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Introduction to Fixed Prosthodontics Dr. William Morgan Clinical Professor UCLA School of Dentistry April 3, 2007 Faculty Dr. William Morgan, Course Co-Chair Dr. Richard Stevenson, Course Co-Chair Dr. Dr. Dr. Dr. Dr. Dr. Dr. Esteban Bonilla Lillian Cheng Donald Fisher Michael Gritz Sue Spackman Jay Watson Andy Wong Course Requirements Attend lecture & lab each week Complete all projects on time Pass midterm & final practical examinations One makeup examination Average 75% or better on all written examinations Each question on quizzes & examinations count the same Quizzes each week on reading assignment Drop one quiz at end of quarter Examinations cover material since last examination Fall & Winter final examinations are cumulative Terminology Prosthodontics The dental specialty concerned with the making of artificial replacements for missing parts of the mouth and jaw. Also prosthetic dentistry or prosthodontia. Fixed Prosthodontics Gold crowns-full and partial veneer Inlays-gold and all ceramic Porcelain-all porcelain and PFM Fixed partial dentures Replace one or more missing teeth Restorative Dentistry Restorative dentistry covers the range from simple direct restorations to complex full mouth rehabilitation. This will include class I & class II direct restorations, simple indirect restorations like inlays, crowns & veneers, to replacing missing teeth with fixed partial dentures & finally to complete rehabilitation with indirect restorations throughout the mouth. Esthetics & function must also be considered. Operative Dentistry Fixed Prosthodontics Esthetic Dentistry Restorations Full Veneer Crowns Gold casting covers all external walls of the tooth & reinforces remaining tooth structure Partial Veneer Crown MOL Gold Inlay/Onlay Healthy tooth structure is preserved Partial Veneer Crown MOL Gold Inlay/Onlay Minimal facial extension preserves esthetics Partial Veneer Crown MOD Gold Onlay Restoration reinforces remaining tooth & leaves tooth structure at gingival area Gold Inlays Conservative preparation & finishing of the gold margins can provide a restoration that will last many years All Ceramic Onlay Esthetic restoration but is subject to fracture All Ceramic Inlay/Onlay Porcelain Fused To Metal Crown (PFM) Porcelain is baked to a thin cast metal coping Porcelain Veneers & Fixed Partial Denture Porcelain Veneers & Fixed Partial Denture Porcelain Veneers Fixed Partial Denture Fixed Partial Denture Porcelain is baked over a cast metal framework Fixed Partial Denture (PFM) Metal framework for strength & porcelain for esthetics Fixed Partial Denture (Gold) Fixed Partial Denture Pier Abutment Pontics Fixed Partial Denture Implants FPD attached to implants Diagnosis History Physical/Emotional Health Premedicate Allergies Medications Physician Consult Diagnosis TMJ/Occlusal Evaluation Within Normal Limits? Maintain Frequent Head, Neck or Shoulder Pain? Evaluate Occlusal Relationship Referral? Muscles & TMJ Diagnosis Intraoral Examination General Oral Hygiene Soft Tissue Periodontal Health Probing/Chart Pockets Mobility Caries Examine Old Restorations Serviceable or failing? Diagnosis Diagnostic Casts-required for all indirect restorations Mount With Facebow & Bite Records Occlusal Evaluation Diagnosis/Treatment Plan Diagnostic Wax-Up Stents For Temporization Diagnosis Full Mouth Radiographs Caries-Interproximal & Recurrent Periapical Lesions? Quality of Previous Endodontics Periodontal Health & Alveolar Bone Levels Crown/Root Ratio Pathosis Treatment Options Intracoronal Restorations Glass Ionomer Composite Resin Simple Amalgam Complex Amalgam Gold Foil Gold Inlay Ceramic Inlay Treatment Options Extracoronal Restorations Ceramic Onlay Gold Onlay Partial Veneer Crowns (3/4, 7/8) Full Gold Crown Porcelain/Metal Crown (PFM) All-Ceramic Crown Ceramic Veneer Treatment Options Reasons For Extracoronal Restorations Previous restoration and/or caries undermines tooth structure, requiring reinforcement that comes from an extracoronal restoration Discoloration present and patient desires esthetic improvement and tooth has been weakened Occlusal modifications Casting Full Gold Crown Casting/Crown Fabrication 1. Tooth Preparation, Including Caries Removal & Build-Up 2. Temporization (Ready before impression) 3. Impression 4. Model (Cast) and Die Fabrication 5. Wax-Up (Exact shape & size of desired crown) 6. Investing and Casting 7. Crown Adjusting and Polishing 8. Clinical Try-In and Cementation Tooth Preparations Full Gold Crown Preparation Indicated when restoration or caries significantly weakened tooth All external walls covered-occlusal & axial with minimal taper of axial walls Gingival finish line may be subgingival or supragingival Adequate reduction to provide bulk of gold Porcelain Fused to Metal (PFM) Indications same as FGC but patient desires more esthetics All walls covered similar to full gold crown Additional reduction necessary on facial to accommodate metal & porcelain without being overcontoured 3/4 Gold Crown Facial wall unprepared Facial cusp minimally reduced occlusally Grooves placed to prevent lingual displacement of crown Minimal facial extension interproximally Fixed Partial Denture Anterior crown preparation (abutment) is a PFM Posterior crown is a full gold crown Ceramic Onlay Restoration is all ceramic with no metal It is bonded to the tooth Weaker than restorations with metal & can fracture during mastication Build-Ups Done to replace missing tooth structure & provide retention for final restoration Types Pin Retained Amalgam or Composite Preformed Posts Retaining Buildup Custom Cast Post and Core Build-Up (Pin retained) Pin holes drilled into vital tooth Pins threaded into tooth & retained in dentin Missing tooth built up with amalgam or non tooth colored composite Build-Up (Pre-formed post) Endodontically treated tooth is missing significant amount of tooth structure One or more canals are shaped & preformed post is fit into the canal & cemented Chamber may also be used to provide additional retention for buildup Build-Up (Pre-formed post) After post is cemented, the tooth is built up with amalgam or composite Walls of preparation must extend beyond the build up to the tooth structure Build-Up (Custom Cast Dowel Core) Single rooted endodontically treated tooth with significant amount of tooth structure missing or undermined-not enough to retain a crown Build-Up (Custom Cast Dowel Core) Canal is shaped & sized with a reamer Resin pattern is made that is an exact impression of the canal & created the desired coronal “tooth structure” Pattern is cast into gold Build-Up (Custom Cast Dowel Core) Cast dowel core is cemented into the canal in the root Dowel core & tooth are reshaped into final crown preparation Impression made of preparation & crown fabricated, adjusted & cemented onto tooth Provisional Restorations (Temporaries) Custom made acrylic Relined polycarbonate crowns Pre-formed metal crowns Provisional Restoration (Custom Made Acrylic) Rough provisional crown causes gingival irritation & difficulty in taking a final impression Provisional restoration smoothed & polished with much better tissue response after only a few days Provisional Restoration (Custom Made Acrylic) Final restorations Provisional Restorations (Relined Polycarbonate Crowns) Pre-formed polycarbonate crown selected & adjusted Polycarbonate crown relined with acrylic, adjusted, polished & cemented Provisional Restorations (Preformed Metal Crowns) Pre-formed soft metal crown selected & adjusted Metal crown relined with acrylic, adjusted, polished & cemented Impressions Full arch impressions Double bite impressions Quadrant impressions Full Arch Impression Impression of whole arch using light & heavy body impression material capturing detail with no bubbles Double Bite Impression Impression of preparation, opposing dentition as well as intercuspal bite Model (Cast) and Die Fabrication Cast & Die Fabrication Full arch impression is used to fabricate full arch cast with removable dies Cast & Die Fabrication Double bite impression is used to fabricate mounted casts with either a separate die or a removable die Series Crown Preparation Casting Fabrication Full Crown Prep #30 Impression & Cast Fabrication Inspect impression for completeness & fabricate cast Wax Pattern Fabrication Fabricate a wax pattern exactly like the desired crown, checking details with the stereo microscope Invest & Cast Crown Finished wax pattern is placed inside ring & investment flowed around it. Pattern is burned out in oven & molten gold flowed into the void in the ring, creating the casting as shown above Crown Cementation Crown tried in, adjusted & cemented