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Table of contents
pages v-ix
PDF (33 KB)
Forthcoming issues
page x
PDF (21 KB)
Preface
Fixed prosthodontics
Agar JR, Taylor TD
pages xi-xii
Full Text | PDF (142 KB)
Review article
Advances in color matching
Brewer JD, Wee A, Seghi R
pages 341-358
Full Text | PDF (462 KB)
Review article
Designing tooth preparations for optimal success
Goodacre CJ
pages 359-385
Full Text | PDF (1072 KB)
Review article
Resistance form in tooth preparation
Parker M H
pages 387-396
Full Text | PDF (214 KB)
Review article
Restoration of endodontically treated teeth
Morgano SM, Rodrigues AHC, Sabrosa CE
pages 397-416
Full Text | PDF (571 KB)
Review article
Cervical margin design with contemporary esthetic restorations
Donovan TE, Chee WWL
pages 417-431
Full Text | PDF (486 KB)
Review article
Current concepts in gingival displacement
Donovan TE, Chee WWL
pages 433-444
Full Text | PDF (347 KB)
Review article
A review of contemporary impression materials and techniques
Donovan TE, Chee WWL
pages 445-470
Full Text | PDF (623 KB)
Review article
Jaw relation records for fixed prosthodontics
Squier RS
pages 471-486
Full Text | PDF (507 KB)
Review article
Interim restorations
Gratton DG, Aquilino SA
pages 487-497
Full Text | PDF (201 KB)
Review article
Casting alloys
Wataha JC, Messer RL
pages 499-512
Full Text | PDF (232 KB)
Review article
Dental ceramics: current thinking and trends
Robert Kelly J
pages 513-530
Full Text | PDF (262 KB)
Review article
Contemporary all-ceramic fixed partial dentures: a review
Raigrodski AJ
pages 531-544
Full Text | PDF (368 KB)
Review article
Fiber-reinforced composite prostheses
Freilich MA, Meiers JC
pages 545-562
Full Text | PDF (873 KB)
Index
pages 563-566
PDF (142 KB)
FIXED PROSTHODONTICS
CONTENTS
Preface xi
John R. Agar and Thomas D. Taylor
vi CONTENTS
article outlines the ideal properties of impression materials and
explains the importance of critical manipulative variables. Avail-
able impression materials are analyzed relative to these variables,
and several "specialized" impression techniques are described. Spe-
cial attention is paid to polyvinyl siloxane impression materials be-
cause they have become the most widely used impression material
in restorative dentistry.
CONTENTS vii
assets in the treatment of missing and severely damaged teeth. Al-
loys have physical, chemical, and biologic properties that exceed
other classes of materials. The selection of the appropriate dental
casting alloy is paramount to the long-term success of dental pros-
theses, and the selection process has become complex with the de-
velopment of many new alloys. However, this selection process is
manageable if the practitioner focuses on the appropriate physical
and biologic properties, such as tensile strength, modulus of elasti-
city, corrosion, and biocompatibility, and avoids dwelling on the
less important properties of alloy color and short-term cost. The
appropriate selection of an alloy helps to ensure a longer-lasting
restoration and better oral health for the patient.
viii CONTENTS
Two somewhat divergent metal-free approaches to fixed tooth
replacement continue to be developed for a variety of clinical ap-
plications. These are all-ceramic and all-polymeric systems. The
polymeric prostheses are the subject of this article.
Index 563
CONTENTS ix
FORTHCOMING ISSUES
July 2004
Removable Prosthodontics
John R. Agar, DDS, MA, and
Thomas D. Taylor, DDS, MSD, Guest Editors
October 2004
Lasers in Practice
Robert A. Convissar, DDS, and
Donald J. Coluzzi, DDS, Guest Editors
January 2005
Soft Tissue Lesions
Thomas P. Sollecito, DMD, Guest Editor
RECENT ISSUES
January 2004
Modern Endodontic Practice
Syngcuk Kim, DDS, MPhil, PhD, MD(hon),
Guest Editor
October 2003
Infections, Infectious Diseases and Dentistry,
Part II
Michael Glick, DMD, Guest Editor
July 2003
Infections, Infectious Diseases and Dentistry,
Part I
Michael Glick, DMD, Guest Editor
Preface
Fixed Prosthodontics
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2004.01.002
xii J.R. Agar, T.D. Taylor / Dent Clin N Am 48 (2004) xixii
area. We hope you will learn and that you enjoy reading the articles in this
symposium as much as we did when we reviewed them.
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2004.01.004
342 J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358
Nature of color
Color is all about light. For color to be seen, light is reected from an
object and stimulates the neural sensors in the eyes retina to send a signal
that is interpreted in the visual cortex of the brain. There are numerous
possibilities along this pathway for altering the nal registration.
Light
Natural white lightdaylightis sunlight reected back from the sky. It
falls between 380 and 770 nm along the electromagnetic spectrum and is
a mixture of component bands containing a continuous contribution from
radiation of each wavelength between these limits. The component bands
produce six dierent sensations (red, orange, yellow, green, blue, violet), but
there are an innite number of gradations, and the boundaries between
component bands are not exact; rather, the colors merge into one another
[20]. Light sources, or illuminants, may be decient in some wavelengths and
therefore be colored themselves.
Object color is dependent on the illuminant in which it is viewed. If
incident light does not contain a particular wavelength segment, the object
cannot reect it. In the achromatic range there are an innite number of
grays that are produced by objects that are nonselective in their
reectance. Colorants, either pigments or dyes, are responsible for
chromatic reection of light. The chemical composition of a colorant makes
it selectively absorb more of one part of the visible spectrum than another.
When a particular wavelength segment of light is reected and enters the
eye, the sensation of color is produced.
Perception
As light enters the eye through the cornea and lens, an image is focused
on the retina. The amount of light entering the eye is controlled by the iris,
which dilates or constricts depending on the level of illumination. Retinal
sensors are positioned to take advantage of this focusing of light. Rods
outnumber cones approximately 19 to 1, are scattered broadly throughout
the retina, and respond to very low light intensity. These sensors are for
registering lightness only. There are three types of cones, sensitive to red,
green, or blue wavelength bands. The distribution of cones is limited
primarily to the fovea centralis, a small area in the center of the retina where
there are no rods. In the area immediately surrounding the fovea, there is
a mixture of both sensors. It is thought that this mixture, unique to each
individual, is responsible for dierences in color discrimination among
observers with normal color vision [20]. The accuracy of color perception
depends on the area of retinal eld stimulated by light. In high illumination,
the pupil narrows, directing light to that small area of the retina where the
cones are located. When light is dim, the pupil widens, and much more of
J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358 343
designed for the specication of color. How a person is involved in the use of
color determines which system is preferred. There are two such systems that
are widely used in dentistry. In the Munsell System, the three-color
attributes are Hue, Chroma, and Value. Hue is the attribute of color
perception by means of which an object is judged to be red, yellow, green,
etc. and is tied to a specic spectral wavelength band. Chroma refers to the
depth or purity of the hue and is commonly referred to as saturation. It can
be thought of as a measure of how dierent the color is from gray [25].
Value is the luminous dimension referred to as lightness of an object
appearance and is completely separate from the chromatic attributes of hue
and saturation.
Although these attributes can be designated numerically and the ranges
for tooth color have been well established, they are more often referred to in
descriptive and relative terms. We refer to Hue nominally (ie, red, green,
blue, etc.). When comparing a target color to a standard (tooth to shade
tab), a shift toward another Hue is described. Natural teeth lie in the yellow-
red area of the color solids, so the shifts are generally toward red or
yellow, or the Hue is described as more yellowish or more reddish. Chroma
is either higher or lower, or more or less, because it is descriptive of
intensity. Value can be higher or lower, or lighter or darker, because it is an
achromatic quality and can be thought of as the amount of light that is
reected to the eye.
When color is measured and specic color dierences are identied, the
CIELAB system is frequently used. It is a nearly uniform color space whose
three coordinates dene lightness, red-green chromaticity, and yellow-blue
chromaticity. This is the most popular means of dening the color of solid
objects and is based on the Commission Internationale de lEclairage (CIE)
1976 L*a*b* uniform color space. In 1931 the CIE dened a standard
observer by a set of three functions x(k)y(k),z(k). These were carefully
prescribed spectral sensitivity curves designed to model the blue-, green-,
and red-sensitive cone receptors of the eye, respectively. These functions are
key to the transformation of spectral energy data into meaningful color
data [26].
the lip retracted and draped naturally. It is helpful to have a second observer
stand about 3 feet behind the primary observer to verify that the value
dimension is appropriate. If the tab stands out, it is most likely too high in
value (ie, too bright).
These procedures can be done at multiple appointments to conrm ones
choice. Provided one has normal color vision, shade selection can be learned
and improved with practice.
Shade guides
Shade guides that are the most widely used today have not changed much
in the last 50 years, except for the addition of a few more tab colors. In the
early 1970s, Sproull [3436] published a series of articles examining color
matching in dentistry and made sound suggestions to the profession and
manufacturers for the direction of research and product development. In the
approximately 25 years that followed, numerous studies identied addi-
tional limitations of available shade guides and porcelain formulations, and
many lecturers and authors called upon dental manufacturers to invest in
reformulation, quality control in porcelain production, and development of
logically ordered shade guides that would allow for proper orientation
within the color space of natural teeth. By identifying the color attributes of
natural tooth and shade guide colors, it was possible to determine that
manufacturers shade guides did not adequately cover the color space
occupied by natural teeth [3739].
Signicant advances in shade guide organization and coverage of natural
tooth color space are coming to the marketplace. An example is the Vitapan
3D-Master Shade System (Vita Zahnfabrik, Bad Sackingen, Germany).
According to the manufacturer, this shade system provides a systematic
arrangement of virtually all existing natural tooth shades, and it has
been determined that the order of color dimensions in this guide is adequate
[40]. Based on spectrophotometric measurements of natural teeth, the shade
guide is organized so that it covers the three-dimensional natural tooth color
space in logical, visually equidistant order. Rather than grouping the shades
by Hue, as in the Vita Classical (Vita Zahnfabrik) and Chromascop (Ivoclar
Vivodent, Amherst, New York) guides, the tabs are arranged in ve clearly
discernible value levels (Figs. 13). Within each level are tabs that represent
different chromas and hues. The ve levels cover that area of the CIELAB
color solid occupied by natural teeth, with approximately 50% of natural
tooth shades occupying the middle value level. The lightest value level has
only two chroma steps of a single hue, and the darkest value level has three
chroma steps of one hue. About 2% of natural teeth occupy these outer
levels. Groups 2, 3, and 4 have three chroma levels of the middle and orange
hue, and two chroma levels in each hue shift toward yellow or red. The
sequence of shade selection is value, then chroma, followed by hue. The way
J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358 347
the shades are formulated allows for one visually perceptible step between
value levels. Unique to this system is the possibility of selecting this in-
between shade; powders can be mixed to achieve it with predictability. There
are no visually perceptible steps between chroma levels of each hue.
Shade-taking devices
These devices have been designed to aid clinicians and technicians in the
specication and control of tooth color. The earliest color-measuring device
designed specically for clinical dental use was a lter colorimeter. The
Chromascan (Sterngold, Stamford, Connecticut) was introduced in the early
1980s but enjoyed limited success due to its inadequate design and accuracy
[41,42]. Further development was hindered primarily by lack of resources
and commitment on industrys sidethe market was too small. Now, with
esthetics as a major focus of dental marketing and with the availability of
improved color-measuring optics, companies are willing to make the
investment required to apply advanced technology to the challenge of shade
control.
Basic design
All color-measuring devices consist of a detector, signal conditioner,
and software that process the signal in a manner that makes the data
usable in the dental operatory or laboratory. Because of the complex rela-
tionship between these elements, accurate colorimetric analysis is dicult
at best.
Colorimeters
Filter colorimeters generally use three or four silicon photodiodes that
have spectral correction lters that closely simulate the standard observer
functions. These lters act as analog function generators that limit the
spectral characteristics of the light that strikes the detector surface. The
inability to exactly match the standard observer functions with lters while
retaining adequate sensitivity for low light levels is the reason that the
absolute accuracy of lter colorimeters is considered inferior to scanning
devices such as spectrophotometers and spectroradiometers. However,
because of their consistent and rapid sensing nature, these devices can be
precise with dierential measurements. This is why they often are used for
quality control.
J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358 349
Table 1
Shade-taking devices
Approximate
System Manufacturer Type cost
ShadeEye Shofu Dental Corp., Colorimeter $7000
San Marcos, CA
EasyShade Vident, Brea, CA Spectrophotometer $5500
ShadeScan Cynovad Inc., Montreal, Digital color $6000
Quebec, Canada imaging/colorimeter
ShadeVision X-Rite Inc., Digital color $6000
Grand Rapids, MI imaging/colorimeter
SpectroShade MHT, Niederhasli, Digital color imaging/ $15,000
Switzerland spectrophotometer
ClearMatch Smart Technology, Software only (to be $3000
Hood River, OR used with digital camera)
a monocoil beroptic cable assembly (Fig. 5). The contact probe tip is
approximately 5 mm in diameter. It contains 19 1-mm-diameter beroptic
bundles. During the measurement process, the tooth is illuminated by the
periphery of the tip, directing the light from a halogen bulb in the base unit
into the tooth surface. There are several spectrometers in the hand piece that
monitor the light source and measure the internally scattered light. A
combination of various lters and photodiode arrays receive the light as it is
directed through the return bers located in the center of the probe tip.
Through this arrangement, spectral reectance of the scattered light is
essentially measured in 25 nm bandwidths. Before measurement, it is
necessary to select a measurement mode (tooth, crown, or shade tab). The
display presents the closest Vita shade in the classical or 3D shade guide
designation.
The rst system to combine digital color imaging with colorimetric
analysis was introduced by Cynovad (Saint-Laurent, Canada). The
ShadeScan is a hand-held device with a color LCD screen to aid in image
location and focus (Fig. 6). Through a beroptic cable, a halogen light
source illuminates the tooth surface at a 45 angle and collects the reected
light at 0 . Light intensity and calibration to gray and color standards are
continuously monitored and adjusted to provide consistent color re-
production. The image is recorded on a ashcard, obviating the need for
a computer in the operatory. The transmitted data can be downloaded to
a computer with the ShadeScan software. Shade and translucency mapping
can therefore be transmitted to the dental laboratory by e-mail or by
including a printout or ashcard with the clinical items required for
restoration fabrication. Surface shade mapping with the standard software
352 J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358
Fig. 6. ShadeScan.
increasing complexity and one for translucency are possible. The software
contains shade guide references for most porcelain systems, and more can be
added. The closest shade and the magnitude of the color difference from
that reference are specied. A digital image of the tooth, the shade mapping,
and the colorimetric data can be transmitted to the laboratory electronically
or by printout.
A dierent approach to digital color matching is achieved with the
ClearMatch System (Smart Technology, Hood River, Oregon). This is
a software system that requires a Window platform PC and a digital camera.
To properly calibrate the digital color signal, a black and white standard
and a shade tab must be included in each photograph. Detailed shade
mapping is provided in shade guide designations, and standard and custom
shade tab information can be entered into the system database. Because this
system is software only, it is the most reasonably priced.
Limitations
There are a number of limitations common to all of these systems, and
for the most part they stem from the nature of what is being measured (ie,
translucent structures). Accuracy of color measurement is aected by the
354 J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358
Fig. 8. Spactroshade.
The accuracy of the target shade obtained from the measurement is only
as good as the database and its distribution of references shades. The
readout provides the shade closest to the measured surface, and if the tooth
to be matched is not close in color space to a designated shade, then
a mismatched restoration results. None of the above instruments are
sophisticated enough to function in a formulation mode (ie, specifying
powders and layering to achieve the actual color designation of any tooth
color or translucency distribution measured).
For this approach to be ecient, the laboratory must have the system as
well, and indeed many commercial laboratories provide a shade-taking
service. The quality control aspect is a real advantage. The technician can
verify that the color replication process was accurate for the shade
requested, and, with the more sophisticated systems, a virtual try-in can
be accomplished. However, the research examining whether or not this
instrumental approach provides a nal result superior to conventional
shade-matching techniques is lacking. Investigations are ongoing, but there
are only a few published studies available [4347].
Shade communication
Tooth appearance information beyond a basic single-shade designation is
required when the restoration is in an esthetically prominent location. Shade
mapping, which can be accomplished visually and instrumentally, is
becoming a basic component of the work authorization. Characterization
can be located on a drawing but may be more helpful if drawn on a cast that
duplicates the size, shape, and contours of the requested restoration.
Appropriate length and incisal edge position is best communicated in this
way. An image of the selected shade tab(s) near the tooth to be restored or
matched should accompany the written order and casts. Although the color
of the image cannot be relied upon for accurate assessment or matching, the
visual appearance of translucency, characterization, and color blending is
far superior to that of a drawing. Digital images can be sent electronically or
on a CD. Discussing with the technician the preferred methods of
documenting and communicating information enhances the shade duplica-
tion process.
Summary
Media emphasis on an esthetic standard is probably responsible for
driving the most recent advances in dental imaging and shade matching.
Although we tend to focus on color matching, it is an appearance match
that we are after, so the optical properties of translucency, light scattering,
surface texture, and gloss and the basic principles of esthetics, including
356 J.D. Brewer et al / Dent Clin N Am 48 (2004) 341358
tooth size and proportion, symmetry, outline form, and overall harmony are
just as important, if not more so, to a successful restorative match. With
more research and development it should be possible to achieve a higher
percentage of successful matches than the approximately 50% experienced
today [4851], but even with the acceleration of progress in color matching
technology, the success of a restorative effort remains dependent on
adequate tooth preparation, tissue management, and treatment planning.
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Dent Clin N Am 48 (2004) 359385
The form of prepared teeth and the amount of tooth structure removed
are important contributors to the mechanical, biologic, and esthetic success
of the overlying crown or xed partial denture. Therefore, it is important to
develop clinical guidelines that can be used to optimize success in xed
prosthodontics.
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.015
360 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385
Fig. 1. The maxillary central incisor has been prepared with minimal convergence of the mesial
and distal surfaces.
clinically, and they therefore identied 16 as the best convergence angle
among those tested. A TOC between 10 and 22 has been recommended in
a recent textbook [11].
When proposing guidelines for TOC, it is important to determine the
angles formed by students and practitioners. Dental students, general
practice residents, general practitioners, and prosthodontists do not usually
produce minimal TOC angles as have historically been recommended.
Instead, the angles range between 12 and 17 (Fig. 2) [1221]. This
Fig. 2. Posterior teeth such as this mandibular molar are usually prepared with greater TOC
than anterior teeth. This tooth has about 15 of TOC.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 361
information and the resistance testing data previously cited lend credence to
the proposal that 10 to 20 is an appropriate clinical goal.
It is important for practitioners and students to measure the convergence
angles they typically produce on various teeth and determine if the proposed
goal is routinely being achieved. Fig. 3 was developed to aid this evaluation
process. Holding a die of the prepared tooth so the axial walls of the die are
superimposed over the lines present on the drawing permits a close
approximation of the TOC.
There are a number of factors that aect the amount of TOC and
therefore make it more dicult to achieve the goal of 10 to 20 . The
preparation of posterior teeth (see Fig. 2) as opposed to anterior teeth (see
Fig. 1) often leads to greater TOC [16,17,21], as does the preparation of
mandibular teeth compared with maxillary teeth [13,17,21]. Mandibular
molars have been identied as the teeth prepared with the greatest TOC
[18,21]. One study reported greater TOC when the facial-lingual surfaces [16]
were prepared, whereas another study identied greater convergence of the
mesial-distal surfaces [21], possibly indicating that variations occur between
practitioners. Fixed partial denture abutments are generally prepared with
greater convergence than teeth prepared for single crowns [19]. The use of
one eye when viewing teeth (monocular vision) produces greater convergence
than the use of both eyes (binocular vision) [19].
Fig. 3. This diagram can be used to measure the TOC of a die by aligning the axial walls of the
die so they become superimposed over the converging lines on the diagram that mostly closely
match the axial convergence of the die.
362 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385
Occlusocervical/incisocervical dimension
It is proposed that anterior teeth and premolars have a minimal
occlusocervical (OC) dimension of 3 mm and that molars have a minimal
dimension of 4 mm. Critical convergence angles have been mathematically
calculated and used to identify angles beyond which a crown would
theoretically not possess adequate resistance to dislodgment [22,23].
Although the validity of such angles has been challenged [8,10], an
assessment of the resistance form of dies from clinically failed restorations
supported a relationship between convergence angles and clinical failure [24].
At 1 and 2 mm of OC dimension, the critical convergence angle
calculations indicate a molar crowns resistance to dislodgment was
inadequate unless the tooth was prepared with less than 6 and 12 of
TOC, respectively. Because it is unlikely that molars can be prepared
routinely at such minimal convergence angles, these dimensions are
inadequate for molars. A molar can possess adequate resistance when the
tooth possesses 3 mm of OC dimension and 17 or less of TOC. However,
achieving 17 also is unlikely to routinely occur on molars, making 3 mm an
inadequate OC dimension for molar tooth preparations. As a result, 4 mm
is proposed as the minimal OC dimension for molars. It is important to
measure prepared teeth with a periodontal probe to determine if the minimal
dimensions have been reached (Fig. 5).
The resistance of crowns made for dies the size of prepared incisors and
premolars has been tested, and it was concluded that 3 mm provides
adequate resistance [25], supporting the recommended OC dimension for
premolars and anterior teeth.
The tipping resistance of molar-sized crowns has also been measured [26].
Three millimeters of OC dimension provided adequate resistance but only at
10 TOC. Three millimeters was inadequate at 20 degrees of TOC, an angle
frequently found on molars. These data support the 4 mm minimal
recommended OC dimension for prepared molars. Therefore, 3 mm is
proposed as the minimal OC dimension for premolars and anterior teeth.
Because molars frequently are prepared with greater convergence than
anterior teeth and premolars are larger and are subjected to greater occlusal
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 363
Fig. 4. (A) It is dicult to assess the degree of convergence from an occlusal view. (B) From
a lingual view, it is much easier to make a quantitative assessment of the TOC. The molar has
20 to convergence.
364 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385
Fig. 5. (A) The maxillary premolar has the minimal recommended OC dimension of 3 mm for
anterior teeth and premolars. (B) The OC dimension of the mesial surface is being measured
with a periodontal probe. The wall has only 2 mm of OC dimension.
Fig. 6. (A) When anterior teeth are prepared for complete coverage crowns, they usually
possess a favorable ratio between the incisocervical crown dimension and the mesiodistal/
faciolingual dimension. (B) Molars have less favorable ratios between the OC dimension and
the FL dimension than anterior teeth. When mandibular molars are prepared, they have
a rectangular form with rounded corners that enhance resistance form.
Fig. 7. The prepared maxillary premolar has an oval crown form, and the prepared molar
resembles a rhomboid.
Reduction uniformity
Teeth should be uniformly reduced, thereby enhancing the potential for
normal crown form and an improved esthetic result. Although there is no
scientic evidence to support the benets of uniform reduction of the facial
and proximal surfaces, clinicians and technicians have long recognized the
benets. Uniform reduction makes it easier for a dental laboratory
technician to create esthetic restorations where the color and translucency
can approximate that of a natural tooth. The reduction uniformity also
promotes the development of normal contours in conjunction with the
desired color and translucency. Reduction uniformity is best achieved by
placing depth grooves into the surface to be reduced (Fig. 9) and then
reducing the tooth in accordance with the grooves.
Fig. 8. (A) The mandibular molar has been modied by placing a groove into the mesial
surface. (B) The prepared maxillary molar has been modied with a facial groove. Facial
grooves are less eective at enhancing resistance to FL dislodging forces than grooves placed
into proximal surfaces.
Fig. 9. (A) Depth grooves have been placed into the facial surfaces of both maxillary central
incisors to aid in the production of uniform facial reduction. (B) Completed metal ceramic tooth
preparations. The facial depth grooves were helpful in the creation of tooth preparations that
possessed adequate and uniform reduction.
Fig. 10. Supragingival nish lines were placed on the mandibular canines because the cervical
aspects of these teeth were not visible during smiling and because sucient retentive length had
been achieved.
used. With all-ceramic crowns, shoulder nish lines should be used with
nonbonded crowns, whereas a chamfer or shoulder can be used when the
crowns are to be bonded to the prepared tooth.
All-metal crowns
Although no scientic studies are available that support the superiority of
chamfer nish lines for all-metal crowns, they have frequently been used
because they are easy to form and suciently distinct to be visible on the
tooth and die. They also provide space for adequate metal thickness com-
bined with normal axial contours (Fig. 11).
Metal-ceramic crowns
Chamfer (Fig. 12A), beveled chamfer, shoulder with a rounded axiogin-
gival line angle (Fig. 12B), shoulder with a sharp axiogingival line angle
(Fig. 12C), and beveled shoulder (Fig. 12D) nish lines have been used for
metal ceramic tooth preparation. Although initial research identied greater
marginal metal distortion when porcelain was fused to castings made for
chamfer nish lines [45,46], subsequent studies failed to measure signicant
dierences in marginal t [4749]. Additional studies that evaluated the eect
of cementation also failed to identify signicant t dierences as related to
the type of nish line [50,51]. Therefore, the selection of nish line form
should not be based upon expectations of enhanced marginal t but rather
on factors such as formation ease, personal preference, esthetic requirements,
and the type of crown being fabricated.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 371
Fig. 11. A chamfer nish line is being formed on the mandibular rst molar using a tapered
round-end diamond instrument. The rotary instrument was extended into the tooth by
a distance equal to one half its tip diameter, and then the instrument was carefully and
methodically moved around the circumference of the tooth.
All-ceramic crowns
Chamfer nish lines produced lower strengths with nonbonded crowns
in laboratory tests [52,53]. However, the negative eect was not replicated
when the crowns were bonded (internally etched crowns cemented to
etched prepared teeth with resin) to the teeth [54,55]. It therefore seems
appropriate to recommend shoulder nish lines (Fig. 13) for all-ceramic
crowns that are not to be bonded to underlying tooth structure, whereas
chamfer or shoulder nish lines can be used when the crowns are to be
bonded.
372 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385
Fig. 12. (A) Chamfer nish lines have been established on the maxillary anterior teeth for metal
ceramic crowns. (Courtesy of Dr. Wayne Campagni, Loma Linda, CA). (B) A shoulder nish
line (nish line meets the unprepared tooth at about 90 ) has been prepared with a rounded
axiogingival (internal) line angle. (C) A shoulder nish line has been prepared with a sharp
axiogingival line angle. (D) The metal ceramic crown preparations have been prepared with
beveled shoulder nish lines. (Courtesy of Dr. Tony Daher, LaVerne, CA.)
Reduction depths
All-metal crowns should have chamfer depths of at least 0.3 mm, axial
surface reductions of at least 0.5 to 0.8 mm, and occlusal reduction depths of
1 to 1.5 mm. For metal ceramic crowns, depths of 1.0 mm or more have
been proposed and are esthetically desirable for the nish line and facial
surface reductions. However, it does not seem that depths of that magnitude
are regularly achieved clinically, and the presence of younger teeth and
greater TOC angles make it more unlikely that teeth can be reduced to those
depths. Occlusally, reduction depths of 2 mm are achievable even on young
teeth that are being prepared for metal-ceramic crowns. Finish line and
facial reductions depths of 1.0 mm are recommended for all-ceramic crowns.
An incisal/occlusal reduction of 2 mm for all-ceramic crowns permits the
development of appropriate color, translucency, and morphology.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 373
Fig. 12 (continued )
374 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385
Fig. 13. A shoulder nish line has been developed for an all-ceramic crown.
All-metal crowns
For all-metal crowns, nish line depths of 0.3 to 0.5 mm have been
recommended [3,5]. This depth allows restorations to closely approximate
normal tooth dimensions, whereas nish lines \0.3 mm in depth are more
likely to produce overcontoured restorations [56]. Therefore, 0.3-mm-deep
chamfer nish lines are well suited for all-metal crowns (see Fig. 11).
For all-metal crowns and xed partial dentures, there are no data that
identify the ideal axial reduction depths. Therefore, the experience of
clinicians and laboratory technicians forms the basis for recommending 0.5
to 0.8 mm of reduction be developed near the occlusal aspect of the facial and
lingual surfaces. This depth of reduction provides adequate space for the
development of normal axial contours and material thickness for strength.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 375
Metal-ceramic crowns
Finish lines for metal ceramic crowns should be 1.0 to 1.5 mm deep
[25,11,57], and the facial surface be reduced between 1.0 and 1.7 mm
[25,11,57]. These recommendations are supported by research that de-
termined 1.0 mm or more of translucent porcelain is required to reproduce
shade guide specimens [5860]. However, actual measurements of prepared
teeth [56,61] indicate reduction depths are often [1 mm (Fig. 14). The reason
for failure to achieve the recommended depths may be related to the amount
of tooth structure available for reduction. The combined dentin and enamel
thickness ranged from 1.7 to 3.1 mm in one study [62], from 2.2 to 2.5 mm in
another study [63], and from 2.0 to 3.0 mm in a third study [64]. These
thicknesses indicate that some teeth can safely be reduced in accordance with
the recommended depth range of 1.0 to 1.7 mm (Fig. 15), whereas other teeth
would have thin areas of remaining dentin.
Younger teeth have tooth structure thicknesses of \2 mm and therefore
cannot be reduced to meet the greater depths that have been proposed [26].
Additionally, the eect of TOC must be considered because it can have
a profound eect on the amount of remaining tooth structure for a certain
reduction depth. The thickness of the remaining tooth structure has been
measured on adolescent premolars prepared with two nish line depths (0.8
and 1.2 mm deep) and four TOC angles (5 , 10 , 15 , and 20 ) [65]. The
combination of a 1.2-mm-deep nish line and 20 of TOC produced a 0.3-mm
thickness of remaining dentin. Therefore, the presence of younger teeth or
greater TOC angles make it unlikely that teeth can be reduced to the greater
proposed depths.
When esthetic materials are to be placed over incisal/occlusal surfaces,
reduction depths of 2.0 to 2.5 mm have been recommended for metal ceramic
restorations to provide space for the development of appropriate color,
anatomic form, and occlusion [25,11]. There is [4 mm of combined enamel-
dentin thickness present on young teeth [5,62]. Teeth in older patients have
greater combined enamel and dentin thicknesses that range from 5 to 7 mm
[5,6264]. It seems that reduction depths of 2 mm or more are achievable
recommendations (Fig. 16).
376 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385
Fig. 14. The metal ceramic tooth preparation has a facial cervical reduction depth of \1 mm.
Fig. 15. The two metal ceramic tooth preparations have facial reduction and nish line depths
that exceed 1 mm.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 377
Fig. 16. The incisal edges of the two central incisors have been reduced by a dimension that
exceeds 2 mm.
All-ceramic crowns
All-ceramic nish line depth recommendations range from 0.5 to 1.0 mm
(Fig. 17) [25,11,57]. From a facial reduction standpoint, there is little
improvement in shade matching when the thickness of all-ceramic crowns is
increased beyond 1 mm with semi-translucent, all-ceramic systems (eg,
Empress and InCeram Spinell) and high-value, low-chroma shades (eg, A1)
[60]. However, thicknesses in excess of 1 mm are benecial when using more
opaceous all-ceramic systems or when using lower value, more chromatic
shades such as C2 and A3 [60]. In addition, the inherent color of the prepared
tooth can inuence the color of the overlying all-ceramic crown, requiring
greater ceramic thickness when the dentin is discolored.
Malament and Socransky [66] investigated the eect of ceramic thickness
on the strength of all-ceramic crowns but were not able to correlate
restoration failure with thickness when the crowns were bonded to the
prepared tooth with resin cement. They found no signicant dierences in the
probability of survival after 11.7 years (3430 cumulative monitoring years)
between bonded crowns that were \1 mm thick and those that were >1 mm
thick. The midaxial thickness of crowns in this study averaged approximately
1.5 mm [66]. Therefore, if the crown is to be bonded with resin cement, the
reduction should be based on the ceramic thickness required to achieve
proper color and contour.
Fig. 17. (A) The facial shoulder nish line on the maxillary lateral incisor is 0.5 mm in depth.
(B) The maxillary central incisor nish line depth is 1.0 mm.
Fig. 18. (A) The maxillary left central incisor has a sharp mesiofacial line angle that should be
rounded. Although the sharpness of the mesioincisal and distoincisal corners of the maxillary
right lateral incisor has been reduced, there are still sharp angles that could be rounded to
reduce stress concentration. (B) There are multiple proximoincisal line angles that could be
further rounded to decrease the stress concentration in the all-ceramic crowns. (C) There are
sharp distofacial and distal cusp tips on the mandibular molar that has been prepared for an all-
metal crown. Rounding these sharp cusps facilitates laboratory fabrication by making it less
likely that air bubbles will be trapped during pouring and die and investing the wax pattern.
380 C.J. Goodacre / Dent Clin N Am 48 (2004) 359385
Surface texture
Tooth preparations should be reasonably smooth to enhance restoration
t. Some surface roughness improves retention when using zinc phosphate
cement but does not seem to have as substantial of an eect when adhesive
cements are used (polycarboxylate, glass ionomer, and resin).
Tooth preparation smoothness has been found to improve the marginal t
of restorations in two studies [70,71], whereas another study [72] found no
dierence in the marginal seating of complete crowns when the axial surfaces
were prepared with coarse diamond instruments (120 lm grit size) and when
they were prepared with ne diamond (50 lm grit size) instruments.
The eect of smoothness on retention seems to be related to the type of
denitive cement. With zinc phosphate cement, seven of nine studies indicate
that preparations with some roughness (see Fig. 11) provide improved
retention compared with smoother preparations. However, when testing the
eect of adhesive-type cements (polycarboxylate, glass ionomer, and resin),
there is no clear benet to surface roughness. Three studies indicate that
roughness increased retention [7274], whereas three other studies found that
roughness did not improve retention [71,75,76]. Therefore, when using zinc
phosphate cement, one can expect an increase in retention through surface
texture, whereas the benets of surface roughness have not been denitively
established when using polycarboxylate, glass ionomer, and resin cements.
Summary
The following guidelines are proposed when preparing teeth for complete
coverage crowns and xed partial dentures:
1. The TOC (angle of convergence between opposing prepared axial
surfaces) should range between 10 and 20 . However, posterior teeth
are frequently prepared with greater convergence angles as are xed
partial denture abutments. When the TOC angles exceed the recom-
mended levels, the tooth preparation should be modied to include
auxiliary features such as grooves or boxes.
2. Three millimeters should be the minimal occlusocervical/incisocervical
(OC/IC) dimension of incisors and premolars when they are prepared
within the recommended TOC range of 10 to 20 . The minimal OC
dimension of molars should be 4 mm when prepared with 10 to 20
TOC. When the OC dimension is less than the recommended dimension,
the tooth preparation should be modied to include auxiliary features
such as grooves or boxes.
3. The ratio of the OC/IC dimension to the FL dimension should be 0.4 or
higher for all teeth. When this ratio is not present, as on large diameter
molars, the tooth preparation should be modied to include auxiliary
features such as grooves or boxes.
C.J. Goodacre / Dent Clin N Am 48 (2004) 359385 381
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doi:10.1016/j.cden.2003.12.009
388 M.H. Parker / Dent Clin N Am 48 (2004) 387396
Fig. 1. The on/o nature of resistance form as a function of taper. Preparation tapers
increases from A to J, all of which have the same base width and preparation height.
Preparations A through E have resistance form, whereas preparations F through J do not (the
Zuckerman circle and the Lewis perpendicular illustrate that preparation F does not have
resistance form). Therefore, for these preparations with the given height and base, the minimally
acceptable taper is the taper of preparation E. The minimally acceptable taper is the dividing
point between tapers that do provide resistance form and those that do not.
where y is large (near the occlusal surface) and x is small (near the center of
rotation). Points on a groove nearer the center of rotation and higher on the
preparation provide resistance form more easily (with larger tapers) than
what is required for points lower and farther from the center.
The on/o nature of resistance form can be applied to the average taper
of the entire preparation (not limited to straight preparation walls but valid
for any shape with even or symmetrical margins), and that value is dened
as the limiting average taper [9]. It is mathematically determined to equal
0.5 arcsine (H/B), where the H and B refer to the height and base of
the preparation. The total convergence angle is twice this value. By calculat-
ing the average height-to-base ratio of preparations of incisors, canines,
premolars, and molars, minimally acceptable guidelines for preparation
tapers by tooth group were determined. The values expressed as total
occlusal convergence were found to be 58 for incisors, 66 for canines, 20
for premolars, and 16 for molars. These values are based on resistance form
recommended for minimally acceptable average tapers (ie, the boundary of
unacceptability to avoid). Resistance form is easily obtained on anterior
teeth, although it is more dicult to obtain with posterior teeth because they
are shorter and wider, making the height-to-base ratio less. When a loose
retainer is found for an FPD extending from a molar to a premolar, in this
authors experience it is usually the molar retainer that is loose. The tooth
group order from largest recommended taper to smallest recommended
taper is opposite that given by Shillingburg [14]. His recommended values
for average ideal tapers (total convergence angle) increase from anterior
(10 ) to posterior (19 to 22 ). Clinically, resistance form being more dicult
to achieve for molars is consistent with the nding that over 50% of molar
preparations evaluated from a large laboratory lacked resistance form [4]
and the type of casting that most commonly comes loose is the molar [10].
390 M.H. Parker / Dent Clin N Am 48 (2004) 387396
It is the molar preparation that must be approached with the most caution
to ensure that resistance form is always obtained.
Fig. 2. Three techniques for evaluating the resistance form of side AC. The Lewis method of
evaluating resistance form of side AC is applied by extending a perpendicular line to side AC
from the center of rotation E at the opposite margin. The intersection of the Lewis line and side
AC is point B, so all points occlusal to B (section BC) are resistive and all points gingival to B
(section AB) are not resistive. The same results are obtained with the Zuckerman circle, where
all points outside of the circle (section BC) are resistive and all points inside (section AB) are
nonresistive. The Weed technique predicts that all points on side AC are not resistive because
they are inside the Weed circle. This contradicts the Lewis and Zuckerman results, indicating
that the Weed hypothesis is not valid.
M.H. Parker / Dent Clin N Am 48 (2004) 387396 391
Weed and Baez [7] presented a method using a boundary circle centered
on the opposing margin to evaluate an opposing wall (see Fig. 2). Their
hypothesis was that if the intersection of the taper line (side of the
preparation) with the horizontal height line falls inside of the circle, it
indicates lack of resistance form. Points of the preparation outside of the
circle have resistance form. They incorrectly concluded that their hypothesis
was valid; it identies tapers as being nonresistive that in fact provide
resistance form [8]. Using an ingenious application of geometry, Zuckerman
[20], similar to Weed, used a boundary circle but centered his circle at the
center of the base of the preparation with a radius one half of the base radius
used by Weed. The points of the side of the preparation within the circle are
nonresistant, whereas all points on the preparation wall that are outside of
the circle provide resistance form. Because the Weed and Zuckerman circles
are dierent, the techniques are contradictory. Zuckermans result is
consistent with the mathematical derivation of Lewis and Owen and has
a mathematical basis for acceptance. Weed concluded that a 3.5-mm high
preparation with a 10-mm base would lack resistance form with a conver-
gence angle of 22 (total occlusal convergence of 44 ). Using Zuckermans
diagram, the formula for the limiting taper is 0.5 Arcsine (2H/B), which gives
22.2 (total occlusal convergence of 44.4 ); 22 falls in the resistive area. The
occlusal half of the preparation wall that falls within Weeds boundary circle
is above the intersection with the perpendicular line used in the Lewis
method for evaluating resistance form. This reveals a contradiction and
indicates an error in the Weed method for determining which tapers are
adequate to provide resistance form.
The resistance form at each point also can be evaluated by drawing
a direction of arc arrow, which is an arc of the circle centered on the
opposite margin [8]. At the point being evaluated, if the direction of the
arrow is into the preparation, that point has resistance form; if it is away
from the preparation, it does not. This technique can be used to evaluate all
preparation shapes, not just straight-walled preparations. Because all
direction of arcs on the same radius line of concentric circles are parallel,
comparing the direction of arc at a point on any radius line of any circle
(centered on the opposite margin) with the preparation reveals whether the
direction is away from or into the preparation wall. In Fig. 2, by visualizing
the direction of arc provide by the Weed circle (which is centered on the
opposite margin), from A to B the direction is away from the preparation
wall; from B to C the direction is into the preparation wall. This supports
the fact that all points on the wall from B to C are resistive, contradicting
Weeds results.
measured and taper. Weed [7] used an Instron (Instron Corp., Canton,
Massachusetts) machine to force cemented castings from metal dies, and
Wiscott [21] developed a cyclic testing apparatus measuring the load level at
which 50% of the samples survived 106 stress cycles. Both studies produced
linear results with no sudden drop observed in the load level required to
dislodge the crowns as taper was increased. These results seem to contradict
the on-o nature of resistance form. Based on his results, Wiscott states that
the concept of limiting taper expressing itself clinically as an all-or-nothing
phenomenon is unrealistic [21], but one would not expect to see the on/o
nature of resistance form expressed if only preparations having resistance
form in the on category were evaluated. That is what happened in both
studies. For a symmetrical straight-walled preparation with 10 of total
occlusal convergence (5 axial inclination on each side) to lack resistance
form, its height would have to be less than 0.7 mm, less than any die studied
by Wiscott. Therefore, all samples had resistance form, and no on/o
boundary eect was seen. It is dicult to make a symmetrical straight-
walled die lack resistance form. For example, the limiting taper for
a symmetrical 4-mm-high, 10-mm-wide preparation equals 0.5Arcsine2H/B
or 26.6 , for a total occlusal convergence of 53.2 . This may seem excessive,
but it is more challenging to achieve the resistive tapers with the clinical
preparations of teeth than it is in the lab with a lathe-cut metal die.
There are clinical preparations that lack resistance form [4]. One must be
wary of uneven margins, which can make a preparation with parallel walls (0
taper) lack resistance form (Fig. 3) [8]. Rounding of sharp occlusal surfaces is
another factor that increases the likelihood that clinical preparations will lack
resistance form. These factors are commonly seen in the preparation of
tipped molars. The tapers used in lab studies may be more consistent with
ideal recommended guidelines than what is achieved clinically. Students
attempting to meet a 12 criterion did not result in achieving that goal [22].
Realizing and accepting that much larger preparation tapers are seen
clinically than normally are advocated as standards should allow us to
examine larger tapers for lab studies to explore the on/o nature of resistance
form. The studies must ensure that there are preparations in the on and
o categories. A clinical study of crowns that have failed by dislodgment
reveals that almost all failures are on preparations lacking resistance form,
supporting the premise that a reasonable standard for acceptable preparation
taper is that it provides resistance form [10]. It also supports the premise that
a relationship exists between clinical success/failure and the all-or-none
nature of resistance form.
Fig. 4. Adding a groove (HIJKLM) to the preparation in Fig. 3 aects the resistance form.
Where the direction of arc arrow from E to F is away from one wall of the groove, it directs into
the other wall so that one of the two opposing walls provides resistance form at each level. For
the portion of the groove below the center of rotation, it is the mesial wall of the groove that has
resistance form (indicated by the heavy line from L to M). For the portion of the groove above
the distal margin, it is the distal wall of the groove from I to J that is resistive.
Summary
Clinical evidence indicates that resistance form is one of the essential
elements in crown preparation design to ensure clinical success. The on/o
nature of resistance form lends itself to the theoretical determination of
minimally acceptable tapers. The boundary between resistive and non-
resistive tapers can be determined at each point on a preparation (limiting
taper) or for the entire preparation (limiting average taper). Using average
height-to-base ratios for incisor, canine, premolar, and molar preparations,
minimally acceptable guidelines can be determined for symmetrical
preparations. The short wide molar with the small height-to-base ratio is
the most dicult tooth preparation to achieve resistance form, and grooves
should be used routinely. The average guidelines for taper do not apply to
preparations with uneven margins, which are frequently seen with tipped
mandibular molars. It is possible to have perfectly parallel opposing mesial
and distal walls and not have resistance form. Buccal and lingual grooves
solve the problem. Every tooth must be analyzed individually. The Lewis,
M.H. Parker / Dent Clin N Am 48 (2004) 387396 395
References
[1] Walton JN, Gardner FM, Agar JR. A survey of crown and xed partial denture failures:
length of service and reasons for replacement. J Prosthet Dent 1985;56:41621.
[2] Goodacre JC, Bernal G, Rungcharassaeng K, Kan JYK. Clinical complications in xed
prosthodontics. J Prosthet Dent 2003;90:3141.
[3] Lewis RM, Owen MM. A mathematical solution of a problem in full crown construction.
J Am Dent Assoc 1959;59:9437.
[4] Parker MH, Malone KH, Trier AC, Striano TS. Evaluation of resistance form for
prepared teeth. J Prosthet Dent 1991;66:7303.
[5] Walton TR. An up to 15-year longitudinal study of 515 metal-ceramic FPDs: part 1.
Outcome. Int J Prosthodont 2002;15:43945.
[6] Hegdahl T, Silness J. Preparation areas resisting displacement of articial crowns. J Oral
Rehabil 1977;4:2017.
[7] Weed RM, Baez RJ. A method for determining adequate resistance form of complete cast
crown preparations. J Prosthet Dent 1984;52:3304.
[8] Parker MH, Gunderson RB, Gardner FM, Calverley MJ. Quantitative determination of
taper adequate to provide resistance form: concept of limiting taper. J Prosthet Dent 1988;
59:2818.
[9] Parker MH, Calverley MJ, Gardner FM, Gunderson RB. New guidelines for preparation
taper. J Prosthodont 1993;2:616.
[10] Trier AC, Parker MH, Cameron SM, Brousseau JS. Evaluation of resistance form of
dislodged crowns and retainers. J Prosthet Dent 1998;80:4059.
[11] Walton TR. An up to 15-year longitudinal study of 515 metal-ceramic FPDs: part 2.
Modes of failure and inuence of various clinical characteristics. Int J Prosthodont 2003;
16:17782.
[12] Caputo AA, Standlee JP. Biomechanics in clinical dentistry. Chicago: Quintessence; 1987.
[13] Dykema RW, Goodacre CJ, Phillips RW. Principles of tooth preparation. In: Pederson D,
editor. Johnstons modern practice in xed prosthodontics. 4th edition. Philadelphia:
W.B. Saunders; 1986. p. 24.
[14] Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Principles of tooth
preparation. In: Bateman LA, editor. Fundamentals of xed prosthodontics. 3rd edition.
Chicago: Quintessence; 1997. p. 11936.
[15] Nordlander J, Weir D, Stoer W, Ochi S. The taper of clinical preparations for xed
prosthodontics. J Prosthet Dent 1988;60:14851.
[16] Woolsey GD, Matich JA. The eect of axial grooves on the resistance form of cast
restorations. J Am Dent Assoc 1978;97:97880.
[17] Owen CP. Retention and resistance in preparations for extracoronal restorations: part II.
Practical and clinical studies. J Prosthet Dent 1986;56:14853.
396 M.H. Parker / Dent Clin N Am 48 (2004) 387396
[18] Jorgensen KD. The relationship between retention and convergence angle in cemented
veneer crowns. Acta Odontol Scand 1955;13:35.
[19] Kaufman EG, Coelho DH, Colin L. Factors inuencing the retention of cemented gold
castings. J Prosthet Dent 1961;11:487502.
[20] Zuckerman GR. Resistance form for the complete veneer crown: principles of design and
analysis. Int J Prosthodont 1988;1:3027.
[21] Wiskott HW, Nicholls JI, Belser UC. The eect of tooth preparation height and diameter
on the resistance of complete crowns to fatigue loading. Int J Prosthodont 1997;10:20715.
[22] Smith TS, Gary JJ, Conkin JE, Franks HL. Eective taper criterion for the full veneer
crown preparation in preclinical prosthodontics. J Prosthodont 1999;8:196200.
[23] Potts RG, Shillingburg HT, Duncanson MG. Retention and resistance of preparations for
cast restorations. J Prosthet Dent 1980;43:3038.
Dent Clin N Am 48 (2004) 397416
Restoration of endodontically
treated teeth
Steven M. Morgano, DMDa,b,*,
Antonio H.C. Rodrigues, DDS, MSDa,c,
Carlos Eduardo Sabrosa, DDS, MSD, DScDd
a
Department of Restorative Sciences and Biomaterials, Boston University Goldman
School of Dental Medicine, 100 East Newton Street, Room G219 Boston,
MA 02118-2392, USA
b
Division of Postdoctoral Prosthodontics, Boston University Goldman School of
Dental Medicine, 100 East Newton Street, Room G219, Boston, MA 02118-2392, USA
c
Division of Graduate Fixed Prosthodontics, School of Dentistry, Catholic University,
Dom Jose Gaspar 500, Belo Horizonte, MG 30000, Brazil
d
Department of Operative Dentistry, Universidade do Estado do Rio de Janeiro,
Av. Ataulfo de Paiva 482 sl. 502, Rio de Janeiro, RJ 22440-030, Brazil
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.011
398 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416
A ferrule also helps to protect the integrity of the cement seal of the
articial crown. An in vitro study by Libman and Nicholls [18] reported that
there was improved resistance to fatigue failure of the cement seal of the
crown when the crown margin extended at least 1.5 mm apical to the margin
of the core. Torbjorner et al [19] retrospectively evaluated the clinical success
and failure characteristics of teeth restored with posts and articial crowns
and reported a higher potential for the fracture of posts when the cemented
crowns did not provide a ferrule eect. Also, if the margin of the crown and
the margin of the core are at the same cervical level, the retention of the
crown depends entirely on the retentive capacity of the post, and the post is
more likely to become dislodged.
A contrabevel has been advocated when preparing a tooth for a cast post
and core to produce a cast core with a collar of metal that encircles the tooth
and serves as a secondary ferrule independent of the ferrule provided by the
cast crown [20]. Nevertheless, there seems to be little advantage to this
secondary ferrule as a component of the core [21]. A study by Loney et al [22]
reported signicantly higher mean stresses with collared cores, suggesting
that incorporating a ferrule as an integral part of a cast core was undesirable.
Because there is no pulp to expose with a pulpless tooth, many dentists
believe they can over prepare the coronal portion of a pulpless tooth to
provide maximal space for the dental laboratory technician to develop the
best esthetic result with the articial crown. However, current knowledge
suggests that dentists should be conservative of coronal tooth structure when
preparing pulpless teeth for complete crowns to ensure an adequate ferrule
eect. The most commonly accepted guideline for this ferrule is a minimal
height of 1.5 to 2 mm of intact tooth structure above the crown margin for
360 around the circumference of the tooth preparation [1]. If insucient
tooth structure remains coronal to the gingival margin to develop this
ferrule, surgical crown lengthening [23] or orthodontic extrusion [24] should
be considered to expose additional tooth structure. Extraction of the tooth
with replacement by conventional or implant-supported prosthodontics is
usually a better option whenever an adequate ferrule cannot be obtained [1].
Apical seal
After preparation of a root canal for a post, the only barrier against
reinfection of the periapical region is the remaining gutta percha. To avoid
violation of the apical seal, the dentist should retain at least 4 to 5 mm of
apical gutta percha [25,26]. This minimal amount of gutta percha may limit
the length of the post; however, when there is a conict between the
guidelines for the posts length and the length of the apical seal, preservation
of an intact apical seal must prevail. Also, once the post space has been
prepared, the post should be cemented as soon as is practical because
delaying the placement of the post can increase the potential for apical
leakage [27].
400 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416
Fig. 1. For the highest probability of success, (1) the cast post should follow the natural taper
of the instrumented root canal, conserving as much radicular tooth structure as possible; (2)
the post should be as long as practical, preserving 4 to 5 mm of apical gutta percha seal; (3) the
coronal tooth structure should be prepared to provide a positive apical stop for the core; and (4)
the articial crown should encircle at least 1.5 to 2 mm of sound tooth structure apical to
the margin of the core for 360 .
the cusps, and Aquilino and Caplan [35] found a signicantly improved
success rate for pulpless teeth that were crowned (Fig. 3). These
retrospective clinical studies strongly support the placement of a crown or
onlay on a pulpless posterior tooth. Premolars usually are restored with
crowns supported by cast posts and cores, but molars are most often
restored with crowns supported by direct core reconstructions. Materials
that have been recommended for use as direct cores include silver amalgam,
composite resin, and glass ionomer-based materials [36].
402 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416
Fig. 2. The gutta percha should be removed to the desired depth with exible, bud-shaped
rotary instruments (Gates Glidden Drills; Moyco Union Broach, York, PA) or with a heated
instrument. Residual endodontic sealer should be removed from the walls of the canal with
rigid, straight-sided engine reamers (Peeso Reamers; Moyco Union Broach).
Fig. 3. Access preparation for endodontic treatment of posterior teeth requires substantial
removal of coronal tooth structure and destroys the continuity of the occlusal surface.
Uncrowned teeth are subject to fracture as a result of normal intraoral occlusal forces (large
arrow). Placement of an articial crown restores the continuity of the occlusal surface and
encircles the tooth (small arrows) to resist fracture.
S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416 403
Fig. 4. (A) Mandibular molar to be reconstructed with a prefabricated post and a silver
amalgam core to serve as an abutment to a xed partial denture (FPD). (B) A narrow-diameter
prefabricated post was cemented in the distal root, the molar retainer for the provisional FPD
was hollowed out, and the provisional FPD was cemented with temporary cement. (C) Silver
amalgam was condensed by using the crown shell as a matrix and allowed to set for 24 hours.
(D) Completed foundation restoration includes a custom-cast post and core for the premolar
and a prefabricated post with silver amalgam core for the molar.
Fig. 4 (continued )
Prefabricated posts
There are various types and brands of prefabricated posts (Fig. 6). In
a survey of dentists reported in 1994, 40% of general dentists in the United
States reported using prefabricated posts most of the time, and the parallel-
sided serrated post was the most popular type [8]. Passive posts are most
commonly used in the United States [8]. Posts that actively engage radicular
tooth structure with threads are more retentive but can predispose the root
to fracture [38,4850]. Retention of a cemented passive post is greatest when
the post is parallel sided and has a roughened surface. A narrow-diameter,
parallel-sided serrated post can be used eectively in a pulpless molar to
augment the retention of the direct core; however, parallel-sided posts are
406 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416
Fig. 5. Endodontically treated mandibular molar with widely spread roots and a high
furcation. Prognosis is poor because crown lengthening is not possible to develop a ferrule.
Extraction and replacement with an implant-supported crown oers a more favorable prognosis
as a denitive restoration.
Fig. 7. The use of prefabricated parallel-sided posts of acceptable length in anterior teeth and
premolars is dicult because of the natural taper of the roots.
Fig. 8. Anterior tooth restored with a complete crown supported by a ber-reinforced post and
composite core. Normal intraoral forces (large arrow) may cause the post to ex, producing
micro-movement of the core and failure of the cement seal of the crown (small arrow).
combined with the interposed composite resin luting agent suggest that the
exural characteristics of the post do not match that of the root. Another in
vitro study indicated that the form of the post itself inuenced its rigidity
and reported that a smooth, ber-reinforced epoxy resin post was less
exible than the serrated version of the post [59].
A exible post can cause failure of the cement seal at the margin of the
articial crown, especially when the ferrule is minimal (Fig. 8). Because the
post is bonded to the root and the crown is cemented to the composite core,
the crown remains in place, and the problem of leakage at the crown margin
is dicult to detect.
Zirconia posts
Posts composed of zirconium oxide, a material that has been used in
medicine for orthopedic implants, have also been marketed [6063]. These
all-ceramic posts were originally designed for use with a composite core to
improve the esthetic qualities of all-ceramic crowns because it was assumed
that a metal post and core would impede light transmission through the
ceramic crown. However, a recent study has reported that translucent all-
S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416 409
ceramic crowns supported by cast posts and cores made from yellow gold
alloy do not appreciably alter the esthetic outcome when the gold core is
polished; therefore, the esthetic advantage of these ceramic posts can be
questioned [64]. Ceramic materials are tough and have high compressive
strengths, but because of their poor tensile strengths they may fracture when
subjected to sheer stresses [65]. To compensate for their brittle nature, these
posts are made relatively wide, requiring substantial removal of radicular
tooth structure. At this time, little is known about the long-term survival of
these all-ceramic posts, and they seem to have limited applicability.
Dental cements
The post is retained in the prepared post channel with dental cement. The
primary factors that inuence the durability of the bond of the post to the root
are compressive strength, tensile strength, and adhesive qualities of the
cement. Further considerations concerning the selection of a material to
cement posts include the cements potential for plastic deformation, micro-
leakage, and water imbibition. Also, the cements handling characteristics
during mixing and seating of the post and the nature of the setting reaction of
the cement can play a role in the survival of a cemented post in vivo. The
currently available dental cements include zinc phosphate, polycarboxylate,
glass ionomer, resin-modied glass ionomer, and resin cements. These
dierent classes of cements have advantages and disadvantages, and some
should be avoided for use as a cementing medium for endodontic posts.
Another relatively new cement, compomer, is rarely advocated for posts.
Zinc phosphate cement has been used for decades to cement dental
restorations and has a long history of success. The primary disadvantages of
this cement are solubility in oral uids, especially in the presence of acid,
and lack of true adhesion.
Polycarboxylate and glass ionomer cements are also soluble in oral uids,
but they can chemically bond to dentin [69,70]. Polycarboxylate cements
have been shown to undergo plastic deformation after cyclic loading, which
410 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416
Fig. 9. It has been postulated that delayed expansion of resin-modied glass ionomer cement
can fracture an all-ceramic crown (A). This expansion also is a concern with posts because root
fracture is possible (B).
S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416 411
Fig. 10. Tooth with a short post and fractured root displaying typical radiographic appearance
(arrow). Note the thickened periodontal ligament space and widened lamina dura, resembling
an upside-down J.
412 S.M. Morgano et al / Dent Clin N Am 48 (2004) 397416
Summary
A pulpless tooth has commonly lost substantial tooth structure as a result
of previous restorations, dental caries, and the access preparation for
endodontic therapy. Consequently, a pulpless tooth requires a restoration
that conserves and protects the remaining tooth structure. Although there
are many new materials available for the restoration of pulpless teeth, the
prognosis of these teeth relies primarily on the application of sound
biomechanical principles rather than on the materials used for the
restoration.
Posts and cores are commonly required with pulpless teeth. A longer post
that preserves 4 to 5 mm of the apical gutta percha seal combined with an
articial crown that provides a ferrule eect oers the best chances of
success [17]. Custom-cast posts and cores are generally recommended for
anterior teeth and most premolars, and prefabricated posts with direct cores
are commonly preferred for molars. Complete crowns or onlays that cover
all cusps are recommended for all posterior pulpless teeth regardless of the
amount of remaining coronal tooth structure to reduce the chances of
fracture of these teeth.
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* Corresponding author.
E-mail address: tdonovan@usc.edu (T.E. Donovan).
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.013
418 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431
Fig. 1. (AC) When cervical margins are placed too close to the epithelial attachment, biologic
width is violated. This results in a typical chronic inammatory response.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431 419
gingival tissues. The most common error made by clinicians is to atten the
cervical margin in the inter-proximal areas, thereby violating biologic width
and eliciting a chronic inammatory response (Fig. 2).
Several geometric margin designs are available for consideration with
metal-ceramic crowns. Dierent margin designs are indicated in dierent
clinical situations [11]. Specic criteria must be used to assist the clinician in
determining which margin design is optimum for a given clinical situation.
The following criteria for margin selection seem reasonable:
1. The selected margin must provide a predictable level of marginal
integrity.
2. To minimize plaque accumulation, the selected margin must present
smooth materials to the gingival sulcus.
3. In some situations, the margin also must provide acceptable esthetics.
Not all designs meet all of these criteria. Selection of an inappropriate
cervical margin design can have deleterious consequences.
There are many problems that can result from improper preparation and
placement of cervical margins. These include biologic width violation, metal
margins showing through thin marginal gingiva, recession exposing the
tooth/restorative interface, opacity in the cervical third of the restoration,
and roughness of the cervical margin, which contributes to plaque accumu-
lation. Biologic width violations are primarily a function of margin placement
and are independent of margin design. Gingival recession is primarily a
result of improper soft tissue management and is independent of margin de-
sign [5,6]. The other problems can be resolved by proper selection and prep-
aration of the appropriate cervical margin.
With metal-ceramic crowns, there are ve potential cervical margins to
consider. These include the knife-edge, the chamfer, the shoulder or butt
joint, the beveled shoulder, and the slant shoulder or disappearing margin
Fig. 2. The biologic width has been violated in the inter-proximal area because the cervical
margin does not follow the scalloped anatomy of the attachment and the underlying alveolar
housing.
420 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431
Fig. 4. (A, B) These restorations have used a shoulder-bevel margin that provides optimum
marginal integrity and a smooth, polished surface.
Fig. 5. The use of a shoulder margin with a porcelain labial margin results in smooth, glazed
porcelain in the gingival crevice.
Fig. 6. The disappearing margin design results in multiple materials and interfaces at the
marginal terminus that are inherently rough and may have a deleterious eect on plaque
accumulation and retention.
424 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431
Fig. 7. (A, B) These restorations are not visible with a normal or exaggerated smile and the
shoulder-bevel margin was used, providing optimum t with a smooth, polished surface.
Fig. 8. All-ceramic margins should provide a shoulder with a rounded internal angle and
should be between 1.2 and 1.5 mm in width.
the surface (Figs. 9, 10). This can be masked with intrinsic coloration by some
master ceramists but often is an esthetic deciency of this margin design.
The margin of choice in esthetic situations when using metal-ceramic
crowns is a shoulder design with a porcelain labial margin. This design allows
for an adequate thickness of ceramic material at the margin so that
a predictable esthetic result is assured, provides excellent strength, and places
glazed porcelain in the gingival sulcus (Figs. 11, 12) [31].
Several techniques have been described for fabricating porcelain margins,
and all seem to provide acceptable results if the margin has been prepared
properly and the technician pays meticulous attention to detail [3242]. It
Fig. 9. The disappearing margin eectively hides the metal margin but often results in cervical
opacity.
426 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431
Fig. 10. (A, B) If patients accept characterization, cervical opacity can often be masked with
internal coloration.
has been shown theoretically and experimentally that shoulder margins can
be fabricated with acceptable ts. Sucient expansion is achieved with
casting investments, or internal expansion is achieved with the appropriate
thickness of die spacer [43,44]. With proper technique, marginal gaps of 6 to
34 lm can predictably be achieved, which is well within the realm of clinical
acceptability [4547].
The preparation of the porcelain labial margin is identical to that of the all-
ceramic crown, with the exception that the shoulder margin is prepared only
on the labial or buccal surfaces. The shoulder margin is carried interprox-
imally to the proximal-lingual line angle, and a chamfer or beveled shoulder
margin is prepared on the lingual half of the tooth (Fig. 13). The shoulder
should be at 90 to the external surface and 1.2 mm in width. It should be
smooth, and hand instrumentation is generally recommended to achieve
a planed surface [48].
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431 427
Fig. 11. (A, B) The porcelain margins illustrated combine good marginal integrity with
excellent esthetics.
Fig. 12. These metal-ceramic restorations with porcelain labial margins provide acceptable
esthetics when the margins are hidden with healthy gingival tissues.
Summary
When preparing teeth for esthetic crown restorations, the clinician must
determine which cervical nish line is appropriate for each specic clinical
Fig. 13. The preparation for porcelain labial or buccal margins mandates a shoulder margin on
the buccal half of the tooth and a shoulder bevel or chamfer on the lingual half. The premolar
has been prepared for a porcelain shoulder margin, and the molar has been prepared for
a shoulder-bevel margin.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 417431 429
situation. All cervical margins must be placed in the correct position relative
to the free gingival margin, the epithelial attachment, and the alveolar
housing.
With all-ceramic crowns, the optimum nish line is a shoulder margin
with rounded internal angle with a width of 1.2 to 1.5 mm. This depth may
have to be reduced to 1.0 mm with triangular-shaped teeth. It should meet
the external surface of the tooth at an angle of 90 .
With metal-ceramic crowns, knife-edge margins and chamfer margins
should generally be avoided due to concerns with t. Shoulder-bevel margins
are the margins of choice in situations where esthetics is not important
because of their documented ability to provide optimum t and the ability to
polish the inherent metal collar.
Shoulder margins with a labial or buccal porcelain margin are indicated in
situations where esthetics is paramount. These margins should be prepared at
90 to the external tooth surface, should be exceptionally smooth, and should
have a width of 1.2 mm. The metal substructure should be nished 1.0 mm
from the shoulder margin to permit optimum light transmission without
sacricing strength.
Slant shoulder margins are necessary when the tooth preparation extends
some distance on the root surface. In situations where these margins are not
visible, they should use a metal collar. In situations where the smile exposes
these margins, the disappearing margin approach should be used.
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dies. J Prosthet Dent 1976;36:583.
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with porcelain facial margins. J Prosthet Dent 1993;69:19.
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Dent Clin N Am 48 (2004) 433444
* Corresponding author.
E-mail address: tdonovan@usc.edu (T.E. Donovan).
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.012
434 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444
Fig. 1. The gingival tissues need to be displaced laterally to permit injection of a bulk of low-
viscosity impression material into the sulcus.
Fig. 2. A denite amount of impression material must ow beyond the prepared margin to
facilitate trimming of the gypsum die.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444 435
Fig. 3. Trimming of gypsum die is a simple procedure when eective gingival displacement
procedures result in excellent impressions.
Fig. 4. The largest diameter cord that readily ts into the gingival sulcus should be used.
and pulse records, resting pulse rates, resting blood pressure records, and
resting electrocardiograph records miss approximately 45% of latent
cardiovascular problems [48].
Clinicians should avoid using epinephrine for gingival displacement
because of the signicant number of contraindications for the use of
epinephrine and the uncertainty of any given patients cardiovascular status.
Other equally eective medicaments have no systemic manifestations and are
preferred. Fortunately, the use of epinephrine for routine gingival displace-
ment has decreased over the years. In 1985, 79% of dentists routinely used
epinephrine for retraction [18]. A recent article indicated that routine use had
declined to 25% of respondents [49].
Fig. 5. After the cord is in place, the prepared tooth should be carefully examined to determine
that the entire cervical margin can be visualized.
Fig. 6. If excess soft tissue obscures the prepared cervical margin, it should be removed using
electro-surgery or a soft tissue laser.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444 439
Fig. 7. With the double cord technique: (A) A small-diameter cord with no medicament is rst
placed in the depth of the sulcus. (B) A larger-diameter cord with the medicament is placed
above the small-diameter cord. After waiting 8 to 10 minutes, the large-diameter cord is soaked
in water and removed. The small-diameter cord is left in the sulcus during impression making.
440 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 433444
Fig. 7 (continued )
around all prepared teeth may result in strangulation of the gingival papillae
and eventual loss of the papilla. This creates unesthetic black triangles in the
gingival embrasures.
This undesirable outcome can be prevented with the every other tooth
technique. This can be used with the single or double cord technique.
Retraction cord is placed around the most distal prepared tooth. No cord
is placed around the prepared tooth mesial to this tooth. Retraction
procedures are completed on alternate teeth. If, for example, teeth #5
through #12 are prepared, cords would be placed around teeth #5, #7, #9,
and #11. The impression is made; gingival displacement is accomplished on
teeth #6, #8, #10, and #12; and a second impression made. A subsequent
pick-up impression allows fabrication of a master cast with dies for all eight
prepared teeth.
New materials
As with other procedures in restorative dentistry, a few relatively new
products and techniques have been introduced. These include strips of
a sponge-like synthetic polymer that expands after insertion into the sulcus.
This material can theoretically be placed in the sulcus with no local
anesthetic and thus results in minimal trauma [51,52]. Another material is
supplied in a syringe and is designed be injected into the unretracted sulcus
(Expasyl; Kerr Dental Products, Romulus, Michigan). Once in the sulcus it
theoretically expands and provides displacement and hemostasis. The
predictability and ecacy of these materials has yet to be established.
Summary
Gingival displacement is an important procedure with fabricating
indirect restorations. Gingival displacement is relatively simple and eective
when dealing with healthy gingival tissues and when margins are properly
placed a short distance into the sulcus.
The most common technique used with gingival displacement is use of
gingival retraction cords with a hemostatic medicament. Retraction cords of
sucient diameter should be used to provide adequate lateral displacement
to create a mean sulcular width of 0.2 mm. Epinephrine containing re-
traction cords should be avoided.
Several techniques have proven to be relatively predictable, safe, and ef-
cacious. No scientic evidence has established the superiority of one tech-
nique over the others, so the choice of technique depends on the presenting
clinical situation and operator preference.
References
[1] Christensen GJ. What category of impression material is best for your practice? J Am Dent
Assoc 1997;128:10268.
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[2] Winstanley RB, Carrotte PV, Johnson A. The quality of impressions for crowns and
bridges received at commercial dental laboratories. Br Dent J 1997;183:209.
[3] Holmes HM. Gingival displacement, not retraction. Dent Survey 1968;35.
[4] Nemetz H. Tissue management in xed prosthodontics. J Prosthet Dent 1974;31:628.
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approach for the control of hemorrhage. J Prosthet Dent 1984;51:647.
[6] Laufer BZ, Baharav H, Cardash HS. The linear accuracy of impressions and stone dies as
aected by the thickness of the impression margin. Int J Prosthodont 1994;7:247.
[7] Donovan TE. A review of contemporary impression materials. Cal Dent Inst 1988;27:9.
[8] Laufer BZ, Baharav H, Ganor Y, Cardash HS. The eect of marginal thickness on the
distortion of dierent impression materials. J Prosthet Dent 1996;76:466.
[9] Donovan TE, Cho GC. Soft tissue management with metal-ceramic and all-ceramic
crowns. J Cal Dent Assoc 1998;26:107.
[10] Donovan TE, Cho GC. Predictable esthetics with metal-ceramic and all-ceramic crowns:
the critical importance of soft-tissue management. Periodontol 2000;27:12130.
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[12] Donovan TE, Cho GC. Diagnostic provisional restorations: the blueprint for success.
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Compend Contin Educ Dent 1994;15:318.
[14] Block PL. Restorative margins and periodontal health: a new look at an old problem.
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[15] Kois JC. Altering gingival levels: the restorative connection, part I. Biologic variables.
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[20] Adams HF. Managing gingival tissues during denitive restorative treatment. Quintessencs
Int 1981;2:141.
[21] Baily JH, Fisher DE. Procedural hemostasis and sulcular uid control: a prerequisite in
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gingiva. Oper Dent 1980;5:138.
[24] Ramadan FA, El-Sadeek M, Hassanein ES. Histopathologic response of gingival tissues to
Hemodent and aluminum chloride solutions as tissue displacement materials. Egypt Dent J
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[25] Wilson CA, Tay WM. Alum solution as an adjunct to gingival retraction. Br Dent J 1977;
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[26] Harris R. Gingival retraction. Aust Dent J 1978;24:359.
[27] Ramadan FA, Harrison JD. Literature review of the eectiveness of tissue replacement
materials. Egypt Dent J 1970;16:271.
[28] Woycheshin FF. An evaluation of the drugs used for gingival retraction. J Prosthet Dent
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[29] Mokbel AM, Mohamed YR. Local eect of applying aluminum chloride on the dento-
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[30] Weir DJ, Williams BH. Clinical eectiveness of mechanical-chemical tissue displacement
methods. J Prosthet Dent 1984;51:326.
[31] Runyan DA, Reddy TG, Shimoda LM. Fluid absorbency of retraction cords after soaking
in aluminum chloride solution. J Prosthet Dent 1988;60:676.
[32] Bowles WH, Tardy SJ, Vahadi A. Evaluation of new gingival retraction agents. J Dent Res
1991;70:1447.
[33] de Gennaro GG, Landesman HM, Clahoun JE, Martino JT. A comparison of gingival
inammation related to retraction cords. J Prosthet Dent 1982;47:384.
[34] Pelzner RB, Kempler EK, Stark MM, Lum LB, Nicholson RJ. Human blood pressure and
pulse rate response to racemic epinephrine retraction cord. J Prosthet Dent 1978;39:287.
[35] Houston JB, Appleby R, DeCounter L, Callaghan N, Funk DC. Eect of r-epinephrine-
impregnated retraction cord on the cariovascular system. J Prosthet Dent 1970;24:373.
[36] Tolas AG, Pug AE, Halter JB. Arterial plasma epinephrine concentration and
hemodynamic responses after dental injection of local anesthetic with epinephrine. J Am
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[37] Shaw D, Krejci RF. Epinephrine containing gingival retraction cords: how safe are they?
Oral Health 1978;68:47.
[38] Munoz RJ. The cardiovascular eects of anxiety and r-epinephrine retraction cord in
routine xed prosthodontic procedures. J Calif Dent Assoc 1970;46:103.
[39] Phatak NM, Lang RL. Systemic hemodynamic eects of epinephrine gingival retraction
cord in clinic patients. J Oral Ther Pharmacol 1966;2:393.
[40] Thayer KE, Sawyer JD. Gingival retraction agents: reactions in dogs. Iowa Dent J 1963;382.
[41] Gogerty JH, Strand HA, Ogilvie AL, Dille JM. Vasopressor eects of topical epinephrine
in certain dental procedures. J Oral Surg 1957;10:614.
[42] Hatch CL, Chernow B, Terezhalmy GT, Van Ness M, Hall-Boyer K, Lake CR. Plasma
catecholamine and hemodynamic responses to the placement of epinephrine-impregnated
gingival retraction cord. Oral Surg 1984;58:540.
[43] Buchanan WT, Thayer KE. Systemic eects of epinephrine-impregnated retraction cord in
xed partial denture prosthodontics. J Am Dent Assoc 1982;104:482.
[44] Shaw DH, Krejci RF, Todd GL, Reinhardt RA. Determination of plasma catecholamines
in dogs after experimental gingival retraction with epinephrine-impregnated retraction
cord. Arch Oral Biol 1987;32:217.
[45] Mito RS, Yagiela JA. Hypertensive response to levonordefrin in a patient receiving
propranolol: report of a case. J Am Dent Assoc 1988;116:55.
[46] Kellam SA, Smith JR, Scheel SJ. Epinephrine absorption from commercial gingival
retraction cords in clinical patients. J Prosthet Dent 1992;68:761.
[47] Yagiela JA. Adverse drug interactions in dental practice: interactions associated with
vasoconstrictors. J Am Dent Assoc 1999;130:701.
[48] Ellestad MH. Stress testing in asymptomatic patients. In: Ellestad MH, editor. Stress
testing principles and practice. 2nd edition. Philadelphia: F.A. Davis; 1980.
[49] Hansen PA, Tira DE, Barlow J. Current methods of nish-line exposure by practicing
prosthodontists. J Prosthodont 1999;8:163.
[50] Anneroth G, Nordenram A. Reaction of the gingiva to the application of threads in the
gingival pocket for taking impressions with elastic material. Odontol Rev 1969;20:301.
[51] Ferrari M, Nathanson D. Tissue management and retraction technique combined with all-
ceramic crowns. Pract Periodontics Aesthet Dent 1995;7:87.
[52] Ferrari M, Cagidiaco MC, Ercoli C. Tissue management with a new gingival retraction
material: a preliminary clinical report. J Prosthet Dent 1996;75:242.
Dent Clin N Am 48 (2004) 445470
* Corresponding author.
E-mail address: tdonovan@usc.edu (T.E. Donovan).
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.014
446 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470
Accuracy
There are two aspects to evaluating the accuracy of impression materials.
According to American Dental Association specication #19, elastomeric
impression materials used to fabricate precision castings must be able to
reproduce ne detail of 25 lm or less. All currently available impression
materials meet this specication. PVS impression materials are the best in
this regard, and reversible hydrocolloid (a water-based impression material)
is the worst, although it can meet the 25-lm limit [5]. Dierences in detail
reproduction are not likely of major clinical consideration because the
limiting factor in the system is the ability of gypsum die materials to replicate
ne detail. The corresponding specication for gypsum die materials is 50 lm.
Most die materials do considerably better than this but fall far short of the
impression materials in their ability to reproduce ne detail.
There are signicant dierences in the ability of various viscosities of
impression materials to reproduce ne detail. In general, the lower the
viscosity of impression material, the better it records ne detail. The putty
materials, in general, cannot reproduce ne detail at the 25-lm level and are
required only to record detail of 75 lm [6]. One of the deciencies of some
putty/wash techniques is that, often, critical areas of the tooth preparation,
including cervical margins, are recorded in putty material (Fig. 1). This has
a deleterious eect on the accuracy of the gypsum die.
A second aspect of accuracy is dimensional accuracy, which is evaluated
by measuring tooth-to-tooth distances within the same quadrant and cross
arch. There is some evidence that reversible hydrocolloid is slightly superior
to the elastomers in this respect [7]. However, it is likely that there are greater
dierences resulting from the use of dierent die stones or the manipulation
of the gypsum than exist between dierent types of impression materials.
Most of the impression materials available today provide superb
accuracy if they are manipulated correctly. Although PVS materials are
likely to be more accurate than other materials, dierences in accuracy
(assuming correct manipulation) are likely not clinically signicant.
Elastic recovery
Impression material needs to be able to ow readily into undercut areas
in the mouth, set in that position, and to be able to rebound back to its
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 447
Fig. 1. One deciency of the putty/wash techniques is that the prepared margins are captured in
part with putty material, which is unable to record ne detail 25 lm or less.
original shape when the set impression is removed from the mouth. This
process is called elastic recovery. No impression material has 100% elastic
recovery, and, for all impression materials, the greater the depth of the
undercut, the greater is the permanent distortion of the impression material.
PVS impression materials have the best elastic recovery at over 99% elastic
recovery with a specic test undercut [8]. This property, coupled with the
excellent dimensional stability of PVS materials, makes it the most accurate
material for second pours.
The operator need not delay pouring of the impression to allow elastic
recovery to occur. Elastic recovery occurs almost instantaneously as the
impression is removed from the mouth or the primary cast [8]. An excellent
procedure to maximize the elastic recovery of the impression material is to
eliminate or block out any undercuts in the tooth preparation before making
the impression. This can be accomplished with any of the modied or resin-
modied glass ionomer products on the market. Many operators neglect to
do this on the premise that the undercuts can be blocked out by the
laboratory technician. Although this is possible, this approach forces the
impression material to spring out around the undercut and is thus
responsible for distortion that could easily be avoided.
Dimensional stability
An ideal impression material would be dimensionally stable over time
and thus could be poured at the convenience of the operator. Because there
is no by-product to the chemical setting reaction of addition silicones, PVS
materials possess ideal dimensional stability. They can be poured at the
convenience of the operator and are the impression material of choice if the
impression is to be sent to the laboratory where the dentist loses control of
448 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470
Workability
The advent of auto-mix devices for mixing elastomeric impression
materials has dramatically improved the workability of these materials. The
sophisticated electronic mixing devices (eg, Pentamix; 3M-ESPE, St. Paul,
Minnesota) and the simpler mixing guns used by the majority of systems
provide a standardized mix with fewer inherent porosities, increased
working time, and an economic savings due to less waste of material.
Working times can be varied by the manufacturer, and most auto-mix
devices provide materials with standard-set and quick-set capabilities. When
using the dual arch technique for a single-crown preparation, the operator
may opt for a quick-set material with a short working time. When making
a full-arch impression with several prepared teeth, the clinician may choose
a material with a longer working time. When making impressions of
multiple prepared teeth, the clinician may also opt to refrigerate the low-
viscosity material, which increases working time without sacricing
accuracy [11].
Hydrophilicity
Reversible hydrocolloid impression materials are truly hydrophilic and
can eectively make accurate impressions in the presence of moisture. The
wet technique purposefully lls the gingival sulcus with water before
making the impression and then relies on the water-loving tendency of the
material to ow into the sulcus and capture the prepared subgingival
margins in the impression.
450 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470
Shelf-life
The exact shelf-life of impression materials is not known, but it is not
advisable to use materials that have passed the expiry date established by the
manufacturers. The clinician should become familiar with the code used by
the manufacturer of the products being used and insure that current materials
are consistently provided. It is arbitrarily suggested that no more than 6
months supply of impression material should be kept on hand at any time.
Patient comfort
Contemporary materials are far more patient friendly than the old
polysulde rubber materials or reversible hydrocolloid that had to use bulky
water-cooled trays. Contemporary materials are essentially colorless,
odorless, and tasteless. The rigidity of polyether materials can be a dis-
advantage, particularly if the patient has existing xed prostheses or has
multiple open gingival embrasures due to loss of periodontal support. In
these situations, it is advisable to use a more exible material and to block
out the undercuts with utility wax before impression making. The use of the
dual-arch impression technique, where appropriate, is also pleasant for
patients in that it uses a minimal amount of material and avoids the
necessity of an opposing arch impression.
When full-arch impressions are indicated, the use of a custom tray is
advocated (Fig. 2). Some studies indicate that custom trays are more
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 451
accurate than stock trays, but even if both are suciently accurate, the level
of patient comfort with custom trays is substantially improved. In addition,
signicantly less material is used, and it has been speculated that the
material savings alone plus the reduced number of remakes more than
absorb the cost of making the tray [12].
Economic factors
There can be signicant dierences in the cost of impression materials.
Reversible hydrocolloid is less expensive that elastomeric materials, but
there are costs associated with conditioning and tempering baths and costs
for water-cooled trays. Polyether and PVS materials are similar in cost and
are more expensive than competing elastomers. However, it is likely true in
most practices that dierences in the costs of impression materials are of
minimal consequence. Practitioners can reduce costs by using auto-mix
devices, by using the dual-arch technique when indicated and custom trays
for full-arch impressions, and by reducing the number of remakes.
Fig. 2. Full arch impressions with multiple preparations should be made with custom trays. Use
of custom trays provides optimum accuracy, conserves material, and provides patient comfort.
452 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470
Uniform bulk
All impression materials shrink slightly upon setting. Reversible
hydrocolloid material is chilled using water cooler trays, and as the material
cools, shrinkage occurs as a thermoplastic event. Elastomeric impression
materials set by means of polymerization reactions with monomeric units
forming polymer chains. When clinical setting begins, substantial cross-
linking of the polymer chains has occurred. With these materials there is
a slight amount of polymerization shrinkage. To obtain the most accurate
impression, it is imperative to use a relatively uniform amount of bulk in
the impression so that there is uniform shrinkage throughout the body of
the impression. This shrinkage is counteracted by slight expansion of the
gypsum casting material.
Dierent impression materials require dierent cross-sectional thick-
nesses of impression material to provide optimum accuracy. Water-based
impression materials, such as reversible and irreversible hydrocolloid,
provide maximum accuracy with a cross-sectional thickness of 4 to 6 mm
[13]. This thickness is achieved with the use of a properly sized stock tray.
Elastomeric impressions are most accurate when used with a cross-
sectional thickness of approximately 2 mm [14]. This thickness is optimally
provided with a custom tray. Numerous articles have compared accuracy of
impressions made with a custom tray with the accuracy of impressions made
with a stock tray [1524]. Although a few recent studies indicate that
impressions for single restorations can be adequately made with PVS
impression material in a stock tray, these studies generally demonstrate
improved accuracy with custom trays.
The dierence in cross-sectional thickness of material in a stock tray
is only about 1.5 to 2 mm thicker than that in a custom tray [25]. This
mandates precision in fabrication of the custom tray because small dif-
ferences in cross-sectional thickness can aect accuracy. Custom trays
should be constructed on the diagnostic cast using one layer of base plate
wax as a spacer. Trays can be fabricated with polymethylmethacrylate
(PMM), photo-cure bisacryl materials (Triad; Dentsply International,
Milford, Delaware), or PVS putty materials [26]. PMM trays should be
fabricated at least 24 hours in advance to insure stability.
Occlusal stops are critical for proper orientation of the tray in the mouth.
Three occlusal stops are ideal, with at least one stop posterior to the prepared
teeth. Stops should be placed on nonfunctioning cusp tips to minimize
distortion in the area of the stops. Stops are prepared by removing the base
plate wax from the nonfunctioning cusp tips with a hand instrument. The
wax spacer should be covered with tin foil before making the tray to facilitate
removal the wax from the tray and to prevent incorporation of a wax residue
on the internal surface of the tray due to the inherent exotherm that occurs
during the setting reaction of the PMM tray material. This residue can
interfere with the proper functioning of tray adhesives.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 453
Viscosity control
Elastomeric impression materials are supplied in a number of viscosities,
ranging from very low viscosity to very high viscosity putty materials. The
main dierence between the dierent viscosities is the amount of inert ller
in the material. Two rules of thumb regarding dierent viscosity materials
are (1) the lower the viscosity, the better the ne detail reproduction and (2)
the lower the viscosity, the greater the polymerization shrinkage during the
setting reaction. Thus, the optimum method of impression making is to use
as little low-viscosity material as possible to capture the ne detail of the
prepared margin, grooves, box-forms, etc., and the bulk of the impression
should be made with high-viscosity material. The heavy-body material helps
push the light-body material into the gingival sulcus and results in minimal
distortion due to polymerization shrinkage.
454 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470
Adequate mixing
Most elastomeric impression materials are provided as base/catalyst
systems. When separate tubes of base and catalyst material are provided,
hand mixing is required. Usually, the base and catalyst materials are of
contrasting colors, and generally equal lengths of both materials are
extruded on the mixing pad. The materials then should be vigorously
stropped until a homogeneous material is obtained.
Almost all contemporary impression materials are dispensed using some
type of auto-mix system. These systems provide optimum mixing of the
material with signicantly fewer inherent voids, extend the essential working
time of the material, and reduce waste of the material because they are
loaded from the dispenser directly into the syringe or tray [28,29].
Disinfection
Microorganisms in the oral cavity can be transmitted from impressions to
the dental laboratory [30]. The clinician must disinfect impressions before
pouring the cast or sending the impressions to the dental laboratory. An
alternative to disinfecting impressions is to use disinfected die stones [31].
This approach avoids potential distortions related to procedures essential
for disinfecting impressions.
The rst step of any disinfecting technique is to rinse the impression in
tap water. This step removes a signicant portion of the microorganisms
from the impression. Disinfection techniques involve spraying the impres-
sions with disinfection agents or immersion of the impression materials in
chemical agents such as sodium hypochlorite [32]. PVS materials are stable
in this regard, but special care must be taken with water-based materials and
polyethers to insure that adequate immersion times are used to eliminate
microorganisms but that extended immersion times are avoided to prevent
excess imbibition of the disinfecting solution and distortion of the
impression.
Fig. 3. These casts have unpolymerized impression material on the margins of the preparations
as a result of indirect inhibition of polymerization of the PVS material by latex gloves.
Fig. 4. Custom trays can be fabricated from PMM acrylic resin, light-cured resin, or PVS putty
materials.
Fig. 5. Occlusal view of arch requiring impressions of implants and prepared teeth.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 457
Fig. 7. The segmental impression with tooth preparations and impression copings.
458 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470
Fig. 8. Arch with resultant denitive restorations on teeth and tissue bar on implants.
Fig. 9. When radicular attachments are used to retain over-denture bars, impressions of the
dowel space may be necessary to fabricate working casts.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 459
Fig. 11. Silver plated cast obtained from the impression in Fig. 10.
460 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470
Fig. 13. The corrected impression is made with the provisional restorations seated in the master
impression.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 461
Fig. 14. The provisional restoration indexed to the master cast with corrected pontic contours.
inaccurate occlusal pattern for the resultant cast. Thus, the entire
impression, rather than just the relieved area, should be washed. This
creates the potential problem of hydraulic distortion of the putty material as
the impression is seated in the mouth. This is impossible to detect on
a clinical level but may have a deleterious eect on the accuracy if the
impression and resulting restoration.
The third approach to putty/wash impressions is the so-called simul-
taneous or squash technique. With this technique, a stock tray is loaded
with putty material, and the syringe material is injected around the prepared
tooth or teeth. The tray containing the putty material is squashed over the
Fig. 15. Occlusal view of the pontic sites after the corrected soft-tissue cast is poured against the
provisional restoration.
462 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470
Fig. 16. Occlusal view of the pontic and peri-implant soft tissue to be captured in the
impression.
syringe material, and the impression is made with the putty material and the
syringe material setting simultaneously. This approach is unacceptable
because it is impossible to control the thickness of impression material and
excess bulk is used. It is impossible to control what material records the
margin detail of the preparation(s). Usually portions of the prepared margin
are captured in the putty, and putty materials are essentially decient in
their ability to record marginal detail [6].
It is generally recommended that complete arch impressions should be
made wherever possible; however, there are numerous clinical situations
where specialized impression techniques can be used to great advantage.
Fig. 17. Impression of the tooth preparations, implant copings, and provisional restorations.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 463
Fig. 19. The soft tissue contours are registered with the modied impression technique.
464 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470
The dual-arch technique should be used only with patients that have existing
anterior guidance. Because a half-arch impression is used, no recording of
the contralateral arch guidance is made. If the patient does not have existing
anterior guidance, nonworking (balancing) interferences may be introduced
in the new restorations.
For this technique to be successful, the patient must be able to close
completely in MIP with the impression tray in place. This should be tested
diagnostically before the preparation appointment so a custom tray can be
fabricated if the patient cannot close in the correct position. The patient
should be instructed to close in MIP with the tray out of the mouth. The
operator should visually note the nature of the contact on the contralateral
side and verify the patient is in MIP using Mylar shim-stock (Silver Mylar
Strips; Du Pont, Wilmington, Delaware). Once this is veried, the dual-arch
impression should be placed in position, and the patient should be
instructed to again close in MIP. This should be in the identical position
to that previously achieved, and this should be conrmed visually and with
Mylar strips. Finally, when the tooth or teeth are prepared, Mylar strips on
the contra-lateral side should be used as the patient closes into the
impression material to conrm the patient has closed in the MIP position.
The presence of third molars, a rapidly ascending ramus, or excess soft
tissue distal to the molars often prevents complete closure with the tray in
place. The double-bite technique should not be used in these patients.
Rigid metal trays are ideal for this technique (Quad Trays; Clinicians
Choice, London, Ontario). Rigid PVS or polyether materials should be used
as well. Many plastic-mesh trays are available for this technique, but they
should be avoided because they are too exible. Often the buccal-lingual
width of the arch is wider than the trays. The resilient tray exes outward
when the impression is made and rebounds when the impression is removed
from the mouth, thus permanently distorting the impression.
T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470 465
The advantages of the dual arch technique include its clinical simplicity
and the accurate recording of the MIP position. An additional advantage
is that a closed-mouth technique is used that eliminates any mandibular
exure that might be associated with opening [46]. The laboratory
procedures associated with the technique are slightly more complicated
but can easily be handled once the technique is understood by the dentist
and the laboratory technician.
Tooth/implant impressions
Dental implants have become an integral part of restorative dentistry,
and frequently impressions for master casts include implants and prepared
teeth. In these situations, implant copings can reduce access to the prepared
teeth and impede the extrusion of impression material to the margins of
the prepared teeth. A useful method to precisely record the detail of
the prepared teeth and the implants is to use a combination of cus-
tom impression trays to impress the prepared teeth and then place the im-
plant impression copings and make an over-impression of the arch (Fig. 5)
[4851].
With this technique, the teeth must be preliminarily prepared, and a cast
of these prepared teeth must be obtained to fabricate the custom impression
trays. A wax spacer of approximately 1 mm is placed around the prepared
teeth, and PMM acrylic resin custom trays are fabricated with external
undercuts to facilitate pick up with an over-impression (Fig. 6). The
appropriate impression adhesive is applied to the custom tray(s) internally
and externally and allowed to dry. If the margins of the tooth preparations
are within 0.5 mm of the gingival margin, no gingival displacement is
required. A heavy-bodied PVS impression material is placed in the in-
dividual custom tray and is seated over the preparation(s). The heavy-body
impression material is allowed to set, and the impression tray is removed
and the impression is inspected for completeness and lack of voids. The
impression and tray are perforated through the occlusal surface with a #6
round bur. This preliminary impression is then lled with light-body
material and replaced over the prepared teeth. The hydraulics of this
technique force impression material beyond the prepared subgingival
margins. The implant copings are then attached, and an over-impression
is made (Figs. 7, 8).
Summary
Clinicians have an excellent array of impression materials and techniques
to use in the fabrication of tooth- and implant-supported restorations.
Obtaining maximum accuracy of impressions is critical to the provision of
precise restorative dentistry.
Based on the quality of impressions sent to commercial laboratories, it
seems that many impressions fall far short of the level of quality made
possible by current impression materials. The clinician is urged to review
468 T.E. Donovan, W.W.L. Chee / Dent Clin N Am 48 (2004) 445470
References
[1] Christensen GJ. What category of impression material is best for your practice? J Am Dent
Assoc 1997;128:10268.
[2] Winstanley RV, Carrotte PV, Johnson A. The quality of impressions for crowns and
bridges received at commercial dental laboratories. Br Dent J 1997;183:209.
[3] Donovan TE, Cho GC. Predictable esthetics with metal-ceramic and all-ceramic crowns:
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Dent Clin N Am 48 (2004) 471486
General principles
If the goal of restorative treatment is to maintain a patients pretreatment
intercuspation and vertical dimension of occlusion (VDO), casts should be
mounted in a manner that maintains the same tooth-to-tooth relationship
that existed before treatment. This maximum intercuspal position (MIP)
facilitates treatment and works with the patients existing occlusion. The
vast majority of cases treated fall within this MIP category. The situation
becomes more dicult if a patient requires extensive treatment or if the
VDO needs to be altered. In these circumstances, a reproducible maxillo-
mandibular position from which treatment is performed is essential and
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2004.01.001
472 R.S. Squier / Dent Clin N Am 48 (2004) 471486
requires a centric relation record made at the terminal hinge axis. This
article deals with situations where the patients MIP and VDO do not
change as a result of treatment.
Fig. 1. (A) An existing tripod of widely spaced contacts with good intercuspation of the teeth
does not require an interocclusal record. (B) An interocclusal record was unnecessarily made
and will most likely prevent the two casts from articulating well.
Fig. 2. (A) An interocclusal record was made unnecessarily. (B) Removal of the interocclusal
record shows that it was not needed due to a good tripod of vertical support and horizontal
stability.
Fig. 3. (A) An interocclusal record that has not been trimmed. (B) An interocclusal record that
has been trimmed properly on one side to remove all areas of the record that contact soft tissues
and the axial surfaces of the teeth. The other side has not been fully trimmed to demonstrate the
dierence in the amount of material needed.
in an inaccurate mounting that may lead to the need for excessive adjust-
ments upon delivery of the restoration or the possibility of no occlusion
between the restoration and the opposing teeth.
Fig. 4. Interocclusal record made with a rigid autopolymerizing resin. In a distal extension
situation, resin placed conservatively between the tooth preparation and the opposing tooth
creates the needed leg of the tripod for mounting the casts.
The record base is adapted to the edentulous portion of the cast and often
to the lingual surfaces of the remaining teeth to enhance stability and
retention (Fig. 5). Record bases usually are made from light-activated resin
or autopolymerizing resin. The occlusion rim is able to function only as
a substitute for a leg of a tripod when the record base is stable in the mouth
and on the cast. The occlusion rim can easily and cheaply be made from
baseplate wax to imprint the cusp tips of the opposing teeth, or other mate-
rials may be used, including metal-impregnated wax or the more rigid of
the elastomeric interocclusal recording materials (eg, Blu-Mousse; Parkell,
Farmingdale, New York).
If the working cast with crown preparations contains the edentulous
areas where tripod stops are desired, the record base cannot be made until
the nal impression is made, poured, and separated and the cast is trimmed.
This usually requires that the patient make a separate brief appointment for
a jaw relationship record before fabrication of the restorations. However, if
the edentulous areas are located in the opposing arch, the practitioner who
has planned ahead may have the record base-occlusion rim made on the
opposing cast before the nal impression visit, allowing the interocclusal
record to be made at the nal impression appointment.
Because of the popularity of the elastomeric materials for interocclusal
records, they are often abused. One situation where this is the case is when
there is an absence of a tripod of support and there is a need to create the
tripod. Polyvinylsiloxane and polyether are ineective materials when
creating a tripod of support due to their inherent compressibility. Although
the materials are easy to use for interocclusal records, their use during the
mounting of the casts can be technique sensitive. It is dicult to objectively
determine the amount of force that should be exerted on the casts when
mounting them with the interocclusal record. Too much force can cause
compression of the elastic record, resulting in some part of the casts placed
R.S. Squier / Dent Clin N Am 48 (2004) 471486 477
Fig. 5. (A) A light-activated resin record base with wax occlusion rim for making an
interocclusal record. (B and C) Light-activated resin record bases with respective interocclusal
records made in an elastomeric recording material. Note how the record bases are supported by
the lingual surfaces on the remaining teeth and that a minimum of recording material is used to
record only the cusp tips of the opposing teeth.
too closely together, and too little force can allow for inadequate seating of
the cast into the record, resulting in casts that are too far apart. Therefore,
despite the relative accuracy and dimensional stability of elastomeric
materials and their ease of use and convenience, their use in these cir-
cumstances is likely to result in an inaccurate mounting and subsequent
478 R.S. Squier / Dent Clin N Am 48 (2004) 471486
Articulator choice
When fabricating xed and removable prostheses, the use of an ad-
justable articulator usually reduces the amount of intraoral adjustment
Fig. 6. A tted RPD framework used as a record base and the occlusion rim formed directly
into the meshwork areas. The framework adds retention and stability for the interocclusal
records, thereby increasing its accuracy.
R.S. Squier / Dent Clin N Am 48 (2004) 471486 479
Purpose of a facebow
The purpose of a facebow transfer is to orient the maxillary cast to
the transverse axis of the articulator. Its use is limited to adjustable and
semi-adjustable articulators. Facebows are not necessary if there will be no
change in the VDO. However, if any alteration of the VDO is planned, as in
a full-mouth rehabilitation, a facebow (and a full-sized articulator) should
be used. Another positive aspect of using a facebow is that it makes it easier
to mount a maxillary cast to a full-sized articulator.
Fig. 7. (A) An overextended alginate should never be placed directly into contact with a at
surface. This causes distortion of the unsupported alginate material and results in an inaccurate
cast. (B) Ideally, an alginate impression with distal extensions should be placed in a holding
tree where the impression hangs from its handle rather than rests on a countertop during
disinfection and pouring in dental stone.
from the impression material. This loss of water distorts an impression and
produces inaccuracies in the cast that aect the working dies for a xed
restoration or the articulation of the casts. It is important when using
any impression material to read the manufacturers recommendations for
the maximum time allowable before pouring the impression to reduce
inaccuracies.
Mush bites
When a patient is asked to bite into a large amount of material, it is often
impossible to determine whether their teeth are coming into contact with
one another because the amount of material obscures the practitioner from
visualizing good tooth contact (Figs. 8 and 9). In addition, when applying
the material for this type of record, if part of it sets while the rest of it is
dead soft, the accuracy is compromised. In general, interocclusal records
should be made with a minimum of material between the teeth or applied to
a record base.
Fig. 8. (A) This patient was asked to bite into a large amount of putty material as an
interocclusal record. (B) In the laboratory, it was clear from the marks on the adjacent teeth
that the mush bite prevented the patient from fully closing. In addition, there was insucient
occlusal reduction of the tooth preparations. In this situation where the restorations serve as the
third leg of the tripod, a more rigid interocclusal material, such as resin, would be preferred over
an elastomeric impression material due to increased accuracy.
same. If not, there is likelihood that the patient did not close correctly or
fully through the impression material.
Fig. 10. A triple tray impression can be problematic because it is often dicult to visualize
tooth contacts with a large amount of impression material in a patients mouth. In this case, it is
clear that the teeth on the opposite side of the arch are not contacting. If the tooth contacts are
not the same as without the impression in the mouth, there is likelihood that the patient did not
close correctly or fully through the impression material, and the impression should be remade.
R.S. Squier / Dent Clin N Am 48 (2004) 471486 485
Fig. 11. The best method of mounting maxillary and mandibular casts on an articulator to
avoid any potential movement is to join the dry casts with a combination of rigid sticks and
compound. Before joining the two casts, the heels of the casts were checked for any interference.
Note that the maxillary cast has already been mounted using a facebow, and the articulator has
been inverted to mount the mandibular cast after the two have been joined rigidly.
the restoration to the dentist for delivery. This step can reduce the number
of returns of the restorations to the laboratory for the addition of proximal
and occlusal contacts and can make delivery of nal restorations easier and
more pleasurable.
Summary
This article discusses and reviews general principles of jaw relation
records, including the purpose of a jaw relation record and the concept of
486 R.S. Squier / Dent Clin N Am 48 (2004) 471486
Acknowledgments
The author thanks Dr. Martin Freilich for his expertise and guidance in
the writing of this article.
References
[1] Freilich MA, Altieri JV, Wahle JJ. Principles for selecting interocclusal records for
articulation of dentate and partially dentate casts. J Prosthet Dent 1992;68:3617.
[2] Balthazar-Hart Y, Sandrik JL, Malone WFP, Mazur B, Hart T. Accuracy and dimensional
stability of four interocclusal recording materials. J Prosthet Dent 1981;45:58691.
[3] Fattore LD, Malone WFP, Sandrik JL, Mazur B, Hart T. Clincial evaluation of the
accuracy of interocclusal recording materials. J Prosthet Dent 1984;51:1527.
[4] McGivney GP, Castleberry DJ. McCrackens removable partial denture prosthodontics.
8th ed. St. Louis: CV Mosby; 1989.
[5] Warren K, Capp N. A review of principles and techniques for making interocclusal records
for mounting working casts. Int J Prosthodont 1990;3:3418.
Dent Clin N Am 48 (2004) 487497
Interim restorations
David G. Gratton, DDS, MS*,
Steven A. Aquilino, DDS, MS
Department of Prosthodontics, College of Dentistry, University of Iowa,
Iowa City, IA 52242-1001, USA
Biologic requirements
An interim restoration must maintain the health of the pulpal and
periodontal tissues [4]. Once the dentinal tubules are exposed through tooth
preparation, the internal adaptation, the marginal integrity of the interim
restoration, and the provisional luting agent help protect the pulp from the
* Corresponding author.
E-mail address: david-gratton@uiowa.edu (D.G. Gratton).
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.007
488 D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497
Biomechanical requirements
Interim restorations must be able to withstand the functional forces of
mastication without fracture or displacement. This is particularly true for
interim xed partial dentures. In addition, the interim restoration must
maintain the position of the prepared teeth and the stability of inter- and
intra-arch relationships through the establishment of optimum proximal
and occlusal contacts. Maintenance of these contacts prevents the prepared
teeth or opposing teeth from mesial or distal drifting and supraeruption. It is
essential that interim xed partial dentures maintain the interabutment
relationship recorded during the nal impression procedure until the
denitive prosthesis is placed. Anterior interim restorations must maintain
the appropriate protrusive and lateral guidance for the patient.
Reinforcement
To enhance the mechanical properties of acrylic resins, various reinforcing
techniques have been advocated. These have included glass bers, nylon
bers, aluminum and sapphire whiskers, polycarbonates, metal strengtheners,
and carbon graphite bers [15,2326]. The eectiveness of these strengthening
mechanisms varies, with the over-riding requirement being adequate bond
formation between the reinforcing material and the parent resin. If there is not
an adequate bond, the ller may act as an inclusion body and weaken the
prosthesis. In addition, although the incorporation of materials such as
polyethylene and carbon graphite bers has been shown to increase the moduli
of elasticity of commonly used provisional xed partial denture materials,
technical diculties and esthetic concerns have prevented their widespread use
[15]. If these ber reinforcements protrude from the interim restoration
surface, they may be dicult to polish and can act as a wick, attracting oral
bacteria.
D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497 491
Exothermic reaction
For all interim materials, the potential for pulpal injury exists during the
fabrication of direct interim crown or xed partial denture restorations due
to the heat generated during the exothermic setting reaction [27]. In vivo
investigation has determined that a 10 F (5.6 C) increase in pulpal
temperature resulted in a 15% loss of vitality of tested pulps, a 20 F
(11.2 C) increase in pulpal temperature resulted in a 60% loss of pulpal
vitality, and a 30 F (16.8 C) increase in pulpal temperature resulted in 100%
pulpal necrosis [28]. The temperature increase during polymerization of
PMMA has been shown to be signicantly higher than that for PVEMA,
VLC urethane dimethacrylate, and bis-acryl composite resin, with the VLC
urethane dimethacrylate exhibiting signicantly less polymerization tem-
perature increase than the other resins [29]. In a study that compared two
auto-polymerizing bis-acryl resins with three dual-cured bis-acryl resins, the
peak polymerization temperature of the auto-polymerizing bis-acryl resins
was signicantly higher than that of the three dual-cured bis-acryl resins
[30]. Peak polymerization temperature increases have been associated with
the volume of acrylic resin [31].
Contrary to manufacturer claims, all resin materials used in the
fabrication of interim prostheses exhibit an exothermic reaction. In general,
PMMA exhibits the greatest exothermic reaction, followed by PVEMA,
PEMA, bis-acryl composite, and VLC urethane dimethacrylate resins. In
addition to the chemical class of material used, various fabrication
techniques have been shown to substantially inuence the peak temperature
rise during direct fabrication of interim restorations [3234].
The clinician should limit the thermal insult to the pulp by selecting an
appropriate interim material, minimizing the volume of material, and
choosing an appropriate fabrication technique.
Color stability
As patients become more esthetically aware and demanding, it is
paramount that the clinician provides an esthetically acceptable interim
restoration. The shade selected for the interim prosthesis should match the
adjacent and opposing teeth and should not exhibit a color shift during the
time of provisionalization. Interim restoration color instability may be due
to the incomplete polymerization of the material, sorption of oral uids,
surface reactivity, dietary habits, and oral hygiene. Historically, the PMMA
provisional materials were found to be more color stable than PEMA and
PVEMA provisional materials [3538]. As with other physical properties,
color stability cannot be predicted solely on the chemical classication of the
material [3941]. Surface nish may also contribute to the propensity of
provisional materials to stain, with porous unpolished surfaces exhibiting
signicantly more darkening than highly polished materials [35].
492 D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497
Fabrication techniques
Multiple techniques exist for the fabrication of interim restorations.
Essentially, a matrix is required to form the external contours of the interim
restoration. The internal adaptation of the interim restoration can be
formed directly on the prepared tooth or teeth (the direct technique) or on
a stone cast of the prepared tooth or teeth in the dental laboratory (the
indirect technique).
Matrices
For either technique, a matrix is required to create the external axial and
occlusal contours of the interim restoration. Prefabricated or preformed
aluminum, tin, stainless steel, polycarbonate, and cellulose acetate external
crown forms are available in various tooth sizes and shapes. They are
limited to single-unit restorations and may require substantial adjustment to
achieve appropriate proximal contours and occlusion. These crown forms
are usually relined directly with a resin-based material to achieve in-
dividualized internal adaptation and marginal t [4].
The use of a custom matrix is preferable for the fabrication of multiple
unit and complex interim restorations [42]. These matrices are fabricated
from thin vacuum-formed materials or elastomeric impression materials.
Whereas a duplicate stone cast of the diagnostic wax-up is required for
thermoplastic vacuum-formed materials, a polyvinyl Siloxane putty
material is convenient to use and can be adapted directly to the stone cast
or the diagnostic wax-up of the proposed restoration, resulting in precise
anatomic detail. The use of a polyvinyl siloxane material as the matrix has
been shown to signicantly reduce peak polymerization temperatures as
compared with the use of a vacuum-formed polypropylene matrix material
[32,33]. Other materials that have been advocated for use as a custom matrix
include wax, thermoplastic resins, and irreversible hydrocolloid impression
materials.
Direct technique
The direct technique involves the use of a mold or matrix that is related
intraorally to the prepared teeth. The matrix is made from a preoperative
diagnostic cast or from a diagnostic wax-up. After tooth preparation, the
matrix is trial tted in the patients mouth. The prepared teeth are washed,
gently dried (not desiccated), and lubricated with petroleum jelly. Any
surrounding composite resin restorations should also be lubricated with
petroleum jelly. The selected provisional material is mixed according to the
manufacturers instructions and placed into the matrix; care is taken not to
incorporate any air bubbles. The matrix with the provisional restorative
material is then seated over the prepared teeth and allowed to polymerize.
At this point, careful attention must be paid to the working and setting
D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497 493
times of the material being used to minimize heat build-up due to the
exothermic reaction and to prevent the restoration from becoming locked
into any undercuts on the preparation or adjacent gingival embrasures [33].
Using the air water syringe may aid the dissipation of the heat generated. To
prevent pulpal damage or locking of the interim restoration on the
preparations, some advocate that the interim restoration be removed after
the rubbery stage has been reached and allowed complete polymerization
outside the mouth. This technique is problematic with PMMA resins due to
their polymerization shrinkage. It is more appropriate for the bis acrylics,
which have less polymerization shrinkage as compared with PMMA. An
on-o technique is advocated to prevent locking the interim restoration
on to the preparations during polymerization. After the provisional material
has reached the rubbery stage, the interim restoration is teased partially o of
the preparations and reseated several times throughout the setting reaction
while the area is ushed with water as a coolant until polymerization is
complete [34]. Unfortunately, this technique has been shown to result in
relatively poor marginal integrity [43]. Other researchers advocate letting the
restoration achieve nal set in situ but emphasize the need to continually ush
the area with water to prevent thermal damage to the pulp. This technique is
not realistic; the interim prosthesis will likely be dicult to remove due to the
presence of interproximal undercuts on the teeth adjacent to the preparations.
The advantage of the direct technique is that it is the most ecient use of
time and materials because no intermediate impression or stone cast is
required. The disadvantages of the direct technique are that the freshly cut
dentin and the vital pulpal tissues are exposed to the heat generated during
the exothermic polymerization reaction and to the free monomer or other
irritating chemicals present in the unpolymerized interim restorative
materials. The direct technique is well suited for single crowns and short-
span (up to three units) xed partial dentures.
Indirect technique
A similar, although more complex, protocol is followed when the
indirect technique for interim restoration fabrication is planned. After tooth
preparation, an irreversible hydrocolloid impression or a fast setting
multipurpose nonaqueous elastomeric impression is made of prepared teeth.
The impression is poured in fast setting plaster or stone. The decreased
strength of the dental plaster can be helpful when removing the interim
restoration from the cast. The matrix is trial tted to the cast, and
modications are made to the matrix or cast until complete seating of the
matrix is achieved. A separating medium (petroleum jelly or tinfoil substitute)
is applied liberally to the prepared teeth, adjacent teeth, and tissues on the cast.
The desired provisional material is mixed according to the manufacturers
instructions and carefully loaded into the matrix. The matrix is then
positioned over and rmly seated onto the cast until complete seating of the
494 D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497
matrix is achieved. A gypsum core can be used in conjunction with the matrix
to ensure full seating and to optimize the interim restorations occlusal vertical
dimension [42]. The matrix can be stabilized with elastic bands and the cast/
matrix assembly placed in warm water in a pressure pot to increase density and
to optimize the physical properties of the completely polymerized restoration.
The indirect technique has several advantages over the direct technique
for interim restoration fabrication. Because the provisional materials do not
polymerize intraorally, the pulpal tissues are not exposed to the exothermic
polymerization reaction or to unreacted free monomer or other chemical
irritants. Because the amount of heat generated is proportional to the
volume of material used, the indirect technique is most often indicated for
the fabrication of interim restorations for multiple crowns or complex xed
partial dentures with multiple pontics where the exothermic reaction cannot
easily be controlled intraorally. Although the indirect technique has been
described as more accurate [44], incomplete capture of preparation margins
and polymerization changes may require repair or reline of the restoration
intraorally.
The main disadvantage of the indirect technique is that an intermediate
impression and stone cast are required to fabricate the interim restoration,
resulting in increased time and materials required for fabrication.
Indirect-direct technique
A combination of the two techniques is proposed to provide a relatively
atraumatic means to achieve the most accurate tting interim prosthesis [4].
The technique involves the fabrication of a thin shell indirectly on
a minimally reduced cast of the proposed restorations. These shells are
relined with the provisional restorative material intraorally. This technique
combines the best marginal accuracy with the least potential for thermal
damage to the pulpal tissues. However, as with the indirect technique, the
indirect-direct technique requires greater time and laboratory support.
Marginal integrity
Regardless of the technique used in fabrication, one of the key require-
ments of an interim prosthesis is to provide a denitive marginal seal to
prevent pulpal sensitivity, provisional cement washout, bacterial ingress, and
secondary caries or pulpal necrosis. A denitive marginal seal also promotes
optimal periodontal and gingival health and facilitates the impression and
cementation procedures and maintenance of the gingival architecture [45].
The specic technique used in the fabrication of an interim restoration has
a signicant impact on the resultant marginal integrity. Having the material
polymerize completely and undisturbed intraorally on the tooth preparation
or on a gypsum cast of the preparation provides the most accurate marginal
adaptation [43]. However, this method is impractical with the direct
technique because leaving the material undisturbed leads to locking the
D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497 495
Summary
Interim restorations are a critical component of xed prosthodontic
treatment. In addition to their biologic and biomechanical requirements,
interim restorations provide the clinician with valuable diagnostic informa-
tion. They act as a functional and esthetic try-in and serve as a blueprint for the
design of the denitive prosthesis. In selecting a material for the fabrication of
a single crown or multi-unit interim restoration, the clinician must consider
multiple factors, such as physical properties (eg, exural strength, surface
hardness, wear resistance, dimensional stability, polymerization shrinkage,
color range and stability, and radiopacity), handling properties (eg, mixing
time, working time, predictable and consistent setting time, ease of trimming
and polishability, and repairability), patient acceptance (eg, smell and taste),
and material cost. There is no one material that meets all requirements [16].
Complicating the clinicians ability to choose a material is the fact that the
material classication alone of a given product is not a predictor of clinical
performance. However, some clinical trends are noteworthy. For single-unit
restorations, the bis-acryl materials oer many desirable properties. They tend
to have low exothermic reactions, minimal polymerization shrinkage, minimal
odor and objectionable taste, and relatively quick setting reaction and are easy
to trim and marginally accurate. In addition, many of the bis-acryl provisional
materials oer convenient cartridge delivery systems, which may allow for
more consistent mixes [49]. Disadvantages include their brittleness and
increased cost, which are not as critical for single-unit interim restorations.
For multi-unit, complex, long-term interim xed prostheses, the PMMA
provisional materials remain the material of choice. They have high exural
strength, good reparability, high polishability, acceptable marginal t, good
color stability, excellent esthetics, and cost eectiveness.
The clinician must have a thorough knowledge of the handling
characteristics and properties of the interim restoration material selected.
496 D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497
The technique used for fabrication will most likely have a greater eect on
the nal result than the specic material chosen.
References
[1] The glossary of prosthodontic terms. J Prosthet Dent 1999;81:39110.
[2] Skurow HM, Nevins M. The rationale of the preperiodontal provisional biologic trial
restoration. Int J Periodontics Restorative Dent 1988;8:829.
[3] Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Provisional restorations:
fundamentals of xed prosthodontics. Chicago: Quintessence; 1997.
[4] Gegau AG, Holloway JA. Provisional restorations. In: Rosenstiel SF, Land MF,
Fujimoto J, editors. Contemporary xed prosthodontics. St. Louis: Mosby; 2001.
p. 380416.
[5] Fox K, Gutteridge DL. An in vitro study of coronal microleakage in root-canal-treated
teeth restored by the post and core technique. Int Endod J 1997;30:3618.
[6] Baldissara P, Comin G, Martone F, Scotti R. Comparative study of the marginal
microleakage of six cements in xed provisional crowns. J Prosthet Dent 1998;80:41722.
[7] Donaldson D. The etiology of gingival recession associated with temporary crowns.
J Periodontol 1974;45:46871.
[8] Amsterdam M, Fox L. Provisional splinting - principles and technics. Dent Clin North Am
1959;4:7399.
[9] Federick DR. The provisional xed partial denture. J Prosthet Dent 1975;34:5206.
[10] Waerhaug J. Temporary restorations: advantages and disadvantages. Dent Clin North Am
1980;24:30516.
[11] Kaiser DA, Cavazos E Jr. Temporization techniques in xed prosthodontics. Dent Clin
North Am 1985;29:40312.
[12] Rieder CE. Use of provisional restorations to develop and achieve esthetic expectations.
Int J Periodontics Restorative Dent 1989;9:12239.
[13] Yuodelis RA, Faucher R. Provisional restorations: an integrated approach to periodontics
and restorative dentistry. Dent Clin North Am 1980;24:285303.
[14] Haselton DR, Diaz-Arnold AM, Vargas MA. Flexural strength of provisional crown and
xed partial denture resins. J Prosthet Dent 2002;87:2258.
[15] Larson WR, Dixon DL, Aquilino SA, Clancy JM. The eect of carbon graphite ber
reinforcement on the strength of provisional crown and xed partial denture resins.
J Prosthet Dent 1991;66:81620.
[16] Wang RL, Moore BK, Goodacre CJ, Swartz ML, Andres CJ. A comparison of resins for
fabricating provisional xed restorations. Int J Prosthodont 1989;2:17384.
[17] Ireland MF, Dixon DL, Breeding LC, Ramp MH. In vitro mechanical property
comparison of four resins used for fabrication of provisional xed restorations. J Prosthet
Dent 1998;80:15862.
[18] Osman YI, Owen CP. Flexural strength of provisional restorative materials. J Prosthet
Dent 1993;70:946.
[19] Diaz-Arnold AM, Dunne JT, Jones AH. Microhardness of provisional xed prosthodontic
materials. J Prosthet Dent 1999;82:5258.
[20] Gegau AG, Pryor HG. Fracture toughness of provisional resins for xed prosthodontics.
J Prosthet Dent 1987;58:239.
[21] Gegau AG, Wilkerson JJ. Fracture toughness testing of visible light- and chemical-
initiated provisional restoration resins. Int J Prosthodont 1995;8:628.
[22] Koumjian JH, Nimmo A. Evaluation of fracture resistance of resins used for provisional
restorations. J Prosthet Dent 1990;64:6547.
[23] Bjork N, Ekstrand K, Ruyter IE. Implant-xed, dental bridges from carbon/graphite bre
reinforced poly(methyl methacrylate). Biomaterials 1986;7:735.
D.G. Gratton, S.A. Aquilino / Dent Clin N Am 48 (2004) 487497 497
Casting alloys
John C. Wataha, DMD, PhD*, Regina L. Messer, PhD
Medical College of Georgia School of Dentistry, Augusta, GA 30912-1260, USA
* Corresponding author.
E-mail address: watahaj@mail.mcg.edu (J.C. Wataha).
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.010
500 J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512
this strength increases to 395 MPa [1,2]. With the appropriate addition of
other elements and proper casting conditions, the strength increases to over
500 MPa. Even more impressive is the increase in hardness: from 28 kg/mm2
for pure gold to nearly 200 kg/mm2 for a typical gold-based casting alloy.
Thus, the use of alloys provides physical and biologic properties that are
required for successful, long-term xed prostheses.
Phase structure
When metals and nonmetals are mixed to create an alloy, they have
varying degrees of solubilities in each other [4]. The ability of elements to
dissolve in each other is similar to compounds encountered in everyday life,
such as alcohol and water or vinegar and oil. If most of the components of
the alloy dissolve in one another, the alloy is described as a single-phase alloy
and has a more or less homogeneous composition throughout. If one or more
components are not soluble in the other, then two or more phases form in the
solid state, each having a dierent composition. In this case, the alloy is
described as a multiple-phase alloy. Single-phase alloys are generally easier to
manipulate (ie, easier to cast) and have lower corrosion rates than multiple-
phase alloys [3]; however, multiple-phase alloys may be etched for bonding
and may be signicantly stronger than single-phase alloys [1,2]. Before 1975,
the majority of alloys were single phase, being based on gold, which is
miscible with silver, copper, and palladium [4]. Todays alloys often use more
complex chemistries based on other elements that are not soluble in each
other. A typical nickel-based alloy has 8 to 10 dierent metals and 3 or 4
distinct phases. The phase structure of an alloy is not discernible by the
naked eye, so the clinician must rely on laboratory or manufacturer
information to know an alloys phase structure.
J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512 501
Grain size
A second important microstructural feature of casting alloys is their grain
size. Grains are crystals of the alloy that form upon solidication from small
nuclei, much as ice crystals form from water. As an alloy cools from the
liquid state, these crystals grow until they meet each other at boundaries
called grain boundaries. The size of the grains is inuenced by factors such as
the cooling rate of the alloy, the presence of special nucleating elements such
as iridium, heat treatment after casting, and the composition of the alloy [5].
For gold-based alloys, a small (\30 lm) grain size has been shown to
improve tensile strength and elongation [6]. For base-metal alloys, small,
dispersed secondary phases (each with a small grain structure) are critical to
the strength of the alloys. In other base-metal alloys, the grains are large and
may approach 1 mm in diameter [7]. These large grains, which do not have
anisotropic properties, may be a clinical liability if they occur in critical areas
such as the connectors between units of a multiple-unit xed restoration. As
with phase structure, grain structure is not visible to the naked eye.
metal in the restoration has solidied, the shrinkage as the alloy cools from
its solidus to room temperature cannot be compensated for by the addition of
liquid. If the dimensions of the hot casting were the right clinical size, then the
nal cooled casting would be too small because of this shrinkage. The higher
the solidus temperature, the more shrinkage occurs; these shrinkage values
range from about 0.3% to 0.5% for high-gold alloys with solidi of about
950 C to nearly 2.5% for nickel- and cobalt-based alloys with solidi of
1300 C to 1400 C [9]. The shrinkage must be compensated for by expansion
of the die, application of die spacers, the use of special expanding investment
mechanisms, or increasing the burnout temperature of the investment. The
risk of ill-tting crowns is much greater for alloys with high solidi, and this
factor is a signicant consideration in the choice of alloys.
Corrosion
Perhaps no property has captured as much attention in recent years as
alloy corrosion. The degree of corrosion, which results when one or more
components of the alloys is oxidized, is critical to the long-term success of
a xed prosthesis for several reasons. Corrosion may compromise the
strength of the restoration, leading to catastrophic failure [2] or the release of
oxidized components may discolor natural teeth, porcelain veneers, or even
the soft tissues in severe cases [10]. Corrosion may leave the restoration itself
esthetically unacceptable because of the formation of pits or colored patinas.
The electrons released during corrosion may be detectable by the patient as
a shock (galvanic corrosion) that can be disconcerting and even debilitating.
Released metallic components may cause an undesirable metallic taste
leading the patient to request that the restoration be removed.
The measurement of corrosion is complex, and although many
investigators have tried to predict corrosion of an alloy based on its
composition, such predictions are dicult at best. Corrosion may be
quantied by measuring the current ow associated with metal oxidation or
the concentrations of released metals. These measurements may be made
under a variety of conditions in vitro or, in some cases, in vivo. Although
corrosion is clearly visible to the naked eye when it is severe (such as rust on
iron), most corrosion of dental casting alloys is insidious and invisible to the
naked eye. Manufacturers of alloys must measure corrosion by specic
(ASTM or ISO) standards to gain ISO or ADA certication of their alloys,
and this information is usually available from manufacturers, although it is
not commonly reported in brochures. Because corrosion generally results in
the release of mass from the alloy into the oral environment, it is related in
complex ways to alloy biocompatibility [10].
Biocompatibility
Biocompatibility is best described as how an alloy interacts with and
aects biologic systems. Although the interactions between an alloy and
J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512 503
tissues may take many forms, the release of elements from the alloy into the
oral cavity is a primary focus of alloy biocompatibility because most adverse
biologic eects, such as allergy or inammation, have been attributed to such
release [3,10,11]. In this sense, biocompatibility is related to the corrosion of
an alloy. However, care must be taken not to assume poor biocompatibility
on the basis of elemental release alone because the ability of tissues to tolerate
this element release varies widely [12]. In theory, the biocompatibility of
casting alloys could be predicted on the basis of their corrosion properties,
but in practice, this strategy has proven almost impossible because of the
complex dynamics of release of multiple elements and the interactions among
them. Thus, direct assessment of biocompatibility, by in vitro, animal, or
clinical tests, is necessary.
One common misperception of dental casting alloys is that they may be
inert in the oral environment [3]. The placement of a material into the oral
cavity creates active interfaces through which the body aects the material
and the material aects the body. Regardless of the material placed, these
interactions occur. Thus, inertness of dental casting alloys is not possible.
Furthermore, the interactions that occur are dynamic and may change as the
environment of the interface changes. For example, the development of
periodontal inammation, changes in occlusal loading, or a change in diet
may alter the way the alloy and oral tissues interact. Additional research is
need in this area.
The biocompatibility of alloys may have legal implications for dental
practitioners. Litigation by patients over issues of biocompatibility is rare
but usually involves reactions of taste, inammation, or infectionpur-
portedly from elemental release from casting alloys [10]. These allegations
by patients are dicult to prove conclusively but can be avoided altogether
by careful selection and proper manipulation of the alloys by laboratories
and the practitioner. Procedures such as casting, soldering, polishing, or
porcelain application may alter the nominal corrosion properties of casting
alloys and their biologic behavior if these procedures are improperly
performed [2,7,10].
Porcelain application
The application of porcelain to casting alloys plays a prominent role in the
restoration of teeth with xed prostheses, and several properties of casting
alloys are particularly important to the long-term integrity of the porcelain
alloy restoration. The failure (through debonding or cracking) of porcelain
on a porcelainmetal restoration is a signicant and often emergent clinical
problem that is expensive, time consuming, and inconvenient to repair.
Furthermore, the failure of the porcelain may not occur for months or years
after the restoration is placed. Avoiding these failures is more desirable than
trying to correct them. One property of casting alloys that is critical to the
successful long-term integrity of porcelainmetal bonds is the melting range
504 J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512
of the alloy. The alloy solidus (lower temperature of the melting range) must
be at least 50 C higher than the temperature needed to apply the porcelain
(including degassing) or the alloy substructure will deform as the porcelain is
applied [9] These distortions are commonly referred to as sagging and are
exacerbated by thin metal substructures or long spans. Certain types of
casting alloys, such as Pd-Cu alloys, are prone to sagging and should be
avoided in these situations [2].
More insidious is the problem of residual stress in the porcelain of
a porcelainmetal restoration as the porcelain and alloy cool after ring [1].
These stresses result from dierences in the amount of shrinkage that occurs
as the materials cool. The coecient of thermal expansion is used to quantify
such shrinkage, and a higher coecient of thermal expansion implies that
more shrinkage will occur on cooling (and more expansion on heating). To
avoid residual stresses in porcelainmetal restorations, a matching of
coecient of thermal expansion (CTE) for the porcelain and metal are
necessary [1,2]. In practice it is nearly impossible to get the CTE to match
over the wide range of cooling temperatures, so current practice is to design
the metal to have a slightly (0.5/ C) greater CTE than the porcelain [1]. Thus,
the metal shrinks slightly more, and the porcelain, which is bonded to the
metal, will be in compression. Compressive stresses are better tolerated by
the porcelain than tensile stresses because of the brittle nature of porcelain,
and porcelainmetal restorations using this paradigm are generally more
stable long-term. In practice, the manufacturer controls the CTE of the alloy
and the porcelain, but the laboratory or practitioner should use only
combinations of porcelain casting alloys recommended by the manufacturer.
Porcelain bonds to most casting alloys through a metal oxide formed on
the metal surface during the degassing stage of porcelain application.
Properties of the oxide layer such as oxide color, thickness, and strength vary
widely by alloy type and are critical to the strength and esthetics of the
porcelainmetal bond [13]. Almost all oxides are brittle, and therefore the
thickness of the oxide layer should be minimized to avoid failure of
the porcelainmetal bond within this layer. Alloys based on nickel and cobalt
commonly form thick oxides, and it is common laboratory practice to
remove some of the oxide before porcelain application [9]. On the other
hand, alloys based on gold or palladium form thinner oxide layers because of
the nobility of these metals. In general, oxide-forming elements such as tin or
gallium must be added to gold- or palladium-based alloys to ensure adequate
oxide formation [1,9]. Because some of these oxide formers are lost during
casting (which is an oxidizing process), the re-use of gold- and palladium-
based alloys may result in inferior porcelainmetal bonds unless sucient
(usually at least half) new metal is added to the casting. Although these issues
are beyond the direct control of the practitioner, they exemplify the need of
the practitioner to choose a high-quality dental laboratory.
The color of the oxide layer must be properly managed to ensure the
correct shade of a porcelainmetal restoration. Although the oxide and metal
J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512 505
Soldering
Soldering of alloys is highly dependent on the type of alloy and may be
a signicant factor in the clinicians choice of alloy. Soldering becomes even
more complex if porcelainmetal restorations are involved. Aside from the
issues of soldering below the solidus of the alloys (at least 50 C is generally
a safe margin) [2], the compatibility of solders and uxes is not straightfor-
ward. If the treatment plan requires soldering wires, clasps, attachments, or
pontics, then the ability of the alloy to be reliably soldered must be
considered. In general, gold-based alloys are most easily soldered compared
with palladium-, nickel-, silver-, or nickel-based alloys. Furthermore, the
heating that occurs during soldering is more likely to alter complex phase
structures of basemetal alloys than of high-noble alloys.
Fig. 1. Symbols adopted by the ADA for its three major classications of alloys based on
composition.
High-noble alloys
High-noble dental casting alloys (Table 2) can be divided arbitrarily into
those based on gold-platinum (Au-Pt), gold-palladium (Au-Pd), or gold-
copper-silver (Au-Cu-Ag). Of these groups, the rst two alloy types are
appropriate for full-cast or porcelainmetal applications. The latter group is
appropriate only for full-cast applications because of its higher silver and
copper content and its lower melting range. The Au-Pt alloys are the newest
of the high-noble alloys and were designed to avoid the use of palladium,
which became expensive and biologically controversial between 1995 and
1999. Both of these issues have since resolved, but this class of alloys is still
J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512 507
Table 1
Classication of casting alloys by physical properties
ADA designation Yield strength (MPa, in tension) Elongation (%)
Soft \140 18
Medium 140200 18
Hard 201340 12
Extra-hard [340 10
Table 2
Selected properties of major types of high-noble alloys
Yield
Solidus- Elastic Vickers strength
liquidus Phase modulus hardness (tension,
Alloy type ( C) Color structure (static, GPa) (kg/mm2) 0.2%, MPa)
Au-Pt (Zn)a 10601140 Yellow Multiple 6596 165210 360580
Au-Pd (Ag)a 11601260 White Single 105 280 385
Au-Cu-Ag 905960 White Single 100 210 450
a
In many formations.
508 J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512
also can be head hardened by heating to about 600 C and then letting the
alloy cool to room temperature slowly [2]. Their relatively low melting range
makes them castable using gypsum-bonded investments and gas-air torches.
Noble alloys
Noble alloys are much more compositionally diverse than high-noble
alloys because they include gold-based alloys and those based on other
elements such as palladium or silver (Table 3). They are comprised of four
groups: Au-Cu-Ag, Pd-Cu-Ga, Pd-Ag, and Ag-Pd. The Au-Cu-Ag noble
alloys are similar in composition and metallurgy to the high-noble Au-Cu-Ag
alloys. They were developed in the early 1980s when the price of gold
dramatically increased, making their high-noble counterparts too expensive.
These alloys have decreased gold content and compensate for the reduced
gold by increasing copper, silver, or palladium. These alloys have moderate
moduli of elasticity but are higher in hardness and yield strength than their
high-noble counterparts. Depending on the amount of silver or copper
present, Au-Cu-Ag alloys may be used in porcelainmetal applications but
are more commonly used for full-cast restorations. The melting range of these
alloys is lower than that of their high-noble counterparts if the copper or silver
has been supplemented, and the color of these alloys varies from yellow to
reddish-yellow to silver depending how the reduced gold is compensated for
in the composition. For example, alloys with 10 wt % or more of palladium
have a silver color, whereas those with 20 to 30 wt % of copper are more
reddish in color [2]. Most often single-phase alloys, the Au-Ag-Cu alloys
generally have poorer corrosion properties than their high-noble counter-
parts if the copper or silver has been increased to more than 15 wt % [12].
The Pd-Cu-Ga alloys are the most metallurgically complex of the noble
alloys (see Table 3). They nearly always have multiple phases, but their
corrosion is highly variable depending on the specic nature of the phases.
The phase microstructure of these alloys is complex and dependent on how
the alloy is manipulated [16]. This manipulation dependence makes selection
of an experienced laboratory paramount. The Pd-Cu-Ga alloys are among
the strongest alloys used in dentistry for cast restorations and are 25% stier
Table 3
Selected properties of major types of noble alloys
Yield
Solidus- Elastic Vickers strength
liquidus Phase modulus hardness (tension,
Alloy type ( C) Color structure (static, GPa) (kg/mm2) 0.2%, MPa)
Au-Cu-Ag-(Pd)a 880930 Yellow/white Single 100 250 690
Pd-Cu-Ga 11451270 White Multiple 127 280 580
Pd-Ag 11851230 White Multiple 125 275 620
Ag-Pd 9901045 White Multiple 93 230 480
a
In many formations.
J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512 509
than any of the high-noble alloys or the Au-Cu-Ag noble alloys. These
alloys have high melting ranges and must be cast using induction-casting
and special high-temperature investments [1,2]. They are dicult to nish
and polish. Depending on the amount of copper and its high-temperature
volatility, the Pd-Cu-Ga alloys are useful for porcelainmetal applications.
However, the higher melting range of these alloys makes them more dicult
to ensure a good t of the restoration intraorally. These alloys also are
susceptible to sag during porcelain application.
The Pd-Ag and Ag-Pd alloys are essentially a continuum of the same alloy
system but are dierent in terms of their manipulation and clinical
performance (see Table 3). Of the two groups, the Pd-Ag alloys are far more
common in dentistry and are far superior in strength, corrosion resistance,
modulus, and hardness. The Pd-Ag alloys are used for porcelainmetal
restorations, but the high silver content of the Ag-Pd systems makes them
unusable for anything but full-cast restorations. Because palladium has a very
high melting point (over 1400 C), the Pd-Ag alloys (which typically contain
over 60 wt % Pd) have high melting ranges, and obtaining good clinical t of
these alloys depends heavily on properly compensating for casting shrinkage.
Furthermore, these alloys require the use of induction-casting and high-
temperature investments. Of all the noble and high-noble alloys, the Pd-Ag
alloys have the highest moduli, making them most suitable for long-span xed
partial dentures; however, even these alloys are not as sti as the nickel- or
cobalt-based alloys. The Ag-Pd alloys are usually only in the noble category by
the use of a minimal amount of Pd (25 wt %) or a combination of palladium
and gold totaling 25 wt %. The physical and corrosion properties of these
alloys are inferior, and they oer few advantages over the base-metal alloys.
Table 4
Selected properties of major types of predominantly base-metal alloys
Solidus- Elastic Vickers Yield strength
liquidus Phase modulus hardness (tension,
Alloy type ( C) Color structure (static, GPa) (kg/mm2) 0.2%, MPa)
Ni-Cr-Be 11601270 White Multiple 192 350 325
Ni-Cr 13301390 White Multiple 159 350 310
Ni-high-Cr 12501310 White Multiple 205 205 180
Co-Cr 12151300 White Multiple 155 155 390
from the dental laboratory. The practitioner often focuses on the cost and
color of the alloy as major factors in this decision, but cost and color are the
least important factors in selecting a material for a successful prosthesis.
Furthermore, the initial cost of the alloy is often a poor indicator of the
overall long-term cost of the restoration. If the restoration fails because of
poor clinical performance and must be replace prematurely, the costs of these
repairs (in patient discomfort, time, and money) will far exceed the initial
savings of using a cheaper but inferior alloy.
The selection of a casting alloy is best customized for a particular clinical
situation. The systemic health of the patient should be the rst consideration,
and the practitioner should avoid alloys that contain elements to which the
patient is hypersensitive. These elements are most commonly nickel and
cobalt, although allergies to palladium and gold have been reported. The
complete composition of the alloys therefore must be considered by the
practitioner in this regard because even trace elements can elicit reactions
through disproportional corrosion from grain boundaries or secondary
phases [12]. The physical requirements of the alloy are also a primary
consideration. For example, if the restoration involves long spans, then an
alloy with the highest modulus of elasticity is advisable, particularly if the
prosthesis is porcelainmetal. The t of the restoration depends to a large
extent on the ability of the laboratory to manage casting shrinkage. This
issue is most dicult with high-melting alloys. The tensile strength is
important if the restoration involves connectors between multiple units and if
these connectors are narrow occlusal-gingivally because of short clinical
crowns, periodontal considerations, or esthetic requirements. The color of
the alloys oxide may be important in porcelainmetal restorations.
Finally, practitioners should maintain records of the materials that they
use for cast restorations and should give patients this information. The
Identalloy system is a convenient means to maintain good dental records and
inform patients [1]. Most manufacturers supply laboratories with stickers
that contain the name and composition of the their alloys, and most good
laboratories supply these stickers to the practitioner upon request.
Practitioners should use this, or other means, to maintain records of the
materials used. These records are important to help diagnose future problems
that might occur (biologic reactions or mechanical failures) and are
important legal resources to defend the practitioner in the event of litigation.
Acknowledgments
This work was supported by grants from Metalor Technologies, SA
(Neuchatel, Switzerland) and the Whitaker Foundation. The authors thank
Metalor Technologies, SA for their support of alloy research over years and
the Whitaker Foundation for their support of biomedical research in the
area of alloy corrosion.
512 J.C. Wataha, R.L. Messer / Dent Clin N Am 48 (2004) 499512
References
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dental materials. 11th edition. St. Louis: Mosby; 2002. p. 16384.
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materials. 11th edition. St. Louis: Mosby; 2002. p. 67124.
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materials. 11th edition. St. Louis: Mosby; 2002. p. 51550.
[10] Wataha JC. Biocompatibility of dental casting alloys: a review. J Prosthet Dent 2000;83:
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1996;12:18693.
[12] Wataha JC, Lockwood PE. Release of elements from dental casting alloys into cell-culture
medium over 10 months. Dent Mater 1998;14:15863.
[13] OBrien WJ. Dental porcelain. In: OBrien WJ, editor. Dental materials: properties and
selection. Chicago: Quintessence; 1989. p. 397418.
[14] Wataha JC, Lockwood PE, Khajotia SS, Turner R. Eect of pH on element release from
dental casting alloys. J Prosthet Dent 1998;80:6918.
[15] Gerstrofer JG, Sauer HK, Passler K. Ion release from Ni-Cr-Mo and Co-Cr-Mo casting
alloys. Int J Prosthodont 1991;4:1528.
[16] Vermilyea SG, Cai Z, Brantley WA, Mitchell JC. Metallurgical structure and microhard-
ness of four new palladium-based alloys. J Prosthodont 1996;5:28894.
[17] Bumgardner JD, Lucas LC. Surface analysis of nickel-chromium dental alloys. Dent Mater
1993;9:2529.
[18] Hildebrand HF, Veron C, Martin P. Nickel, chromium, cobalt dental alloys and allergic
reactions: an overview. Biomaterials 1989;10:5458.
Dent Clin N Am 48 (2004) 513530
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2004.01.003
514 J.R. Kelly / Dent Clin N Am 48 (2004) 513530
Table 1
Esthetic ceramics: basic composition, uses, and commercial examples
Base Fillers Uses Commercial examples
Predominantly glassy ceramics
Feldspathic glass Colorants Veneer for ceramic Alpha, VM7 (Vita)
Opaciers substructures, inlays, Mark II (Vita)
High-melting onlays, veneers Allceram (Degudent)
glass
particles
Moderately lled glassy ceramics
Feldspathic glass Leucite Veneer for metal substructures, VMK-95 (Vita)
(1725 inlays, onlays, veneers Omega 900 (Vita)
mass%) Vita Response (Vita)
Colorants Ceramco II (Dentsply)
Opaciers Ceramco 3 (Dentsply)
High-melting IPS d.SIGN
glass (Ivoclar-Vivadent)
particles Avante (Pentron)
Reex (Wieland Dental)
Highly lled glassy ceramics
Feldspathic glass Leucite Single-unit crowns, Empress (Ivoclar)
(4055 inlays, onlays, veneers OPC (Pentron)
mass%) Finesse All-Ceramic
Colorants (Dentsply)
Opaciers
Particle-lled glasses
Filler particles are added to the base glass composition to improve
mechanical properties and to control optical eects such as opalescence, color,
and opacity. These llers are usually crystalline but can also be particles of
a higher melting glass. Such compositions based on two or more distinct
entities (phases) are formally known as composites, a term often reserved in
dentistry to mean resin-based composites. Thinking about dental ceramics as
being composites is a helpful and valid simplifying concept. Much confusion is
cleared up in organizing ceramics by the ller particles they contain (and how
much), why the particles were added, and how they got into the glass.
J.R. Kelly / Dent Clin N Am 48 (2004) 513530 515
Table 2
Substructure ceramics: basic composition, uses, and commercial examples
Glass Fillers Uses Commercial examples
Highly lled glassy ceramics
Feldspathic glass Leucite Inlays, onlays, veneers, Empress (Ivoclar)
(4055 mass%) single-unit crowns OPC (Pentron)
Finesse All-ceramic
(Dentsply)
Feldspathic glass Aluminum oxide Single-unit crowns Vitadur-N (Vita)
(55 mass%)
Lanthanum Aluminum oxide Single-Unit crowns, In-Ceram Alumina
(70 vol%) anterior three-unit (Vita)
bridges
LABS Aluminum oxide Single-unit crowns, In-Ceram Zirconia
(50 vol% three-unit bridges (Vita)
Zirconium oxide
(20 vol%)
Modied Lithium disilicate Single-unit crowns, Empress 2 (Ivoclar)
feldspathic glass (70 vol%) anterior three-unit 3G (Pentron)
bridges
Polycrystalline ceramics
Aluminum oxide \0.5 mass%a Single-unit crowns Procera (Nobel Biocare)
Zirconium oxide Yttrium oxide Single-unit crowns Procera (Nobel Biocare)
(35 mass%)a
Zirconium oxide Yttrium oxide Single-unit crowns, Cercon (Dentsply)
(35 mass%)a Three-unit bridges, Lava (3M-ESPE)
Four-unit bridges (?) Y- (Vita)
Abbreviation: LABS, aluminoborosilicate.
a
Dopants.
Polycrystalline ceramics
Polycrystalline ceramics have no glassy components; all of the atoms are
densely packed into regular arrays that are much more dicult to drive
a crack through than atoms in the less dense and irregular network found in
glasses. Hence, polycrystalline ceramics are generally much tougher and
stronger than glassy ceramics. Polycrystalline ceramics are more dicult to
process into complex shapes (eg, a prosthesis) than are glassy ceramics. Well-
tting prostheses made from polycrystalline ceramics were not practical
before the availability of computer-aided manufacturing. In general, these
computer-aided systems use a 3-D data set representing the prepared tooth
or a wax model of the desired substructure. This 3-D data set is used to create
an enlarged die upon which ceramic powder is packed (Procera; Nobel
Biocare, Goteborg, Sweden) or to machine an oversized part for ring by
machining blocks of partially red ceramic powder (Cercon, Dentsply
J.R. Kelly / Dent Clin N Am 48 (2004) 513530 517
Substructure ceramics
The development of higher-strength ceramics for veneered all-ceramic
prostheses can be represented as a transition toward increases in the volume
percentage of crystalline material with decreasingly less glass and nally no
glass. In 1965, McLean [6] reported on the strengthening of a feldspathic
glass via addition of aluminum oxide particles, the same year that General
Electric rst applied that new technology (dispersion strengthening of
glasses) to high-tension power line insulators. In the late 1980s, a method
was developed to signicantly increase the aluminum oxide content (from
55 mass% to 70 vol%) by rst lightly ring packed alumina powder and
then inltrating the still porous alumina compact with glass [12]. During the
rst light ring, adjacent alumina particles become bonded where they
touch, forming a 3-D network of linked particles. Inltration involves a
low-viscosity glass drawn into the porous alumina network by capillary pres-
sure, forming an interpenetrating 3-D composite (the alumina and glass
being continuous throughout the ceramic and neither representing an
isolated ller). Although, with only 70 vol% aluminum oxide, this
ceramic (In-Ceram Alumina; Vita) has strength and fracture toughness
identical to many 100% polycrystalline alumina ceramics.
Two key developments allowed fully polycrystalline ceramics to become
practical for xed prostheses: (1) the availability of highly controlled
starting powders and (2) the application of computers to ceramics
processing. Unlike glassy ceramics, polycrystalline ceramics cannot be
pressed as a fully dense material into slightly oversized molds (molds that
have expanded just enough to compensate for cooling shrinkage as is done
in the casting of metals). Polycrystalline ceramics are formed from powders
that can be packed only to 70% of their theoretical density. Hence,
polycrystalline ceramics shrink around 30% by volume (10% linear) when
made fully dense during ring. For the nal prostheses to t well, the
amount of shrinkage needs to be accurately predicted and compensated for.
Well-characterized starting powders that can be uniformly packed are
518 J.R. Kelly / Dent Clin N Am 48 (2004) 513530
material. Possible problems with these zirconia ceramics may involve long-
term instability in the presence of water, porcelain compatibility issues, and
some limitations in case selection due to their opacity. However, as of this
writing, 3-year clinical data involving many posterior single-unit and three-
unit prostheses (plus one ve-unit) have revealed no major problems
(discussed more fully below).
Strength
Strength is a global measure of three things: (1) the type and size of failure-
starting aws and their distribution, (2) the fracture toughness, and (3) the
inuence of water. If all three things are well controlled to faithfully represent
clinical prostheses, then comparisons based on strength have some meaning.
Flaws are most often the result of processing steps (dental laboratory and
dentist) used to fabricate prostheses, but aws can also be inherent to the
material. Hence, the best measure of strength comes from testing parts that
have received all dental laboratory and dentist processing steps. Because it
often is not practical to fabricate standardized test specimens (eg, bend bars)
using all dental laboratory and dentist steps, the condition of the test
specimen may not reect the condition of nished prostheses, and reported
strengths may not be meaningful. On the other hand, although actual
prostheses adequately reect the processing condition of the ceramic, stresses
in prostheses at the point of failure (ie, strength) are dicult to calculate. In
addition, most attempts to duplicate clinical loading of prostheses, especially
single-unit crowns (crunch the crown tests), create failure from articial
damage produced during testing that is never seen clinically [14].
It has been known since 1958 that water decreases the strength of most
glasses and ceramics. Water, acting chemically at crack tips, allows the slow
growth of cracks under conditions where growth would not occur otherwise.
Ceramics dier in sensitivity to water, a fact not well controlled for or taken
into account in strength testing of dental ceramics or in published
comparisons of strength data. Water is available to any surfaces exposed
to saliva, but it also is available to cementation surfaces from dentinal
520 J.R. Kelly / Dent Clin N Am 48 (2004) 513530
tubules. All dental cements allow water (from saliva and dentin) to reach
internal ceramic surfaces by diusion.
Strength also is generally reported only for single materials. Prostheses
often are made of multiple materials having dierent properties. The
performance of such prostheses may depend as much on variables related to
the use of multiple materials, such as bond strengths, residual stresses at
material interfaces due to thermal contraction mismatches, and interfacial
stresses during loading arising from mismatches in material stiness (elastic
moduli). For example, one type of all-ceramic three-unit prosthesis was
found to fail clinically primarily from stresses and aws within connectors at
the core-veneer interface [15]. Similarly, single-unit crowns have been
reported to fail from their internal (cementation or intaglio) surface due to
chewing loads, not from damage or stresses on their occlusal surface [1618].
With the cementation surface being at risk, survival probabilities can be
inuenced by the type of cement used or the surface treatment given.
Thus, strength is more of a conditional measure than an inherent material
property and must be used cautiously (if at all) in judging the likely clinical
performance of a new ceramic system. One better measure for comparing the
structural performance of ceramics is fracture toughness, but this is limited in
describing single material behavior. Overall, the case for clinical trial data
becomes compelling given the factors discussed here that may inuence clinical
success and yet remain absent from laboratory testing protocols.
Fracture toughness
Because ceramics fail via crack growth from existing aws, it is useful to
have some measure of the ease with which this happens. Tensile loads
(pulling) create stresses (load per area) at crack tips. As loads increase, the
intensity of crack tip stresses rises rapidly. Purely straight opening, without
the crack sliding or shearing, is termed mode I opening (mode one), and
the stress intensity caused by this is designated by the letter K; thus, the
stress intensity at a crack tip in simple mode I opening is written as KI. At
some critical stress intensity, conditions are right for the crack to become
unstable and separate the ceramic part into two pieces.
Critical stress intensities for mode I opening, written as KIC (with units of
MPa m) are generally not dependent on the condition of the material
(ie, they are aw size insensitive) and can be used to compare dierent
materials. KIC values for metal-ceramic porcelains are 0.9 to 1.2; for
leucite-reinforced dental ceramics KIC values are 1.5 to 1.7 (eg, Empress,
Ivoclar); and for alumina KIC values are 4.5 (eg, In-Ceram, Vita; Procera,
Nobel Biocare), with transformation toughened zirconia ranging from 8 to
12 and metal alloys starting around 20.
Metal-ceramic systems
Advantages of metal-ceramic systems lie in their predictable structural
performance, their versatility, and that fact that less knowledge is required
for choosing an appropriate system. The structural performance of metal-
ceramic systems remains far better than for any all-ceramic system. As is
discussed in more detail below, bulk failure and porcelain cracking aect
522 J.R. Kelly / Dent Clin N Am 48 (2004) 513530
12 24
Time (months)
Fig. 1. Frequency of crowns cemented per month in Study A. Grey bars represent the number
of cemented crowns. Overlaid dark bars represent the number of failed crowns in any given
month.
the crowns of Study B are failing miserably. Such life table analysis allows
clinicians to make valid comparisons among clinical trial data.
12 24
Time (months)
Fig. 2. Frequency of crowns cemented per month in Study B. Grey bars represent the number
of cemented crowns. Overlaid dark bars represent the number of failed crowns in any given
month.
524 J.R. Kelly / Dent Clin N Am 48 (2004) 513530
60
40
20
3 6 9 12 15 18 21 24
Time (months)
Fig. 3. Life table analysis (Kaplan Meier) of crowns in Study A calculating actual survival per
month.
80 87%
60 63%
40
33%
20
3 6 9 12 15 18 21 24
Time (months)
Fig. 4. Life table analysis (Kaplan Meier) of crowns in Study B calculating actual survival per
month.
J.R. Kelly / Dent Clin N Am 48 (2004) 513530 525
clinical trials found a mean survival rate of 97.4% over 4.2 years with
excellent color stability and wear [31]. An 8-year follow-up of 16 patients,
each receiving two inlays, reported that 3 of the 32 restorations fractured
[32]. Cerec inlays and onlays (200 restorations) provided in a private
practice were reported to have a survival rate (Kaplan-Meier) of 90.4%
over 10 years with failures being due to ceramic fracture (53%), tooth
fracture (20%), and endodontic problems (7%) [33]. One of the leucite-
reinforced pressed ceramics has also been relatively well studied as an
inlay/onlay material (Empress, Ivoclar). A literature review of six clinical
trials reported that survival rates ranged from 96% at 4.5 years to 91% at
7 years [34].
Single-unit crowns
Four ceramic systems have received notable attention in peer-reviewed
literature: (1) a leucite-reinforced glass (Empress, Ivoclar), (2) a glass-
inltrated alumina (In-Ceram Alumina, Vita), (3) a glass-inltrated
magnesium aluminate spinell (In-Ceram Spinell, Vita), and (4) a poly-
crystalline alumina (Procera, Nobel Biocare). In most cases, fracture rates
seem to be lower for anterior crowns than for molar crowns, with the lowest
failure rates for posterior restorations being reported for the high fracture
toughness/high strength alumina-like and alumina materials (In-Ceram
Alumina and Procera).
The glass-inltrated material based on magnesium aluminate spinell (a
more translucent, but lower strength cousin of the glass-inltrated alumina)
seems to be indicated for anterior restorations. One 5-year study of 40
anterior crowns reported a 97.5% survival rate (Kaplan-Meier) [35]. Data
for anterior versus posterior leucite-reinforced crowns seem to trend toward
higher survival for anterior teeth [36], but this can be nonsignicant
statistically [37], and one contrary study exists [38]. This confusion is likely
due to in part to the inclusion of premolar crowns in the posterior
category and the relatively low number of failing crowns and studied
restorations (ie, low statistical power). In a review of six clinical trials, the
survival rate for leucite-reinforced crowns (Empress, Ivoclar) ranged from
92% to 99% at 3 to 3.5 years [39].
Studies of crowns having substructures of the higher toughness/strength
alumina-based ceramics (In-Ceram Alumina, Vita; Procera, Nobel Biocare)
report generally similar results for both materials. No bulk fracture was
reported for 28 anterior and 68 posterior In-Ceram crowns at 4 years [40]. In
a private practice setting, 223 In-Ceram crowns had a survival rate of 96%
after 3 years, with anterior crowns trending toward higher survival (98%)
than premolars or molars (94%) [41]. In a 4-year university trial of 80 In-
Ceram crowns (73% anterior, 27% posterior), one molar crown fractured
and the marginal ridge of one premolar crown chipped [42]. Of 97
Procera alumina crowns followed for 5 years, three crowns experienced
bulk fracture, and two had some loss of veneering porcelain [43]. The 5- and
526 J.R. Kelly / Dent Clin N Am 48 (2004) 513530
Multi-unit prostheses
Two all-ceramic systems have been recommended by their manufacturer
for anterior three-unit prostheses: a glass-inltrated alumina (In-Ceram
Alumina, Vita) and lithium disilicate glass-ceramics (Empress 2, Ivoclar;
G3, Pentron). In a study of 18 In-Ceram Alumina prostheses (64%
cantilevered two-unit and 36% three-unit) with 62% involving a posterior
tooth, the survival rate (Kaplan-Meier) was 93% at 5 years and 83% after
10 years [45]. There do not yet seem to be peer-reviewed publications
regarding the clinical performance of multi-unit prostheses fabricated with
lithium disilicate glass-ceramics.
Two other all-ceramic systems are being recommended for posterior
three-unit prostheses by their manufacturers: a glass-inltrated alumina/
zirconia (In-Ceram Zirconia, Vita) and transformation toughened poly-
crystalline zirconia (Cercon, Dentsply Prosthetics; Lava, 3M-ESPE; Y-Z,
Vita). Ongoing trials of zirconia prostheses are heavily focused on posterior
multi-unit prostheses, including studies at the University of Zurich (58
posterior prostheses; three-unit, four-unit, and one ve-unit), Saarland
University (38 posterior multi-unit prostheses), University of Gottingen (62
posterior prostheses; three-unit and four-unit), and the Louisiana State
University (20 posterior three-unit prostheses). Although results from these
trials have yet to be fully published, updates have been presented at
international research meetings with no instances of bulk fracture reported.
The longest trial, at the University of Zurich, recently completed the 3-year
recall for all active patients.
Practical aspects
Choosing a system by translucency (value)
Many leaders in the use of all-ceramic and metal-ceramic systems
recommend choosing a system based on the value (Munsell lightness-
darkness scale) of the dentition being restored. Opaque teeth (often whitish)
are best matched using an opaque substructure; this includes many of the
highly crystalline ceramics and metal-ceramic systems. Highly translucent
teeth (often grayish) are dicult to match unless the substructure allows
more light transmission than is characteristic of metals and opaque
ceramics. Most systems allow the incorporation of internal coloration,
variations in incisal translucency, and the addition of opalescence. If an all-
ceramic system is to be chosen, consideration should be given to the
structural indications developed from clinical data and manufacturer
recommendations.
J.R. Kelly / Dent Clin N Am 48 (2004) 513530 527
Repair
Approaches to the repair of porcelains have recently been reviewed [48].
Repair often oers a cost-eective alternative to replacement. Repair
528 J.R. Kelly / Dent Clin N Am 48 (2004) 513530
Summary
Ceramics are widely used in dentistry due to their ability to mimic the
optical characteristics of enamel and dentin and their biocompatibility and
chemical durability. Most highly esthetic ceramics are lled glass composites
based on aluminosilicate glasses derived from mined feldspathic minerals.
One common crystalline ller is the mineral leucite, used in relatively low
concentrations in porcelains for metal-ceramic systems and in higher
concentrations as a strengthening ller in numerous all-ceramic systems. In
general, the higher the fraction of polycrystalline components, the higher is
the strength and toughness of a ceramic. The development of substructure
ceramics for xed prosthodontics represents a transition toward fully
polycrystalline materials. Although the strength of a dental ceramic can be
a meaningful number, it is not an inherent property and varies due to
testing parameters that are often not well controlled to optimize clinical
relevance. Fracture toughness is a far more inherent measure of the
structural potential of a ceramic and represents a more easily compared
value. Clinical data for all-ceramic systems are becoming available, and
results exist for many commercial materials, providing guidance regarding
clinical indications.
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[42] Haselton DR, Diaz-Arnold AM, Hillis SL. Clinical assessment of high-strength all-ceramic
crowns. J Prosthet Dent 2000;83:396401.
[43] Oden A, Andersson M, Krystek-Ondracek I, Magnusson D. Five-year clinical evaluation
of Procera AllCeram crowns. J Prosthet Dent 1998;80:4506.
[44] Odman P, Andersson B. Procera AllCeram crowns followed for 5 to 10.5 years: a
prospective clinical study. Int J Prosthodont 2001;14:5049.
[45] Olsson KG, Furst B, Andersson B, Carlsson GE. A long-term restrospective and clinical
follow-up study of In-Ceram alumina FPDs. Int J Prosthodont 2003;16:1506.
[46] Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental restorations over 16
years. Part III: eect of luting agent and tooth-substitute core structure. J Prosthet Dent
2001;86:5119.
[47] al-Wahadni A, Martin DM. Glazing and nishing dental porcelain: a literature review.
J Can Dent Assoc 1998;64:5803.
[48] Latta M, Barkmeier WW. Approaches for intraoral repair of ceramic restorations.
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Dent Clin N Am 48 (2004) 531544
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2003.12.008
532 A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544
Framework design
The clinical fracture resistance of FPDs is related to the size, shape, and
position of the connectors and to the span of the pontic. The basis for the
proper design of the connectors and the pontic is the law of beams: Deection
of a beam increases as the cube of its length, it is inversely proportional to its
width, and it is inversely proportional to the cube of its height [13]. A three-
point bending test is one of the most commonly used tests to determine the
modulus of rupture or the transverse exural strength of a rectangular beam
made of a brittle material [14,15]. When occlusal forces are applied directly
through the long axis of an all-ceramic bridge connector, compressive stresses
develop at the occlusal aspect of the connector at the marginal ridge, and
tensile stresses develop at the gingival surface of the connector. These tensile
stresses contribute to the propagation of microcracks located at the gingival
surface of the connector through the core material in an occlusal direction
A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544 533
and may lead to a fracture. The most common mode of failure of all-ceramic
FPDs is a fracture of the connectors, with 70% to 78% of the cracks
originating from the interface between the core and the ceramics [6]. Oh et al
[16] demonstrated in a nite element analysis and a fractographic analysis
that connector fracture was initiated at the gingival embrasure and that
a larger radius of curvature at the gingival embrasure reduces the con-
centration tensile stresses, thus affecting the fracture resistance of the FPD.
Oh and Anusavice [17] demonstrated the same in an in vitro study. To
promote achieving the required connector dimensions without compromising
the health of the supporting tissues, it was suggested to fabricate the gingival
and lingual aspects of the connectors out of the framework material
exclusively [18]. In addition, the span of the pontic should not exceed the
length of a rst mandibular molar, depending on the properties of core
material and framework design.
Evolution
A high-alumina ceramic for the fabrication of FPD pontic structures
was rst introduced by McLean in 1967 [19]. In 1982, he introduced the
platinum-bonded alumina FPD to reduce the problem of fracture through
the connector area while eliminating the traditional cast-metal framework
[20]. However, this restorative option was not feasible due to a high rate of
failure at the connector sites.
New developments in dental ceramics have led to the introduction of
new systems for all-ceramic FPDs. The In-Ceram alumina system (Vita
Zahnfabric, Bad Sackingen, Germany), which uses high-temperature,
sintered-alumina glass-inltrated copings for all-ceramic crowns, was
introduced for the fabrication of three-unit anterior FPDs [21]. To fabricate
the framework the ceramist can use the slip-casting technique or copy
milling technique with prefabricated partially sintered blanks. The trans-
verse exural strength of the framework material was demonstrated to be
about 446 MPa [22]. With this system, the minimal critical dimensions for
the connectors are 4 mm occlusal/gingivally and 3 mm buccal/lingually [18].
The Empress II system (Ivoclar North America, Amherst, New York)
uses a lithium-disilicate glass framework that is veneered with uoroapatite-
based veneering porcelain. The framework is fabricated with the lost-wax
and heat-pressure technique or is milled out of prefabricated blanks. The
transverse exural strength of the framework material ranges between 350
and 400 MPa [23]. Although these glass-containing materials allow the
fabrication of relatively translucent restorations, it is recommended that
these restorations be etched and adhesively cemented to enhance their
strength. The system is conned to fabricating three-unit FPDs that replace
a missing tooth anterior to the second premolar. The minimal critical
dimensions for the connectors are 4 to 5 mm occlusal/gingivally and 4 mm
buccal/lingually [8].
534 A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544
Fig. 1. Preoperative lateral view in maximum intercuspation. The opposing teeth did not
dramatically supraerupt in a manner that contraindicates the fabrication of a Y-TZPbased all-
ceramic FPD.
Fig. 2. Preoperative lateral view of a patient missing his left mandibular rst molar. A
measurement of the distance between the marginal ridge and the free gingival margin conrmed
that adequate prospective connector height (4 mm) exists for the fabrication of a Y-TZPbased
all-ceramic FPD.
A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544 537
Fig. 3. A view of the CAD FPD framework designed on the computer (Lava; 3M ESPE,
St. Paul, Minnesota).
538 A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544
Fig. 4. Lingual view of the completed framework tted to the working dies. Note the excellent
marginal t.
Fig. 5. Buccal view of the completed framework tted to the working dies. Note the excellent
marginal t.
A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544 539
Fig. 6. Buccal view of the framework try-in. Note the excellent blending of the framework with
the gingival tissue and the open gingival embrasures for oral hygiene maintenance.
core material in patients who lack space for lingual veneering porcelain [44].
Special feldspathic veneering porcelains were designed to match the Y-TZP
based frameworks in terms of physical and optical properties, with
a coefcient of thermal expansion closely matched (Fig. 7) [44].
Clinicians may place the nish line of a tooth preparation at the free
gingival margin or slightly below it (0.5 mm) without compromising the
esthetic result (Fig. 8). This reduces the possibility of iatrogenic periodontal
disease [4547]. Moreover, the ability to place the nish line at or below the
free gingival margin facilitates the making of an accurate impression.
Ceramic materials in general are considered to be great insulators. All-
ceramic systems have reduced thermal conductivity, resulting in less thermal
sensitivity and potential pulpal irritation [8].
Fig. 7. The completed restoration before cementation. Note the blending of the Y-TZPbased
framework with the veneering porcelain.
540 A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544
Limitations
The main limitation of Y-TZPbased all-ceramic FPDs is that in many
cases their use may be contraindicated because of a lack of required
dimensions for the prospective connector resulting from restricted
interocclusal distance, prospective abutment mobility, or severe parafunc-
tion. When all-ceramic FPD systems do not t precisely, a new denitive
impression must be made because they cannot be sectioned and soldered like
metal-ceramic FPDs. The other limitation is the lack of long-term clinical
data on the success of these restorations.
Clinical procedures
Clinical procedures and radiographic evaluation are similar to those used
with metal-ceramic FPDs. Metal-ceramiclike preparation design, which
A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544 541
Summary
Because of their material-inherent advantages, Y-TZPbased all-ceramic
restorative systems may allow clinicians to use traditional clinical
procedures similar to those used in the fabrication of metal-ceramic restora-
tions in terms of preparation design and cementation procedures. With
Y-TZPbased systems that use a CAD/CAM technology, ceramists use
new techniques and technologies in addition to traditional ones. Such
new technologies may allow the production of consistent high-quality Y-TZP
frameworks in terms of design and fabrication, strength, fracture toughness,
and stress-corrosion resistance. They are esthetic, have clinically acceptable
marginal t, and allow the ceramist to use traditional veneering procedures
with the compatible esthetic porcelain. In addition, such systems may prove to
be simple to handle and less technique sensitive from a clinical standpoint
while providing patients with esthetic and functional restorations. Although
542 A.J. Raigrodski / Dent Clin N Am 48 (2004) 531544
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Dent Clin N Am 48 (2004) 545562
* Corresponding author.
E-mail address: freilich@nso2.ichc.edu (M.A. Freilich).
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2004.01.005
546 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562
Fig. 1. Two anterior full-coverage (three-unit) xed partial dentures replacing the maxillary
lateral incisors. These prostheses are made in the dental laboratory with a FiberKor
(unidirectional pre-impregnated glass) substructure and Scupture composite veneer. (From
Freilich MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical
dentistry. Chicago: Quintessence; 2000; with permission.)
Fig. 2. Magnied view of Ribbond, nonimpregnated woven polyethylene ber. (From Freilich
MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry.
Chicago: Quintessence; 2000; with permission.)
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 547
Fig. 3. Magnied view of Connect, nonimpregnated braided polyethylene ber. (From Freilich
MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry.
Chicago: Quintessence; 2000; with permission.)
Fig. 5. Unidirectional glass ber poorly wetted (impregnated) by surrounded resin matrix
resulting in very poor exure properties. (From Freilich MA, Duncan JP, Alarcon EK, Eckrote
KA, Goldberg AJ. The design and fabrication of ber-reinforced implant prostheses. J Prosthet
Dent 2002;88:44954; with permission.)
548 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562
the veneer made from a fairly brittle material, such as particulate composite.
The ultimate exure strength of manufacturer-impregnated (also known as
pre-impregnated), unidirectional, glass FRC materials range from over 500
to 1000 Mpa. This is greater than the exure strength of noble ceramic
alloys [8]. In this article, the clinical tooth replacement applications of FRC-
supported prostheses are organized into two categories: laboratory-
fabricated prostheses and chairside prostheses.
Laboratory-fabricated prostheses
Laboratory-fabricated FRC prostheses can be retained by teeth or
implants. The polymer prostheses include a surface that does not wear
opposing tooth enamel, and the substructure does not require waxing,
casting, or soldering procedures during fabrication. Supported by a strong,
metal-free substructure, the esthetic qualities of the FRC polymer prostheses
Table 1
Flexure properties of FRC products
Flexure Strength elastic Strength
Product modulus (GPa) limit (MPa) ultimate (MPa)
FibreKor 28.3 471 539
everStick 24.3 605 739
Vectris 28.9 516 614
GlasSpan 13.9 266 321
Construct 8.3 59 222
Ribbond 3.9 56 206
Abbreviation: FRC, Fiber-reinforced composite.
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 549
Fig. 7. Tooth preparations for posterior intracoronal (inlay) FRC prosthesis. (From Freilich
MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry.
Chicago: Quintessence; 2000; with permission.)
occlusal isthmus
(1.0 mm depth)
proximal step
(1.0 mm axial depth)
Fig. 8. Drawing of full-coverage posterior tooth preparation exhibiting consistent axial depth
of preparation to the nish line around the entire circumference of the tooth, the proximal step
(on the side adjacent to the edentulous space), and the occlusal isthmus. (From Freilich MA,
Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry. Chicago:
Quintessence; 2000; with permission.)
550 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562
linguoproximal step
(1.0 mm axial depth)
Fig. 9. Drawing of the full-coverage anterior tooth preparation also exhibiting consistent axial
depth of preparation around the entire circumference of the tooth and the linguoproximal step.
The proximal aspect of the step is only needed adjacent to the edentulous area. (From Freilich
MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry.
Chicago: Quintessence; 2000; with permission.)
been bonded to the abutment teeth. Tooth preparation designs of full and
partial coverage FRC prostheses are shown in Figs. 7, 8, and 9.
Data have shown that substructure design is a key ingredient of the
clinical success of FRC prostheses. Increased substructure bulk added at the
pontic region (high volume design) provides additional rigidity along with
greater vertical support of the veneer material. Successful chemical bonding
of the veneer composite to the FRC substructure is another critical element
of clinical success. The maintenance of the air-inhibited layer on the external
surface of the completed substructure seems to be a crucial element in
Fig. 10. Full-coverage retainer FiberKor unidirectional glass substructure with less than
adequate bulk placed in the edentulous region. (From Freilich MA, Meiers JC, Duncan JP,
Eckrote KA, Goldberg AJ. Clinical evaluation of ber-reinforced xed bridges. JADA
2002;133:152434; Copyright 2002 American Dental Association. All rights reserved.
Reprinted by permission.)
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 551
Fig. 11. Full-coverage retainer FiberKor unidirectional glass substructure with optimal bulk
(high-volume design) placed in the edentulous region. This design results in better
substructure rigidity and better support of the composite veneer material. (From Freilich
MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry.
Chicago: Quintessence; 2000; with permission.)
achieving this bond. Examples of FRC substructures are shown in Figs. 10,
11, and 12. Two separate clinical studies of FRC prostheses made with
Stick (StickTech LTD, Turku Finland) and FiberKor (Pentron Corp,
Wallingford, CT) have demonstrated [90% survival of partial and full
coverage prostheses for up to 5 years [4,6]. Examples of various prosthesis
designs are shown in Figs. 13, 14, and 15.
Implant-retained FRC prostheses can be screw retained or luted to the
implant abutment. In contrast with tooth-supported prostheses, the
component of the FRC prosthesis retainer that provides an attachment to
the implant abutment can be premanufactured. This is because the implant
abutment is generally not custom made but is machined by the
manufacturer. For luted prostheses, a woven FRC coping can be used to
make this underside or foundation of the retainer. The remainder of the
FRC substructure can be bonded directly to these copings. An example of
a luted FRC substructure can be seen in Fig. 16. For screw-retained FRC
prostheses, a cylinder with a screw channel that ts directly to the implant
Chairside prostheses
One of the most exciting and potentially useful applications for pre-
impregnated FRC technology is its use in replacing missing teeth in a timely
and cost-eective manner. The ability to deliver a functional, esthetic tooth
replacement with no to minimal tooth preparation to the adjacent abutment
teeth in a single visit is a realistic treatment option with our current adhesive
technologies and reinforced composites. The increase in physical properties
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 553
Fig. 16. Luted implant prosthesis substructure made with pre-impregnated unidirectional
(FiberKor) and woven glass (Sticknet) components. (From Freilich MA, Duncan JP, Alarcon
EK, Eckrote KA, Goldberg AJ. The design and fabrication of ber-reinforced implant
prostheses. J Prosthet Dent 2002;88:44954; with permission.)
Fig. 17. Screw-retained titanium ceramic cylinders placed on implant abutment replicas located
within a master cast. In addition to the ceramic surface that provides an opaque mask and resin
adhesion, the grooves on the facial and lingual surfaces and proximal boxes exhibited by the
cylinders provide macro-mechanical retention and support, respectively, to the incorporated
FRC.
Fig. 18. Completed screw-retained implant prosthesis substructure including titanium ceramic
cylinders and pre-impregnated unidirectional glass FRC.
Fig. 19. (A) Completed three-unit, screw-retained FRC implant prosthesis. (B) Completed
three-unit luted FRC implant prosthesis.
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 555
Fig. 20. Completed full-arch xed detachable (hybrid) FRC-supported implant prosthesis
beforeplacement in mouth. (From Freilich MA, Duncan JP, Alarcon EK, Eckrote KA,
Goldberg AJ. The design and fabrication of ber-reinforced implant prostheses. J Prosthet
Dent 2002;88:44954; with permission.)
Fig. 21. Layout showing the pieces of Splint-Itmaterial required to fabricate the rst generation
of prefabricated FRC framework shown in Fig. 22. (From Meiers JC, Freilich MA. Chairside
prefabricated ber-reinforced resin composite xed partial dentures. Quintessence Int
2001;32:99104; with permission.)
Fig. 22. The pre-fabricated FRC framework formed from the Splint-It pieces shown on Fig. 1
and then the nished product ready for chairside use. The pontic in this design was designed to
t specic spaces. This one was for a mandibular incisor. The foil protects the wings from
premature polymerization and allows for exibility in adapting them to the tooth surfaces.
M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562 557
Fig. 23. The three generations of pre-fabricated FRC bridges: generations 1 and 2 used Splint-
It as the pre-impregnated FRC material, and generation 3 is designed from everStick.
Generation 1 is the rst design using a fully formed pontic shape duplicating the replacement
tooth. Generation 2 used a partial pontic form that required more chairside work to develop the
nal pontic form. Generation 3 had only an FRC pontic substructure that required complete
development of the pontic shape after placement. Each had its own advantages and
disadvantages.
Bonding Layer
Dentin
FRC Layer
Particulate
Composite
Layer
Enamel
Etched Enamel/Resin Tags
Fig. 24. Cross-sectional diagram showing the concept of a cohesive unit of adhesive resin/
particulate luting resin and FRC at the etched tooth interface. (From Meiers JC, Freilich MA.
Chairside prefabricated ber-reinforced resin composite xed partial dentures. Quintessence Int
2001;32:99104; with permission.)
558 M.A. Freilich, J.C. Meiers / Dent Clin N Am 48 (2004) 545562
Fig. 25. Diagrams depicting tooth replacement options. (A) A dual-wing pre-fabricated FRC
approach to replacing a missing tooth. (B) A cantilever approach involving only one abutment
tooth. These can be placed on the facial or lingual surfaces of the abutment teeth, depending on
occlusion. (From Meiers JC, Freilich MA. Chairside prefabricated ber-reinforced resin
composite xed partial dentures. Quintessence Int 2001;32:99104; with permission.)
Fig. 26. Dual-wing pre-fabricated chairside FRC bridge. (A) Patient with missing #23, facial
view. (B) Patient with missing #23, lingual view. (C) Appearance of pre-fabricated FRC
framework (everStick) showing pontic support, facial view. (D) Lingual view of pre-fabricated
FRC framework. Note the lack of bulk on the lingual and the good adaptation of the wings to
the lingual contour of the abutment teeth. Compare with (B). (E ) Facial view of completed
pontic on pre-fabricated FRC framework. (F ) Lingual view of completed pontic. Compare with
Fig. 26B and D.
Fig. 27. Cantilever pre-fabricated chairside FRC bridge. (A) Patient with extracted #9 and bone
augmentation awaiting future implant placement. An immediate cantilever FRC bridge was
treatment planned to replace #9 until implant placement. (B) Lingual view of pre-fabricated
framework (everStick) showing wing adapted to lingual surface of #8. (C ) Facial view of
nished pontic #9 on cantilever chairside FRC bridge. (D) Lingual view of nished cantilever
chairside FRC bridge showing intimate adaptation of lingual wing on #8.
Clinical cases
Figures 26 through 28 show some examples of chairside bridges made
from pre-fabricated FRC frameworks.
Fig. 28. Premolar FRC pre-fabricated chairside bridge. (A) Patient with missing #5. The
mesial-occlusal amalgam in #4 will be removed to allow room to place a wing of the pre-
fabricated bridge into the preparation. (B) The pre-fabricated framework (everStick) has been
placed onto the abutment teeth. The wing placed into the mesial-occlusal preparation of #4 has
been polymerized in a bed of owable resin. The foil on the lingual of #6 has protected this wing
from polymerization and will be removed next to allow adaptation and attachment. (C )
Occlusal view of completed FRC chairside bridge showing pontic and wing adaptation to the
abutment teeth. (D) Buccal view of completed FRC chairside bridge showing good esthetics and
functional relationships.
normally used when the bridge is to function for a short period of time.
Examples of its use include the edentulous area that is a future implant site and
as a tooth replacement covering the implant immediately after placement but
before loading. In both of these cases, the usual removable provisional
prosthesis (ipper) is replaced by a xed prosthesis. Preparation of the
abutment tooth surface receiving the wing is not needed, and when the bridge
needs to be removed, the removal of the FRC wing from the abutment has
proven to be easily accomplished with essentially no loss of enamel.
References
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Dent Clin N Am 48 (2004) 563566
Index
Note: Page numbers of article titles are in boldface type.
0011-8532/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S0011-8532(04)00045-X
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