Recent preparation guidelines

Biologically Oriented Preparation Technique

 Introduction

 The fundamental concepts relating to conventional and modified tooth

preparation are the same: (1) No friable tooth structure can be left; (2) the fault,
defect, or caries is removed; (3) the remaining tooth structure is left as strong as
possible; (4) the underlying pulpal tissue is protected; and (5) the restorative
material is retained in a strong, esthetic (in some cases), and functional manner.
 Conventional preparations achieve these concepts by specific, exact forms and
shapes. Modified preparations are usually smaller and have more variable and
less complex forms and shapes (Boushell et al., 2014).
 Tooth preparations for fixed prosthetic restorations can be performed in different
ways. There are basically two kinds of preparation: 1) preparation with defined
margin, and 2) the so-called vertical (or feather-edge) preparation (Loi and Di
Felice, 2013).
 This approach may represent a less-invasive alternative to a horizontal margin in
various clinical conditions (DiFebo et al., 1985).
 The ‘rotary gingival curettage’ (gingitage, vertical prep, edgeless) method,
originally developed by Vick Pollard and Rex Ingraham, has been further
developed by Di Febo, Carnevale, and more recently by Ignazio Loi (Loi and Di
Felice, 2013).
 Vertical or Shoulderless Preparations in Contemporary Prosthodontics means a
tooth preparations without a defined finish line that have been termed in several
different ways, such as knife edge, feather edge, or shoulderless. With slight
differences between each other, all this preparation types may be defined
“vertical” as opposed to “horizontal” ones (shoulder, chamfers) and since the
introduction of metal ceramic they have been almost abandoned, with limited
exceptions (i.e.: periodontically involved abutments) (Hülsmann et al., 2005).

 The definition of the vertical margin

 In this approach there is a finishing area rather than a line.

 It is a full-crown preparation technique that extends to the subgingival part of the
root and is indicated for teeth with a loss of periodontal attachment.
 This particular and unique feature allows the prosthetic margin to be positioned
at different heights on the abutment surface, maintaining a reliable marginal
closure.
 It is also known as the ‘biologically oriented preparation technique’ (BOPT) and
consists of 1) placing the finish line subgingivally, 2) sealing the preparation
coronally to the finish line, and 3) shaping the natural edge of an emergence
profile above the cemento-enamel junction (CEJ, with the creation of a new
prosthetic emergence edge adjacent to the gingival edge (prosthetic cemento-
enamel junction / PCEJ).
 The boundary range of this preparation may be located at different depths of the
gingival pocket, depending on the available biological width (Comlekoglu et al.,
2009).
 The convergence between the final part of the prepared surface and the
unprepared surface results in a transition angle which, however, will be fully
covered by the regrowth of the healed periodontal tissues (junctional epithelium)
injured during the preparation procedures and will hence be irrelevant from the
clinical perspective. To avoid interference during tissue-healing processes, the
margin of the provisional crown will be placed extragingivally.
 Adversaries of the method claim that it often results in irreversible damage to the
periodontal attachment and violates the biological width.
 Supporters, however, pay attention to using special round-ended 2 degrees
tapered diamond burs a non-working tip (batt bur). It has coronal diameter of 1.2
mm, apical diameter of 0.7 mm, and non-cutting end of 1 mm, which reduces or
avoids damage to the connective attachment and allows a tooth-guided
preparation procedure. The length of the non-cutting end and its width should be
chosen according to the biological width (BW) (Lang et al., 1983).
 Rotary curettage leads to minor bleeding but is limited only to oral sulcular
epithelium. According to research results, such new epithelium is thicker and
adheres closely to a new prosthetic restoration; however, it is conditioned by
manufacturing a very precise, smooth and polished temporary and final
reconstruction (Ramos et al., 2017).
 An emergency profile of a crown placed on the shoulderless abutment should
besmaller than in case of an edgeless abutment, where gingival tissues need a
support for predictable growth. This means that the final restoration will be over-
contoured by conventional standards (Labno and Drobnik, 2020).
 Indications of vertical preparation

 Restoration of patients with advanced periodontal disease: When a patient has

recession and an exposed root face it is often desirable to finish at the gingival
margin to optimize esthetics. However, preparing a root face for a linear margin
obviously requires cutting into the root and may run the risk of devitalization of
the tooth or a reduction of the biomechanical performance of the tooth risking
fracture. The vertical margin requires no preparation of the root at all and is
therefore more conservative in these cases (Jason Smithson, 2021).The root
surface whose periodontal attachment is lost consists of necrotic cement and
dentin; these tissues are exposed to pathogens and could be compromised by
toxins and bacteria. Preparing these parts of the tooth helps protect the dental
tissues from the oral environment and eliminates the external and more
compromised part of the root. This procedure is possible only on teeth with a loss
of periodontal attachment, as performing it on a periodontally intact tooth would
result in periodontal damage.
 Restoration of endodontically treated teeth: For the same reason as above the
vertical margin does not compromise the horizontal ferrule of root treated teeth
(Jason Smithson, 2021).
 Provision of splinted crowns: Used to stabilize mobile teeth multiple units of
cross-arch braced crowns can be difficult to prepare with parallel paths of
insertion. The vertical margin makes this a simpler proposition since the
technician has some degree of flexibility in margin positioning and can
compensate for minor alignment errors (Goodacre et al., 2001).
 Preparation of crowns with a previous biologic width invasion: The existing
horizontal margin (if minimal depth) can be deleted during the preparation of a
vertical margin. If the margin of the provisional crown is placed more coronally
than the previous margin the tissue can re-establish a healthy biologic width
without the need for crown lengthening surgery. This is often advantageous with
challenging crown: root ratios (Ingraham et al., 1981).

 Main Advantages of vertical preparation

 Minimally invasive in the cervical area.

 Saves dental structure and allows enamel preservation in the cervical area.
 In fact, this approach may contribute to limiting pulpal irritation in vital teeth as a
consequence of a well-preserved pulp-preparation distance in the cervical area,
which represents the most sensitive zone for the pulp (Wisithphrom et al., 2006).
 Possibility of positioning the final finish line at different levels, either more
coronally or more apically within the gingival sulcus, without affecting the quality
of the restoration’s marginal adaptation.
 Possibility of modulating the emergence profile.
 Easy and fast to execute.
 Ease of impression taking.
 Ease of provisional manufacturing and finishing.
 Moreover, the introduction of high strength ceramics has allowed the clinician to
use this margin preparation also in full-ceramic restorations. The vertical finish
line has already been tested in vitro and in vivo with zirconia crowns.
 Furthermore, in vitro and clinical observations reported results with high success
rates with lithium disilicate full crowns on vertical preparations (Imburgia et al.,
2016).

 Main disadvantages and drawback of vertical preparation compared

to the horizontal
 For many years tooth crown preparation with vertical finish lines (knife edge,
feather edge) has been a method of treatment by choice due to the applied
technique of making Scharp’s crowns. The implementation of metal-casting
technology made it possible to produce prosthetic crowns on shoulder-prepared
abutments with horizontal finish lines (shoulder and chamfer). It was then
possible to compare both methods, and the following drawbacks of vertical
preparation were most often noticed: overhangs, uneven edges, biological width
disruption, lack of aesthetic appearance, over-contouring, difficulty of
determining a finishing line, lack of control on marginal seal and integrity,
damage to the epithelial attachment and unpredictable tissue healing, difficulties
in removing cement excess, etc. Many disadvantages of vertical finish line made
shoulder preparation become acknowledged by the academic world as the gold
standard (Shillingburg et al., 2003).

 The challenges of the vertical margin

 Esthetics: this margin design is unsuitable for porcelain-fused to metal crowns
since a visible metal margin will result.
 Stress-distribution: If not carefully managed this margin creates high stress
distributions in comparison with other margin types during firing and when
occlusally loaded (El Ebrashi et al, 1969). This may result in a margin which is
weak in tension and therefore subject to distortion. In view of this, the vertical
margin is only suitable for porcelain fused to metal crowns with a metal collar (for
non-esthetic zones, e.g. lower molars) or zirconia crowns. Some recent research
has also seen success with lithium disilicate (Kuwata, 1989).
 Vertical preparation approaches

 Vertical preparation – shoulderless approach

 the shoulderless type of tooth crown preparation (also known as bevel
preparation) has been referred to differently according to the rising taper:
feather edge, knife edge, chisel edge, but researchers agree that for many years it
has been the most conservative approach towards dental structure and the less
prone to marginal gap (Limkangwalmongkol et al., 2007).
 The historical method was to restore the tooth structure with a Scharp’s crown,
which was possible even in case of non-parallel preparation thanks to the soft
alloy. At present, shoulderless preparation has been practically abandoned due to
the application of modern - laboratory technologies and to its numerous defects
(Piemjai, 2001).

 Vertical preparation – edgeless approach

 VEP differs from other vertical preparation techniques since, unlike VEP,
traditional feather-edge or knife-edge preparations present a defined finishing
line, and they often use the provisional crown to manage soft tissues.
 This technique is indicated for patients with thick/medium periodontal
phenotype, and when the tooth presents a loss of periodontal attachment and a
probing depth greater than 2 mm.
 Moreover, VEP is particularly indicated when extending the prosthetically usable
area is necessary to obtain more excellent retention and stability and to hide the
crown margin below the gingival level.
 Additionally, it helps approach old preparation or restoration margins and small
carious lesions below the gingival margin.
 Finally, it is indicated when the clinician needs to bypass morphologic or
structural alteration in the gingival margin area, or when preparing a tooth with a
long clinical crown in which a horizontal preparation technique would result in a
more significant loss of dental tissue.
 Advantages and disadvantages of different preparation techniques

1 Horizontal preparation

A- Advantages (Labno and Drobnik, 2020)

 No over-contouring, avoidance of overhangs.
 Low risk of porcelain chipping due to limited stress within the cervical area.
 Preservation of biological width.
 Preparation depth provides space for colour changes within cervical area.
 Good cooperation with laboratory leads to clear definition of the margins of
preparation and precise determination of its position and tightness.
 Easy elimination of cement excess.
 No damage to the epithelial attachment and predictable tissue healing.

B- Disadvantages (Ichim et al., 2006)

 High risk of post-operative complications, e.g. hypersensetivity, inflammation,
pulp necrosis, endodontic treatment in the future.
 Loss of hard tooth tissue by 50-60%.
 Exposure of dentine which facilitates penetration of bacteria in the case of
bacterial micro-leakage.
 Lack of marginal seal due to imperfections of technology and workmanship
(marginal gap).
 Lack of ferrule ( tooth structure removal and stress concentration ).
 More complicated procedure in relation to vertical preparation.

2 Vertical preparation – shoulderless

A- Advantages (Smith, 1957)

 Small loss of tooth hard tissue.
 Good marginal seal and integrity.
 Preparation mostly within enamel and little within dentine.
 Reduced number of post-operative complications, e.g. pain, hypersensitivity, pulp
inflammation, need for endodontic treatment.
 Thin layer of ceramics within the cervical area may result in a change in the colour
of its crown.
 Ferrule preservation.
 Good retention.
 Easy tooth preparation.
B- Disadvantages (Paniz et al., 2017)
 Unaesthetic ( thin, opaque porcelain layer in cerviacal area ).
 Present overhangs, uneven edges.
 Causing damage to the epithelial attachment and unpredictable tissue healing.
 Waiting time for tissue healing at the stage of temporary restorations – 6 weeks.
 Porcelain chipping due to stress within the cervical area.
 No control on marginal seal and integrity.
 Biological width disruption.
 Not possible to assess the final fit of a crown.
 Difficult cooperation with laboratory, especially in terms of providing information
on the proper range of prosthetic restoration.
 Difficulties in removing cement excess.

3 Vertical preparation – edgeless

A- Advantages (Agustín-Panadero et al., 2016)

 Small loss of tooth hard tissue.
 Preparation mostly within enamel and little within dentine, which provides
protection for remaining part of the tooth, consequently reducing pain thanks to
the possibility of conducting preparation without anaesthesia.
 Reduction of post-operative complications, e.g. pain, hypersensitivity, pulp
inflammation and necrosis.
 Low risk of creating a marginal gap.
 No damage to the epithelial attachment; predictable tissue healing.
 Ferrule preservation.
 High friction due to low wall convergence.

B- Disadvantages(Agustín-Panadero et al., 2016)

 Demanding work due to the applied instrumentation; operational microscope ,
intraoral scanner , dental model printer.
 High level of difficulty of clinical operations.
 Quite narrow range of application at the moment; zirconium-oxide based
restorations.
 Difficulties in removing cement excess.
 No control of marginal seal and integrity.
 Not possible to assess the final fit of a crown.
 Waiting time for tissue healing at the stage of temporary restorations – 2 weeks.
 Small number of prospective clinical research studies assessing the efficacy of this
method.
 Technique

1. Periodontal mapping:
 The first step is to map the periodontium of the tooth with a periodontal probe.
 Hence, the evaluation is repeated with a steady Komet 862 bur.
 The tip of the steady bur tilted 30◦ leans on the root surface.
 Moving it in the sulcus allows the periodontal site mapping as if it were a probe,
obtaining the necessary anatomical information.

2. Initial reduction:
 Subsequently, the occlusal part of the tooth is reduced to create adequate
prosthetic space.
 The amount of occlusal reduction is defined by the necessary thickness of the
material used for the crown and the distance between the to-be abutment and
the opposing tooth.
 Usually, and specifically, when the tooth is close to other dental structures not
included in the prosthetic rehabilitation, the preparation phase is preceded by an
interproximal separation phase which prevents sound structures from being
damaged by the burs during subsequent steps.

3. Primary progressive reduction:

 This procedure is performed by using the bur with an
inclination of 30◦ so that only the final part of the bur is
in contact with the tooth structure.
 The bur is kept more coronal than the previously
measured depth of the gingival sulcus of that site.
 In this way, the tissue of the root surface and a small
component of the internal part of the gingival sulcus is
removed.
 This reduction will result in a small step at the level
corresponding to the tip of the bur.
 At this point, the preparation is “bur-shaped” as with
most of the complete crown techniques.

4. Secondary progressive reduction:

 The previously performed reduction of tooth structure and the push of the bur on
the gingival margin, together with the unavoidable gingitage, will result in an
augmented space between the tooth structures and the gingival margin.
 This allows the clinician to obtain better vision and access to the deepest parts of
the sulcus and, therefore, to see and remove any calculus, steps, grooves, or
undercuts from the root surfaces.
 Using a “toe-heel” technique, the apical part of the root
surface is structured, creating the edgeless profile of this
preparation.
 Then, the coronal portion of the abutment is reduced by
using a bur with reverse angulation.
 In this phase, it is also necessary to connect the different
reduction planes created during the various stages .

5. Finishing:
 At the end of these steps, which are performed with
coarse-grain burs, the abutment preparation is finished with fine-grain burs.

6. Temporary crown relining and delivery:

 Next, the insertion and the housing of the temporary crown are checked and then
relined.
 It is essential not to move the crown during the relining stage so that the margin
will not open, guaranteeing an adequate closure .
 After that, refining is necessary, keeping the margin as thin as possible.
 After polishing, the temporary crown is cemented with eugenol-free temporary
cement.
 With the VEP technique, as with the intraoperative preparation technique, the
apical part of the abutment reached by the bur does not correspond with the
prosthetic margins, both for the provisional crown and the ceramic one.
 The cervical margin of the temporary crown is placed coronally to the
corresponding gingival margin to allow undisturbed healing of the soft tissues
surrounding the abutment.
 The abutment now presents a “prosthetically usable surface” which is edgeless in
all its extensions rather than a defined preparation margin.
 VEP is a vertical prosthetic preparation technique because due to the fact that as
the drill penetrates apically inside the sulcus or pocket, its removal of tissue from
the root wall will tend to decrease until it is zero.
 It will therefore result in the formation of a transi-tion angle between the
prepared part of the root and the unprepared part. This angle will not be exposed
as it will be submerged by sulcular epithelium adhering to the root wall after the
healing phase. Therefore, it will be irrelevant from a clinical-practical point of
view.
 At the end of soft tissue maturation, choosing the ideal position of the final
prosthetic margins will also be possible.

 Temporary Crown Management

 The absence of undercuts in all the abutment “prosthetically usable” area and of
a beyond-preparation zone, which is usually positioned in an undercut, allows the
clinician to avoid an “on-off” movement during the temporary crown relining,
avoiding the opening of the margins and the consequent need to reperform the
relining procedure.
 Additionally, the absence of a preparation margin lets the clinician prevent lining
the temporary crown external wall to beyond the preparation surface; this
procedure is necessary to obtain a correct emergence profile when using
techniques with a defined preparation margin.
 As previously described, with the VEP technique, temporary crown margins
should be positioned extra-gingivally so that they do not interfere with the
healing procedures of the soft tissues injured with the bur during the preparation
phases.
 However, other aspects must be considered; if the esthetic area is involved, the
probing depth of the tooth is low, and it does not need periodontal surgery, it is
possible to place the temporary crown margin under the gingival level, since this
would improve the esthetic outcome of the provisional restoration and there are
no predictable factors which can cause movements of the gingival level.
 Impression Phase
 Final impressions require great precision to correctly reproduce the details of the
abutment, adjacent teeth, and soft tissues so that the final crown can fulfill all of
its esthetic, functional, and biological requirements.
 From this perspective, standard
impression techniques are very
effective and reliable for VEP-
prepared abutments.
 The clinician should simply consider
that, being an “edgeless” abutment,
there are no margins nor a beyond
preparation zone, which are
essential elements in different, not
edgeless, preparations, but that
sometimes are difficult to read correctly, both with analog and digital impression
systems.
 With VEP, the prosthetically usable (and readable) area defines the apical
extension of the preparation, making the impression phase easier to manage.

 Crown Margins
 With techniques that involve a defined preparation margin, the position of this
margin establishes the position of the crown margin, be it a shoulder, a chamfer,
a knife edge, or other edges created by the bur during the preparation phases.
 If these preparation techniques are used, the technician should also be able to
see the beyond-preparation (beyond-edge) zone so that the profile of the crown
is coherent and aligned with the unprepared part of the tooth, avoiding
undercontours and overcontours.
 With VEP, instead, during lab procedures it is fundamental to point out on the
model the position of the margin itself.
 Once the position of the margin and the final form of the crown have been
defined, the part of the model representing the surrounding soft tissues is
removed until the most apical part of the abutment is displayed.
 Then, a groove is created under the displayed apical area (ditching procedure).
 VEP does not require the integration of the crown on the prepared abutment;
consequently, it will always lead to a positive misalignment (controlled
overcontouring) of the crown.
 The thickness and the height of the prosthetic margin are therefore defined by
the soft tissues’ characteristics and not by the position of an edge.
 Once again, VEP proves to be a periodontally driven tooth preparation technique.
 The apical part of the prosthetic margin, whose section presents a triangular form,
must be as thin as possible so that it does not create overcontours.
 The presence of overcontours leads to more plaque retention and potentially to
periodontal diseases.
 Horizontal preparation techniques allow the creation of a thicker and, therefore,
more resistant margin.
 With vertical preparations, attention to detail and respecting indications are
critical factors in determining a long-term successful therapy.
 In particular, attention to occlusal contacts and dynamic schemes is of the utmost
importance, since an occlusal overload could lead to a severe restoration failure.
 However, complete ceramic materials such as zirconia and lithium disilicate
proved to be a safe and reliable choice for complete crowns on vertical
preparations and showed excellent performance in the long term and a failure
rate comparable to those on horizontal preparations, even when monolithic
lithium disilicate was used in the posterior region.
 The possibility of deciding the position of the prosthetic margin after soft tissue
healing and maturation guarantees an excellent esthetic since the crown margin
is always placed in the sulcus.
 Typically, subgingival clinical precision checks are difficult to perform, and the
correctness of margin adaptation on the preparation finishing line is not always
evident.
 With VEP, thanks to the presence of a prosthetically usable area, the margin
closure on the abutment is far more predictable; as with all the vertical
preparation techniques, VEP guarantees a better marginal closure of the
prosthetic crown, particularly after cementation.
 Furthermore, the creation of an undercontour is virtually impossible.
 It is well known from the classic literature that the correct seating of prosthetic
restoration on their abutment is more predictable on vertical preparations than
on horizontal preparations, or at least comparable and in the range of clinical
efficacy . On the other hand, more recent studies suggest that horizontal
preparation could lead to a more precise marginal fit.
 When using metal–ceramic restorations, more factors must be considered: to
maintain the crown margin thickness below certain limits, the apical part of the
margin is made of metal alone, starting with the esthetic part as soon as the
thickness allows the presence of metal, opaque, and ceramic.
 The metal margin can therefore create esthetic concerns, especially in cases of
gingival recession.
 Modern complete ceramic materials prevent these issues, guaranteeing an
excellent esthetic even if a gingival recession occurs in the future.
 Soft Tissues Management
 The preparation of a subgingival area and the light gingitage caused by the bur
help remove bacteria from
contaminated hard and
soft tissues and can
therefore lead to a
healthier periodontium.
 As previously described,
temporary crown margins
are placed extra-gingivally
so that they can not
interfere with the healing process following the gingitage.
 This procedure allows the subsequent impression phase to be more predictable,
avoiding the risk of inflammation and consequent tissue bleeding because of the
resin crown margin in the sulcus.

 The marginal accuracy of zirconia crowns with two margin designs

( feather edge and deep chamfer )

 It was reported that a good marginal fit seems to be one of the most important
technical factors for the long-term success of any restoration. Because a big
marginal opening allows plaque accumulation, gingival sulcular fluid flow, and
bone loss, resulting in microleakage, recurrent caries, periodontal disease and a
decrease in the longevity of the prosthetics restorations (Sakrana, 2013).
 Zirconia reinforced lithium silicate (Vita Suprinity) was selected in the study as it
combines the advantages of glass ceramics as esthetics and bonding protocol
with a relatively high ceramic strength from zirconia particles addition (8-12%).
 A feather edge marginal design was chosen as a test group because it was
proposed that such vertical margins would offer the procedural advantages of
easier impression making, even for multiple abutments, and enhanced marginal
adaptation after cementation (Schmitz et al., 2017). Furthermore a smaller gap
will cause less extrusion of cement that would be in direct contact with highly
sensitive gingival sulcus environment as proposed by (Scutellà et al., 2017).
 A deep chamfer finish line design 0.7mm was selected as a control group as
suggested that chamfer finish line design aid in increased fracture resistance of
ceramic restoration than shoulder one as the deep chamfer finish line produces
an angled enamel cut that increases the enamel's susceptibility to etching and
bonding, so we have a good bond between the restoration and the teeth which
 improves the resistance to fracture compared to the shoulder finish line (Jalalian
and Aletaha, 2011).
 Since the deep chamfer marginal design provides more round angle between the
axial and gingival seat which will enable a more precise crown seat than with
shoulder finish line (90°).
 Shoulder marginal design results in incomplete crown seat and raises the vertical
marginal gap. Also it may be due to the accuracy of digital scanner detection that
is being affected by differences in depth of the preparation which could be easily
detected in deep chamfer marginal design as suggested by (Al-Zubaidi and Al-
Shamma, 2015).
 With regard to the effect of margin design, it was found that deep chamfer
margin design recorded statistically non-significant higher marginal gap mean
value (27.20 ± 3.52 μm) than feather edge design (26.21 ± 1.49 μm).This could be
attributed to the fact that the more the margin of the restoration ends with an
acute angle, the shorter the distance between the tooth and the margin of the
restoration (Comlekoglu et al., 2009).

 The following conclusions were obtained from the recent study (El Eneen et al.,
2019).
1. Monolithic zirconia reinforced lithium silicate (Vita Suprinity) ceramic crowns
fabricated with feather edge margin design yielded comparable marginal
accuracy as that obtained with deep chamfer margin design.
2. Feather edge margin design could be a promising conservative alternative to
deep chamfer margin design with regard to marginal accuracy, when it is used for
construction of zirconia reinforced lithium silicate (Vita Suprinity) ceramic crowns.
3. Cementation affects the marginal accuracy negatively with both tested margin
designs ( feather edge and deep chamfer ).
4. Marginal accuracy values for both marginal designs ( feather edge and deep
chamfer ) are within the clinically accepted values.
 Technique description of Minimally invasive vertical preparation
design for ceramic veneers
 The clinical approach to preparation is founded on the selective reduction of
tooth substance guided by a mock-up that mimics the golden reference: the wax-
up itself. Regarding of thickness control, the preparations were performed
according to the aesthetic pre-evaluative temporary (APT) protocol (Gurel et al.,
2012).
 With this technique, after a three-dimensional (3D) smile design analysis, the
clinician gives all the information and clinical records to the technician to execute
the diagnostic wax-up. A digital analysis of the clinical picture is performed to
evaluate the esthetic changes. Preoperative impressions are taken, and a wax-up
is performed. One of the key points in developing a proper wax up is the
evaluation of the emergence profile. The use of this technique is particularly
indicated in cases of a semi-additive approach in the gingival third. The clinical
evaluation and the cast analysis could give the proper information about the
possible modification of the emergence profile. The gingival third is modified to
obtain a contour that could mimic the morphology of the gingival tissues and the
natural light over the contoured crown of the natural tooth (Kay, 1985).
 This approach has several advantages:
1. Improves the emergence profile of the restoration, allowing a more natural appearance.
2. Saves tooth structure, especially enamel in the cervical third.
3. Reduces patient discomfort (if the final volume of the restoration allows a semi-additive
approach, local anesthesia is unnecessary in most cases).
 The wax-up is then transferred to the mouth using a silicone index , which is
tested esthetically and functionally. This wax-up represents the enhanced natural
dentition, is the cornerstone of the entire approach, and will provide critical
guidelines such as the position and length of the maxillary incisors. In most cases,
the additive wax-up allows for the maintenance of the preparation entirely, or at
least in the majority of cases within enamel limiting the need for immediate
dentin sealing (IDS) (Magne and Douglas, 1999).
 Moreover, besides restoring esthetics, the restorative treatment improves the
function of the anterior guidance, which is tried immediately after the application
of the mock-up. The mock-up should be tested for 1 to 2 weeks to ascertain the
length and shape of the future restoration and ensure that there are no
interferences with function, phonetics, and overall patient comfort.
 Once approved by the restorative team and the patient, the APT restoration is
used as a precise guideline to prepare the tooth structure, based on the planned
final tooth contours. The tooth structure will undergo only the most necessary
and minimal preparation, or even no preparation in certain areas, using depth
cutter burs through the APT restoration, according to the pre-established final
contour (Imburgia et al., 2019).
 Laboratory procedure
 The definitive cast was molded and the definitive wax-up performed following
the initial project and the clinician’s indications.
 The key point in the laboratory procedure is starting the wax-up of the gingival
third before ditching the cast, so as to have the gingival tissues as point of
reference (SchwartzArad, 2019).
 The difference between horizontal and vertical preparations is that in the former,
the margin is positioned by the clinician and leaves a well-defined line on the
tooth, which is then replicated in the impression and the working model (Loi and
Di Felice, 2013).
 In vertical preparations, the margin is positioned by the technician, based on the
gingival tissue information. In most cases, the position of the finishing line is
performed by the technician, taking as point of reference the cervical margin
detected by the impression(Ferrari Cagidiaco et al., 2021).
 The emergence profile is developed following the profile of the gingival tissue.
 The final wax-up is pressed and sintered , and finishing and mechanical polishing
were performed, always considering the maintenance of the planned emergence
profile .
 The finished veneers were tried on the tooth preparation, and the translucency is
checked through the try-in paste of the luting agent (Patroni, 2020).
 Careful attention is paid to the cervical appearance and shade transition, The
thickness of the veneers, once verified by an Iwanson gauge, is equal to the
volume of the planned prosthetic restoration .
 The emergence profile of the veneers must be checked carefully before starting
with the luting procedure.
 Following an adhesive protocol and the conditioning of the intaglio surfaces of
the veneers, the restorations are luted (O'Sullivan, 2019).
 The finishing of the margin is performed using a cutting blade, scalers, and a
diamond rubber point specifically for intraoral adjustment of high-strength
ceramics. The same adjustment is carried out for the occlusal surface (Edelhoff et
al., 2018).
 The clinical control of the emergence profile in different steps is the key point of
this technique.
 The ideal situation is a semi-additive scenario in which the controlled preparation
and the vertical finishing line allow for the preservation of the enamel in the
cervical third, as well as an improvement of the relationship between the
emergence profile and surrounding tissues, avoiding bulky veneer restorations
(Imburgia et al., 2016).
 Conclusions
 Current research has confirmed that there is no single universal and
recommended method in all cases type of tooth preparation for a prosthetic
crown. The choice of a finish line depends on a number of factors, such as pulp
vitality, location of the tooth, its inclination, type of material from which a
restoration will be manufactured, crown convexity, patient’s age, and size of such
a construction (Labno and Drobnik, 2020).
 At the same time, it should be emphasized that in some clinical situations, such as
abutment discoloration or insufficient amount of tooth structures visible after an
old crown removal, the decision on the type of preparation and/or reconstruction
to be made is taken intra-procedurally (Meyenberg, 2013).
 In spite of the intensive development of technology, both with reference to
clinical tooth preparations for permanent restorations and to laboratory
technologies, the range of indications for the application of vertical preparation is
minor, and at present is limited to restorations made only of full-contour
zirconium oxide.
 Due to the small number of clinical studies undertaken to assess the efficacy of
this method of preparation, it is necessary to conduct further research studies
and observations (Powers and Wataha, 2014).

 Referances

 Noè, G.; Toffoli, A.; Foce, E.; Di Febo, G.; Carnevale, G.; Bonfiglioli, R.; Macaluso,
G.M.; Manfredi, E. Vertical Edgeless Preparation: Periodontal Dominance in
Prosthetic Crown Preparation. Prosthesis 2023
 Foce, E.; Noè, G.; di Febo, G.; Bonfiglioli, R.; Carnevale, G. VEP—Vertical Edgeless
Preparation—La dominanza parodontale nella preparazione protesica;
Quintessenza: Milano, Italy, 2022
 Agustín-Panadero, R., Solá-Ruíz, M.F., Chust, C. and Ferreiroa, A., 2016. Fixed
dental prostheses with vertical tooth preparations without finish lines: A report of
two patients. The Journal of prosthetic dentistry
 Al-Zubaidi, Z.A.K. and Al-Shamma, A.M.W., 2015. The effect of different finishing
lines on the marginal fitness of full contour zirconia and glass ceramic CAD/CAM
crowns (an in-vitro study). Journal of Dental Materials and Techniques
 Asavapanumas, C. and Leevailoj, C., 2013. The influence of finish line curvature on
the marginal gap width of ceramic copings. The Journal of prosthetic dentistry
 Recent Biomechanical Principles Of Tooth Preparation

⚫ Contents

⚫ Introduction

⚫ Planning Indirect Restorations in vital teeth, non-vital teeth and worn dentitions.

⚫ What does the evidence say on direct vs. indirect restorations for vital teeth?

⚫ Full vs. Partial coverage restorations long term outcome data in general dental
practice .

⚫ Minimally Invasive Restoration of Vital Teeth – why shift towards partial coverage
indirect restorations

⚫ for vital teeth?

⚫ Minimally Invasive Restoration of the Endodontically treated teeth .

⚫ Minimally Invasive Restoration of Erosive Tooth Wear .

⚫ References .

⚫ Introduction
Increasingly, a worldwide consensus exists towards minimally invasive
approaches for managing dental caries ; which for non-cavitated carious lesions
often involves non-invasive or micro-invasive management.

⚫ In contrast, no such consensus yet exists for the prescription, design and
preparation of indirect restorations.

⚫ The majority of the half-a-billion dental restorations placed worldwide every

year are direct composite-resin restorations (which are more conservative than
amalgam restorations), whereas, in contrast, the majority of indirect restorations
placed are still full coverage crowns, which are less conservative than biomimetic
partial coverage indirect restorations.
 This suggests that biomechanical preparations which allow for a more
conservative biomimetic approach to planning restorations are still not popular
when it comes to indirect restorations.

⚫ Indeed, in the United States 95% of indirect restorations are still full coverage
crowns rather than partial coverage
indirect restorations.

⚫ Moreover, surveys of UK General Dental Practice reveal that the most

commonly used methods for planning and designing tooth preparation are the
dimensions of the preparation burs and the form of the opposing/adjacent teeth,
as opposed to minimally invasive
partial coverage designs.

⚫ This is a missed opportunity, given the technological advances for planning

restorative treatments, including the ability for digital planning of minimally
invasive endodontic access cavities and digital diagnostic wax ups having
potential to be more precise than conventional wax ups.
benefits of adopting a minimally invasive approach to indirect restorations.

⚫ Planning Indirect Restorations in vital teeth, non-vital teeth and worn dentitions.
What does the evidence say on direct vs. indirect restorations for vital teeth?
The most important consideration regarding minimally invasive indirect dentistry
is to consider whether to provide a direct restoration as opposed to an indirect
restoration.

⚫ restorations sacrifices more healthy tooth tissue than direct restorations and
moreover full coverage crown restorations require more tooth tissue removal
than partial coverage restorations.
Online evidence-based syntheses algorithms are emerging to help resolve this
dilemma.
⚫ To date more than 10 systemic reviews with meta-analyses, provide data from
prospective clinical outcome studies looking into indirect restorations which are

⚫ Crown-or-fill app summarizes the evidence regarding indirect or direct restoration

of teeth, depending on specific preexisting factors (i.e. location of tooth in
dentition, pulpal status, amount of coronal tooth tissue remaining and quality of
pre-existing root canal treatment).

⚫ The algorithm includes the fixed prosthodontic replacement options in terms of

bridges and implant supported restorations, which is particularly helpful for
discussions of all possible options with patients.

⚫ Once the clinical features are entered, prospective outcome data is presented (5-
year % failure rate) for each restorative option, in terms of either direct (amalgam
/ composite resin) or indirect (crown)
restoration (with or without a post for non-vital teeth), as well as the fixed
prosthodontic replacement options (implant crown /bridge).

⚫ There is no doubt that this type of evidence synthesis will increasingly

guide the decision-making process, when considering whether to directly restore,
crown, root fill or extract and replace.

⚫ This will help consent and communication with patients and potentially save
clinicians time and money whilst improving patient outcomes.

The main key benefits for dentists using the algorithm are listed in

Benefits to dentists for using the Crown-of-Fill Evidence Based Algorithm

 Decision making
Options appraisal Strengths Limitations
Topic
Especially helpful
given
number of dentine
walls
available and Doesn’t
location of explicitly
tooth in dental mention the
Crown vs. direct
arch. ferrule
restoration?
Can be combined effect
Direct or indirect If direct
with Doesn’t take
restoration? restoration;
measurements into
amalgam vs.
taken consideration
composite?
from a of
restorability periodontal
assessment or health
intra-oral
scan of tooth with
restorations
removed
Core with or Doesn’t
Core plus post? Very useful to help
without a consider

indirect vs/ direct

justify added time and
posts or other
post? expense of post
factors (e..g cement,
placement
which root etc.)
Doesn’t’ factor in
costs and cost
effectiveness, would
Whether to endo treat or Ensures that patients
be good to be able to
extract? are aware of annual
input financial
Whether to replace with failure rates especially
aspects of care.
a bridge or dental when a tooth is heavily
Doesn’t factor in risk
Implant? broken down and
factors for
development of peri
implantitis.
⚫ Extraction and replacement vs restoration requires endo plus crown.
Helps consider
⚫ Whether an implant/bridge
maybe more cost effective than An endo/crown
However, one of the key drawbacks of this application for general dental practice
is that although this provides highly standardized data, there are many modifying
dentist and patient factors have a major influence on restoration survival.
⚫ In addition, the above evidence doesn’t discriminate between choice of material
or restoration design (partial or full coverage).
Factors such as practice setting, patient cohort, renumeration arrangements and
clinicians’ experience, also make generalisation about indirect restoration
outcomes very difficult and therefore we must consider practice-based data
which is more applicable to the general dental practitioner.

⚫ Full vs. Partial coverage restorations

Many readers of this series on minimally invasive (MI) dentistry may already have
a preference towards more MI adhesive strategies for teeth that were previously
deemed as requiring full coverage crowns.
However, full coverage crowns remain a popular choice amongst dentists, with
long term practice-based outcome data supporting their use.
Outcome data from single operators, caring for highly motivated cohorts of
patients, have 5 decades of follow-up data of indirect restorations following
traditional principles.
⚫ These data reveal that, in patients with regular recall intervals, including strict
control of oral hygiene and meticulous occlusal management, the mean survival
of metal-ceramic crowns can be up to 47.53 years in a general practice
cohort and 25-year survival of 85.40% for a cohort of tooth wear cases in a
specialist prosthodontic practice.
⚫ Whilst not generalizable to all UK General Dental Practices, it does reinforce that
experienced operators and case selection play an important role in survival of
restorations.
⚫ Minimally Invasive Restoration of Vital Teeth – why shift towards partial
coverage indirect restorations for vital teeth?
⚫ In the last few decades, 3 major drivers are changing clinician’s attitudes towards
design of indirect
restorations, away from full coverage conventional mechanical preparations and
towards provision of indirect tooth colored restorations for vital teeth.
Firstly, indirect restorative dentistry is benefitting from the adhesive bonding
protocols pioneered in direct adhesive dentistry, whilst also benefitting from
more aesthetic translucent etchable/sandblasted/silanated indirect materials.
⚫ This is allowing a profound shift away from mechanical preparation designs
towards adhesive approaches focusing on preservation of enamel and dentine.
The second major shift is adoption of biomimetic additive approaches, which
refers to the use of digital or analogue wax-ups.
⚫ The use of digital wax ups have evolved from simple additive approaches based
on digital smile design and intra-oral try-in to more extensive full-arch restorative
cases as shown in , where digital superimposition of a subtractive wax up is used
to guide tooth structure removal.
⚫ This allows for a more precise plan of different preparations for each specific
surface of each individual tooth based on the final proposed contour rather than
a standardized tooth removal for all teeth.
Finally, the third profound transformation driving partial coverage indirect
restorations is the use of
digital dentistry and both additive and subtractive in-surgery computer aided
manufacturing.
However, whilst these technological advances have brought benefits, the
introduction of novel hybrid
ceramic-polymer materials also has brought some challenges.
⚫ Early practice-based data shows clinically concerning outcomes in certain
situations, namely premature de-bonding or terminal fracture of the material
when used as a full coverage crown in load bearing situations.
⚫ Indeed some practice-based data is finding almost a third of novel ceramic-
polymer hybrid restorations experienced debonding after 1 year and a quarter
novel non-crystallized lithium disilicate restorations experienced terminal
fracture after 1 year, indeed the same data showed almost 60% of Zirconia
crowns causing greater than expected wear of the opposing dentition after 1 year.
⚫ This clinically concerning data led to some manufactures withdrawing indications
for their novel ceramic-polymer hybrid materials as a full coverage crown.
⚫ The poor performance of these materials as full coverage restorations is thought
to be due to the hoop stress concentration at the occlusal/axial transition when
used as a conventional full coverage crown, as highlighted by Finite Element
Analysis which resulted in the fracture at the transition from occlusal to axial.
⚫ Therefore, these practice-based data of novel indirect materials show clinically
concerning results –So, where does this leave us?
⚫ Should we be changing our preparation design away from full coverage
restorations and towards partial coverage tooth-coloured materials and if so how
to maximize the success of these restorations?
Preservation of tooth structure has always been the first key principle of all
indirect restorations and there have been several recent major changes which are
increasing the predictability of minimally invasive indirect restorations.
⚫ When the survival of partial coverage ceramic restorations is considered, the
largest practice based research data is the Ceramic Survival Analysis (CSA) project
(mostly Germany and US).
⚫ Analysis of 5791 ceramic inlay or onlays in 5523 patients shows that inlays and
onlays constructed from many glass ceramic materials (mostly lithium disilicate)
have good outcomes for a large number of dentists (167) working in different
settings over two decades .
⚫ The CSA reported annual failure rates (AFR) of 1.6 % at 10 years regardless of
type of glass ceramic and or whether CAD/CAM or pressed techniques.
⚫ However, perhaps predictably, restorations with a deep marginal extension into
dentine showed an increased failure rate of 78 % compared to restorations in
enamel.
Unsurprisingly, use of glass-ionomer cement as a core material and use of
simplified adhesive protocols (single or dual step dentine bonding agents) also
presented a 142 % increased risk of failure as opposed to gold standard 3-step
etch/prime/bond protocols.
Therefore any clinician considering a change to their clinical practice, such as
adopting a novel CAD/CAM material with a minimally invasive approach, is
encouraged to enroll onto the open-source CSA (www.csa-online.net) and enter
as a minimum, data on their first 50 consecutive cases using the new material,
with full details of their entire protocol.
⚫ On subsequent review of every case, clinicians determine as soon as possible they
are experiencing any issues with their cases, which may require modification of
case selection, preparation design or bonding protocol for example.
⚫ Minimally Invasive Restoration of the Endodontically treated teeth
Root canal treatment is needed when pulpal health is irreversibly damaged by
caries, cracks, restorations and trauma.
⚫ Timely restoration back to form, function and aesthetics is as important as the
quality of the root canal treatment, in order to protect endodontically treated
teeth from future fracture or loss of coronal seal and re-infection (ETT).
⚫ Many clinical studies are now available to support cuspal coverage of ETT in order
to improve outcomes for ETT.
Even prior to the restoration, a key aim during endodontic treatment is the
preservation of tooth structure with multiple prospective clinical studies
correlating increased tooth structure with improved outcomes .
⚫ Provision of cuspal coverage for ETT has specific benefits for premolars and
molars, with a non-functional cusp sparing approach advocated to preserve tooth
tissue, as opposed to full coverage crowns.
⚫ However, this approach, whilst showing promise in finite element analyses , has
not been widely adopted.
⚫ It is also perhaps surprising that more clinical research has not been carried out
towards direct cuspal coverage restoration of ETT, even when extensively broken
down.
In terms of which cusps to cover a key parameter to consider is the thickness of
the remaining dentine walls.
⚫ Krifka et al (2009) investigated the influence of remaining cusp wall thickness on
the marginal integrity and enamel crack formation and concluded that if non
fuctional cusps are to be left uncovered they should be of at least 2 mm
thickness .
⚫ This measurement maybe carried out simply using Iwanson calipers or
alternatively by scanning the remaining tooth structure once all the old
restorations and caries has been removed and using cross sectional measurement
tools provided within chairside CAD/CAM software.

⚫ Restoration of Erosive Tooth Wear

Clearly, when managing a disease process which involves gradual loss of hard
tooth tissue, a minimally invasive approach aimed at preservation of tooth tissue
is required. In the first instance, a thorough diagnostic phase is required to
ascertain whether indeed a non-operative strategy can be employed, in
order to avoid restorations.
⚫ Once it has been decided to provide restorations, initial prescription of direct
adhesive restorations, in addition with other minimally invasive methods such as
tooth whitening is the recommended course of action, especially for mild erosive
tooth wear cases where most of the enamel has been retained.
⚫ However, the long-term outcome of minimally invasive direct restorations for
patients with moderate to severe tooth wear with extensive dentine exposure
 coupled with reduced surface area for bonding and parafunctional habits is
uncertain and reported annual failure rates vary widely, from 0.4-26.3% for
direct resin composite, 0-14.9% for indirect resin composite and 2.7% for indirect
ceramic restorations.
This leads to the conclusion that choice of a direct or indirect approach is largely
operator and patient dependent, therefore it seems sensible to try to avoid
indirect restorations until direct restorations have been tried.
⚫ Recent prospective clinical trials of direct restorations for tooth wear have found
that a key factor influencing success of anterior composite restorations for tooth
wear cases is ensuring that the anterior restorations are provided at a single visit,
thus maximizing control of both the adhesive bonding to a fresh substrate and
also provision of an appropriate occlusal scheme.
For cases whose tooth wear is primarily of an erosive component who presented
with amelogenesis imperfecta, hypodontia and erosive tooth wear primarily
related to acid erosion, partial coverage ceramic or resin restorations are likely to
have a good prognosis and be the first choice of restorative treatment.
⚫ However for cases with parafunctional bruxism, whose tooth
wear is so severe that all the enamel has been lost for adhesive bonding, full
coverage conventional crowns provided with traditional retention and resistance
form are the more appropriate treatment choice.
Would the site require post-extraction bone regeneration for
Where is the tooth that needs treatment?