ",
H 17K
15
l6
J7
18
"IS "'"
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15K
'sK
Key: Fe: full cro w n
PC: partial cro wn
MP: minimal_p reparation
CI III; CI III inlay

Several of th ese designs wo uld on ly be co nsidered in unusual circ umstances. The most
commo n designs are indicated with an asterisk. In addition. when the adjacent teeth are
so und. and in particu lar when the anterior teeth are spac ed. a single-to oth implant may
well be t he treatment of choice.
Desifr>irJg and planning bridges
just o ne ce ntral inciso r wou ld be sufficient. In
other cases, however, th e upper late ral inciso r
would be re placed almost incidentally as part o f
a much larger splint . In t hat case all the uppe r
inciso rs and perhaps teeth furth er back in the
arch would also be included.
So the list co uld be furthe r extended to show
Practical points
• Criteria for planning bridges are similar to
those fo r cro wn s.
However:
• W ith bridge s, a partia l denture can first be tried
and later re placed by a bridge if necessary.
• Teeth with active periodontal disease should be
avoided as abutmen t teet h.
221
an even greate r var iety of po tential abu tmen t
teeth , and even further to show the choice of
materi als. The impo rta nt po int is to sho w the
eno rm ou s variety o f designs possible and the
dangers inhe rent in beco ming too re liant upon a
limited number or an over-sim plifi ed 'cookery-
book' appr oach to designing br idges.
• The co ntour of the saddle area will be taken
into co nsideratio n in deciding o n w hether a
bridge , a bridge wit h removable buccal ven eer
or a partial denture sho uld be made .
• It is best to predict the final appearance of th e
br idge using tri al wax-ups o n study casts and
to ensu re t he patient's accepta nce from th e
outset.
• The use of provisional bridges allows fo r
furth er modification befo re final fi tting of the
permanent brid ge .
 II Clinical techniques
for bridge
•
construction
T his chapter shou ld be rea d in co njuncti on with
Chapte r 6. Many of the technique s are identical,
and so this chapter w ill de al o nly with t hose th at
are peculiar t o bridges o r where a differe nt
emphasis Is necessary.
Pre-operative procedures
All t he planning stages described in Cha pte rs 5. 6
and 10 sho uld be unde rtaken . In particu lar. t he
shade should be ta ken an d an impressio n fo r the
opposing cast made. The followi ng additi onal pre -
operative procedures may also be re qu ired.
Occlusal adjustment
It is mo re often ne cessary to ca rry o ut an occl usal
ad just ment in prepar ation fo r a bridge t han fo r
crow ns. A new impressio n must be ta ken fo r t he
oppo sing cast, since th e study cast will o bviously
no longe r be acc urat e.
Add itional space for ante r ior minimal-prepara-
t ion retainers ca n be pr o duced by using a Dahl
appliance (see Ch apte r 6).
Preparations for a temporary bridge
It m ust be decided whether a t emp o rary bridg e
wi ll be made or wheth er t he patie nt will be left
w ith ind ividual te m pora ry res to ratio ns to protect
t he abu t men t t eeth. When th e pati en t has a satis-
factory te mpo rar y dentu re an d especially if t he
m
des ign is a cantilever or fixed -movable con ven-
tion al bridge or any design of minimal-prepar at ion
bridge, it is often better to mak e separate t empo-
rary resto rations rathe r than a temporary bridge.
When t he des ign is fixed - movable and t he path s
of insertion of the retaine rs w ill not be parallel
to eac h othe r, it may be impractica l to make a
te m po rar y bridge. Beside s, whe n a minor retainer
such as a distal-occlusal inlay is to be made fo r a
fixe d- movable bridge, t he tem po rary bridge
(whi ch w ill be fixed-fixed) may loo sen at th e
m inor retainer.
Howev er, in many cases, parti cularly for larger
fixed-fixed con ven t io na l bridge s, a tem porary
bridge is essential to protect the abu tment tee th
and to retain t heir relations hip with each other
and the o pposing teeth. Tempo rary br idges may
be made in one of tw o ways: eith er by one of the
chair side tech niqu e s desc r ibe d in Chapter 6, o r
by making an ac rylic te mpora ry bridge on the
study ca st , using t he trial preparatio ns, an d then
re lining and ad justi ng t his at th e chair-side as
nec essa ry.
If a ch airside techn ique is to be used, a t rial
wax -up on the stu dy cast shou ld be made and
du plicat ed (by means of an alginate or elasto meric
impressio n) to make a stone cast. A vacuum -
fo rm ed pvc slip can then be prod uce d (see Figur e
6.17, page 124). Alternatively, a silicone im pre s-
sio n of t he waxed- up st udy ca st may be used
directly in the mouth to make the t emporary
bridge .
Figu re I 1.1 shows a labo rato ry-made tempo-
rary bridge, construc ted befo re the teeth are
prepared so t hat it can be adapted and ce mente d
at th e tooth preparatio n visit . Techniqu es fo r
constructi ng ch airs ide te mpo rary bridges ar e
des cribe d late r.
Clinical lech",qu es for bridge construa;on
Prepa r ing th e abutment t e e th
Parallelin g technique s for
conventional preparations
When the de sign of a co nvent io nal br idge
req uires two or mo re teeth to be pr e pared in a
co mmon path of inse rtio n, spe cial techniques are
used to ensure that there are no unde rcuts and
yet each individual prepa ration is as retentive as
possib le. These are listed in increasing order of
complexity.
P a r all el in g by e ye
Two o r th ree teeth dose together can be made
parallel by eye. The clinician will become more
adept at doing th is with experience, and shou ld
concentrate o n developing the skill. In the anterio r
part of the mouth it is possible to see aiong the
long axts o f t he teeth by direc t vision. O nly one
eye should be used, since binocu lar vision can 'sec
aro und' undercuts. Figure I l .2a sho ws a dentist
assessing th e path of insertion of the upper canine
teeth. wh ich are being prepared fo r a bridge
replacing the fo ur inciso r teeth. It helps to lo o k
fro m as far aW<lY as possible . It may also be useful
to make a sm<lll pe ncil mark on the two surfaces
tha t may srill be undercut . An asse ssme nt o f paral-
lelism or undercut Gin then be made by dosing
one eye and mo ving the head so that one o f the
pencil mar ks just disappears and then co ntinuing to
move the head until the other penc il mark appears.
In the lower jaw and in pos terior parts of the
mouth large mirrors are useful to show all the
123
Figu re 11.1
A laboratory-made temporary acrylic bridge (see also
Figure 9..4d).
pr e parat ion s in t he same field. Parallelism cannot
be assessed satisfacto r ily when two or mo re
pr epa ration s can be seen o nly by mov ing the
small mouth mirror . Many of the pho tographs in
t his bo ok have be en taken in large r. front-surface-
re flecting mirror s (see Figure 11.2b).
It is also he lpful to use a straight pro be like a
labo ra to ry surveyor. but in the mo uth. The probe
is placed against one o f the prepared too th
surfaces . and then. he ld rigidly, it is moved over
to the other abutment tooth witho ut its angula-
tio n being changed . Th is is no t a completely
re liable guide of course. and will detect only f<lirly
gross undercuts or overtape r. But many clinicians
do find it useful (see Figure 11 .2c).
Ex t r a -o r al survey
W ith larger br idges and wh en teeth ar e pr epar ed
on both sides o f the ar ch. the simp lest and most
re liable method of ass essing parallelism is to ta ke
a simple impre ssio n (usually in alginat e) on ce the
basic reduct io n has been carried ou t o n all th e
ab utm ent te eth . Th e impr essio n is cas t at the
chair-side in a fast-setting plaste r. usually with an
accele rator such as alum added . The cas t is then
surveyed at the cha irside and furt he r pr e parat ion
carried out as req uired (see Figure 11.3). The
pro ce dure may be repeated several time s with
mo re difficult cases o r with large numbers o f
abut ment te eth. W hen the abutments are satis-
factory fo r the path of inse rtion. the final
smoothing and finish ing of the preparations is
carried out.
224 Oonicol fechnique s (or bndge ( emstrud """

Fig ure 11.2

Clinical methods of asses sing parallelism of bridge

abutme nt prepara tions .

o Using direct visio n, fr o m a durance with o ne eye

d osed wh en . fo r example. up pe r canine teem a re being
prepared for a fixed-fixed bridge .

b U sing a full ar ch m irro r fo r th e same purpose in th e

lower jaw . Full a rch mir rors a re used in chnical photog-
ra ph)' and many of th e photogr aphs m th is book were
ta ke n w it h o ne of these large m irr ors.

( Using a st raight pr o be as an "intr a o ral surveyor'. The

operato r must stilr very stilt other than mO\ling the
probe ro und the abutment teet h in a cont rolled
fashion. This, o n its own, may not be eno ugh but gtves
a guide to t he presence of unde rcuts, Op erators who
make a significant number of bridges develo p consid-
e rable skill in t his tec hnique.

Parall eling device s fo r crow n preparations
Many of the devices available are cumbersome,
unre lia ble o r extreme ly expens ive. One of the
sim pler ones consists o f a sta inle ss-steel mirror
w ith vertical lines sc ribed o n it. This is placed
bucc ally or lingually and used to assess the
mes iod istal parallelism o f a but me nt preparations.
It ca nnot be used for m e buccal- lingua l surfaces.
Anothe r dev ice co nsists of a clea r plast ic disc
w ith a pin pass ing th ro ugh it. T his is held against
t he occlusal surfaces and can be mo ved a round,
Clini<:oJ techniques for bridge construction 22S

Figu re 11.3

Surveying pre paration s.

a initial pre parations have been carried out o n the

uppe r canine teeth in the mouth and this cast has been
made from an alginate impress io n. The two prepara-
tio ns have been varnished. The bridge will be a six-un it
immediate insert ion pro visional bridge. and the two
re maining incisors with exte nsive alveolar bone loss will
be extracted.

b The prepa ratio ns are surveyed with a fine ro d, and the cast is
tri mmed until the y are para llel. Tr immed areas show up in contrast
to t he unto uched varnished areas. Similar re duction is carrie d out in
the mo uth. The process may need to be repeated.

act ing as a surveyor. Th ese t wo de vices may be
us efu l, but the inexperien ced de ntist is bett e r
advised to master t he basic tech niqu es of survey-
ing by eye a nd extra-ora l s urv e ying.
Preparations for minimal-preparation
bridges
Since t he introduction of minimal-pre pa rat ion
bridges, t he re have been fluctuatio ns in fash ion as
to th e degree of tooth pr eparat io n that should be
carried out. Initially very little preparatio n w as
undertake n, and t hen o ve r t he ne xt few ye a rs
various aut ho rs re com mended mo re a nd more
e xtensive preparat ion wit h finishing lines, se ating
groove s at right a ngles to the path of insertion
an d location groo ves in t he line of t he path of
inse rti on all being ad vocated . Some de ntists e ven
went as fa r as using ope rating mic ro sco pes a nd
com plicated paralleling de vices.
The re is ve ry litt le relia ble evidence that a ny of
t he se prod uce s ignifica nt benefit, a nd s o the
fashion has sw ung back away fro m e xtensive
preparat io n of t he e namel. One dange r of
o ve r pre pa ring tee th for t hese t ypes of re tainer is
t hat if th e retainer beco m es de bo nded but the

bridge is he ld in place by ot he r retaine rs. feat ure s
such as grooves tend to be come carious mo re
rapidly than unprepare d enamel surfaces, and,
because the den t ine is clo ser to the base of the
gro ove. it to o becomes cariou s with the result
that a furt he r minimal-prepara tio n retainer is no t
possible,
T he th ree principles that sho uld guide the
operato r in deci ding how much prepara tio n is
necessary are as follows:
• The maximum surface area o f enamel shoul d
be used fo r re te ntio n o f major retai ners .
Figu re 1 1.4
a The lingual view of an incomple tely erupted upper
canine tooth [0 be used as an abutment for a minimum.
prepara uon bridge.
b C rown lengthe ning has been carried o ut to give a
great er surface area and a ho rizo ntal seat ing ledge has
been prepared at t he cingulum. This is very small but
sufficient for the purpose.
Figure 11 .5
A fixc<S- fixed minimal-preparation bridge will requ ire
preparation of the pro ximal surfaces of the abutment
teeth shown in the uppe r model [0 increase the surface
area of enamel. In the lower model this Ius bee n done.
However. th is cou ld be avoided by using a
fixcd-movable design.
• The bridge should seat po sitively so that it can
be held fi rm ly in place witho ut moveme nt
against the re sistance of rubber dam while the
cem en t is setting.
• Pre parat ion may be nece ssary to allow an
adeq uate th ickne ss of retaine r whe n the o cclu-
sion is unfavourabl e.
Th e maximum enamel surface are a can e tten
be achieved with anter ior brid ges with out any
tooth pre paration o ther than a seating ledge (see
Figure I' .4). However. with pos terior fi xed-fixed
bridges. the abutment teeth have commonly tilted
Clifticol tedln-ques for bridge construetlOO
towards t he space a nd t he re is an underc ut
between their proximal s urfaces. Slight reduction
on o ne o r both of the a butment teeth w ill allo w
not o nly a gr ea te r su rface area of e na mel but also
more ' wra p around' o f t he retaine r to t he bucca l
surface (see f igu re 11.5 ). An a lte rn ativ e an d
better so lution if the oc clusio n pe r mits is to ma ke
a fixed -movable bridge (see Fig ur e B.3, page 175 ).
With posterior bridges, o cclu sal rest seats a re
used to prov ide a finn stop against which t he
bri dge can be s ea te d. A shallow preparation is
ma de in t he e namel of th e ma rginal ridge much
m
fi gure 11.6
Temporary incisal hooks to allow firm stable pressu re
to be applied while the bridge is cememed. Once the
cement has set . they will be cut off
Fig ure 11.7
C han-ode te mpo rary-bridge construc tion .
a An alginate impression is taken befor e t he prepara-
tions are sta rte d. with the te mpo rary de nture in place.
The alginate is re moved fro m the buccal sulcus area to
facilitate rese aung in the mouth befor e t he tempo rary
cro wn and bridge material is put into the impress ion.
b The plasnc temporary bridge re mo ved from the
mouth. The material has flo wed palat ially into the space
left by the plate of the dentu re. This can now be
removed together with the thin flash over the adjacent
unprepared tee th. The almost-transparent buccal-
incisal surface of the upper right central incisor retainer
shows that more pre paration of the abvtmenr tooth is
needed here or the retaine r will be too thick. To a
lesser e xtent the same is tr ue at the tip of the uppe r
left latera l incrscr. These modifications shou ld be made
to the prep arations befor e the impre ssion is take n.
like a rest scat fo r a partia l den ture, a lthough it
ca n be s hallo we r. W it h retaine rs o n anterior
teeth, horizontal seating ledges or dimples are
prepared . An alternative is to m ake the cas ting
w ith an incis al hook th at is CUt pa rt wa y through
fro m th e' fit su rface before ce me ntatio n an d is
then cut off afte r ce mentation o nce it has do ne
its jo b (see f igure 11.6).
Although some preparation of th e a xial walts of
poste rio r abutment teeth is occasionally neces-
sa ry. it should be avoided w he re possible and in
any case kept to a minimum. Grea t ca re must be
228
tak en not to penetrate th rough to dentine. and
this is somet imes difficult. particularly near to the
gingival margin. Fig ur e I 1.8 shows 3. section of an
unprepared molar [oath [a], together with a
panern fe r a m inimu m preparati o n r etain er
wit hou t preparing th e tooth (b) and afte r prepar-
ing the tooth (c). In both Figures II .Bb and c there
is inevitably a change o f co nto ur at the margin o f
the retainer, wh ich must be kep t dean by the
patient. In th is and many cases, th e re would be no
adva ntage in preparing th is ax ial surfac e . It has
been suggested that a fini shing line indicates to the
technician where the retainer is to finish. Th is is
a complete ly unjustifiable reason. because the
same indicatio n could be given by th e dentist
drawi ng the retainer ou dine on the stu dy cas t.
Making temporary and provisional
bridges
Choice of material
Temporary bridges are nearly always mad e of one
o f th e plastic materi als. If made at the chairside.
o ne of th e higher acrylics. with or without
reinforcing filler part icles will be used; if made in
the labo rato ry. t hey will usually be co nvent io nal
acrylic or o ne o f the higher acrylics . alt ho ugh
labo ratory light-cured co mpo sites may also be
used. Metal castings o r o ther meta l co mpo nents
may be inco r po rated into longer-te rm provisiona l
bridges. particularly those with long spans.
However, the occlusal surface should usua lly be
acry lic so that o cclusa l adjustments can be made
readily if necessary. Mo dem plastics are suffi·
cientJy res ista nt to wea r for th is to be possible.
Choice of technique
Chairside construction
The majority of temporary bridge s can readily be
made at the chairside. often in less time than it
takes to modify a laboratory-made te mporary
bridge. and o f co urse avo iding the add itio nal
labo ratory co st.
The chairsid e technique illustr ated in Figure
I 1.7 is similar to the temporary crown techniques
shown in Figures 6.17. pages 124-5 and 6. 18. page
126. The mould may be an impression of a study
cast with the pontic made from a dentu re tooth.
o r it may be a vacuum-formed PVC slip. tn many
anterior bridges. though. the patient is alre ady
wearing a temporary dent ure. and it is sufficie nt
to take an alginate or silicone putty impressio n of
the arch with the de ntu re in place and use this
to make th e te mporary bridge. T his is t he
technique illustrated in Figure 11 .7. T he excess
material fl owi ng into the areas of the impressio n
previo usly occupied by the de ntu re. can be
rem oved with an acrylic bur in a' straight
handpiece . on ce the plastic has set and the
temporary bridge has bee n re mo ved from the
mouth.
Fo r pos teri o r bridges. wher e t here is often no
temporary de nture. but where the appearance of
the pontic is no t important. an alginate impres-
sion may be taken (wit h nothing in t he sadd le
area) before the teeth are pre pare d. and used to
make ind ividual tem po rary crowns for the
abutm ent tee th.
Laboratory-made provisional bridges
If the pro visio nal bridge is to last for mo re tha n
a week or two. if it is large o r if its appearance
is part icularly important th en <'I laboratory-made
provisional bridge is pr eferable to a bridge made
at the chan-side .
O ne tech nique is to make pre paratio ns of the
abutment teeth o n a Study cast so that when the
full-scale prepa ration is done in the mouth the
temporary bridge will be a loose fit. If the prepa-
rat ions o n the stu dy cast are co mpleted to full
depth. it will be impossible to duplicate them
exac tly in the mouth. and the pro visional bridge
will not seat.
If full-scale tr ial preparations have been made
to asse ss parallelism. this cast may st ill be used
to make a provisio nal bridge. the prepared teeth
o n the study cast must be covered with a spacer
of tin foil. or the fit surfaces o f th e bridge
enlarged wit h a bur in the labo rato ry before the
bridge is returned to the chair-side. The bridge is
waxed up and processed in the labo rato ry using
conventiona l acry lic techn iques. or acrylic denture
teeth o r special acrylic facings are ground to
sha pe and incorpo rated as th e facings for the
bridge (see Figure I I.l).
(lin,wl techniques (or bridge cOrlw wetion 229

www.allislam.nel
Problem

Figure 11 .8

Alte rna tive minimum -pre paration re taine r des igns ,

a A section thro ugh an extracted molar tooth ,

b T he tooth has not been pre pa re d and t he retai ner

w ill be bo nded directl y to t he ena me l surface,

c T here has bee n some prepa ratio n, e nt irely withi n

e na me l, and so the reta iner is partly wit hin an d partly
o uts ide t he original too th contour.

O nce the abutm ent tee th have been prepa red
in the mo uth . the pro visio nal bridge is tried-in an d
will us ually need to be relined with a higher acryl ic.
The tech nique using an accurate working
impress io n of t he prepa red teet h to make a
provisio nal bridge is mo re reliable. and ofte n
produces a better marginal fit but ta kes an ex tra
appointment. Thi s is necessary. however, if a
metal casting is to be inco rpo rated for extra
strength (Figure 11.8).
Cementing temporary and provisional
bridges
Temporary bridges sho uld be sufficiently rete ntive
no t to cause tro uble betwe e n appoi ntments . but
it should be possible to remove them w itho ut
e xce ssive force or dam age . The temporary crow n
and brid ge ccment mg mat e rials arc supplied w ith
Figure 11.9
A long-term, immediate-insertion, provisional bridge in
heat-cured acrylic incor porating a metal casting. The
bridge has been in place six months while extraction
sockets have healed. Note the space beneath the
pcnncs that has resulted from the healing.
Figure 11.10
A plastic stock impression tray. stiffened with a higher
acrylic and providing a soft tissue stop on the palate.
A large amount of clearance is available for me im pres~
sion of the anterior teem .
a mo difying paste that may be combined in varying
proportions with the base and catalyst pastes to
weaken th e final mix. Mo d ified ce ment is recom-
me nded w ith large or very retentive bridges.
Expe rie nce w ill guide th e operato r as to the
co rrect proportions for the particu lar bridge and
the particular patient. Fifty perce nt or more of
the to tal mix may co nsist o f the modifyi ng paste.
Provision al bridges may also be cemented with
te m po rary cro wn and bridge ceme nt , but usually
witho ut modifying pas te. If more rete ntion is
needed . a zinc oxi de/euge no l cement may be
used; in scene cases zinc phospha te cement is
nece ssary.
The working impression
Any of the impress ion mat erials or te chniques
desc ribed in Chapte r 6 ar c suita ble fo r br idge-
Clinical technjques for bridge conwuetjon
wo rk. Wi th fixed-fixed br idges it is often an
advantage to have tw o w orking casts, o ne wit h
removable dies for ma king the individual retain-
ers and o ne t hat is not section ed and the refo re
preserves t he full contour o f t he sadd le area
togethe r wit h the relatio nship o f t he abutment
teeth. W ith good die locatio n and a sma ll bridge,
an unsectioned mo del is not nec es sar y, but wit h
large r rec o nst ructions w here t he dies have t o be
removed and re placed ofte n, die locat io n syste ms
tend to wear, allowing mo veme nt of th e dies.
Then a so lid mo de l may be necessary.
All bridge s sho uld be made w ith full arch
wo r king impression s for maximum sta bility of
occlusion . W hen all t he t eeth in on e quad ran t ar e
missing o r pr epa red, it is neces sary t o provide
adequate stops o n the impress ion tray to pr even t
it from seating o nto th e pr epared teeth. In so me
cases t hese will be so ft-t issue stops. Figure I 1.10
shows an acryl ic st ock tray mo dified wit h a higher
acrylic at t he chairs ide to give a palata l soft-tissue
sto p. Th ere are also imp rovemen ts to the pe riph-
eral adaptat ion and r igidity. Th is tray w ou ld be
su ita ble for use w ith a po lyethe r imp re ssio n
material o r an addi t ion-c uring silicone.
Figur e 6.4 shows th e constr uct ion of sp ecia l
t rays.
Occlusal records
For the choice of ap pro priate o cclusal records,
see C hapte r 4. T he larger t he bridge, the more
time-co nsu ming is any occl usal adjust me nt at the
chairslde, so it is likely t hat a semi-adjustable o r
fully adjusta ble articulator win be cho sen
(togethe r wit h the appropriate occl usal reco rd s)
to minimize this ad justm e nt t ime.
Trying- in the metal framework or
separate units
Metal -ceram ic co nvent ional bridges sh o uld be
tri ed -in at the metal st age . Experi enced operators
making small bridges, w ho are familiar wit h th eir
t echnician's w ork, sometime s om it t his st age , but
th is is inad visable unde r othe r cond itions.
Metal--ce ram ic bridge s of up to six units are
ofte n cast in one piece. Whe n t hey are tried in,
23
all the checks liste d in C hapter 6 should be made,
and if th e fram ewo rk is acce pta ble, it may be
retu rned to t he laborato ry fo r th e po rcelain to
be adde d.
If the framew o rk does not seat, and once
obvio us causes have been eliminated. such as tight
co ntact poin ts or air blows on t he fit su rface of
t he cast ing. it must be ass umed t hat the relatio n-
ship betwee n the ab utment teeth is the problem.
This may be wrong e ither because th e ab utment
teeth have moved since t he impression was ta ken
(perhap s becau se a t emporary bridge was not
provided) o r because the die lo cat ion is at fault.
If th is is sus pected, the br idge should be divided
and t he se par ate co mponents tried in. It is better
to saw thro ugh th e bridge with a fine fretsaw
cutting diago nally t hrough one of t he pontics
rathe r t han thr o ugh a connector (see Figure
11 .1 Ia). This gives a large r surface area for the
bridge to be resoldere d. and the solder jo int will
be cov e red by po rce lain, wh ich w ill furthe r
st re ngthen it. If t he se parate unit s fit , the br idge
is relocated (se e below) and so lde red w ith a high-
temperature solder before the po rcelain is added.
It is ad visable to retry t he bridge now.
If, once t he bridge is sectio ne d, some of the
retainers fit and others do not, a further impres-
sion is needed. This w ill be of the unsatisfacto ry
ab utm e nt s. wit h the sa tisfact ory re tainers and the
attached parts of t he po ntic left in sit u. They will
be a guide to the technician in waxing-up the
repeated sections. A furth er retry and lo calizatio n
in the mouth is necessary before so ldering.
With lar ger br idges not cast in o ne piece . the
sep ara te sections should be t rie d-in before local-
izat ion and so lde ring.
Bridges made in other materials are usually
completed and not t ried-in as separate units.
Pos te rior all-me tal bridges are necessarily relatively
small, as are anter ior all-porcelain bridges. W here
metal units are to be solde red to me tal-ceramic
units, it is poss ible to try -in the sep ara te retaine rs
before the co nnecto rs are so lde re d.
Localization techniques
Now that full arch imp ressions are ta ken almos t
universa lly for bridgework, there is less nee d for
lo calizat ion of individual retainers than w hen
individual impressio ns w e re ta ken of each
lJl
abutment tooth. How ever, prob lems still ar ise, as
o utl ined in t he pre vious sect io n. with th e fit of
o ne-p iece castings. It may also be difficult to get
a single impre ssio n of all the t eet h at on ce,
especially when large bridges are made in the
lower ar ch. Th e t o ngue makes it difficult to obtain
a dry field o n bo th sides of the arch at th e same
time. In t hese cases separate impressions of
gro ups o f ab ut men t teeth have to be taken and
re lated to eac h othe r wit h a localizatio n
technique .
OnKal lechmques (or bridge conw uw on
Fig ure 11.11
Lo calizatio n
a T he meta l framewo r k for a thr ee-unit metal-ceramic
br idge. T his has been tried in the mouth and found not
to fit . W hen sectioned diagonally thro ugh the pon tic. the
separate re ta ine rs fitted, and so it was relccahzed in the
mouth and soldered before the porce lain was added.
b A I~ rge bridge. cast in fou r sect ions. being localized
in th e mouth wit h fast-setting ~crylic. To stabilize it. a
bar w ill be at tached 3CrOSS the back with more acrylic.
c Multiple Separ.lle bridge recamers co nnecte d with
acrylic and old bur shanks. The castings have been
remove d fro m the 3crylic. This assemb ly can now be
rcseared in the mo ut h and a new impression taken
over it to r-eco rd the saddle area s. The pe ones are th en
made and soldered to the r etain ers.
An overall imp ression of t he cast ings in place
may be used fo r lo calizatio n. A rigid e lasto meric
mate rial such as po lyether must be used, since
softe r materials distort when t he casting and dies
are seated in t he impress ion. An alte rnative is to
use acry lic with a paint -on tec hnique . When
adjacent re tainers are to be lo cated o r a cut
po ntic resoldered it is sufficient simply to clean
the surfaces. paint a fast-setting co ld-cu re acry lic
ove r the surface and allow it to harde n befo re
withdrawing the bridge (see Figure Il.Il b).

When the pontics are not yet made or where
me bridge is large. the localizatio n is stiffened and
supported w ith me tal bars or a metal fra mework.
The bars may be o ld bur shanks cut to suita ble
length (see Figur e 11 .11c).
Try-in and tri a l cementation o f
fin ished bridges
The chec king procedure is as described in
Cha pter 6. In some cases th e bridge does no t fully
sea t and the operator may suspect that the te eth
have moved. particu larly if a meta l stage try-in
was satisfactory. Rat her than sectioni ng t he bridge
again, it may be left in t he mo uth for a few ho urs,
prefera bly w ith no cement. o r w ith petro leum
jclly and zinc ox ide powder (wh ich does no t set)
to pr eve nt o ral fluids from irritating the expo sed
dentine . If after a few ho urs the bridge has not
seated, the next stage is to cement it with a very
weak temporary crow n and bridge cem e nt with
a large pro portion o f modifier. Bridges ce mented
in this way may be left for days o r even weeks
to settl e betore be ing finally cemented. This
should be do ne routinely with larger bridges.
The advantages of t rial ceme ntatio n are that, as
well as po ssible im p r o vements in marginal fit, th e
pat ient has a chanc e to beco me acc ustomed to
th e appearance and feel o f th e bridge. which can
still be mo dified o ut of t he mo uth if nec essary.
Any problems w ith the occl usio n are likely t o
show themselves and can be dealt w ith before the
bridge is pe rmanen tly cemented .
Tria l ce mentation should no t be attempted
with all-po rcelain bridges o r the mino r re tainers
of fixed-movable br idges. Tr ial ce mentation is no t
possible with minimal-pre paration bridges .
Permanent c ementation
The cem entation of conve ntio nal bridge s
differs from that of cro wns o nly in that with
fixed-fixed bridges the surface are a o f th e
co mbined abutm ent preparat ion s is large r t han an
individual crown and so t he hydrostatic pressure
of the unset ce ment is much greater. Greater
forc e therefore has t o be applied to seat the
bridg e fully.
133
Because of the difficulty of cementing large
bridges and the nee d for a long working time
befo re the ceme nt starts to set, zinc pho sphate
cem ent is still the most po pular fo r large bridges.
Its working time can be ext e nded considerably :
the mixing slab is co o le d, very small increments
of powder are added at a t ime, and mixed fo r a
lo ng period (app roxim ately 90 seconds). Ready
pr o po rtio ned ce me nt in a plastic syringe is also
available and is mixed in a mechanical vibrator. If
th e syringe is used straig ht fro m th e refrigerator,
a consiste nt, slow-setti ng, air-bubble-free mix is
obtained .
For prep arations with nearly para llel walls the
tec hnician may use an add itional layer of die-relief
varnish o n t he axial wa lls. Th is increases the
ce me nt-film th ickness in t his area witho ut increas-
ing it at t he margins. and so reduces hydro static
pressure du ring cementatio n.
Gla$S ionomer luting ce ment is preferred fo r
small conve ntio nal bridges fo r t he re aso ns
de scribed in Ch apter 6.
The cem entation of ml nlmum-prepara-
ti on bridg es depends o n t he technique use d to
make the br idge and the luting cement . Th e
commonest types are now th o se with sand-
blasted flr- surface s lut ed with an adhesive res in.
o r Roch ette (macro-mec hanically rete ntive)
bridges o r splints ceme nted wit h a co nve nt ional.
chemically cured co mposite marertal. These are
used when it is like ly that t hey will have to be
removed atraumatical1y. In add itio n. etc hed metal
surface s luted with chemically cured. low-viscos-
ity luting cem ents are also still used .
Rgure 11.12 sho ws the luting pro cess for an
e tche d br idge with a chemically cure d co mpo site
ce ment. The proc ess is ve ry similar wit h adhesive
resin ceme nts except that the marg ins must be
pro tected w ith a gel material to avoid air co ntam-
inatio n while t he ceme nt sets.
Summary o f clinical t echnique for
minimal-preparation bridge s
Minimal-preparatio n bridges are constructed as
fo llows (see Figure I 1.12).
• Thoroughly scale and po lish t he abutment teeth
- and t he remainder o f the mouth, of course
23<
• Carry o ut any necessary t oo th prepar atio n
• Take an accurate wo rking impr essio n m
elasrom enc material
• Prepare the metal framework and pontic in the
labo ratory; the po ntic is usually meta l-ceramic
• Try- in the br idge ; if it is a Maryland bridge, etch
t he metal fitt ing surface after trying it. and then
do no t touch th e etche d surface o r retry th e
br idge. otherwise the de licate e tche d surface
will be damaged
• Repol ish the ena mal surfac es to which the
Fig u r e 1 1. 12
C linical techn iq....e for a minimum-preparatio n bridge .
o T he working imp re ssion.
b Th e m etal fr amework and po nti c o n the model. Th is
is t ried in the mouth and ad justed before etch ing o r
sandblasting. It should not be retried after etch ing. or
the delicate etche d surface Will be damaged. The deSign
is fixed-fixed because the tooth being replaced is an
upper canine that will be in occlusion in lateral excur-
sio ns. A cantilever bridge from t he premolar would not
have been adequat e with this occlusion, and t here was
insuff,cient space to make a movable connector in the
latera l incisor without excessive tooth preparation .
c Polishing the abutment teeth with pumice and water
after applying rubber dam.
bri dge is to be ceme nted, ap ply rubber dam
a nd acid-e tch th e e namel surfaces
• Cement th e bridge w ith a c hemically cured
composite resin (one made specially for t he
pu rpose), and remove excess co mposite from
t he margins
• If t he bridge is t o be ce me nt ed with a chemi-
cally adhes ive ce me nt , t he metal should be
sa ndblasted as late as possible before ce men-
tation . The bridge sho uld be ceme nted unde r
ru bber dam and the gel mate rial supplied with

th e cement applied (0 the margins o f the
retainer to ex clude air since th e setti ng of the
ce me nt is inh ibited by air .
Oral hygiene instruction s and
maintenance
This is pa r-ticular-ly impo run t wit h bridge s, and in
so me cases th e t echn iques w ill be enti r ely differ-
ent from those the patient has been taught to
m
d Pho sphori c acid gel applied carefully with a paillt-
bru sh o r with a syringe t o th e areas t o be co vered by
the re ta iners.
e Lut ing t he etched br idge wi th a chemi cally cured
composite specially made for the purpose. It wo uld
have been a good idea to place some floss bet ween the
abutment and the adjacent teeth before cementing the
bridge. Pulling thi s thr ou gh the co nta ct po in ts bef ore
the ce ment set wou ld have he lped to remo ve excess
cement. If the bridge had been sandblasted and luted
with an adhesive resin. the margins would be coated
with gel to exclude air while the cement set.
( Immediately after removing the rubber dam.
date or fo r cro wns. The ar eas whe re differe nt
cleaning tech niques may be needed ar e between
the pontic and t he ridge and the gingival margins
of th e ab utment tee th be neath the co nnec to r'S.
Th e tech nique w ill de pe nd upo n th e desig n of t he
ridge surface of t he po ntic. t he pan: o f the mouth
w here the bridge ~s situat ed and th e patient' s
manual dexterity. W ith ridge-lap and saddle
panties, dental floss or ta pe may be th readed
th ro ugh an em bra su re space and then passed
under the ponti c to clean it and the ridge . Even
Figure 11.11
a Clean ing aids fo r use with bridges.
From the lOp: a soft toothbrush w ith two ro ws of
bristles that can be used aroun d do me and ridge-lap
po ntics;
two single tuft inte rspace br ushes - these are often tOO
stiff ex cept in very large o pen em bras ure spaces;
two 'bo ttle' bru shes WIth mult iple small lateral tufts
that ar e useful for med ium-sized embrasure spaces;
a 'bottle ' brush w ith a simple wire handle ;
supe rflcss. the most useful of th e bridge cleaning aids
_ th is has a Stiffen ed e nd, right. and a furry secncn that
is ve ry useful fo r cleaning under pantics. and espe<:ially
und er smooth saddle pant ies:
regular floss. which can som etimes be passed thro ugh
embrasure spaces to clean unde r peones; but when this
is difficult it is used in con junct ion WIth
a floss th r eader. a flexible nylon loop with a st Iff end
that passes easily betw een t ight embrasure spaces.

b Supe rfioss being used to clean beneath the pantie

c The clinical use of some of th e cleaning aids shown

in a and b _ they wou ld no t no rmally all be used at
o nce!

better is superfloss. Its furry section makes clean-
ing unde r peones much caster (see Figures 9.5.
page 199 and 11.1 3).
Was h-through and dome-shaped pcnucs are
usually cleansablc enti rely with the toothbrush,
although in some cases an interspace br ush or
other special bru sh may be an advantage.
O ral hygiene instruction shou ld be given at t he
same appo intment as th e bridge is ce me nted. The
patient sho uld be seen again in one or two weeks
to ensure that the new cleaning techniques ar e
Practical points
• Te eth should be prepared par alle l to each
othe r by eye, and if in do ubt, and for larger
bridges, a mo del of the init ial pr eparatio ns
surveyed in the labo rato ry.
• Mo st tem po rary bridges can be made at the
c ha ir-side.
• All br idges sho uld be made wit h maximu m
stabi lity of occlusion.
217
successful. At this stage it may be helpful to use
disclo sing tablets o r solutions. At the same
appointm e nt the oc clusion and the reta ine rs
shou ld be checked.
It is advisable to see th e patient at regular
intervals. usually six-monthly, when the full range
of checks of margins. gingival health , cleaning.
o cclusio n and the mec hanical integrity of the
bridge are made. Cha pter 13 dea ls with repairs
and mo difications to bridges where these checks
reveal any pr oblems.
• Localizat ion tec hniques may be nee de d whe n
o ne-piece cast ings have to be cut and individ-
ual retainers are not sat isfacto ry.
• T rial ce mentation will allow fo r po ssible
improve me nts and will give the patient time to
beco me acc usto med to t he fee l and appearance
of the br idge .
• Good homecare by th e patien t is essential if
bridges are to succe ed.
Part 3 Splints
 12 Fixed splints
Many of t he tec hniques used in constructing fixed
splints are similar to t hose used to make crowns
and br idges. Large splints often contain one o r
mo re po ntics. an d are th erefo re combination
br idge/splints. There is no attempt he re to
descri be removea ble sp lints in detail, since the
tech niques for constructi ng the m are mo re ak in
to partial denture co nstruction. There is,
however, a section o f th is chapter comparing
fixed and remova ble splints.
Differe nt types of sp li nt are used depending o n
the t ime for whic h they will be needed. Short-term
splints arc made as an emergency measure, inter-
med iate splints are made to last for a few mo nths,
usually wh ile other forms of treatment are being
ca rried out, and permanent splints are intended to
last for the lifetime of the dentition or the pat ient.
Indicat ions fo r fixed splints
Trauma
A blow may result in an inciso r tooth being
partially or completely sublu xated . If the tooth is
repositioned correctly in its socket very shortly
after the accident, particularly with yo ung
patients, it has a good chance of surviving for a
useful pe riod, providing it is kept clea n and other
conditions are favourable . It will no rmally nee d to
be stabilized by being attached to adjacent teeth
w hile the periodontal ligament heals and t he
alveolar bone remodels. It is not usua lly neces-
sary to provide int er mediate or permanent splint-
ing for tra umatized teeth.
Perio d o nt al d isease
At o ne t ime splints were prescribed as a way of
treating pe riodo ntal disease and preventing t he
lo ss of teeth through progressive loo se ning. This
is no longer accepted as a reaso nable for m of
treatment; and the proper treatment of pe riodo n-
tal disease itse lf is beyond t he scope of this book.
Ho we ve r, once t he d isease has been successfull y
tre ated, the re may be two co ndit ions when a
fixed splint is indicated:
• W he n t he residua l mo bility o f the teeth is such
th at the patient finds t hem uncomfortable and
no rmal masticato ry funct io n is im practical.
• When teeth are missing and m ust be replaced
for o ne of the re ason s list ed in Chapter 7. In
many cas es th e re maining teeth are not sat is-
facto ry as de ntu re abutm ents in view of their
mobility o r because it is considered that a
partial de ntu re will ma ke oral hygiene proce-
dures mo re diffi cult and will be like ly to
shorten t he life expectancy of the remaining
teeth. Individual teet h may also be unsuita ble
as bridge abut me nts, but a number of t eeth
splinted together may form a satisfactory
abutment for a br idge or perhaps a precision-
attachment retained partial de nture,
Orthodontic retenti on
In the great majority o f co urses of orthodontic
t rea tment the teeth are moved into new
positions w he re, fo llowing a pe riod of settling in,
t hey are sta ble. There is sometimes a persistent
tendency to re lapse , and for full er explanations
for th is the reader is refe rred to textbooks of
orthodontics. Orthodontic re lapse is more likely,
and may inde ed be anticipated, if the t oo th
moveme nt is to realign teeth that have drifted
fo llowing pe riodontal disease. Figures 4.5c and d,
page 70 illustrate a case where, if orthodontic
t reatment is to be provided , fixed splint retention
is very likely to be nec essary.
Congenital defects
Cl e ft palate
O ne metho d of t reating cleft -palate cases is to
expand the palate rapid ly by orthodontic mea ns
H I
242

Figure 12.1

A bridge to stabilize a mo bile pr emaxilla r esulti ng from

a bilateral cleft palate .

(J The preoperative co nd ition fo llOWing surgical

treatment.

b The prepared t ee th. T w o abutments in each buccal

segment are used t ogeth e r with the two teeth in the
premaXilla.

c T he co mpleted bridge stabilizing th e pre maXilla.

and to insert a bone graft . In some ca se s the
result is not completely sta ble. and if the re arc
mi ssing ante r ior t eet h (w hich is co mmon). a
br idge re placeme nt may be made and a number
of teet h on eac h side o f t he cleft splinted to form
the abutments. Th ese splinte d ab utments w ill also
stab ilize t he tw o halves o f the upper arch.
O ccasicnany t he prem axilla is separat ed fro m
the re mainde r of the uppe r arch. and . to gether
w it h any t eeth car ri ed in it, it will be mob ile. T his
can be splint ed by means of a fix ed splint/bridge
(see Figure 12.1) .
D ental d efects
Ac quir ed o r co ngenit al denta l abno r malities can
result in tee t h of an unsual shape o r co nsistency.
fjxed ,pljnts
If crowns a re necessa ry, re t e nt io n ma y be unu su-
ally difficu lt, but can be improved by splinting a
nu mb er to gethe r. Figure 12.2 s hows a case of
gr oss tooth wear where th e lo wer incisors are
to o small for adeq uate rete ntio n of conventional
resto ra tio ns and w here radio graphs showed pu lp
calcifica tion so that post c rowns we re not possi-
ble. Splinted pin-retained crowns we re made,
each one gaining support fro m its neigh bours.
H'
Figure 12.2
(land b Pin-retained splinted cro wns to restor e vital
but badly wo rn lowe r inciso r teeth . The uppe r incisor
teeth were also crowned, but sufficient dent ine
remained for these cro wns to be sepa rate.
Figure 12.1
Splinted abutme nt teeth for a precision-attachme nt
reta ined-tree-end saddle dentu re. The silO; anterior
teeth have red uced alveolar support and have been
successfully treated per iod o nu lly. They were also
heavily restored. Splinted crowns provide support for
e xtra-coronal precisio n attachments that retam and
stabilize a de nture and avoid visible clasps.
Additional retention
W ith precision-a ttac hment re ta ined pa rtial
de nt ures. t he ab utment tee th carrying t he
attachme nt may need to be splinted togethe r.
This provides extra re tentio n to re sist t he
additional force d uri ng removal o f t he appl ia nce
(see Figures 7.1a, page 151 and 12.3).
•
2«
Shorr-teem, intermediate and
p ermanent splints and diodontic
implants
Short-term splinu
Wh en a tooth is loosened by a blow or is
completely lost and replanted. an immediate
temporary splint is necessary. The usual method of
splint ing is to attach th e to ot h invo lved to adjacent
tee th w ith acid-etc h reta ined composite (see
Rgure 8,9 page 181). Vari o us other techniques ar e
used for tempon.ry splints . such as wiring th e teeth
together o r ce me nting a ca p splint made of acrylic.
some other vacuu m-formed material or cast meta l.
Howeve r, if sufficient enamel is pre se nt for acid
etching, t hese other t echnique s <I re less satisfacto ry
than composite splints because the y are less
hygienic and int erfer e with th e occl usio n.
Inte rm e di at e-t erm splints
These are used wh en teeth need to be immobi-
lized for perio ds of between a few weeks and a
few months, for exa mple wh ile periodonta l treat-
me nt is ca rried out. before pennanent restora-
tions are made. Th ey are usually o ne of the less
pe rmanent minimal-preparation types (see
opposite), but may be intra-co ro nal. Ceme nte d
cap splints are no t suitable, since they inte rfere
w ith the occlusion and create great difficu lty in
clea ning.
Pe rmanent splints
Co nventio nal permane nt splints for resto red teeth
are euhe r partial o r com plete crow ns, connected,
or one o f the proprietary sp lints . Ho wever, w ith
unrestc red teeth a minimal-preparation type of
splint is now the treatment o f cho ice.
Diodontic im plants
An entirely different approach to permanendy
splinting an individual tooth is to stabilize it with
a dio do nnc implant (see page 249) . These are
used w hen the root o f th e tooth is short. as a
re sult of ho r izon tal fract ure in t he middle th ird
of th e ro ot. apical res orption or repeated uns uc-
cess ful apicectcrmes.
Fixed splints compared with
removable splints
Advantages of fixed splints
• The most reliable splints for mobile teeth o r
those with a tendency to drift
• C an be kept en tirely clear o f the gingival tissues
• Occupy minimal or no addit iona l space
• Ca nnot be left o ut by t he patient.
Disadvantages of fixed splints
• Conve ntional sp lints are expensive and
destruct ive to tooth t issue
• Minimal-pre paration splints may be plaque-
rete ntive and unreliable . T he conseq ue nce of
loo~ening and rapi d caries devel opment may be
the loss of teeth.
Advantages of removable splints (e .g.
cast cobalt-ehromium)
• Can be removed for cleaning
• May be less expensive than fixed conve ntional
sp lints and may be less des truct ive to sound
tooth tiss ue.
Disadvantages of removable splints
• Remo val and insertion ineVitab ly causes
mo ve ment of t he teeth tha t are meant to be
stabilized , and th is may increase mo bility
• W ith long-te rm orthodo nt ic retention and
cleft-palate cases, a rem ovable splint has to be
worn for 24 ho urs a day (e xcept fo r cleaning),
and this has harmful effects on the perio-
dontium

• If th e splint is bro ken o r lo st o r has to be
re t urned to the la bora to ry for re pair, there is
a risk of teeth moving wh ile the appl iance is
o ut, so t hat th e a pplia nce will not fit w hen it
is re tu rn ed to th e mout h.
Types of sho r -t-ter m intermediate
a n d permanent fixed splint
Min;mal-preparat;on (resin-bonded)
splints
This group ca n be used eith e r as short-term,
int e rm ediat e or, in some cases , pe rma nent splints.
The y have t he advantage th a t t he y can be
rem oved. a nd since t he teeth have often no t bee n
pre pared, t he y do not ha ve to be rest o red.
Ho we ve r, because t hese splints a re appl ied to th e
s urface o f t he teeth, th ey ine vitably add to the ir
bu lk a nd make o ral hygie ne mo re diffic ult. T he re
is also the proble m o f th e m interfe rin g w ith the
2<,
Figure 12.4
The right central incisor was partly displaced by a blow.
It was mobile and uncomfortab le . This wir e-and-
compcsue splint is rigid, allows the tooth to be
positioned correctly in the occlusion while the splint is
being a ttached, allo ws the tooth to be tested for vital-
ity, doe s not inte rfere with the occlusion, and is acces-
sible for cleaning. It was re moved ah er three wee ks,
by which time the injured toot h was firm.
Figure 12.5
A wire-and-acrylic splint. This splint served a useful
purpose during initial period ontal therapy, after which
the rc c cs of the four incisors we re resected . The splint
has remained effect ive until comple te alveo lar healing
has occurr ed. and now the patient is ready to have a
bridge - a temporary p.artial denture haVing been
avoided .
o cclusio n; a nd in so me cases th e idea l des ign for
re te ntio n and splint ing ca nnot be used be ca use of
t he occlusio n.
A ci d -etch r eta in ed composite s p lin ts (see
Figure 12:4)
A simple s ha n -term splinting tec hniq ue is to aci d-
etch the app rox ima l surfaces of ad jac e nt tee th
and attach them w it h acid-e tc h retaine d compos -
it e. Th e tech nique is not s ufficiently rigid t o
funct io n as a. perma nent splint. To stre ngthe n t he
splint. it is usu ally nec essa. ry to add stai nless-stee l
w ire o r one o f the proprieta ry splints that a re
sim ila.r to onhodo ntic brackets (see la te r ).
Wire-and-a c ryli c o r w ire-and-c ompo sit e
splint (see Figure 12.5)
A satisfacto ry fo rm of inte rmediat e sp lint ing,
pa rtl cu la rfy fo r low e r incisors , is the wire -a nd-
2<,
acrylic splint. Th e t echn ique can be use d when
some of the te eth are cro wned and so canno t be
etc he d fo r the re te ntio n of co mpo site.
Br iefly. th e t echn ique is to pass a wi re loop
around all the teeth to be splinted. Furt he r loo ps.
in thi nner wire, are pas sed arou nd the contact
points. tak ing in the first lo o p bucca lly and
lingually. The se co ndary loo ps arc twi sted and
tighte ned in turn a litt le at a time , allowing adjust.
me nt of th e po sition of t he mobile t ee th . Whe n
all is firm. the wire ends arc cut o ff, tucked into
th e embrasures and the who le painted over w ith
acrylic or composite without etching any enamel
tha t is present. This typ e of splint is eas ier to
re move than etch-retained splints.
Cast-metal m inimal-preparation (Rochette
and Ma ryl a n d ) s p lin ts
T hese have become the mo st common type of
inte rmediate and pe rman ent splints . Th ey have
the advantage that they do not requ ire much o r
any preparation of the tooth and yet are t hin and
uno btrusive and do no t significantly affect th e
patient's appea rance . Figur e 12.6 shows a
Roche tte splint . The se splints have the advan tage
t hat it is possible to remove them fairly au-au-
matically by cutting the cement o ut of the re ten-
tive ho le s. Minimal-preparatio n-type splints o f th e
micro- mechanical o r che mical-adhesive types arc
ma rc difficult to rem ove , and if removal is ne ces-
sary, they usually have to be cut off. othe rw ise
there is a risk of extracting any teeth with
reduced alveolar support with the fo rce neces-
sary to remove t hem . Ho wever, fo r pe rma nent
Figu re 12.6
A mimmal-preparatsoo sphnt!bl-idge of the Rochette
type.These large retention holes are no longer used
(see FIgure 8.9a). One central incisor has also been
replaced."
ret ention of o rt ho do ntically t reate d te eth with
sound periodontal health, a minimal-prepa ration
type of splint is pr eferred since it is more re ten-
tive and smoother lingually.
These splints are made and cement ed in the
same way as the minimal-pr eparation bridges
descr ibed in Ch apte r II . It is essential to use
ru bber dam while ce menti ng the m.
Int ra-c oron al splints
A variety of t echn iques have been suggested for
splinting adjacent teeth .....ith int ra-co ronal
restoratio ns using either amalgam or co mposite,
with t he t eeth li nked by wire or a proprietary
device . Figure 12.7 (cen tre) show s a typical
exam ple o f such a splint.
The major problems with this type of splint are
first that forces applied to th e unprotected part
o f t he tooth surface ten d to break down the sea l
between the resto rat ion and to oth, with marginal
lea kage occurring follow ed by secon dary caries.
Second, mechanical fail ure at th e connectors is
fairly common. Third , beca use th ey are diffic ult to
fi nish and po lish, it is o ften harder to dean
around th is type of splint than around partial or
co mplete crown splints with polished co nnectors.
Proprietar y splint s
A variety of splint systems invo lving ancho ring a
cast framework to th e teeth with threaded pins
 Fixed splims
were use d at o ne t ime. Th e s e have be en super-
seded by the acid-etch retained syste ms, b ut
many patients w e re trea te d w ith the m. Dentists
st ill ne ed to be ab le to reco gn ize t he se s plints so
t hat at le ast t he y can provide s uita ble
maintena nce.
247
Figure 12.7
Two fo r ms of composite retained proprieta ry sp lint.
To p: a preformed splint. available in a variety of fo rms,
is retentive fo r com pos ite and is attached by the acid-
etch techn ique to the lingual surfaces o f t he tee th to
be splinted. It is comm o nly used as a perm anent or
semi-permanent o rt hodonti c retainer. Centre: t he chain
is embedde d in cavities pre pared in the teeth from t he
lingual or occl usal surface and held in place with
th read ed pins. A self-shearing pin on a con t ra-angle
shank is shown . Once t he chain has been anchored in
place, the cavities are filled wit h co mposite. This
method is only used in cases whe re th ere are already
multiple, large approxim al re sto rat ions in th e anterior
teeth and therefore insuffi cie nt palatal or lingual en amel
to retain one of t he ot her syste ms. A full-crown splint
is an alte rnat ive, but is often too expe nsive in view of
the prob able prog nosis of the te eth to be splinted .
Figure 12.8
o and b A ho rizontal no n-parallel-pin splint. T his has
been pres ent for several years, but failed thro ugh caries
develop ing around the pins in two of the lo we r
incisors. W ith the splint re moved, the pinholes fi lled
and periodo ntal treat ment prov ided. the teeth became
sufficie ntly fi r m not to re quire furt her splint ing.
The t ype t hat has su r vived mo re tha n o t he rs is
t he no n- para llel ho r izontal-pin s plint, T his w as
use d for anterio r te e th (s e e Figure 12.8 ). T he
lingua l surface w as prepa re d a nd ho rizo ntal ho le s
dri lle d right t h rough t he tooth b uc co-l ing ually. An
im p ressio n was ta ken in a sp e cia l tray with
,<8
impressi on pins provid ed as part of the kit an d a
cast-metal backing corresponding to th e pinho le s
in t he teeth, T he backing was then ce men ted, an d,
before the ce ment set, pins we re passed thro ugh
t he too th and sc rewed th ro ugh t he backing. The
heads of the pins fitted into co untersinks o n t he
bucca l surface of t he toot h. Whe n the ce ment
was set, the exce ss pin was re mov ed , bo th
bu ccally and lingually. The heads of th e pins we re
re duced below the level of the buc ca l su rface , and
the teeth w e re resto red w ith com posite.
Partial-crown splints
As wit h pro prietary splints . thes e have been
su pe rseded by minimum -prep aratio n sp lints.
However, aga in, maintena nc e is so metime s neces-
sary, and it is ea sy fo r t he inexperienced de ntist
to confuse a pa rti al-c rown retained sp lint (se e
Figure 12.9c) wit h a minimal-p rep ar at io n splint .
Figure 12.9 s hows a pa rtial-crown spl int
retained by ve rt ical parallel pins. Most partial-
c row n splints w e re retained in this way.
Fig ure 12.9
A partial-crown splint made before minimal-prepara-
tion te chniques were available. Splints are now rarely
or never made this way. but some patients still have
partial-crow n splints that need to be maintained.
o Teeth prepared with ledges and with thr ee parallel-
sided pins each. The pinholes were prepared using an
int ra-oral paralleling device. (See Figure 6.21c for the
impressio n stage and Figure 7.8 for the buccal appear-
anc e.}
b The ceme nted cast ing.
Come'ete- crown splint s
Despite the advantage of m inimal-pre paration
sp lints, compl ete-cro wn sp lints are st ill common.
This is be cause the nat ural crow ns of t he teeth
being splinted often alrea dy hav e lar ge resto ra-
tio ns o r c rowns. a nd so me te eth may have been
extracted, so that t he a pp liance becomes a
splint/b ridge. Figure 12.10 shows a typical 12-unit
splint/b ridge wh ere s ix teet h ar e m issing and
where the re mai ning teeth we re unco mfo rtably
mobile. A partial de nture to re place t he missing
teet h wo uld probably have increased t he mobility
of the re maining teeth: and the pat ient was mo st
unha ppy about wearing a removable appliance.
The rad iogr aph s o f this patient a re s hown in
Figure 7.5.
The d isadvanta ges of t his techn ique are tha t it
is very time-consumi ng, both at t he cha irs ide and
in t he laboratory, and th erefore very expe nsive:
an d if failur e occurs. it may be necessa ry to
remove th e en ti re splint a nd maybe extract
se veral oth e r t eeth. Thi s type of applian ce s ho uld
the refore onl y be pr ovid ed fo r very highly
motivat ed pat ie nt s.
fixtd SplmlS
Diodontic splints
A diodontic sp lint consists of a me ta l po st that
passes th rough th e root canal and into bone ap ical
to th e root. It may e xtend a little beyond th e
po sitio n o f the o riginal apex of the tooth. but no t
so far that there is a risk o f o ther structures being
perforated. such as th e floor of the nose or the
maxillary sinus . Figure 12.11 shows a case where
th e roots o f bot h upper late ra l inciso rs had been
partly resorbed by une rupted ca nine teeth in t he
palate . Followi ng the removal of the can ines. t he
roots of th e lateral inciso rs continued to reso rb .
Befo re th e diodontic implants were placed. both
late ral inciso rs were very mo bile.
W ith diodontic implants the t ooth sho uld be
firm fro m the moment the implant is placed. and
no furth e r splint ing is required . The tech nique w ill
wo r k o nly if there is sufficie nt hea lthy periodo n-
ta l attach men t at the gingival end of the root. Th e
min imum is 2-3 mm of und istu rbed periodontal
attac hment aro und the enti re cir cumfe rence of
the tooth.
Diod ont ic splints are placed less o fte n th e se
days. but are still useful in so me cases. Fo r
exam ple. in yo ung people w ho are still growing
and wh e n. although the long-ter m t reatment may
well be ex tra ctio n and a Single -to oth implant, a
diodontic sp lint will tide them over their late
teenage years w ith o ut invo lving the adjacent
teeth.
'"
Figu re 12. 10
A 12-unit fixed splint/bridge. There are six abutment
tee th and six ponticS. Not e the supragingival margins
which have helped to maintain a good level of gingival
health. Note also the opaque appearance of the
retainl'r margins. This is because in order to make the
six preparations parallel to each other it was not possi-
ble to prepare sufficiently wide shoulders WIthout over-
preparing the whole tooth and risking exposure. This
was anticipated from the trial preparations and the
patient was fully informed about this before the prcpa-
rations were undertaken so that her consent to 't he
procedu re included understa nding that the appearance
would be compromised in this way.
T he app earan ce of anterior sp lints
A patient w ho has had e xt ensive pe rio donta l
disease and trea tment (particularly surgical treat-
ment) often has upper anterio r teeth th at appear
very lo ng. W hen the bpbne is high this is an
aes thetic problem (see Figur e 7.Be). If the incisor
teeth are extracted and a partial denture made.
artificial teeth. fitted to th e ridge. will also appear
to be to o long; otherwise a flange may be use d.
and t he edges w ill have an ex tre mely artificial
appearance. In any case. if th e patient has been
cooperative dur ing pe riodo nta l t reatme nt and this
has been succe ssful. he o r she will obviously no t
want the teeth e xtracted.
If a full-crown splint is made , it w ill be nece s-
sary to prepare cro w n margi ns at th e ce me nt -
e namel junction and try to disguise th e cro w n
margin as t he eEJ. or at t he gingival margin.
producing very lo ng t hin p re paratio ns th at
e ndange r the pu lp. Th e first alternative is o ften
unsatisfact ory. since the opacity o f the
metal-ceramic retain er is greater th an tha t of
the ro o t surfac e . N eithe r makes any impro ve-
ment in the app ea ran ce of the lengt h of the
teeth (se e Figure 12. 10).
W ith all th e se aesthetic pro blem s. some
patients and dentists would elec t to ex tra ct the
upper inciso r teeth , re-co ntour the ridge by bone
augme ntation and replace the tee th with
implants.
2SO

Fig ure 12.1 I

Dicdo nnc implants .

c Unerupted canines nave bee n re move d from the

palat e in t his young te enage pat ient, but re so rption of
the roots of th e lat e ral incisors is co nt inu ing. T his has
been de mo nst rated by a ser ies of rad iographs taken
ove r a number of mo nth s.

b Dicdonnc implants have been placed by an open

approac h. The apical par t o f the ro ot surface has been
re moved to reduce the likelihood of the resorption
continuing. The late ral inciso rs we re firm immediately
follOWi ng the surgery

c Six month s late r, with bone refo rmation almost

complete. These implants rema ined in place f~ more
than ten years and we re re placed by single tooth
osse omregrared implants when the patient was in her
mid-twenties.

Sel ectin g a n anterior splint
It is im po rtant to make sure the patien t under-
stands how th e spli nt will lo ok. and what com pro-
mises are nec es ~ry . In a typical case the patient
has:
• Mobile un co mfortable uppe r anterior teeth
that have bee n succe ssfully tr eate d per io do n-
ta lly
• A high lipline with unanracnv e appearance of
t he up per inciso r te e th
• An e xt reme re luct ance to w ear a rem ovable
a ppliance .
The re is no ideal so lutio n to t hese pro ble ms; t he
o ptions a re as fo llows , in inc rea sing o rder o f
COSt :
a Offer no trea tme nt; th e result w ill be a patient
wh o continu e s to com plain about mobil ity. the
lack of comfo rt. t he appea ra nce a nd possible
further d rifting o f the upper inciso rs
b Prov ide a rmmma l-prepararion splint With o r
w ithou t a re mo vab le gingival prost he sis; t he
Fixe d ,pl/nt<
co mp ro mise here is the. 'metal shine -thr oug h',
but o n t he plus side are t he co nse rvative
nature of th e prepar at ions and th e re lative ly
low cost compared with the alternat ives.
Someti mes th is option is not possi ble because
so me of t he teeth are heavily resto red or
cro wned or th e o cclusio n is unfavo urable
c Ext ract the upper inciso r teeth and pro vide a
partial denture; some patients will re fuse, and
in any case it will provide o nly parti al impr ove-
ment in appearance
d Extract t he uppe r incisors and provide a bridge ;
there is still the problem of th e length of the
pontics, but th is may be the preferred treat-
ment in some cases - there is little point in
keeping teeth with a very poor prog nosis if the
same number of additional abutment teeth
would be necessary to support them as would
be prepared for a br idge; a removable gingival
prosthesis may also be provided
e Provide a complete-crown splint with or
without a removable gingival prosthesis; this
has the disadvantages of time, cost and appear-
ance describe d above, but may still be the
preferred treatment in some cases
f Extract the teeth and provide ridge augme nta-
tion and implants .
Clinical techniques for permanent
splints
The reader is referred to the literatu re o n the
treatment of t rau mat ized teeth and th e pe rio do n-
ta l literatu re fo r full desc ription s of temporary
and Intra-c o ro nal splinting techniques . Similarly,
t he surgical procedures fo r placing dlod on tic
im plants are desc ribed in textbooks on surgical
endo do ntics. The clinical techniqu es for minimal-
preparatio n splints are the same as for bridges
(sec Cha pter I I ). Th erefo re clinical techniques
will be desc ribe d only fo r com plete-crow n splints.
Tooth preparation for complete-
crown splints
O ne of t he t ech niques described in C hapter 11
sho uld be used to e nsur e that the preparation s
251
are parallel. In t he case of multip le-un it com plete-
crow n splints, it may be necessary to take se veral
intermediate impressions to chec k t he paral lelism
of t he preparatio ns wit h a surveyo r befo re the
fi nal impression is taken. Figure 12.10 shows a 12-
unit splint/ br idge wit h six abutm ent teeth. Six
intermed iate impressions we re ta ken. T his sou nds
very time-consum ing, but with fast- setting plaster
and a surveyor at t he chairside, o nly two appoint-
ments we re needed.
It is highly advisable to ca rry o ut trial p repara~
tions o n a study cast to ensure that the ideal path
of insertion is selected. T his may not be in t he
long axis of all the teeth.
Temporary splints
With complete-cro wn splints it is poss ible to
make a temporary splint at the chan-side or in the
laboratory using one of the techniques described
in Chapter II.
Impressions
When teeth are mobile, they should be splinted
so as to be in an unsrrained position with in their
remain ing periodontal support, and preserving
optimum occlusal re latio nships. There is a danger
of them being moved awa y from t his position by
the force of the imp ression be ing inserted, so that
t he finished splint, although it may fit, will distort
the alignment of t he teeth . This risk is greater if
a viscous mate r ia) is used , par ticularly in a close-
fitt ing special t ra y. This me ans t hat the putty -wash
techniques and po lysulphide impressio n materials
are not ideal for t hese impressions.
The re are two ways aro und th is problem. O ne
is to use an imp ress io n technique in w hich the
teeth can 'float' into the ir natu ral po sitio ns before
the mate rial sets, t he ideal material being
re versible hydro co lloid. The se co nd way is to
ta ke an impression in any material and have
se parate transfer co pings made for each toot h.
T hese are located in the mout h using a gen tle
technique that does no t disturb the alignment of
the teeth, for exam ple painting on a sclt-ccrtng
acry lic materia l (sec C hapter I I).
lSl
Cementation
Some teeth being splinted are likely to be mo re
mob ile than others, and this produces a cementa-
tion problem. Altho ugh the splint may fit well at the
margins wh en it is tried-in, if some tee t h can be
moved apically in t heir sockets and others cannot,
when the splint is being ceme nted the mo bile teeth
may be depressed by the hydrostatic press ure in
the unset cement. The marginal fit of the retainers
o f thes e teeth is therefo re unsatisfactory.
Precau tio ns should be ta ken to avoid th is happe n-
ing. In some cases the retainers are vented to allow
Practical points
• Permane nt splints are not used in t he treatment
of periodonta l disease, but may be necessary to
stab ilize mobile teeth and replace missing teeth
afte r su ccessful periodontal treatment.
• Permanent splints are also use d in some cases
of congen ita l defect and occasionally fo llowing
orthodo ntic treatment.
• Short- and inte rmed iate- term sp lints may be
usefu l afte r injury o r du ring a co urse of
pe rio do ntal trea tment.
free es cape of cemen t, in oth ers the splint should
be pressed firmly ho me o nto th e sta ble abutments
and then an instrument such as a Mitc hell's trimmer
hooked on to th e abu tment tooth. preferably at the
amelo-cernental junction, and the too th drawn
down into its retainer. Because this ta kes time, zinc
phosphate cement, mixed to produce an extended
working time . is preferred to glass ionomer
ce ment. Alternatively, Ross is tied round each of the
mobile teeth between the preparation margin and
the gingival margins. After fully seating o n the sta ble
abutments , th e mobile teeth can be pulled down
Into their retai ners with the Ross.
• Minimal-p rep ara tion splint s may be succ essfully
used as pe rmanent splints as alternatives to
crown s.
• Overall, fixed splints have grea ter advantages
than removable o nes .
• Where ant e rio r teeth need splinting and appear
long as a resu lt of periodontal disease, th e final
appearance w ill need careful co nsideratio n.
Part 4 Failures and repairs
 13 Crown and bridge
failures and repairs
Tile difficulties of es timating t ile risk of failure
before a brid ge is sta rted and da nge rs of mis-
interpreting failure statistics were discussed in
Chapter 7. A reaso nable method of recording
failures is as a percen tage per year . Recent large
surveys of bri dges made in practi ce and elsewhere
in differ ent co unt rie s show tha t abou t 90 % of
bridges last at least 10 years .
Dealing w ith failures of implant fixtures and/or the
prosthetic elements is a specialist subject beyond
the scope of this book. If a dentist finds evidence of
failure in an implant, the pat ient sho uld be referred
unless the den tist has had specialist train ing.
There are tw o major problems w ith these
surv eys o f bridges. Rrst. th ey are usually of selected
and therefore biased samples - restorations made
in den tal schools, or specific practices - and second,
there are difficulties in defining failure.
looking at any crown or bridge. it is always
possible to find some minor fault with the fit or
the appeara nce of so me othe r aspect . In many
cases it is a matter of deg ree. T he re is no t hing
se rio usly wrong wit h the rest o ration. o nly th at
one dentist, loo king at another's w ork, wo uld
have ap plied his or her skills in different ways -
would have introduce d a little mo re incisal
t ranslucence o r placed th e margin a little mo re
su bgingivally or supragingivally. or finished it
bener. These variations in judge ment are to be
expected and ne ed to be encouraged . If every
crow n o r bridge were standardized, the re would
be no ro o m for deve lopm ent and improve ment.
At the o the r e xtreme the re are undisputed
failures . for examp le. the fractu red PJC o r the
lo o se bridge wh e re extensive caries has devel-
o ped. Between th ese extremes lies a large grey
ar ea of partial failure s and partial successes. W ith
th ese it is be tter to sp eak of levels o f acceptabil-
ity t o patient and dentist (w hich may be different)
and to co nside r wh at needs to be done to
impro ve matters. Th is chapter first des cribes t he
cause s of failure and so me so lutio ns. and then
gives the techn iques for ad justme nt o r repair.
Causes o f failure a n d so me
solution s
Loss of retention
With t he exceptions of pos t cro w ns, where
failur e is usually due to inadequate post design or
co nstru ctio n (sec figure 13. 1). loss of re tention
is not a common cause of failure of individual
cro wns. But because o f the leverage forces on
bridges, on e of the more co mmo n ways in w hich
th ey fail is by o ne of th e retainers beco ming loos e
from the abutment to oth.
Fixe d-fi xe d bridges a nd sp linted retainers
W hen o nly one reta iner beco me s loose. th is can
be disastrous. Without a ceme nt seal . plaque
forms in th e space between the retainer and the
abutment tooth. and caries develo ps rap idly
acro ss t he wh ol e of t he den tine surface of the
preparation (see Figure 13.2). The same problems
arise w it h loss of re tentio n of one part of a
minimal-prepara t io n bridge, but. alt ho ugh caries
do es so metimes develo p rap idly. because the
surface of the tooth is e nam el rath er than
dentine, the developme nt o f caries is usually
slo wer.
Sometimes the patie nt is aware o f movement
de veloping in t he br idge o r expe riences a bad
taste from de br is be ing pumped in and out of the
sp ace w ith inte rmittent pressure o n the bridge. A
good diagnostic test for a loose retainer is to
examine the bridge carefully witho ut drying the
teeth. pressing the bridg e up and do wn and
looking fo r small bub bles in the saliva at the
margins o f the re ta iners.
If one retainer docs become loo se. it is a
matter of urgency to rem o ve at least that
re tainer. and usually the wh o le bridge. If a
fixed -fix ed minimal-preparation bridge beco mes
loose at one e nd but seems firm ly attached at the
25S
1>,
www.all islam.net
Problem
othe r. o ne o ption is to c ut o ff t he loo se re ta ine r,
leaving the brid ge as a cant ilever.
O ther b ri dges
In th e! case of Simple cant ilever brid ges w it h one
abut ment to o th. o r the major retaine r of a three-
unit fixed-mo vable bridge. th e lo ss of re tention
will resu lt in t he br idge falling ou t. T he same is
true if bo th ends of a fixed-fixed bridge become
loose. There is usually less pe rmanent damage in
the se cases, since plaque is no t retained against
t he su rface of the prep ar atio n, and the pat ient is
o bvio usly aware o f the prob lem and seeks treat-
me nt quickly.
Mini m al -preparati o n bridg e s
Partial o r co mp lete lo ss of retent io n is the
commonest cause o f failure of these bridges. It is
argued by some that if th e brldge can be cleaned
and re-cememed w itho ut further treat men t, it is
no t a true failure but o nly a partial failure. T his is
Figure 1) .1
The upper central incisor had a pan -retained crown
but no diaphragm cover ing the root face . The tooth
has split longitudinally and must now be extracted.
Figure 1) .2
CariOUS abutment teeth re vealed by removing a bridge
was stili firmly atta ched to the sound abutment
[h ill
teeth.
a reaso nable poin t of view , and whe n minimal-
prepa ra• tio n bridges are made. th e pat ien t sho uld
be wa rned that re -cemen tauon may be necessary
as pa rt of normal maintenance and should no t be
regard ed as a disaster.
Th ere is some evidence that minimal-preparatio n
bridges arc retained for lo nge r periods wh en they
have been re-c emenred. It is diffi cult to imagine why
th is shou ld be. other than pe rhaps the operator
taking greater care the second time arou nd.
There is now good evidence t hat fixed- fixed
m inimal-preparat io n bridges fail th rough lo ss o f
retention mo re readily th an cantilever (wit h o ne
ab utm ent tooth) and fixe d- movable design s. This
is w hy th e se designs have been advocate d earlier
in this book. It is very unusual for a m ino r
retai ner fo r a fixed-movable minimal-pre para t io n
bridge to lo se trs rete ntio n. because the re are no
significant fo r ce s to dislo dge it.
S oluti ons
If the re is no ex te ns ive da mage to the prep ara -
tion, it may be po ssible to re- cc me nr the cro wn

or bridge, provided that t he cause can be ide nti-
fi ed and eliminated . It may be that a bridge was
dislodged by a blow or th at some pr o blem duri ng
cementatio n was the cause. How ever, if the
underlying r easo n is that th e preparatio n is not
adequately retentive. it may be pos sible to
provide addi tional re t ention by cross-pinning th e
preparation (see Figure 13.3). although ideally it
sho uld be made more retentive and the crow n o r
bridge (o r at least th e unsat isfact o ry retainer)
remade .
Alternative ly it may be necessary to include
add itional abutm ent teeth in a bri dge to increa se
the overall ret ention or to chang e the design in
some other way.
Mechanical failure of crowns or
bndge components
Typieal mech anical failures are:
• Porcelain fract ure
• Failure of so lder joints
• Distortion
• Occlusal wear an d perforatio n
• Lost b eings.
P orcel ain fracture
At one time pieces of porce lain fracturi ng off
metal-cer amic cro w ns, o r t he los s of th e entire
fac ing due to failure of t he metal-ceramic bond,
w ere re latively common place. W ith mo der n
materials and techniques this is much less
commo n; but w he n it does occ ur it is partic ularl y
frustrating since, even though the dam age may be
slight. t here is often little that can be do ne to
repair it satisfact o rily with out remak ing th e
cro wn o r the who le bridge .
T o prevent th is typ e of da mage to
metal-ceramic bridges. the framework m ust be
properly designed w ith an adequa te thicknes s o f
metal to avo id distortion . pa rticularly with lo ng-
spa n bridges. If there is any risk of the pontic area
flex ing. the porcelain should be ca rried o n to th e
lingual side of po nucs to stiffen th e m further.
An all-porcelain crown or bridge t hat is
frac tured m ust be replaced . Som etimes th e cause
is a blow. and th en the choice of material can be
2S1
regarded as fortunate: had a metal-ceramic
mate rial been used it is mo re like ly that the root
of the toot h wo uld have fracture d. If the fractu re
is due to trauma, and particularly if th e crown or
bridge had served successfully fo r so me time . it
should be re placed by means of anothe r all-
cera mic restoration. However. if the failure
occurs during normal func tio n. sh ortly afte r th e
cr own or bridge is fitted, the imp lication is that
the co nditio ns arc no t su itable for an all-ceramic
re st oration. and the replacement should be
metal-ceramic.
Failure of solder joints
O ccasionally a solder jo int that appears to be
so und fails und er occlusal load ing. T his may be
due to :
• A flaw or inclu sion in t he solder its elf
• Failure to bond to th e surface of the me ta l
• The solder joint no t be ing sufficiently large for
the co nditio ns in w hich it is placed.
A pr ob lem . particularly w ith metal-ceramic
bridgework. is tha t soldered connectors should
be rest ricted fro m e ncroac hing o n the buccal side
too much to avoid metal showing. restricted
gingivally in orde r to provide access for clea ning.
and rest ricted incisally to cr eate the im pressio n
of separate teeth. T oo m uch restriction ca n lead
to an inadequate area of solder and to failure.
It is better w henever possible to join m ultiple-
unit bridge s by solder joints in th e m idd le o f
pontics -befo re th e porcelain is add ed . Th is give s
a much large r surface area for th e solder jo int.
and it is also strengthen ed by th e porce lain cover-
ing. A failed so lder jo int is a d isaster in a large
meral-ceranuc bridge. and ofte n mea ns that the
w hole brid ge has to be remov ed and remade .
Figure 9.4f. page 197, sho w s a failed solder joint.
There are no satisfaCtory int ra-o ral repair
methods, and it is not usually poss ible to remove
the bridg e to resolder t he jo int without do ing
further damage .
Distortion
Distortion of all-metal bridges may occur, for
e xam ple. wh en wash -t hro ugh pontics are made
Figure 1] .]

Cross-pinning for addit ional rete nt io n,

(I A telesc op ic cr own that has be en in place for many years but is

e ves-tapered. The bridge cemented to th is has bec om e loose and been
removed.

b The re tainer (which f,n over the telescopic cr own) is drilled to

r eceive go ld-w ire pins.

c The bridge is re placed and sho rt ho les cut th rough the telescopic
crown (th es e can be seen in (I), wit h the ho les in t he r etainer being
use d as guides. A O.7-mm-diamete r tw ist drill that mat che s the go ld wire
is used . The retainer has now be en ce mented. and the gold pins
cem ented th rough It imo the telescopic cro wn and the dentine bene ath.
When set, th e ex cess gold wire will be rem oved and the surface
po lished ,
Crown and bridge (arluft'1 and .epo.ro;
to o th in o r if a bridge is re mo ved using too much
force. Whe n this happe ns the br idge has to be
rem ade.
In me tal-cerami c bridges distortion o f the
framework can o ccur dur ing functio n o r as a
result of t rauma. Th is is like ly if the framework is
too small in cross-sec tion for t he length of span
and t he mate rial used. Disto rtion of a
me ral-c eramtc framework invariably results in the
loss o f porce lain.
O cclusal w e a r and perfo r ation
Even with no r mal attr itio n. th e occl usal surfaces
o f posteri o r teeth wear down substa ntially o ver
a lifetime . Gold crow ns made with 0.5 mm o r so
o f go ld ccciusany may wea r through over a period
o f tw o o r th ree decades. If pe rfora tio n has been
the result of no rmal wear and it is spo tted before
caries has develo ped. it may be re paired wit h an
appropriate restorat io n. O ccasio nally. par ticularly
if the perfo ratio n is o ver an amalgam core . it is
sat isfacto ry simply to leave the pe rfor atio n
untreat ed and chec k it peri o d ically (se e Figure s
8. lb. page 174 and Figure 13. l l h. page 269).
Occlusal perforations may also be made delib-
erately fo r endodo ntic treatment o r - vitality
test ing (see Figure 10.2c. page 209).
Lo st facing s
Mat erials are available to repair po rcelain in the
mouth (se e Figure 13.10. page 266) . Even if they
lS9
Figure 13.4
Badly worn acrylic bridge facings.
last o nly a few years befo re disco lo uring or
wear ing, they can be re placed and are a re ason -
ably satisfacto ry and less costly alternative to
rep lacing the w ho le resto rat ion.
Labo rato ry-m ade ceramic o r acrylic facings may
be ent ire ly lost, and with acry lic facmgs. we ar and
discolo ration are also co mmo n (sec Figure 13:4).
Alt ho ugh very few crow ns o r bridges are made
nowa days with proprietary facings. it is no t
unco mmo n to find pat ients with o ld br idges
miss ing lo ng-pin, Ste ele' s or other proprieta ry
facings.
Chang es in the abutment tooth
P e ri o d on tal di se a se
Period on tal disease may be ge ne ralized. or in a
po orl y designed . made o r maintained re st o rati o n
its prog ress may be accelerated lo cally. If the lo ss
of per iodonta l attachment is diagno se d early
e no ugh and t he cause re mo ved. no further treat-
me nt is usually necessary. However. if t he disease
has progressed to t he po int w he re the progno sis
of the tooth is significantly reduced then the
crow n o r br idge. or the tooth itself. may have to
be re moved.
W ith a br idge t he o riginal indicat io n will still be
pr ese nt, and so some thing will have to be do ne
to repl ace the missing teet h. It may be possible
to make a large r bridge. o r the abut ment t eet h
may be reduced and use d as abu tm ents for an
ove r-dent ure. Te et h that have lo st so much
160

support that t hey are not suitable as bridge Frac ture o f the p r e pared natural crown
abut me nts are not su ita ble e ither as ab utments or ro o t
for co nventional part ial de ntures.
frac tures of th e tooth o ccasionally occur as a
resu lt of trau ma. and sometimes even dUring
nor mal function. although the crown o r br idge
Pro b le nlS w ith t h e p u lp has bee n present for some time. With a bridge
ab utm ent it is usually ne cessary to rem o ve the
Unfortunately. despite taking the usual precautions
br idge, but occasionally the abutment tooth can
during tooth preparation, abutm e nt teeth may
be dispen sed w ith and th e root re mo ved surgi-
become no n-vital after a cro w n or brid ge has been
cally, the tissue surface of t he retainer being
ce me nted . It is usually reasonable to attempt
repaired and converted into a po ntic.
e ndodo ntic treatment by making an access cavity
thro ugh the cro w n. There are of course pro blems
in the appl ication of a ru bber dam, although these
can usually be ov ercome by punching a large hol e Move m e n t o f the tooth
and applying the rubbe r dam only to o ne tooth.
Occlusal trauma, pe riodo ntal disease or relapsing
st retching the rubber over the co nnecto rs.
o rthodo ntic treatmen t may result in t he crowned
It is often difficult to gain access to the pulp
tooth o r bridge abutm ent bec o ming loose. drift-
chamber and re mo ve the coro nal pulp co mple tely
ing, o r bo th . When t he cause is periodontal
without enlarging th e access cavity to a po int
disea se o r relapSing o rtho do ntic trea tment, th is
whcre the remaining tooth prep aration bec o me s
must be remedied before the crown or bridge is
too th in and weak to suppo rt the crown satis-
remade.
factorily, or w he re the pin retentio n of 3 core is
damaged. T he crown may have be en madc w ith
rather different anato my fro m t he natu ral cr o w n
of the tooth for aesthetic o r occlusal reasons, so
Design failures
that the angulation of the root is no t immediately
appa re nt. Provided t hese problems ca n be
A but m e n t p r eparation d esig n
overcome and a satisfacto ry root fil ling placed.
the prognosis of the cro wn o r bridgc is onl y The pitfalls of inadeq uate crow n preparat ion
marginally reduced. des ign were described in Chapter 3, and are the
Teeth that w ere already satisfactorily roo t- und erlyin g cau se of many of t he problems- listed
filled when the crown o r bridge was made may so far in this chapter.
lat er give tro uble. Occasionally it may be possible
to root-fill th e tooth again t hrough the cro)Yl1,
but more co mm only apk ecto m y is th e so lution.
Inadequate bridge d e si gn
Care must be taken not to sho rt e n t he ro o t of
an abutme nt tooth more than is absol utely neces- Designing bridges is difficult. It is neither a precise
sary so t hat t he maximu m suppo rt for the bridge scien ce no r a creat ive art. It needs knowl edge,
ca n be ma intai ned. exp erien ce and judgement. whi ch ta ke year s to
acc um ulate.
So it is no t sur prising th at some designs of
bridge. even th oug h w ell int entio ned and consci-
C a r ie s
entiously executed, fail. A simple classificatio n of
Secondary caries oc curring at the margins of these failures is as 'under- prescribed' and 'ove r-
crowns o r br idge retainers usually mean s that the pres cribed' bridges.
paticnt has cha nged his o r he r diet, th e sta ndard
of oral hygic ne has lapsed or there is some inade- U n d e r -p re scrib e d brid ges T he se include
quacy in th e restoratio n th at is encourag ing the designs that arc cnstablc o r have to o few
fo rmation o f plaque . The cau se of the problem ab ut ment teeth - for example a cant ilever br idge
sho uld be identified and dealt with before repair carrying pontics that cover too lo ng a spa n or a
o r replacement is sta rted. fixed-movable bridge where again the spa n is too

long, or where abut ment te eth wit h too little
suppo rt have be en se lec ted.
Ano the r 'unde r-design' fault is to be tOO
conservative in selecti ng re ta iners , for example
int raco r o nal inlays for fi xed-fixed bridges. With
these design faults little can be do ne other tha n
to re mov e the bridge and usc ano the r type o f
replacemen t (see Figure 13.5).
O ver-pre scribed bridge s Cautious de ntists
will sometimes incl ude more abutment teeth tha n
are nece ssary. and fate usually dictates tha t it is
the un necessary retainer th at fails. T he first lower
premo lar m ight be included as w ell as the secon d
prem olar and seco nd mo lar in a bridge to re place
the lower first mo lar . no doub t so th at the re will
be equal numbe rs of roots each end of t he bridge.
This is no t nece ssary. Anoth er e xamp le wo uld be
to use th e upper cani nes and both premolars o n
ea ch side in replacing the four incisor teeth. As
well as be ing destructive. th is gives rise to un nec-
essary practical d ifficultie s in making the br idge .
This. in tu rn. re duces th e cha nce s of the bridge
be ing su cce ssful.
W he n an unnece ssarily large num be r of
abutme nt teeth have been included in a bridge
and one of th e retaine rs fails. it is so met imes
possible to sectio n t he bridge in the mouth and
remove the failed unit. leaving the remainde r o f
the bridge to co ntinue in functio n. T he failed unit
is re made as an individual resto rati o n (see Figure
13.6).
The retai ners themselves may be over-
pr escr ibed. with complete cro wn s be ing use d
where parti al crowns or intra-coronal retaine rs
161
Figure 13.5
A bad design. The bridge is fixed-fixed and is firmly held
by the premolar retainer. The inlay in the canine is.
however. loose and caries bas developed beneath it.
Either the design should have been fixed-movable with
a mesial movable connecto r or . if fixed-fi xed. the
retainer on the canine sho uld have covered all occlud-
ing surfaces of the to oth and have been mor e rete ntive,
w o uld have been quite ade quate: or
metal- ce ramic cro wns might be used where all-
me ta l cro wns wo uld have been suffi cient. When
th e pulp dies in such a case. it is intere sting to
speculate wh ethe r this might not have o ccurred
w it h a less dras tic reducti o n of th e crow n o f th e
nat ural to o th.
Inadequate clinical or laboratory
technique
It is helpful to allocate problems in the const ruc-
tion of crowns and bridges to o ne of th ree
groups:
• Minor problems to be no ted and mo nito re d
bu t where no o the r actio n is needed
• The typ e of inad equacies that can be co r rected
in sit u. and
• Tho se that ca nno t.
Th is is ofte n a matte r o f deg ree, and ma ny of
the fo llow ing fau lts can fall into any of th e se
groups.
Margina l d e fici en ci e s
Posi ti ve ledg e (ove r hang) A posi tive ledge is
an ex cess of crown mate rial protru d ing beyond
th e margin o f the pre para tio n. The se arc mo re
co mm o n wit h po rcelain th an with any other
margins. Considering that this is a fairly easy fault
262
to recogni ze and correct before the cro wn or
bridge is fitted . it IS sur prising how frequen tly
overhangs arc encountered (see Figure 6.27a,
page 141 ). Ho wever, it is o fte n poss ible to
cor rect t hem without ot he rwise disturbing the
restoration.
N egative l edge T his is a deficiency of crow n
material that leaves the margin of the prepa ratio n
exposed but with no majo r gaps be tween th e
cro wn and the tooth. Again it is a fairly co mmon
fault, particularly with meta l margins. but o ne that
is difficult o r impo ssible to co rrec t at t he try-in
stage (see Figure 6.27b). It ofte n arises because
t he im pr essio n did not give a dear enough indi ca-
t io n of the margin o f the preparati o n and the die
was over-trimmed. resulti ng in under-extension
of the retainer (see Figure 6.28, page 142).
Pro vided t ha t th e crow n margin is sup ragingi-
valor just at the gingival ma rgin, it is sometimes
Figure 1) .6
Overprescribed des ign.
a This four-unit bridge replaces only one centra l incisor.
The partial-crown retamer on the Carline has become
loo se. Wh en the bridge was removed, the central and
lateral in<isors we re found to be sound and adequate
abutments. without the inclusion of the canine. Caries
has spread across the canine, and the pulp has died.
band c Fort unately it was possible to remove the
bridge intact, and. after re moving the canine ret aine r.
the remaining three units could be re-cerne oecd. A
separate POSt cro wn was made for the canine tooth
follOWing e ndodontic treatme nt.
possible to ad just and polish the tooth surface.
When the ledge is s ubgingival, and particularly
wh en th ere is lo calized gingival inflam mation
associated w ith it. it may still be possible to ad just
th e ledge w ith a pointed s tone or bu r. although
this wi ll ca use ging ival damage. Howe ver, it is
us ually nece ssa ry to re move the crow n o r bridge.
Defect A defect is a ga p betwee n the c row n
a nd pre par ation margins. Th ere are fou r possible
caus es:
• The crown or retaine r did not fit and the gap
was prese nt at try-in
• The c rown or retaine r fitted at try-in. but at
the time of cementation the hydrostatic
pressure o f the cement (pa rti cu larly if the
ce ment was beginn ing to se t) pro d uc ed incom-
ple te se ati ng
• W ith a mobile bridge o r s plint abutme nt, t he
Crown and bridge (allures Gild repair.;
cement depressed the mo bile too th in its
socket more than the other abutment teeth.
thus leaving th e gap
• N o gap was present at the t ime of cementa-
t ion, but one developed fo llow ing t he lo ss of
ce ment at the ma rgin. and a crevice has been
created by a combinatio n of ero sion/abrasio n
an d possi bly caries.
In any o f t hese cases. the choice is to rem ov e t he
br idge. rest o re the gap w ith a su itable restora-
tion, o r leave it alone and o bse rv e it per iod ica lly.
Puri sts may say that all de fectiv e retainers
should be re moved and replaced. But th is is no t
always in th e pati en t's best int erest, an d th e skilful
app licatio n of marginal repa irs may extend the life
of th e resto rat ion for many years (see Figure
13.7).
P o or sh a p e o r colou r
Mo re can be done to adjus t the shape of a crown
o r bridge in situ than to modify its colour.
263
Figure 13.7
a A small gap at the mesial margin of the upper canine
retainer on an otherwise very satisfactory bridge that
has been in place for several years. The gap was not
noticed at previous reull appointments. and ah:nougn
it may now have become apparent through gIngival
recession. It is more likely that the gap has been
enlarged by ever-vigorous use of denta l nes s. The
patient demonstrated a faulty and damaging sawlflg
action. With fl oss running into the gap.
b The defect repaired with glass ionomer cement. The
patient has been shown gentler oral hygiene
te ch niques.
although occasionally surface stain on porcelain
ca n be remo ved and the porcelain polished . The
shape of meta l-ce ramic crow ns or bridges can be
adjusted if t hey are too bulky (and t his is us ually
t he pro blem), pro vided tha t it is done slow ly. At
the first sign of th e opa que layer of porcelain. the
ad justment is stopped.
Suc cessful mo difications can o ften be made to
open cram pe d em brasure spaces, re du ce exces-
sive cerv ical bulb osity. sho rte n reta ine rs and
pa nt ies. an d o f course ad just t he occl uding
s urface. In all cases th e ad justed surface, w heth er
it is metal o r porce lain, sho uld be po lished.
O cclusal pro blems
As well as producing abutment too th mobility,
faults in the occlusion invo lve damage to the
re ta iners and ponucs by wear and fracture.
The occlusion can change as a result of the
extractio n of other teeth, o r their restoration. or
through wear on the occlusal su rface.
-
264
Technique s for adjustm ents,
ad aptation s and repairs to c row ns
and brid ge s
Ass essing th e se rio usn ess of the
problem
In ex ist ing res toratio ns there is not infrequentl y
o ne o r other of the faults listed above. A dec ision
has to be made betw e en:
• Leaving it alone. if it is no t causing any serio us
harm
• Adjusting or re pairing the fault
• Re placing the crown o r bridge.
W hen actio n is necessary, it is clearly better to
ex te nd the life of an otherwise-successfu l crown
o r bridge with the second option tha n repl ace
CrOWri and bridge (OJ ltires Gnd repairs
Fi gure 1] ,8
a A set of instruments for polis hing po rcelain,
b Scanning electron micrographs. ar the same magnifi-
cat ion. of th ree areas of the same porcelain surface.
Left t he glazed surface showing some undulation and
occasional defects. Cenl re: t he surface ground w ith a
fine po r celain gnndston e. Right the same surface repoi-
rshed. after grin ding. With th e instrume nts shown in c.
Th e surface is smoot h. W ithout undu lations. bu t with
some fine scratc h mar ks and OC(3.51011al defects.
restorations too frequ ently. If there is any doub t.
or when adjustment or re pair must be carr ied
ou t . the restorat ion must be ke pt under fre quent
and carefu l review .
Adjustments by grinding and polishing
in situ
In some situations the margins of crowns wit h
po sitive ledges can be satisfactorily adjuste d. If the
margin is po rcelain. speci ally designe d po rcelain
fi nishing inst rume nts shou ld be used.
Alte rnatively. a heatless stone o r diamon d po int
can be used. followed by polishing with succes-
sive grades of co mposite finishing burs and discs.
T hese are capablc of giving a very good finish to
no n-porou s porcelain, which the patient can keep
Crown and bndge (aflur~ ond ~I'$
www.allislam.net
Problem
as cle an as glazed porc elain (see Figure 13.8). T he
conto ur o f po rcelain resto rations can be mo dified
in situ using the same instru me nts.
In the case o f metal marg ins. a d iamond sto ne
fo llowed by green sto nes, tungst en carbide stones
o r metal and line n strips may be used.
lnte rdcneally. a trian gu lar-shaped diamond an d an
abrasive r ub be r inst ru ment in a special recipro-
cating handp iece designed specifically fo r remo v-
ing overhangs may be used. The mar gin shou ld be
po li shed with pr op hylacti c paste and a brush o r
r ubbe r cup , an d inte rdentally with finishing st r ips.
Repairs by restoring in situ
Occlusal repa irs
O cclusa l defects in metal reta ine rs can be
repaired wit h ama lgam. w hich usually gives quite
a satisfactory result. Ho weve r, a small gold inlay
may be pr efe rre d. In po rcelain o r me tal-ceramic
restorat io ns composit e material can be used , but
the re pair may need to be re do ne pe rio dica lly.
'61
Figu re 1l .9
a A bridge with defective margins and exte nsive gingi-
val infl ammation.
b The same bridge after J periodontal flap has been
raised. the retainer margins adjusted by grinding and
polishing. and the fl ap then apically repositioned. The
gingival condition is now healthy.
Re p airs at t he margins
Although re pair s are justified to ex tend the life o f
an established crow n or bridge. t hey sho uld neve r
be used to adapt the ma rgins of a poorly fitting
bridge o n insertion.
Secondary caries that is identifie d at an early
stage or early abrasion/ero sio n lesions at cro wn
mar gins can be rep aired using co m po site o r glass
io no rne r ceme nt. T he cause sho uld be inve sti-
gated and preven tive meas ures app lied .
Th e cavity pre para t io n at the margin m ust no t
be so deep th at it endange rs the stre ngt h o f th e
prepara tion. alt ho ugh of course all car ies must be
removed. If t he re is poor access it may be bc rrcr
to remove part o f the cr ow n ma rgin rathe r th an
an excessive amo unt o f tooth tis sue .
ln some cases raising a full gingival flap may be
just ified. Retaine r margins ca n be adjuste d an d
resto red unde r condit ions of optimum acce ss an d
visibility. and any necessary pe rio do ntal w ork o r
end odo ntic surgery carried out at the same time
(se e Figure 13.9).
16' Crown and bndg~ r",lu,1:'1 and reparrs

Figure 13. 10

Repairing porcelain facings.

a The lateral incisor facing has chipped. The bridge is

more than 10 years o ld.

b After be ing polished with pumice and water, a silane

co upling agent is painted over th e surface, fo llo w ed by
a res in bon ding agent and light-cured co mposit e.

c PolishIng the co mposite.

d T he finished resu lt. T his is unsati sfact ory, sinc e the

m eta l shows through. An opa q uer sho uld have bee n
used o ver the m etal.

Repairs t o porc e lain
Materials ar e available to r epair or mo dify th e
shape of ce ramic restorations in the mouth.
These are bas ically composite mate rials w ith a
separate silane coupling agent t hat allows
optimu m bonding. It is not an acid-etch bond like
the bond to enamel and is no t Slro ng. so th e use
of th e material is lim ite d to sites no t ex posed to
large occlusal for ces (see Figur e 13.10).
Repa irs by removing o r replacing
parts of a bridge
Replacing lost faci ngs
It is some times po ssible t o r eplace a failed facing
on a bridge. usefull y ext ending its life. But t his is
not w o rth attempting on ind ividua l cro wns - it is
better to replace the w ho le crown .
P reform ed or proprietary facings So me of
the old er proprie tary faCings were designe d
sp ecifically so th at t hey could be replaced in situ ,
for ex am ple th e long-p in facing. W he n thes e are
lost. provided the remainder o f the br idge is
so und, it is possible to take an im pression of t he
back ing and make a ne w porcelain facing, a
metal-ceramic facing, o r an acrylic o r composite
lacing retained by pins (see Figure 13.1 la . b).
C era m ic faci ngs W hen the po rcelain is lo st
from a me tal-ceramic unit and a composite repair
is no t possible. th e re is ofte n little choice but to
remove the who le crown or bridge. Ho wever,
w ith a po ntic it is some time s possible to drill
ho le s thro ugh the back ing and ta ke an im pression
wit h suita ble pins so that a new pin-reta ined
metal-ceram ic facing ca n be co nstruc ted rath er
like the prop r ietary long-pin facing. Almo st
inevita bly, t his w ill be bulky and w ill no t perfectly
match the appearance of t he o riginal (see Figure
l Lllc, d) .
Alternatively, it is sometime s possible w ith
retainers or pomics to re move all the po rcel ain
and re-prepare the metal part, pr oducing en o ugh
clearance witho ut damaging the strength of th e
metal, A new complete crown covering the skele-
ton of the old retai ner or pontic can the n be
accommodated. These are sometimes made in
hea t-cured acrylic o r laboratory light-cu red
267
composite. They are know n as 'sleeve crowns', A
metal-ce ramic slee ve crown is sho wn in Figur es
IJ . l l e,f and g).
' Unit-construction ' bridge fa cings Before
the routi ne use of metal--ceramic materials,
bridges were often made with a meta l framework
and se pa rate f'JCS ce me nted to it. This design was
known as 'unit-co ns tr uct io n', The individual PJCs
ofte n broke, since the y w e re co ns iderably
r edu ced ap proxi mally to acco mmo dat e the
connector. Howeve r. a new f'J C cou ld easily be
made, and some patie nts we re even provi Bed
w ith a second, spa re set w hen the bridge was
ce mented (see Figure 13.11h and i).
Re m o v in g and/or replacing entire sections
o f a bridge
Bridges are sometimes so designed that if a dou bt-
ful abu tment to o th bec o mes unsaveable. it can be
removed w ith its associa te d sec t ion of the bridge.
leaving th e re mainde r undisturbed . This is one of
th e purposes of remo vable, te lesco pic crow n-
reta ined bridges and of dividing mu ltiple-unit
bridges into sma ller sec tio ns. When part o f a
bridge is removed. the remai nder ca n sometimes
be modi fied, perhaps by cutting a slot for a
mo vable jo int and th e n replacing the lo st section.
Extending bridges
Pr ovisio n is so met ime s made to extend a bridge
if further teeth are lo st. Figure 13.12 shows a
large bridge w ith a slo t in the distal surfac e of the
premolar retainer o n th e left of the picture so
t hat a further fixe d-movable se ction can be added
if th e seco nd premolar (w hich has a qu est io na ble
progno sis) is lost . T he slot is filled in th e
meantime by a small gold inlay.
Rem ov ing c rown s a nd bridges
In remo ving any cr own o r brid ge, and in particu-
lar pos ts and caries, it is o fte n he lpful to break
up the ce ment by vibrating the restoration w ith
an ultrasonic scaler. Th is wo rks best with zinc
phosphate ce me nt.
268 C,ow" and bridpt' (allure s and retw;r;

Figure 13. 1I
9"'~ ~,

{ 1 ;)"".",~_-~""""
Techniques for re pair ing bridges.

a The Gi st of a bridge po nt ic tha t had lost its long-pin

lacing. The impressio ns o f t he pinholes we re taken w ith
stainless-steel wire o f m atch ing diam eter.

b A metal-ceramic labora tory-made r eplaceme nt long-

pin facing.

c Mo st o f the po rce lain facing has been lost fro m this

metal-cer amic pontic. Pinholes ar c dril led th rough the
metal fram ework, the margins shaped and an trop-es-
sto n taken.

d A ne w facing made in meta l-ceramic material. This

is inevita bly bu lky. but if the alte rnative is to re mo ve
the en tire br idge and remake it at very high cos t. th is
com promise may be prefe rable. In any case. furthe r
periodonta l treat ment is needed before a replacement
br idge is made .
•
269
(,uwn and Imdge (OJlures and repai~

e T he porcelam on this br idge r eta iner has fractur ed.

It ha s all been removed and the tooth prepa red for a
·sleeve-crown' .

r The stee ve-cro wn w ith a metal lingual surface replac-

ing the o r iginal lingual porcelain.

g The sleeve-crown in place.

h A fract ured PJC, w hich has been made over a gold

coping on the ca nine retainer fo r a bridge. Apa rt fro m
th is. an d th e hole w o rn in the o cclusa l surface of the
pre mo lar pa rtial c rown re ta ine r . the bridge is sti ll
serving satisfactoril y afte r more th an 20 years. The
peo nes have long-pi n fatings

j Th e re placeme nt PJc ceme nte d

(Note: Tms f,gure (h and I). With the same caption. was
publo shed in th e first ed itio n of th is book in 1986 In
19 9 6 the br idge w ith its re placeme nt PIC is nil! in place
_ showing that repairs of this sort arc well wo rth-
wh ile.)
270
Crowns
Removi ng met a l crow ns
Co mplete and partial metal crowns can
sometimes be removed intact by levering at the
margins with a heavy-duty scale r such as Cumine
o r Mitchc trs trim mer. Alternatively. a slide-
ham mer type of crown- o r br idge -re mover may
be used . o r o ne of the o th e r de vices specially
des igned to re move cr ow ns; Figure 1] .1 J sho ws
a selec t io n. If t hese t echniques do no t work, the
crown will have to be cut off (see unde r
' Remo ving motal-ceram« crowns').
Rem oving po st s and co res
Unret entive po sts can often be removed by
gr ipping the co re in extraction forceps and giving
it a series of s harp twists. Th is sho uld not be
attempted by t he inexperienced !
T he re are se veral devices designed to re move
postS and cores intact and to rem o ve broken
POStS (see Figure 13.1 3).
Rem o ving PJC5
The se canno t usua lly be re moved intact, and
shou ld be cut off. A vertical groove is made wit h
a diamond bur in the buccal surface. j;jst th ro ugh
Crown Gnd brid~e (aj/ures and re llairs
Figure 11.1 2
Provrslen for the extension of a bridge [see- text for
details).
to the cement. and the n the cro w n is split with
a suitable heavy-duty instrument (see Figure
13.1401).
Remo ving m e t ake r a m ic crow ns
It is so me times possible to remove metal-ce ramic
crowns intact by using o ne of the devices sho wn
in Figure 13.13, but they are more rigid than gold
cro w ns and the po rcelain is liable to break. and
so they usually have to be cut o ff.
A groove is cut vertically fro m the gingival
margin to the oc clusal surface. preferab ly on the
buccal side just thro ugh to the cement, and then
the cro wn is spr ung open with a heavy instrum ent
such as a Cumine scaler. Mitchell's trimmer o r a
heavy chisel, breaking t he cement lute. Somet imes
t he cut will need to extend across the occlusal
surface (see Figure 13.14 b-<l).
Cas t metal is best cut with a special solid
tun gst en car bide bur with very fine cross-cuts
(be ave r bur). Th is is capab le of cutt ing meta l
wit ho ut judde r ing or jamming, and there is less
risk of the bur itse lf breaking t han with a conv en-
t ional tungste n carbide bur. Eye protection should
always be worn by the patient. the de ntal nurse
and dentist. particularly w he n cutting me ta l.
Diamo nd burs cut cast metal slowly, but are
idea l for rap idly cutti ng porcelain. and so
metal-ceramic units are best sectioned using
different burs for the tw o materials. Since it is
 fOHU~
Crown and bridrt and rt pc.rs
possible to cut po rcelain muc h more q uickly tha n
meta l, the metal o n the bu ccal surface is usu ally
th inne r than th at on the palata l or lingual surface,
and visibility a nd access a re far better buccally,
the groove is easier to mak e on the bu ccal side.
Removing bridges
Th e re are t hree se ts o f circ umstances:
• When the abutm e nt tee th are to be extrac ted
a nd so it does not ma tte r if the preparatio ns
a re damaged, the bridge w ill be remo ved in the
most convenient way. ofte n w ith a cro wn- a nd
br idge -remover. In some cases it may no t be
necessary to remo ve th e bridge at all. for
example with simple cantilever br idges w ith
o ne abu tm en t tooth. In others it is qu icker to
divide the bridge through a pontic o r ccnnec -
'"
Figure 1) .1 )
A selection of instruments for removing crowns and
bridges. From tht ~fi:
a slide-hammer remover with two alternative sCrew-in
tip..: the tip is hook ed into a crown margin or under
a bridge connector. and the weight slid down the
handle and upped against the stop at the end ;
a spring-loaded slide hammer , also with replaceable
ups:
a special heavy-duty instrument that is hoo ked unde r
crown margins and twisted to remove them;
belaw: a turqu oise-coloured polymer that is softened in
hot wate r and bitt en upo n by the patie nt. The mate rial
is cooled with water and the patient asked to jerk the
jaw open:
above: th is instrument is clamped beneath the crown
and the two screws (the heads visible here) are
screwed down 0f1 to the occlusal surfaces of adjacent
teeth. lifting the crown;
two clamps that fit on to poses and cor es, with a screw
that pre sses 00 to the shoulder of a post-c rown prepa-
rat ion and draws the post and core out of the too th.
tor a nd extrac t th e ab utment tee th individ ually
with th e ir re tain er-s in place .
• W hen it is th e inte ntio n to retain th e ab utme nt
teeth - either to mak e a new bridge o r to use
them to support a partial denture o r an ove r-
denture - it does no t matter w he th e r the
bridge is dam aged d uring its removal. but the
preparation s s ho uld be pr otected . The re tain-
ers sho uld be c ut and t he br idge ca re fully
removed with the bridge-remover.
• There a re occas ions when it wo uld be helpful
to remove the bridge inta ct, modify or re pair
it and th e n re place it. if o nly as a tempora ry
measure. In thi s case ne ith e r the br idge no r the
preparatio ns s hould be da maged .
Removing bridg e s in t act
T he slightly mo re flexible structu re o f all-metal
bridges and of minima l-preparation bridges allows
l7l (,o wn a nd bri<Jg~ (oj/ures and repairs

Figu re 13.1 4

Rem ov ing cr owns and bridges.

o Re moving PJCS. A c ut is made with a d ia mo nd bur

down the buccal surface and across the incisal edge.
The crown can then be split w ilh a suitable h~ vy .duty
instrument.

b Removing ;l rneta l-<eramic bddge by cutting th ro ugh

th e buccal po rcelain W ith a diamo nd bur.

c Then changing to a special meta l-cutti ng (beaver ) bur

to cut thro ugh th e m etal un til the cement just sho ws.

d Springing open t he r eta iner W ith a heavy-duty msrr u.

men lo It is som eti mes necessa ry to co nt inue the cut
rou nd to the lingual surface.
 27J

Figure 13. 15

a Speoalced equipment for n:omoving crowns . The

pistol-shaped instru ment is su pplied wi th compressed
air and vibra tes o ne o r ot he r o f the attachme nts against
the crown o r bridge . The eq uipmen t is expensive and
o nly available in specialist centr es.

b Th e eq utprnern show n in a being used clinically.

www.all islam.net
Problem

Figu re 13. 16

Remo ving a br idge with a soft brass wire loop. The

loc king forceps are clipping th e twisted ends of th e WIre
tog ether t o prevent the sharp ends danuging the ch'n.
The slide-hammer (see Figure 13.13) is being used in
th e wire loop nther than und e r the bridge pon tic. This
is more co ntrol b ble and effective and less <bngerous.

the m to be rem o ved intact rath er more readily
than metal-ceramic co nventional br idges.
However, all types can sometimes be removed by
sharp tapping. w hich fractures the cement lure
witho ut too much risk to the pe rio do ntal
mem bran e of the abutment teeth . The nat ure o f
th e force is quite differe nt to the slow tearing
applied in e xtracti ng teeth.
Slide hammers are specially designed for the
purpose with rep laceable tips to fit under re tainer
margins. under po nrics o r into embrasure spaces
(see Figur e 13.13). Some time s it is necessary to
drill a ho le in the palatal su rface of the reta iner
o r po ntic and fit an attachment from t he slide
hammer into it .
Practical points
• A large pro po rtion of 'failures' are parti al. and
a le vel of acceptability need s to be established
between patient and de ntist. This is particularly
true for minimal-p reparat ion br idges.
• Changes in th e abutm ent teeth due . for
example. to periodontal d iseas e can frequently
be treate d so that the progno sis fo r the cro wn
o r bridge is not significantly affected.
Crown and bndg~ fa,lur~s and " 'pain
Vario us othe r te chn iques can be used. Figure
13. 15 shows an air-d riven appliance and ult rason ic
vibra tio n with a scaler can loosen cro wns and
bridge s.
A more co mmon techn ique is to make loops
o f soft wire beneath the co nta ct po ints of the
bridge and use a slide hammer in the wire loop
(see Figure 13.16) . Ahernauvely, if a slide hammer
is no t available. a heavy metal object is passed
th ro ugh the loo ps well outside th e mouth. and
sharp blows applied to it with a mallet or other
heavy inst rument. This is a rather dramatic
app ro ach. and the patie nt needs to have a phleg-
mat te pe rsonality and to be prope rly info rmed of
w hat is proposed beforehand .
• Alt hough repair-s are justifi ed to exte nd the life
of an es ta blishe d crown o r br idge. they sho uld
never be used to cover-up poor design. for
exam ple to adapt t he margins of a po orly fi tting
brid ge on inserti o n.
• Br idges can be made with 'fail-safe' feat ures -
for example so that one section can be
removed jf necessary, leaving th e rema inder
undisturbed.
 Further reading
Chapter I
Treatm ent of trauma tized tee th
Andrease n 10. Traumatic injuries of the teeth
(198 1) Saunders, Philadelphia.
Tooth wear
Smith BGN, Knight JK. A co mpariso n of patterns
of tooth wea r w ith aetlological factors, Brit Dent
J ( 1984) 157; 16-1 9.
Smith B G N_ Some facets of tooth wear . Ann R
Aust Col! Dent Surg ( 1991) II : 37-5 L
BJead llng
W ar ren K . Bleachi ng discoloure d end odontically
tr eated teeth, Restorative Dent (1985) 1: 132- 8.
Fisher N L and Radford J R. Inte rnal bleaching of
discol oured teeth. Dental Update ( 1990) 17:
r 10- 114.
Anterior composifes
lutz F. Philips RW. A classification and evaluation
of com pos ite res in systems, J Prosth Deer ( 1983)
50 : 480--8.
Facings in composit e
Jo rdan RE et al, labial resin venee r restorations
using visible cured co mpo site materials. Alpha
Omega Sd entifk Issue (198 1) 74 : 31-9.
Porcelain veneers
McC o nne ll RJ et at, Etched porcelain vene ers,
ReslOfative Dent (1986) 2: 124-3 I.
D unne S M and Millar B J. A longitudinal Sfudy of
the clinical performance o f porcelain veneers. Brit
Dent) (1 994) 175: 317- 32 1.
Restoration of root-fi!le d teeth
Martin OM, G lyn Jo nes [C. The relatio nsh ip of
endodontic procedures to the coronal restora-
tion. Restorative Dent (1986 ) I: 10-1 6.
Chapter 2
Porcelain and m etak eramie restorations
Mclean JW , The science ond ort of dental ceram ics,
Vo l. I ( 1979), Vol II ( 1980). Quintessence.
Chicago.
Ahernatives to precious metal alloys
C ouncil on dental materials. instruments and
equipm ent. Sta tutory report on lo w-geld-co ntent
alloys for fixed prostheses.) Am Dent Assn ( 1980)
1DO: 237---..m.
Retention
Lorey RE. Myers GE, The retentive qualitie s of
bridge reta iners. J Am Dent Assn (1968) 76:
568-72.
C ha pt e r 3
Crown preparation taper
Jo rge nse n KO. The relationship be twee n rere n-
tio n and co nverge nce angles in ce me nted veneer
cro w ns, Acta Odom Scand ( 1955) 13: 35.
Mack PJ. A theoretical and clinical invest igatio n
into the ta pe r achieved o n cro wn and inlay prepa-
rations. J Orol Rehab ( 1980) 7: 255-65.
Crowns margins an d gingival health
Silness J. Periodontal trea tment of patients w ith
de nta l bridges. 3 T he relatio nsh ip between the
location of the cro wn margin and the periodon-
ta l co nditio n.) Periodontal Res (1970) 5 : 225-9 .
Chapter 4
Occlusion, general
Ash MM. Ramfjord SP. An introduetion to fun ctional
occlusion (1982) Saunde rs. Philade lph ia.
Mo hl N O. Za rb G A. Carlsso n G. Rugh J 0 Eds.
A textbook of o cclusio n. Quintessence, Chi cago
( 1988). .
Gross MD. Mathews JO. Occlusion in restorative
dentistry ( 1982) Churchill Livingstone. Edinbu rgh .
Occlusa l records
Sim pso n JW e t al, Arbitary mandibular hing axis
locati o ns. J Prosth dent ( 1984) 5 I : 8 19-22.
275
276
Mandibular dysfunction
Zarb G A. Carlsson G E. Sessle B J. Mo hl N D
Eds. Te mporomandibular joint and masti catory
muscl e disorders . Munksgaard . C o penhagen
(1994).
Robinson P D . A r eview o f t emporomandib ular
jo int pain . Pain Reviews .(1 99S) 2: 138- 151.
Chapte r S
Examining lhe whole patient
Tyldesley W R. Oral diagnosis (1978) Pergamo n
Press. Ox fo rd.
Pfanning (fOWnS for endodontically treated teeth
Nich oll s E. Endodontics (1984) John Wright,
Bristo l.
Appearance
or
Mclean JW. The science ond on dental ceramics.
Vo l. I ( 19 79). Vol. 2 ( 1980) Q uinte ssence .
C hicago .
Chapter 6
Sh ade seleaion
Scha rer P et al, Esthetic guidelines (or restorative
dentistry ( 1982) Quin tessence, Chicago.
Tooth preparation
Shillingburg HT et 'II. Fundamentals of fixed
prosthodonlics ( 1997) Quintessence, Chic ago .
General
Mclea n JW. Dental ceramics. Proceedings a( the first
intemalional sym posium on dental ceramics ( 198 3)
Q uinte ssence. Chicago .
Cha pt er 7
Choice between fIXed and removable prostheses
Zarb GA e t ai, ProsthadonlJC O"eatment (or parliolly
edentulous patients ( 19 78) Mo sby. Sr l o uis.
Embouchure: musicians
Co rco rcon O F. De ntal pro blems in musicians. }
Irish dent Assn (198 5) 31 : 4-7.
Precision ottachments
Preiskel HW, Precision attachments in prosthodon-
tics, Vol. I ( 1984) Q uintesse nce, C hicago.
Implants
Hobkirk J A and Watson R M. Den ta l and
maxillofacial implantology. Mo sby-W o lfe, l o ndon
( 1995).
C ha pt e r 8
Minimal-preparation bridges
Roc hette Al , Attachment o f a splint to ename l of
lowe r ante rio r teeth.} Prosth Dent ( 1973) ) 0: 418.
livaditis Gl, Thompson. VP, Etched castings: an
imp ro ved r etent io n mec hanism for resin bo nded
retaine re . j Prosth Dent ( 1982) -41: 52.
C ha pt e r 9
Panties
Ste in RS, Pontic-r esidual ridge relatio nships: a
research re po rt. ] Prosth Dent ( 1966) 16: 25 1-85.
Clayto n JA. G reen E, Ro ughne ss o f pontic mate ri-
aid and den tal plaque, } Prosth Dent ( 1970) 23 :
407-11.
C ha pt e r 10
Abutment support (or bridges:
'Engineering' evidence
Reynolds JM. Abut ment se lect io n for fixed
pr o sth o dont ics.) Prosth Dent ( 1968) 19: 483-7.
W right KWJ, Yetrram Al, Reacti ve fo rce distri-
butions for teeth when lo aded singly and when
used as fixed partial dent ure abutme ntsc] Prosth
Dent (1979) -41 : 4 11- 16.
Clinical evidence
Nyman S, lindhe J. Prosthetic rehabi litation of
pat ient s with advance d peri o don ta l disea se, j Clin
Periodont (1976) r. 13S-47.
Nyman S. Ericsson I, T he capacity of reduced
pe riodontal tissues to supp ort fixed bridgework.
} (lin Penodont ( 199 2) 9: 409- 14.
Cha pte r II
Provisional and temporary bridges
Capp NJ. Th e diagnostic use of provisional
restorat io ns, Restorative Dent ( 1985) I: 92- 8.

Technique (or minimal-p reporotion bridges
G ratton DR et al, Th e re sin bonded cast metal
bridge : a re view, Restorative Dem ( 1985) I : 68- 76.
Cha pt e r 12
Splints and periodontal disease
Lindhc J, Textbook of clinical periodontology ( 1983)
Munksgaard, Copenhage n.
Oeft polote and splints
Kantorowicz GF. Bridge pro stheses for cleft
palate patients : an analysis. Brit Dent ] (197 5) 139:
9 1-7.
Den tal defects and splints
Mars M. Smith BGN , dentinogenesis imperfccta :
and integra ted conservative approach to treat-
m enlo Brit Dent ] ( 1982) 152: 1S-18.
m
Chapter 13
Failures in general
Wise MD Failure in the re sto red dentition ( 1994)
Quintessence. Lon don .
Surveys of bridge failures
Roberts DH. T he failure o f re tainers in br idge
prostheses, Brit Dent J ( 1970) 128 : 117-24.
Reute r JE. Bro se MO. Failur es in full crown
retained dental bridge s. Brit Dent J (1984 ) 157 :
61-3.
Dunn e 5 M and Millar B J. A lo ngitu dinal study of
th e clinical performance o f resin bo nded bridges
and splint s. Br Dent J (1993) 174 : 40 5---41 1.
Removal of bridges
Keotcrowrcr. G F. The repair and re moval of
br idges. Dent Practitioner (197 1) 2 1: 341-6.
 Index

Not e. Main headi ngs fo r appliances use d in br idgew o rl< ar e in UK te rm ino logy. WIth cros s-re ferences pm vided fmm t he US
te rms.

Abutment teem
allgnme nlof. reter.t>on and. 192 - 3 """"'"'
bone loss. and re placement of misSIng l e-eth . 162. 164
ch;lnges ClIusong problems. 259-60 ndge. see Ridge
condItion of. rnem ion and. 1',1-4 Amalgam (for reStontions)
definition. 173 choosing. n
ex am in at io n, 1 11 ~ 12 co ppe r r ing and. t em porary cr ow ns o f. 125
healing. in ri dge augmentatio n, 164. 165 cor cs of. 36
ocd u~ 1 load on, 207--8 merc ur y toxi CIty. 19
pre~r'ng. 223-9 pIn-re ta ined . 17- 19. 36
rem<;....1 of bridge and e" rr..ction 0.- , ,,u mOon of. 211 Amelogenesis imperle<: la, crow ns., ..
le1ect1f'l. 207- 10. 21S--16 M tenor-crowns.. 8 -9. 24-3". s... 1"'- 15
splintIng WIth precis,on -auach....en t parti al den tu re. 243 aleeena nves, 9- 16
support by. 207- 10 complete . 24-33. 109. 114- 15
t ransmuto s.. I, se e Tr ans m uc o n l a butme nt vital t eeth. 24-9
Acid-etch re ta ined (ampm it c splims, 245 de signing. 53. 54. 58 - 9
Aery ic(s). 5~ aIw Wi r e-and-acryl ic splim indocatiom . 8-9
botepbne. 14 partIa l. 50"'" Par t,al crow ns
bucu.l pl"O$lh"" ,s. 161 pre pol ration of teeth, 109 . 114-15. 116--22
cu t -me tll uown b eings. 29 roolAilied ~I'I. 29- ))
pounng WIth tem porary crowns. 12 2. 124 M leri or splinl s. H 'J- SI
provisio nal bridge . 197 appearance. 2"9- 50
special t ra ys. 103. 1(}f- 5 se lec M g. 25 I
ve ne en, I I. 13 Ar ue's r lilc/ law. 207. 209
Adaptations. see Ad jun m ents and adapta t io ns Appearance/ae sth etics
Adhes ive bridge. S~ M,nim:tl pr"P~ration bridge crowns., (H3. 43--4. 89 -90. 92- 5
Adheslye cements. "7 . I.... after fitti ngfce menation. 146
Adjustments and a<Upuuons. 26+--5 meuJ.....: enrnic. 29
wirn br Idges. 26 4-5 planning. 89-90. 92 - 5. 10 1- 5
occlusion. 212 porcelaIn, 25
wit h crowns. 264--5 r eplacements for missing te et h (br idge s et c.). l S4. 16 1-2 .
axial co nt ours du ring t rying_in. 143 2 10- 11
i ntercu sp~1 po sitio n. 83 po nt ics, 195
in mo urn. 8)--4. 1'16 r etainers. 192-3
~de. I") splInts. 2..9....50
Aesrn eoc s.. see Appe 'VV"ICe Appo mUTlCOt s.. 98
",. App ro,,,ma.1 surfaces.. see Pro,,,rnal surface s
~ nd cr owros. 8 5-7 Arc on -type an iculnor, 80. 8 1
~nd replac~n( of missing t ccth, 159 Art iculal>ng pape r . 7S
Air. compresse d. ginKiY,1 re t racti o n, 1)5 . 136 Ar t Iculato r s, 77-82
Alginate impressions in bridgewor k casu mounted o n. 82
for assessing para lielism . 2n. 225 u udy. 76 . 78- 9
for cha ir-slde t em porary and proYlslOnal bridge fully·adlusa ble. 81 - 2
construction. 228, 229. 230. n l S('mIo;odJl.lStabk. 80- 1
AluminIum temporary crowns.. 122 slmple -hinge. 77-fJO

'"
180 I"d..

Arutude of ~llenn pont>cs. 202-3

crowns, as Build up tech nlqUfl
r e placements of miss ing t eeth, 158--9 cores. •06--9
Autogenous gra fts fo r r idge augmentation, 16 2. 16 4 tempo"'')' partial crown s, 125
Autom;" gun fo r deliveri ng polyme rs , oc clus al re<:;o rd s, 139 Bur (s). •09
Axial su rfaceslc ontO~Jrs (w ith bridges). 228-9 fo r mesial and dls!.ll surface preparat ion . 114
Ax ial surf aces/contour< (with crOWM) Burnish ing crown mar gins. 145
che cking/adjusti ng. duri ng try ing-in. 143
nx luc t io n Ca nines. re tai ners. 19 ]
p,artia l c roWl'lS. 115 Ca ntilever bridge. '5 3. ' 74. • 76
poS'en(lr crowns. 112- 14 advantagesldiu dvanuges. IBI . 182
appro,,,ma l surface, pon tics and, 202
&teplane combined with fixed-fi xed desig n. '7B- 9
1cryl ic. 74 pnctic.:o' e,",""'p les . 2 .7
h e<:! :anterior ([hhl appliance). 7 1. 7 2. 73. 108-9 r eUlners., b i'ur e. 256
Bleaching. 9. 12 span length. 2 12
Bone loss. alveolar. and replacement 01 mISSing teflh, 162. 164 spr ing. 5f'f! Spr ing cantilever br idge
Box ...s . 116 C ar ies
Bridge(s) (US te rm = fixed par tial denture), 149- 237, crow ns for
255-74 ante rior. 8
childr en, ~e Ch ild ren fIllIngs vs.. 3
co mpon .... es. 173. 19. - 206. see olso ~IC com~,,{s sec onda ry. 265
medu nic.a l b ,lure . 258- 9 WIth bridge... ' 57. 260
COIlSmKUOtl. 222-31 w lm crowns. 260
desogns. Sff Designs Cmls)
extendIng. 26 7, 270 artICulatin g. 82
b llur e. 15 7- 8. 2 S ~74 oppoSIng. ' 00
GlUS ," ' . 25>.63 stu dy. see Study casu
solut ions (repa ir/repb cement eec.j. 256--8, 26 7, 27 1-4 trim ming. 82
impr ession materials. 130--1 Cas t ce ramic cro wn, 26
indicat io m (co mpared with partial dem ures and implant - C ast co balt---<: hro m ium removab le splints . 24 4
retain ed prost hese s). 149_72 Ca n co nnect ors. 204
materials used for . see Mate na ls Ca st·me sh br idge. ' 84, 186
occlusal obfe<ti ves. 76-7 Cast""""ul bridges. 180 . 186. 18 7
over-p.-escnbed. 261 Cast·metal crown
plannong. 2 1G- 15 acrylic- faced. 29
p.-edH:Ong fina' resull. 2 12-' 4 anterio<' . 29
removing bndge and PM1's of. see Removal post~ior. H

~Iacing part o f. 267 C ast_me tal mInima' prepantJOn splInts. 246

tem po..-ary and p.-ovlSional. dIfferences between, 128-9 Cast post and co res . 60
te nnino logyfdef,nit,o ns. 149- 52. 173 makIng. clinical and laboratOf)' stag es. % , 97
tr ial pre para ncns . 95. 2. 4-- 15 Cast pos te rio r co res. 39
types , 149, 150. 173-90, ,ee also speci(rc fypes Cast ing, crow ns, diffIcultie s. 53---4
under-pr escr ibed, 260-- 1 Cas t ong alloys, br idge s, 183
Bridge splint (splint/ br idge). 248-9 C ements (and ce me nta tio n), 143-5. 230
Britd ene ss. pon::elain jacket crown s, 25 wit h b<-idges. 233 . 2H -S
Brok en_down teem permanent Cerne<lla tion. 233
ama'gam re st or.lltion . .8 wnh t emporary and p.-ovlsional bndges . 230
ass"",sing n ruUur e and env lronmenl. 98 mal cementatton, 233
cro wn... 4, 5 Wlm crowns
postenor, . 6 cboce. 143- 4
veneers. 13 glass ianomer, see Gla" ionomer cem en t
Buccal pro st heSIS, acrylic, 161 lUling.. 47
Buccal surfac es root filling. removal. • 16
crow ns. red union. 43 techniqu e, 144- 5
an t er ior cr ow ns, 114-·15 wit h te mpo rary and provision al cro wns. 129
posterio r crow ns. 112 with splints. 252
 28

(cnllic occl us ion. 66 Cons em.. info r med . 8S

CenlTi( relu lo n. 66 Cons trUClion/manufacture
Ceoomic materials. see olso Me taK e.-am.c; Porcelain bridges, 222- 37
~s. 180 crowns, 100-46
fr<Jewre. 258 c1inoc:al stag es and tec:hn.ques, 96 - 7. 98-9. 1()l).--46
cr_ Iaboralory Stages. 9~7. 98--9
friKt ur e. 158 oc:c1uloa' obtec:tl'Ves. 76-7
posterior. 34 -5 Conuct(s). oc:clmal. 66. 67
bangs. 267 ched " nc paon" of. durong Iry,ng_,n o f crown, 143
Inti !" for postenor teeth. 21. 22 premuure. 69
Ce-ec muh,ne. 22 Copper r,ng and ama lgam. 12S
Cel'lMlt. 38-9 Cords, rctrawon. 13S, t 36
Chlurslde COl"es. 3~9. 98. 106--9
temporary bridge co nst nxtio n, 228. 229 bu,ld,ng up. 106-9
u~mporary v own s, 122- 5 and cro w n. 36- 9
const r uct ion, 122-5 fo r anter io r teeth w't h root f,llongs. 3 I
plannIng, 106 par tial cr ow n. for parti al r esto rat io n. 18. 23
Checking proce dure. crowns. 140-3 for poste rior teceh , 18. 23. 36-9
Children, cro wns and bridge s. 85- 6 need fo r. 98
oral hygiene and . 89 pifls retaon iflg. see Pin-re tained core s
Choosing resto ratio ns, See Decisio n. making pons afld. see POSt5
Chro ma. 102 rem o val. 270
O Ul IV gold inlays as alte rn ative to anterior cro wns. COst
10- 11 . '2 bridges, 158. 194
( I..aning and deanubihty wit h b<idg<!s. 2 10. 236. 237 crowns, 87
po,u iu. I'H po rcel a,n jacke!. 2S
Cleft p,llue C ro's-pifln"'g. 2S7. 2S8
bndgewor\(, 156 Crowns (restorations) and Crown ~ep;orauons. 1- 146. 2S5-74
$plin[$. 14 1- 2 alternatJves to. 9- 16
Q"'IQI sug... and t e<hniques aflle.-.or. see Ante<ior Crowns
W!U'o crowns. 71--83. 96-7. 98-9. 100--46 child<-O!'fl. see Ch.ld r....
",adequat e tectonique. 261-3 con t ra,ndocatlOfls, 3-23
CobIIt-<hrom,um rwno-able splonts. cut. 24<4 cores and. see Cores
Colour of l eelh (mooching of c"'....n r "Stol"a tion sl. 10 2 de<:,sion-ma~,ng. 21-3 . 92
poor match. 26 ) dcs'gn,ng. 4 1-6 1. 76-7
poste flor res rc rations. 19---2. impr"ss,o n mat ....ials. U o-I
Com binat Ion deS Igns. btidge s. 178-9 indionions, see Indoc:atiom
Compcsne materials (restorations made fro m), see o/S(J length ....ing. 46. 106
W ire-and-compos;te splint making, see Conu mc:uon
uid-etched reta ined, 'phnt, attached w,th, H S multiple. 6
as alternative 10 am er ior crowm , 10 paralleling devic es. 214- 5
appeara nce. 7 partial, see Partial cro wns
core, fo r post er io r cr ow ns, 38 plann ing. see Planning
core and crow n. for root-filled am er io r te et h. 31 po sterior, see Po ster ior cr ow ns
for crown fati ng. 29 pro blemslfa,lure , 8, 255-74
inlays, 20, 21 avoiding. 4 7- 54
vene<.'rs. 11- 16 causes. 255-63
Compressed air. gingival re tr action . 135. 136 re paw, see Rep air
Conf,dence o f patien n. replac e ment o f missing t~tb and. pro visio nal, ' 28- 9

'"
Congenital defccn. sphnts. 241- 3
as retamers, 173. 191
sleeve. 267. 269
Connectors/ jo ,ms, 204-6 5pIints re uuned b y
dofin,tJon. 173 by corn plet ll' cr owns. 248-9, 2S1
fi"ed-f,,,ed bridge. 176. 205, 206 by partial (Towns. 248
fi"ed--mova~ bridg e. 176 tempo«lry. see Tem po«lry crown,
on hybrod OeSlgnS. 179 try''''g-in. 140-3
w!e<tlf'ol. 216 types, 2<4-40. SC't oho 5/JCO{<c ~
282 'nde~

Crowns (Ieeth). cood.t,o n whe n cOIlsuk " ng crown fa ce bow. 78

restOr.Jtion, 90. S~ also ee roes u~ lnln<oron~1 Facill(~
C VlOp. fulKtionat I 12 lost. 259. 268
r epla cin g. 267. 268
D~hl oappliance. 7 1. 12. 73, 108-9 peeoe. see PonlK s
O e<:iS'O'H'Jak ing (selec tion/cho lco,,) preformed. 267
;Int er ior sp lints . 2S I pro pr ieta ry. see Propr lCUry facings
bndges. 207- 1 r. 215- 19 r e pa ir . 166
con str uction te chnique . 229-30 ·uAlt_co nst r uctio n·. 267
mat er ials. 229 Flllmgs
re ta iners. 192-4 cr o w ns vs_. 3. 92
crowns. 21- 3. 92 ro o t . see Roo t -filled teet h
h ed V$., re movable pr os theses. 158-6 7 Finish ing
po ste rio r res to rat io ns, 2 1-3 an te rior teet h for cr o w ns. 115
Denu l Dos s. b<-idges . 235-7 fo r pasl cr owns. 121- 2
Den llnogenes is impe r/ec u.. .., 86 pon: ebi'l m mo utll . 84
Dentures. partial. S~ P3rtial eeewres postenOt' teetll fo r crowns. I I 'I
Oes<gns FlI o f crown. ch e<:king. 14 1- 2
bridge, 1 7~O. 207-2 ' Fi><e<:f anteriOt' b<teplane (Dahl appi<a r'lCe). 1 1. 72. 73.
adva nugeVd1u,dvoInugM. IBO. 181. 182 108- 9
com bi....uo ns. 178- 9 F,><e d connec t on, 204
e ~;J,m"'e of de s'gn process. 2 19- 2 1 Fi><ed-fj><ed bridge. 17l---6
pltblls. 260- 1 adva'lu gesJ dlsadvanta ge s. 18 1. 182
pon tics. 194--5 co mbination o f
selectio n cnteria. 20 7- 11 ....,tIl ca nt ilever de sign. 178-9
vuiat io ns, 180 wit h f,>< ed-rnovab le de sign. 179
cro wn, 41--61. 76- 7. 26 1 cc noec ro rs. 116. 205. 206
pitfalls. 47- 5-4, 260 hybri d de signs. 179
Dicdonnc splints. 244 , 249, 250 pra ct ica l e><a mples. 218
Direc t br idges . 18'! pre parati on, 226. 226-8
D Iscomfort. bf"idges. 158 r eta iners. In
D,splacing forc es . r ete nt Io n agaInst. see Retention failure. 25>-6. 256
o.suJ surface pl'"epant1on fOt' crowns . 113-1 4 spa n length. 2 12
Dl~tOf'tlon. all-metal bridges. 258-9 unsa tisfactory de sign, 17'1. 175
Dor--Wped pontIC . 196. 199. 100 Fixpd- mo va ble bridge, 174. 175. 176
advalltagesJdls.:lldvanrage~. 18 1, 182
Eatinl ability. r e pbce mer>ts lOt' missing 1e<,,11l. ISS combined WIth ""e d-fi"ed ~ign. I J'j
Eb n omenc malena l~ hybrid design~. 119
impre~~ion r eco rd ing. 1l0. 1l 2. 114 pra ctica l e ><amp les. 2 19
oc clu sa l r eco rd ing. 139 r etai ners. fa,lur e. 256
Ele<:tr osu rgery. 135 span length, 2 12
Enamel Fi><ed pa rtial dent ures (U S term). see Br idge
hypoplasia. 5. 'IS Fi>< ed pr osthes es (in gen er al). cho ice betwe en rem o vab le
surface area fo r br idge re te nt io n. 12 6-8 and. 158-67
Equipment. see Inst r umen ts and equipment Fi"w re. 153
Erosio n. see Wear definition. 15 1-3
Etche d bi'i<!ge. 2B. 2J5. see also Acid-etc h r etained Flo ss,ng. bridge s. 235-7
coenposne Fractur e
E><amina lion, pati ent br idges. 258
WIth bridges. 2 11- 12 r~,,,.,r. 269

recall. 137 crowns. 258

WltIl crowns. 85- 92
of ocdu.oon. 7'1-0 . 78-9
r ecall, 145
E><tenslon of bridge. 26 7. 270
E><tn.co ronal restorat'ons. genera l
Eye. parallefulg by. 213
pD<"cel.t ,n jack et, see POt'ceU.ln (jacket) crown s
t ooth tissue
In abutment t ee tll. 260
w ,tIl crowns. 52
i ndlcatlon~. 3- 8 f unction (wi th crown s)
design co nside ratio ns. '12- 3
 Inde~

occlu$ion ~ d. 62...... constr uction. 228. 229 . 230. 2) I

res to ru io 8 worlung. 230- 1
fo r cro wn s
Gap betWffl> crown :....d prePM"Uon m~rgl"'$, 26 2- 3 pI~nnlng. 102-5
Gender. see Se~ .....:Hi<,ng. 129-37
Gingm. (wtd> cr ow...~). +4 rnateri:ll$, 00-1
retrKtion. ll l- 5. 116 for pe rma nent splmt$, 251-2
Gi~bal reduction. I I 5 Intilo<ll hooks. t emporary. 228
GI~l.li iof>omer cement (for restoraoon~). I.... Intis:lll--J>a lau l re duc tion. 115
~~ ~llem~tlVe to ~ ...t er ior cecwns. 10 Int inl reduction. 43. II ..
appe~r~ nte. 7 Intisors
br idge$, 2ll crowns for. 106. 108
cere lateral peg -$hape<l inciso rs. 4. " 6
~ ...d trown. for r oot.filled ~nterior leem. 3 I porcel~m j~cket.. preparation , 112
for pa.te rio r crowns. 38-9 re ta mer$, 19 3
Gold ~lloy. H single m ISSIng. br Idge desig ns. 2 17. 2 19-21
Go ld bridges. try ing.;n of r etai ners. 2) I Inclination o f teeth. cro w ns alt ering, 6
Go ld crowns ante r ior, 9
~dju stment in mouth. 84 Indicat io ns
making. clinical and labo rato ry stage s, 97 brid ges (compared with par t ial de ntu re s and imp lant.
poste r ior. 34. 35 re ramed prosthese s, 149-72
des ign"'g. 55--6 crowns. ] -2)
removal. 270 anter ior . 8-9
Gold inlays combi ned indication s. 6
U 3.... t er ior crow n alternatives. 10- 11. 12 po sterio r . 16
u pos te rior trown alter nadve~. 17. 18. 19 $plints . see Splint s
chooSIng. 23 Inflam matIon. alveolar r idge. pon t ics and . 200 . 20 1
G~fu. bone. for r idge augme na tion. 16l 16" Informed conse...t.. 8 5
Gn nding in SItU. 264-5 Inlury . see T ~uma
Groo~. 116 Inla)'$
GU(u ~Iu. root fillmg. removal. 116 a~ anterior crown altenu.tlves. 10- 11, 12
as po steti« crown alten>a tivcs. 17. 18. 19. 20.21
'Half' crown. 36 chc>oSlng. 23
Hammen. slIde. 21 I. 214 Insertion of trOwnS
Hand.....eld models for otclulo<Il r ecord s, 77 after cementatIOn. 1"5
Health, genera l. and replacements fo r min Ing teeth. path . ....
159-6 1 Instrumen t'> and equipmen t
Histo ry. patient, crown~ and. 85~7 for removiog trown s and bri dges . 27 1. 273 . 214
H..... 102 for tooth prepar~uon. 109
Hybrid bndge de signs . 179 Inte rc usp al pa.;tion . 66
Hydr oco llOId. r eversi ble. 130- 1. 132 ad just Ing, 83
Hygiene . ~ee Oral hygiene lnt e rmed'a t e-t er m h ed splints. 2"4. 245 - 50
Hyperpl asia, gingival. crow ns and. 4.. Im er oc ciu. al ' pace. creat ion, 1 1. 72- ]
Hypodontia , partial de ntu res. 168 Int ra-co ro nal reta iners. 191
Hypop lastiC co ndit io ns, crow ns, 5, 45 Int ra -co r ona l ~ p l i nts, 246
ant er io r. 9 Int ra -o ra l pr acti ces, see Mouth

Implant· reta med prosthes es (osseointeg rated implants). Joint s. see Connectors
15 1- 3
definitIon . 151-3 Keratinizat Io n wit h pontic$, 200. 20 1
indi( ~tions for . 169-11
compared WIth bridges. 1" 9- 72 Labo~tory sta~s and technique $
Impregnat ed re t~ctlon cords. I ]5. 1] 6 bridge~. 26 1
ImpresSlOf"lS crowns. 77-8] . 96-7. 98--9. 129
In bridgeworl< ,nade quate Ie<hmque. 26 1 ~]
for UWS$"'f, pa~llelism. 223 . 225 Later:ol ex(ur$ion$ of rnand.b1e. left and ¥ t. 66-8
.. d>al~ te mporary and proYisiofW brodge adjust ments with r estoration in mouth, 84
' 8'

ledge M" u l-<e rami( (rOWfl~ 25-9, 14

negu ive. 262 a'ller ior. 25.--9
poSItive. 261 -2 de~gning. 42. 54. 57
l e ngth I",ctu re of porcelain. 258
of crown prep;llratlon~ 50 making. c1,n,ul and laboratory s~s. 96. 97
root. 'l'O- 1 pcster-ce. H . 36. 57
of ~n. abu tment support ~nd, 209 PIns. 36
l en gthen ing. crowns, 46. 106 pn:paUl>on for-, 110. I II
ught-c unng acrylIC for impresllOl'l trays. 103 rem<:>V",I. 210-1 , 212
l Ingual surlace~ Meu k Kll rntC pon tics. 183
pontic:~ 202 -3 loss of facing. 268
posterIOr crown~ re duction . 112 Meul-c eu mic re u in"n. 18)
l ou liU llo n lechnique~. 23 1- 3 MeLllI cro wn s
lut ing cements dcslgn consid erauons, '" I. S'l
bridges, 2)) mak mg. dlnica l and labora tory su ges. 9 6
crowns. 47 Me ta l powder . glu s ia no me r ce ment (oo u rn'''g, cor es for
po st erio r cro wns. 38-9
Meta l r eu iners, 183
M ac ro·mecll~ni ca l ly re t en t ive br idge s, 184--8, 189- 90 MI cr o-mechanically ret entive bridges. 188. 189
Making crowns and br idges. see C cnstr ucno n Minimal p r eparation (resin-bonded) bri dges
Mandible (MMyland/adhes ive bridges ). 1'19, 150, 173. 184 -90 .
dydun ct ion. 7 1-4 225-9. 227. 233- 5
mov em ents, 64-8 adv3flugesJdisadvantages , 182
and OCclU~ll adjustment in mou th, 84 cementa tion, 2))
ManufJc ture, see Con~trua ion def,n,uo<l. 149
MargIns d,udvama ges. 190
cr own. 4 3-4. t 14, 146 hed-mO>lable. 175
burn ishing. l i 5 practical examples. 2 18
deficienciel; . 261 -3 si,,!le mining in<:isor, 2 17
gtngMIl. retraction, 1l 1- 5, 116 pr~ntlom for- a nd c ons DlJetlon o f. 225-9. 2)]-5
~.rs at. 265 n,tentoon S)"$tems. 184-8. 19 2
Mu lung rNlter",ls. ocduul. 7~, 83 ,",."'re. 256
Maryland brnIge . ..,., Minimal ~ rulOfl bridge on hybnd de~Ign~ 179
Maryland splint. 246 types. l S4- 90
Muemls. I f f also speo(oc motfflOls MmirNll prep;llnmOfl (resin -bonded) ~phnts. 1 45
bridges. IflO-.-3 cUNneul. 246
ponties, 203-4 Mou lding technique~ re mpo ra ry cr owns. 122-5. 127
r eU lner S, 18l. 192 Moum
temporary/proviSional, 229 ~diusunenu in. 26+-5
c rown~. 4 1- 2 c rown~. S3-c 146
im pre~sion , 130-1 rep~ Irs t o crowns ln d bridge~ in. 146. 265- 7
Mechanical problem s tri~ l s of bridge in. 2 14
br idge com pone nts. 258- 9 wh ole. crow ns and co nsider atio n of, 87- 9
c row n ~. B. 258 -9 M ov~ bl e co nne Cto rs . 204-6
Medium-mechJn ically retentive syst ems , 184. 188 Mucou s membrane rea ctio ns w ith pe one s. 200, 201
Me rcury to ~i d ty , 19 Mult iple crow ns, 6
Mesial surface pre par at io n fo r crowns. 113- 14 Muscle hyper activity diso r de r. 7 1-4
Menl (s) Myof~ sci~1 p;lli n dysfunaion ~y nd rom e. 7 1- 4
disto rtion (in crown s). 43
noble and base. 4 1 Nicke l-chro mium me u l surface of bridge. 187
MeU I bridge~ 180 N o n_vlu l t eet h. crowns. 8
dIstortIon, 258-9
Men l-c <:'f"amic bridge~ 180 CKclusal co nu CIS. see COntacts
fraClur... of po rc elaln, 258 Occlusa l interferences. 68-9. 74
solde ring, IS 3 abse nce <'''oc clusal lu.nnony). 69
strensth of pontic. 195 Occ"'sal Ioa.d on bridge. 207~S
trying -in, 231 Occlusal p..-rfontions. 259
 18'
Occluul rebtiomh tpl Parallellns te< hniqlieS
avo;d,ng loss.. 71 compkte-<:ro wn splints, 25 1
WJth «ompor.ny res IO"'tioos. ma lnUlnlng. 77 conventIOnal bridges . 213- 5
Occlusal repa irs. 26S Parti al cr owns. 33-4. 35-6. 61. 115-1 6
Occluul surnces ant erior. JJ---'l
of crow n. shaping, 82 des lgn,ng. 6 1
of pomics, 100 eo ecreco of metal. 53
reductio n. ! 12-14 co r e and , 18. 23
of too th. 90 poste rior , 35--6
Oc cluS31 vertical d Imens io n deSls nmg. 6 1
.....th tx-idge... IS6 pt"ep,irlng te et h for. 115- 16
wrth crowns. 69 - 7 1. 106 as reta"'ers . I9 I
pl.lnning changes t o. 'ill. % . lOb splints. reu ined by. 1~ 8
Oed..,,,,1 wea r WIth crowns, -0 . 259 temporuy. build-up . /25
OccluSIon Pa~l de mures. l SI

WIt h b ridges. I 'H bridge r eplacing. intra -o~1 trial. 2 14

ad jumne nt . 222 definit ion . 151
as.c nme"'.. 212. 2 13 fixed (US te rm ). see Bridge
as indicat o r for br idge, 166. 167 ind,cati om. 168
o bject ives, 76- 7 co mpare d w it h br idges. 149- 72
pla nn ing, 2 19 pr eciSIo n-at ta chmen t. 149- 50
r e<;o.-d ing. 23 1 Patie nt
wid. crowns, 62--84, 90 cro..... s and co nside rat ion of who le . 85 -7
adruwnent. 83--4. •.oI l ,,><alnlll<lI.JOI\. see Examloal.Jon
altera tion, 6 remova ble prostheses (bridges ) and conslderauon of
Checkm g. 1<4 ] ....t>oIe. 2 11-1 2
de.igfl consideratIon s and obje ctives. -42- 3. 76-7 fixed pr os theses ~s_, 158--62
exammauon and analy$ls, 74--6 . 78-9 Peg-w pe d lat era l incISors, 4. 46
functional appr CNCh, 62...... Perforati on s, occlusal. 159
management. clinical and I..bo ruo ry. 77 -fB Periodont ium/p erio do nta l uss oe
recor ding. 77~8 3. 1]8-40 br idges and. 158
reductio n, pa rti ~1 c ro w ns, 115 cr own pr eparation de Sign and. 44-6
re du ct ion, po st er ior te eth. 43 . 110-12 disea se
, (;lbility. 5<'(' SUbility abutment teeth affecte d by. 259---60
pro blem s. 26 ) splints.. I SS. 241 , 249-S0
O ccup.w on and replacemem of missing l ee t h. l5 6. 159 Perma nen t splints. 24 4. 245- 50. 2S 1- 2
Opposing c ases. 100 d inical tec hnique s, 2S1-2
On! hygiene types. 24 S-50
WIt h bf"1(jges. instr\l( t lOf'lS and m3.mteoaoc:e. 1 3S--7 Petroleum jelly- Zinc o xide powder. cementing temporary
With o-c ..... s. 8 7- 9 cr owns, 129
Inu r uctioo s and mamtena nce, H 5 f't>ot ogra phs. 100
Orth odontIC treatmen t. 61-3 Pier , defiOlt ion. 173
bridges and. 156 Pin(s). see also C ros s-pinn", !:
splint s and, 24 I broken -dow n t eet h, 16
Os seoiotc grared imp lan ts. see Implant·r eta ined pro st he ses par allel plast;c. I B , 135
O~erha ng. 161- 2 Pin-re ta ined amalgam re st or nions , 17- 19. 36
Over_pres crib ed br idges. 26 1 Pin-re u lned cores. 16. 18. 36. 37
Overt ri mmed die . 142 construceon. 106. 107
Pinhol es. 137
impr e sslOfl. 135
Palaul re<luct>oo WIth meul-<enmoc: crowns, 28. see also partQI cr owns, 116
Glnglval-pabtal r ed uction; lntisal-palau l redecnon Planning
Pable. deft, see O dt palate bridges, 2 10--- 15
Parallel pinholes, I 16 cr ow ns. 85-99
Para llel ptasuc p< ns. I JJ. 135 clinical sta ges, 98-9, I()()-.9
Para llel_smoo th o r se r rat ed posts. 3 1, 32. J3 labo rato ry stages. 98-9
Para llel-t hreaded pons, 32, J3 Plaque res ist.1 nce , po rcelain jacke t crowns, 25
286
P1UIK pins. p,ar;a llet 1) 3, 135
P1au lc strips (for oc clusa l e uminauonj. 75--6
Plastic t e mporary bri dges, 228
Po lishing in situ . 264-5
Po lyac rylics. S~ Ac ry lics
Polyurbon.1te {('fI\p<>r.lry c rowns, 122. 12J
PoIyo.rbo"'yl.>te «'men u . 144
tempor-ory crowns, 129
Polyether impr ession mat e rials. 130. In. I B
Polymer m;lIena ls
fo r imp re ssion s. 131- 5
fo r oc clusal r ecords _ j 39...·10
POIY' lil phidc impressio n materi als. 130
Po lyvi nylchlonde (PVC) slIp, 122. 12'1
Ponl'CS. t 9+-20<4
defin ition. 17)
des Ign princ Iples. 194 -$
IU lng\.. 20 3, 268
lo ss and replace ment. 268
m etal-<;e ra mic , see Me ta l- ce ra m ic pont ic
se l('ctjng. 2 16
spring cantilever br idge. 176
support. 207-10
surfaces. 195 ...203
Porcebin I_V. re stor-auon s). ~ <Jh;Q
WIt h crowns
in Crown prepantion design. 4 1-2
finishing in mo ut h. 8'1
oc clusal shaping w ith, 82
fracture. 52- 3. 258. 269
~ep~,~Ir-q>lu emem. 2~ . 267
Porceb," unulever bndge. 177
Porcel~ ,n coonectoo.. 204
Porteb in bcing~
pont'c. 20 3
10" and replace me m . 268
repair. 266
Porcelain-Iused· t o- me t<l l ( " metal-c c n mic). see
Me t<ll-ce ",m,c
Porce l ~,n ;n b y ~
U ;anterior cr own alter.... eves, II . 12
u posterior (ro wn ~Item~ uv.,.. 2 1. 22
Po rc ela,n (jac l<l't) crown~ (PJCs)
fo r an te r ior teeth. 24-5. 58. 59
st re ngt he ne d. 27
de~ ign i ng. 52-3. 54, 58 . S9
fract u re. 52- 3. 269
replacement. 269
mak,"g. clInical and bbor~tory ~uges. 96 . 97
fo r posterior teeth. 34-5
preparation of Inc isors fo r. t 12
re moval, 270. 272
Po r ce b ifl veflce r s. 1 1- 16. 17
POst (s). 3 1- 3. 60
a nd co re s. 18. 60
cut. ~ee CUt post ~nd cOl'"es
construc toon techniques. 106 . 107
I,,"..
fOl'" pos terio r cr owns. 39
r e mo val. 270
an d se para t e c rowns. fo r ro ot·fille d an te r io r t eeth. 3 I
shape s. 3! ~3
Po st c row nslpo~t· re ta,ned c ro w n. 54-6 1. 116-22
de~igning. 54-6 1
one l'iece. ))
tcmp<>rary . 125
tooth p re pa "'tion. 1 16 - 22
Post ho le . p repara tion. 116--2 1
Poster ior c r o w ns. t 6. 34-9, 54 . I 10· 14
altern a tive~ . 17-2 1
co mplete (and in ge".,ra l). 16. )4 ·9. 5.... I I ()...-I 4
oo~igning. 5.... 55-.6
IndIca t IonS, 16
lOOlh prepa ra tion. 11()...-14
pa " ,al. SH Pa,-wl c rowns
POSICrlor re storatio ns (in general). 19 -23
d >OOS1Og. 2I -3
tooth -col ou red. 19·-2 1
Poste rior tceth. re duc t io n fo r crow ns. 43. 110-12
Po uri ng l ech niq ue s. le mpora ry c rown~. 122. 124
Preci~Ion-~tt<lchmcnt p;lrtlal dent ur e. 149 -50
I.pl,m.ng of abutment teeth. 243
Cer.ami<; ..,.,tenal, Preforme d bcing~. 267
Prefo rm ed tempora ry c ro wn s
con struc tion. 122
planning. 106
Pre ma tu r e co nt<lct . 69
Pro pr ieu ry bc ings. 26 7
pomlcs. 203
Pr opr lCUry ~Ints, 1-46- 8
Pros th esi s
ac rylic bu<:u l. 161
ch o ice be t we e n fl~ ed an d r e mov ab le . 1 5 ~ 7
d efon ition , 154
implant· r e ta ined . ice lrnplant-re tain ed pro sth eses
Prolru~Ive e ~ c"rsiom o f mand ible. 66
adJ u~tment with restcrauce In mouth. 84
ProYisioful bridges. 2 15. 2 29-30
acryhc. 197
ccmenullon. 2]0
conserucuoo, 229- 30
prac tical e~ am p les . 2 18
Provisio nal re sto ra t io ns (in gene ra l). 128-9
c rowns. 128--9
cemenu tion. 129
d,/ferell( es between tC!fflponary ~od, 128-9
bl>or.otory made. 129
Pr o xi......l/~pproximal su thces
b ridg es. 200--2
c ro wns. r edu ctio n. 43. ... 4
anterior , 114
""'ofpab ut me nt leeth. l,vlng
p~oblem~ laler. 260
In crown preparat eon design. 16--7
re pbcement s for mIn ong teeth d:ilm>.glrtg. 156-7
 18:

Puny M>d ....u h. IJ I chedung. 141- 3

PVC dip. 111. I 14 loss. 255
by pins. see Pins
Recall examinat ion by po stS, le e Po sts
bridge~ 137 in vc n:ical loss pre vention . 47-5 1
cro wns.. 145 o rthodontiCS. 156. 24 1
Recording occh...ion RelnCtion., gingiv;ol. I ] 1- 5. 136
brid~ 131 Retruded contact position (Rcp). 66 . 67
crow l'lS. 77--t!3. 138--40 Retrusive mOVements 01 mandible. 66
RedUCtion (of toOth surtlces for crowns). 11()-1 4. t 14...15 ad, ustment ....lth r esto ra tion in mouth. 84
ante rior, 114- 15 Ridge. alveolar
palatal (with meul-< e ramic crowns), 28 augmc nLltion. 162. 164
poster ior . 43. 110-1 4 peones and the. 195- 200
Removable br idges. 149. 150. 180 shape. 2 12
defj... tion . 149 Ridge. lap po nti(. 197. 198. 199. 200
R~ p.-ostheses (in genera l). clloi<e be tw een ~ xed mod ified. 197. 200
V>d. 158-61 Rochette ma cro-mechanical re ten ow br idges. 184-8.
Removable splints com par ed with fixed splints . 144-5 189-90
Removal Roc hette sp lint. 146
bridges, 27 1-4 Root
parts. 267 of abuun ent teeth, fractur e. 260
crowns. 267 . 270- 1 length . 9()... 1
rcce fitl,ng cements, 116 Root -filled t eeth
Repo.ir1 t o cro""," and bridge-s. 1 56-8. 165-1 a, abutments
in 5itu. 146. 165-1 e lGlmin.ttion , 2 12
Replaceme nt giVIng trouble !aler. 160
bridge part. 261 cro....ns, 16. 19 -33. 90
mi" ing to ot h/t eet h, set' Too th ante r io r, 29~ 33
R,esin(s). che mically re te ntive. 188 r emoving r OOt filling. 11 6
Resin..oosed ce ments, 144
Resln-bonded bridge's and splint s. see M",inql preparatJon $.addle-shaped pontics. 198. 199. 200
bridges; Minima' ~epa ....tion splints s.afety ~euutions. trying.. n of cr own. 140
Reston.tions. se'e ak.o s.peofic ~ s.and blu ting. 8]
crowns u part of ano th e r, 6 Selecucn of r esto ra tion , see Dedsion-tn3king
an terior, 9 Setf-cur ing acry" c for imprenio n l....yS. 10 3. 104-5
poster ior. 16 'Seven- eight hs' cro....n. 36
decision-making. see Decision-making S"
extr a-coronal. genera l indicatio ns. 3--8 cro....n s and. 87
mat e.....ls, see specific mOferN:rls replacemenl of miSSIng teeth and, I S9
prov lSlOOal. Se'e Provisiofu.l r estor:ations SNde. 95, 101 - 2
temporary. see Te mporary n ston.tions chec king and adjll5ting. 143
Retaine wretention syst emS (for bndges). 184-90 . 19 1-4 lechnique s fo r se lecting. 101-2, 10 J
choosing. 191. 1 16 Shape
definitio n. 173 cr o....n, poor, 263
failure . 255--6. 269 r idge, br idges ~ nd, 212
h ed- fIxed bridges. see Fixed -fixed br idge toot h. crown s alt ering. 6
go ld bridges. tryi ng.in. 13 1 anterior. 9
in hybnd de signs. 179 Shaping
me tal--<era mic reulnen, r83 oc;dusal suriaces of crown. 82
metal re U iners. 183 po st hole. 116-2 1
mInImal pr eparatio n retaine rs . see M,nima l preparation Short_le rm ~xed splints, 144 . 245-50
bridges Silico ne imprenion mat erials, 1] 0. 131
over .pr e scri bed , 261 Size of t eeth . crowns alter ing, 6
Retention ant er ior. 9
bridges . see Reta Iners 'Sl"""e <;rowns', 267. 269
« .'res . Se'e Cores Slide ham<ner1. 11 ' . 27 4
CroWfl~ 47-52 SocIiJ hiStory .tl'id crowns. 81
288 Indej

Solderi ng ma inta ining occlusal ~el a tions h i ps. 77

co nnec tors, 20"1 Tem po rary splints. 251
fail ure o f solder joint. H B Tempo romand ibular JOInt dysfunction, 71-4
me ta l--<er amics Tetracycline stai oing, 9, 10 . I I
br Idges, 18 3 Th rea ded po st s, 39
cro wns. 29 pa~a.lel. 32. H
S"'" ta pered. 32- 3. B
defInItio n. I n 'Thr""-qua rte~' crown
IM gth of. 2 12 ant erior", H
abuun ....' support and. 209 poste~io~. l 5--6
Speech qua lity. re place ments fo r missing t eet h. r5S Toor b/teerh
Splint (s). heel, 204 1- 52 abutmen l. ~ Abut menl lee'"
diodomic. 24~. 249, 250 adja cen l
,od iatiom. 24 1...... on C~own de .. gn. 44-6
penodonul d.se.ne. ISS. 24 r. 2 49~SO ~eplac ement of mISsing Ie« h coos,denng. 168
int.,..-med,ate-term. 24" . Z"S-SO art ificial. as ~rt of bridg e. ~ Pont o!:
permanent, see Perma nent sphms broken-down, see Broken -do-'l leeth
remo....bIe splint com~red _ th o H + S colour, see CoIou~
~- [erm. 244 . 24S-SO defe<:t "' elaboor..... t lopl ,nts. 24 2- 3
~ 245-50 e "t ~acuon

Splm~, 2"8-9 br~ ~emoval accom~noed by. 271

Splmtl'd reUJners . fa,lure. 255- 6 <kci slOO_ lur.g. 92
Spans plaY"" and repbcemeo, of min'ng t .... ch. t S9 ,,,clin.ttion. s Incl,nauon
Spnng cantile--« bndge. 174. 176--8 mISsing. ~ epl ac em en t of
ponocs, 203...... ad lacen l l eeth coo5ide~ecI WIth . 168
Subol,ty of ocduSl()n advan tagesld,sadv1ntages, 15+-8
cro wns, 69 . 70 .p1ints and, 24 1
chKk with rntOr3I'OIl ,n mouth. 8-4 non,""al. c~own .. 8
rep lacemems for mining teeth. r5'4--5 p~e~ntion lfor bridges). 22 3-9
StaInless-steel temporary <rowns. 122 p~e~r:o tion (for complete·crown sp lmu). 251
Su-ength pr e par:otion (for crowns), 109--22
meuK<'H'amic crow ns. 28. 29 fo~ cememuioo. I +t
peeves. 195 redec non o f surface. see Red uct io n
Str engthen ed por(f~la,n cro wns. 27 sGige s in. 110--22
Stud y casts remai ning. assessing 5l r \K l u ~ e an d en vi~OIlment. 98
with br idges. 212. 2 1" , 229 root· f,lIed. SH' RooI·filied teet h
with cro wns. 75-6. 78- 9. 100 shape. see Shap e
'ch eating', 92 . 9 4 size. see Size
on. 94 . 98
t~i~ 1 p~"pa~~ti on s t~auma. see Tr auma
Support. p<Jntic. 20 7-1 0 value, 89
Su... eyi ng in br idge pr"par¥ iofl. 223 . 225 "ital, ant",ri or cr own s. 24-9
w ear . see W"ar
Tepe" of cro w n pre paration s. 49 -50. so Tooth t issue
T ape red-smoo th o r s"~rat,,d posts. 3 I. JJ cons", rvation of (Wit h b~idge s ) , 2 10
Tap",red -th read ed pos ts. 32-3. JJ retent ion and. 194
T eet h, see Toot h r emovall destruCt io n
Te mpo rary brid ges. 2 1S. 222. 22 9-3 0 for me tal-c er-amic crow n. 29
cementa tio n, 23 0 fo r porc",lam jacket cro w n. 25
const ru ct ion, 229 -30 t rauma. see T~auma
prepa ration s for . 222, 228 Transmuco sal abutme nt (TMA). 15 2. I S)
Te mpo ra ry crow ns. 122- 9 d" finit io n, I S4
cem enta tio n. 129 in ridge augm entatio n, 165
ccos tr ucncn . cl,niul te.: ho,ques, 122- 7 Tra uma/damage ....e also F~acw~e
planom g. 106 crowns caus, og. 52. 260
POSt crowns , 125 to ad jacent teeth. 44
T",",po~ary ~es to<"a uon s (in geoenl) crowns with . 4. 5
differ" nc<'1O betweee p~o"'s,onat an d. 128·· 9 an te~io~. 8
lnaex 289

replacem'mt$ fo r mining teeth cau$ing. 156--7. 260 W~JI. carving. 82

$pIlnting. 2.. I Wax ....co ..d$. funo; tlon~ lly generated 82-3
Tr:o~ impren ion. $pecial W " JI.-ups
bridge constructi on. no. 2J I WIth b",dges . 2 1"
crown const..UCtlon. 102, 103-5 WIth crowns
TrW cernen tauon. bridge$. 2)) dIagno stic. 9 1
TrW prepv-atoon ~ (br1dges) . 95, 21+-1 5 trW . ';II. 92. 9J , 9+-5, 101
.nU" H,r~t. 2 1.. We~ ../erosion (crowns), "J. 259
TI"i:il I prepar:ooon~ (crowns) We~ ..lero~ion (toot h). g"os$. 1060-9
on study u.sn. 9" , 98 crowns WIth. ... 5. 106- 9
Wll ~ · Ups.. 9 1. 92. 93. 9+--5. 101 amc no-. 6 -9
T nmrning CU t S, 82 partJ~ 1 dentvre~ WIth, 168
Trylng·on venee r-s with, I J - I"
b...d~. 231. nJ. n .. W ind -Inst..umen t players, ..eplac..menn fo r missing tee th,
cro wn, 1<lO- 3 156. I S';I
Wi re-a nd-~cryllc splint, 2'15- 6
Under cuts. inter locking mino r, " 8 W;re _~n d _composite splint. 2<15--6
Under -pre scribed br idges . 260--1 W ire loop , bridge re moval, 273, 274
Unit, defmition, 173 W orking i mp r e ~s l on s
'Unit·CQnnruct io n' brid~e facings, 267 bridgewo rk, am- I
cro wn s. 129 -37
Value W orn teeth and crow ns. se.. Wear
as dImension of colo" r. 102
of tooth. 89 Zinc o~ide-cugenol
V..nee r restor:otions. 11- 16 cemen tIng tcmpor:ory cr o wns. 12';1
Viu.1 teeth. ~nt..rior c..own$. 2'1- 9 oc clusal ..egistratlon paste. 138, I <II)
Z inc o Jl.lde--pe trofeum jclly. c..menting tempor~ry cr cwes,
W ash_through po ntic. 196, 1';1 7, 198 129
W ax (for oc clU1.llI .. x~minationJ. 75, I SO Zinc phosphat e cements, I....
Wax-~ddcd technque. 82 te mporary c..own~. 129