Evaluation of Patient in FPD

FIXED PARTIAL DENTURES
PATIENT EXAMINATION
PATIENT EXAMINATION
The scope of fixed prosthodontic treatment can range from the restoration of a single tooth to the rehabilitation of the entire occlusion. It can transform an unhealthy, unattractive dentition with poor function into a comfortable, healthy occlusion capable of giving years of further service while greatly enhancing esthetics. To achieve that success, however, requires meticulous attention to every detail from initial patient interview through the active treatment phases to a planned schedule of follow - up care Diagnosis A thorough diagnosis first must be made of the patients dental condition ,consider ing both hard and soft tissues. This must be correlated with individuals overall physical health and psychological needs. There are 5 elements to a good diagnostic wor up in preparation for a fixed prosthodontic treatment. !. "istory #. T$%&occlusal evaluation '. Intraoral examination (. )iagnostic casts 5. *ull mouth radiographs History It is important to ta e a good history before the initiation of treatment to determine if any special precautions are necessary. +ome elective treatment might be eliminated&postponed because of patients physical&emotional health. It may be necessary to premedicate some patients for certain conditions or to avoid medication for others.
A history of infectious diseases such as serum hepatitis&aids must be nown so that protection can be provided for other patients as well as office personnel. If a patient reports of a previous reaction to a drug it should be determined whether it was an allergic reaction&syncope resulting from anxiety in the dental chair. If there is any possibility of true allergic reaction, offending medication should never be administered&prescribed. ,ocal anaesthetic and antibiotics are the most common offenders. The patient might also report a reaction to a dental material. Impression materials and nic el containing alloys are leading candidates. The patient should be as ed about medication currently being ta en. All medications should be identified and their contraindications noted before proceeding with treatment. -atients who present with a history of cardiovascular problems may require special treatment. .o patient with uncontrolled hypertension should be treated until the blood pressure has been lowered. /enerally, a systolic reading above !01mm "g or a diastolic reading above 25 mm"g should not be treated and should be referred to his&her physician for examination and treatment. -atients with a history of hypertension &coronary artery disease should not receive 3-I.3-"4I.3, since this drug has a tendency both to increase heart rate and elevate 5.-. An individual with a, prosthetic heart valve, a history of previous bacterial endocarditis 6 6 6 4heumatic fever with valvular dysfunction. 7ongenital heart malformation. $itral valve prolapse with valvular regurgitation. +hould be premedicated with Amoxycillin 8or9 in the case of allergy 3rythromycin&7lyndamycin should be given. Tetracyclines and sulfanamides are .:T recommended for patients with recurrent rheumatic fever and
bacterial endocarditis. $any patients with prosthetic heart valves are on 7oumadin, an anticoagulant. These patients physicians should be consulted before beginning any procedures that will cause even minor bleeding. Epilepsy is another condition where it has to be recogni;ed and steps to be ta en to control anxiety in these patients. ,ong fatiguing appointments should be avoided to minimi;e the possibility of initiating a sei;ure. Diabetic patients are prone to periodontal brea down& abscess formation. Those patients who have poorly controlled diabetes tending towards elevated blood sugar or hyperglycemia, could be adversely affected by stress of a dental appointment to a point of falling into a diabetic coma. "yperglycemia can also cause problem.In hypoglycemia patient feels light - headed and appear intoxicated. These patients usually carry some quic source of sucrose and also the patients stress level has to reduced. Xerostomia The prolonged presence of xerostomia&dry mouth < !9 leads to greater caries activity and is therefore extremely susceptible to the margins of cast metal&ceramic restoration. #9 -atients who have had large doses of radiation in the oral region may have drastically diminished salivary flow. '9 It can also occur as a component of s=ogrens syndrome an autoimmune collagen disease. It is frequently seen in con=unction with other autoimmune disease, such as rheumatoid arthritis, lupus erythematosus, antihistamines and scherodermia.(9anticholinergics, produce xerostomia. An effort should be made to get an accurate description of the patients expectations of the treatment results particular attention should be paid to the cosmetic effect anticipated. anorectics, and antihypertensives may
II TMJ/OCCL !AL E"AL ATION -rior to the start of fixed prosthodontic procedures the patient occlusion must be evaluated to determine. If the occlusion is within normal limits, then all treatment should be designed to maintain that occlusal relationship. "owever, if the occlusion is dysfunctional in some manner. It has to be determined whether, the occlusion can be improved prior to the placement of the restoration 8or9 whether the restoration can be employed in the correction of the occlusal problem. It should be chec ed, if the patient has had frequent occasions of head, nec &shoulder pain. If so an attempt must be made to determine the origin of such pain. TMJ !. The temperomandibular =oints have to be assessed. "ealthy T$%>s function quietly with no evidence of clic ing crepetition, or limitation of movement on opening. #. The clinician locate the T$%>s by palpating bilaterally =ust anterior to articular tragi while having the patient open and close. ?ith light anterior pressure helps identifying any potential disorder in the posterior attachment of the dis . '. $aximum =aw opening of less than average opening is greater than 51mm. Any deviation from the midline is also recorded. $aximum lateral movement can then be measured 8normal being about !#mm9. M !CLE! O# MA!TICATION !. A brief palpation of the masseter, temporalis medial pterygoid and lateral pterygoid is done. ,ight pressure must be used and the patient as ed to report any discomfort and to classify it as mild, moderate, severe.
#. -alpation is best accomplished bilaterally and simultaneously. This allows the patient to compare and report any differences between right and left side to the clinician. '. 3vidence of pain&dysfunction in either the T$% or the muscles associated with the head and nec region is an indication for further evaluation prior to starting any fixed prosthodontic procedure. LIP! !. !.The clinicians should next observe the patient for tooth exposure during normal and exaggerated smiling. #. This may be critical in treatment planning and particularly for margin placement of metal-ceramic crowns. '. The extent of the smile depends on the length and mobility of the upper lip and the length of the alveolar process. (. ?hen the patient laughs the =aw opens slightly and a dar space is visible between the maxillary and mandibular teeth. This is called the @.egative +pace@. $issing teeth, diastemas and fractured poorly restored teeth will disrupt the harmony of the negative space and often requires correction. III INT$AO$AL EXAMINATION The intraoral examination should provide information about the condition of the soft tissues teeth and supporting structures. The tongue, floor of the mouth vestibules, chee s, and hard and soft palate are examined and any abnormalities are noted. A% Perio&ontal e'amination A periodontal examination should provide information about the status of 5acterial accumulation 7alculus deposits&stains 4esponse of the host tissue
-oc ets&4ecession )egree of irreversible damage This gives us the information about patients attitude towards
his&heroral hygiene 3xisting periodontal disease must be corrected before any definitive prosthodontic treatment is underta en. (ingi)a The gingiva has to be lightly dried before examination so that moisture does not obscure subtle changes or detail. 7olor, texture, si;e, contour, consistency and position are noted and recorded. The gingiva is then carefully palpated to express any exudate or pus that may be present in the sulcular area. "ealthy gingiva is pin , stippled and firmly bound to the underlying connective tissue. The gingival margin is normal findings should be noted. The width of the band of eratini;ed attached gingiva around each tooth can be assisted by gently depressing the marginal gingiva with the side of a periodontal probe&explorer.It is generally greatest in incisor region8'.5-(.5mm in the maxilla and '.'-'.2mm in the mandible9 and less in posterior segments, with least in first premolar region 8!.2mm in maxilla and !.Bmm in mandible9 At the mucogingival =unction 8$/%9 the effect of the instrument will be seen to end abruptly, indicating the transition from lightly bound gingiva to more flexible mucosa. Perio&on&i*m The periodontal probe is one of the most reliable and useful diagnostic tools available for examining the periodontium. It provides a measurement 8in nife edged and sharply pointed papilla fill the interproximal spaces. Apon examination any deviation from these
mm9 of the depth of periodontal poc et and healthy gingival sulcus around each tooth. In this examination the probe is inserted essentially parallel to the tooth and @?al ed@ circumferentially through the sulcus in firm but gentle steps, always in contact with the base of the apical portion of the sulcus. Thus any sudden change in attachment level can be detected. -oc et depths are recorded at 0 points per tooth usually with ?illiams probe ,along with that we chec for Tooth mobility&malposition open&deficient contact inconsistent marginal ridge height missing&impacted teeth areas of inadequate eratani;ed gingiva /ingival recession, furcation involvement and malpositioned frenum attachment. +% Occl*sal e'amination It should be chec ed for !9 Any large facets&wear whether locali;ed 8or9 widespread, #9 Any non-wor ing interferences, '9 The amount of slide between the retruded position and the position of maximum intercuspation, (9 The presence&absence of simultaneous, contacts on both sides of the mouth, 59 existence and amount of anterior guidance. 4estorations of anterior teeth must duplicate existing guidance in-patients who replace that with which has been lost through wear&trauma. !. The teeth can be evaluated for crowding rotation, overeruption, spacing, malocclusion and vertical and hori;ontal overlap. #. The presence&absence of tooth contact with eccentric movements can be verified with a thin mylar strip 8+him +toc 9. Any posterior cusps that holds the shim stoc will be evident.
'. Tooth movement can be identified by *remitus Test. A more detailed examination of the occlusion is possible with mounted diagnostic casts. I" A$TIC LATED DIA(NO!TIC CA!T! )iagnostic casts are an integral part of the diagnostic procedures. Articulated diagnostic casts are essential in planning fixed prosthodontic treatment as they provide critical information not directly available during the clinical examination. The diagnostic casts must be an accurate reproduction of maxillary and mandibular arches made from distortion free alginate impressions. Anmounted casts can give information as to the alignment of the individual arches but they do not permit analysis of functional relationships. *or this, the diagnostic casts need to be attached to an articulator 8semiad=ustable9 when they have been 8positioned9 with a face bow and the articulator ad=ustments have been set by the use of lateral interocclusal records or chec bites a reasonably accurate simulation of =aw movements will be possible. The articulator settings should be included in the patients permanent record to facilitate resetting the instrument when restorations are fabricated. *inally the mandibular cast should be set in a relationship determined by the patients optimum condylar position. Articulated diagnostic casts allow an unobstructed view of the edentulous spaces and an accurate assessment of the span length, as well as occluso gingival dimension. The curvature of the arch in the edentulous region can be determined so that it will be possible to predict whether the pontics will act as a lever arm on the abutment teeth. adequate retention and resistance. The length of abutment teeth can be accurately gauged to determine which preparation designs will provides
The true inclination of the abutment teeth will also become evident, so that problems in a common path of insertion can be anticipated. $esiodistal drifting, rotation and faciolingual displacement of abutment teeth can also be clearly seen. :cclusal discrepancies can be evaluated and the presence of centric prematurities&excursive interferences determined. )iscrepancies in the occlusal plane become very apparent on the articulated casts. Teeth that have supraerupted into the opposing edentulous spaces are easily spotted and the amount of correction needed can be determined. " # LL MO TH $ADIO($APH! 4adiographs provide essential information to supplement the clinical examination. The radiographs should be examined carefully for signs of caries, presence of periapical lesions as well as the existence and quality of previous endodontic treatment. /eneral alveolar bone levels, especially on the abutment teeth. The crown root ratio of the abutment teeth can be calculated. The length configuration and direction of those roots should also be examined. Any widening of the periodontal ligament should be correlated with occlusal prematurities or occlusal trauma. An evaluation can be made of the thic ness of the cortical plate of bone around the teeth and of the trabaculation of the bone. The presence of retained root tips or other pathosis in the dentulous areas should be recorded. Thus a full mouth periapical series is normally required. -atient exposure can be minimi;ed by using a technique that gives maximum information with the least need for repeat films and by using appropriate protection.
10
-anaromic films provide useful information as to the presence&absence of teeth. They are especially useful in !9 Assessing third molars, #9 3valuating the bone prior to implant placement, and '9 *or screening edentulous mouths for retained root tips. "owever, they do not provide a sufficiently detailed view for assessing bone support root morphology&caries. +pecial radiographs may be needed for the assessment of T$% disorders. Transcranial exposure with the help of a positioning device, will reveal the lateral third of the mandibular condyle and can be used to detect structural and positional changes. $ore information can be got from serial topography, arthrography, 7T-+canning, $agnetic 4esonance Imaging of the =oints. CONCL !ION The history and examination must provide sufficient data to enable the practitioner to give a successful treatment plan. If they are too hastily accomplished, details may be missed that can cause significant problems during treatment, at which time it may be difficult or impossible to ma e correction. Articulated diagnostic casts can provide a great deal of information for diagnosing problems and arriving at the treatment plan.
11
A.T34I:4 74:?.+< *A,, C -A4TIA,
12
ANTE$IO$ C$O,N!
The metal-ceramic restoration, also called a porcelain-fused-to-metal restoration, consists of a ceramic layer bonded to a thin cast metal coping that fits over the tooth preparation. +uch a restoration combines the strength and accurate fit of a cast metal crown with the cosmetic effect of a ceramic crown. ?ith a metal understructure, metal-ceramic restorations have greater strength than restorations made of the ceramic alone. #rie&lan&er et al found the metal-ceramic restoration to be #.B times as strong. As a result, the longevity of metal-ceramic restorations is greater, and it can be used in a wider variety of situations, including the replacement of missing teeth with fixed partial dentures. +ince the restoration is a combination of metal and ceramic, it is not surprising that the tooth preparation for it is li ewise a combination. There is deep reduction on the facial surface to provide space for the coping and a ceramic layer thic enough to achieve the desired cosmetic result. :n the lingual surface and the lingual aspects of the proximal surfaces, there is shallower reduction similar to that used for a full metal crown. There may be a wing on each proximal surface where the deep facial reduction ends and the shallower proximal reduction begins. Adequate reduction is essential to achieving a good cosmetic result. ?ithout the space for a sufficient thic ness of ceramic material, two things can happen< The restoration will be poorly contoured, adversely affecting both the cosmetic effect of the crown and the health of the surrounding gingiva. The shade and translucency of the restoration will not match ad=acent natural teeth.
13
Anterior Metal-Ceramic Cro.ns A uniform reduction of approximately !.# mm is needed over the entire facial surface. To achieve adequate reduction without encroaching upon the pulp, the facial surface must be prepared in two planes that correspond roughly to the two geometric planes present on the facial surface of an uncut tooth. If the facial surface is reduced in one plane that is an extension of the gingival plane, the incisal edge will protrude, resulting in a bad shade match or an over contoured @bloc .@ If the facial surface is prepared in one plane that has adequate facial reduction in the incisal aspect, the facial surface will be over tapered and too close to the pulp. Armamentari*m !. ,aboratory nife with no. #5 blade #. +ilicone putty and accelerator '. "andpiece (. *lat-end tapered diamond. 5. +mall wheel diamond 0. ,ong needle diamond D. Torpedo diamond B. Torpedo bur 2. "!5B-1!# radial fissure bur !1. 4+-! biangle chisel If an index is made before the preparation is begun it will be possible to have a positive chec on reduction produced by the preparation. If the contours of the existing tooth are correct, the index can be made intraorally while waiting for the anesthetic to ta e effect. "owever the tooth is badly bro en down, or if contours are to change in the finished restoration, the index should made from a preoperative wax-up on the diagnostic cast.
14
:ne-half scoop of putty is mixed with the appropriate amount of accelerator and neaded in the palm of hand until all strea s of the accelerator have dispersed. The putty is then adapted with a thumb and forefinger over the tooth to be prepared. It should be allowed to polymeri;e on the tooth, which should be about # minutes. The index should cover the entire labial and lingual surface of the tooth to be prepared, plus corresponding surfaces of at least one ad=acent tooth. The index is then removed from the teeth. A laboratory nife with a no. #5 blade is used to cut along the incisal edges of the tooth imprints to separate the index into a labial and a lingual half. The lingual half is ept aside for the time being. The labial portion of the index is cut from mesial to distal across the imprints of the labia surfaces of the teeth to produce an incisal and a gingival half. The gingival half of the labial portion is positioned the teeth to insure that it is closely adapted to the labial surface. After removing the labial index, lingual index is put in position and its adaptation to incisal edges of the teeth is chec ed. The labial and lingual indices are set aside until preparation is completed. Then the gingival half of labial index is positioned and chec ed for adequate labial clearance for a metal coping and porcelain. If the reduction is inadequate, the index is removed from the mouth and more tooth structure must removed. -utting the lingual index in place and evaluating the distal between the incisal edge of the prepared tooth and incisal edge of the tooth imprint on the index chec the incisal clearance. The initial step in the preparation for a metal-ceramic crown is the placement of depth-orientation grooves the labial and incisal surfaces with a flat-end tapered diamond. These orientation cuts, recommended by -reston and $iller, are a means of =udging the amount
15
!tep-+y-!tep Proce&*re% The preparation is divided into five ma=or steps< guiding grooves, incisal reduction, labial reduction in the area to be veneered with porcelain, axial reduction of the proximal and lingual surfaces, and final finishing of all prepared surfaces. Guiding Grooves 1. -lace three depth grooves one in the center of the facial surface and one each in the approximate locations of the mesiofacial and distofacial line angles. These will be in two planes< the cervical portion to parallel the long axis of the tooth, the incisal 8occlusal9 portion to follow the normal facial contour /% -erform the facial reduction in the cervical and incisal planes. The cervical plane will determine the path of withdrawal of the completed restoration. The incisal or occlusal plane will provide the space needed for the porcelain veneerE it should be approximately !.' mm deep to allow for additional reduction during finishing. The incisal grooves usually extend halfway down the facial surface, although 8depending on the shape of the tooth9 they may extend to include the incisal two thirds. 7ervical grooves are generally made parallel to the long axis of the tooth. "owever, they can be ad=usted slightly to create a more desirable path of withdrawalE in particular, some labial inclination will improve retention on a tooth with little cingulum height. :n small teeth it may be advisable to shallower near the margin. 0% -lace two depth grooves 8about !.B mm deep9 in the incisal edge of an anterior tooth. This will provide the needed reduction of mm and allow finishing. Ferify the depth of these grooves can be verified with a periodontal probe. ?hen initially positioning the diamond for anterior teeth, it may be helpful to observe the long axis of the opposing tooth in the intercuspal position and to orient the instrument perpendicular to that. The grooves must eep the cervical grooves somewhat
16
not be too deepE otherwise, an over reduced and undulating surface will result. Incisal Reduction. The completed reduction of the incisal edge on an anterior tooth should allow # mm for adequate material thic ness to permit translucency in the completed restoration. 7aution must used, however, because excessive occlusal reduction shortens the axial walls and thus is a common cause of inadequate retention and resistance form the completed preparation. This can be particularly problematic on anterior teeth 8where as a consequence of tooth form, most of the retention is derived from the proximal walls9. 1% 4emove the islands of remaining tooth structure. :n anterior teeth, access is usually unrestricted, and the thic est portion of the cutting instrument can be used to maximi;e cutting efficiency. Labial Reduction. ?hen completed, the reduction of the facial surface should have produced sufficient space to accommodate the metal substructure and porcelain veneer. A minimum of !.# mm is necessary to permit the ceramist to produce a restoration with satisfactory appearance 8!.5 mm is preferable9. This requires significant tooth reduction. *or comparison, the cervical diameter of a maxillary central incisor averages between 0 and D mm. In the cervical area of small teeth, obtaining optimal reduction is not always feasible. :ften a compromise is made with lesser reduction in the area where the cervical shoulder margin is prepared. 2% 4emove the remaining tooth structure between depth grooves, creating a shoulder at the cervical margin. If a restoration with a narrow subgingival metal collar is to be fabricated and sufficient sulcular depth is present, place the shoulder approximately 1.5 mm apical to the crest of the free gingiva at
17
this time. Additional finishing will then result in a margin that is 1.D5 to ! mm subgingival. Ase adequate water spray during the entire phase of preparation, because a significant amount of tooth structure is being removed and copious irrigation 8along with intermittent stro es9 will expedite the preparation process. +uch a cautious approach will prevent unnecessary trauma to the pulp. The resulting shoulder should be approximately ! mm wide and should extend well into the proximal embrasures when viewed from the incisal side. ?here access permits, establishing this shoulder from the proximal gingival crest toward the middle of the facial wall is preferred. This will minimi;e placement of the initial shoulder preparation too close to the epithelial attachment. If the margin is established from facial to proximal, a tendency exists to @bury@ the instrument and encroach on the epithelial attachment. A conscious effort to maintain proper margin position relative to the crest of the free gingiva is critical. The location and specific configuration of the facial margin depend on several factors< the type of metal-ceramic restoration selected, the cosmetic expectations of the patient, and operator preference. *rom a periodontal point of view, a supragingival margin is always preferred. Its application is restricted, however, because patients often ob=ect to a visible metal collar or discolored root surface. +uch ob=ections are common, even when the gingival margin is not visible during normal function, as in patients with a low lip line. The optimum location of the margin should be carefully determined with the full cooperation of the patient. ?here a subgingival margin is to be placed, careful tissue manipulation is essentialE if otherwise, there will be damage that leads to permanent gingival recession and subsequent exposure of the metal collar. This is most effectively avoided through meticulous gingival displacement with cord before finishing. The configuration of the margin is also finali;ed at this time.
18
Axial Reduction of the Proximal and Lingual Surfaces, +ufficient tooth structure must be removed to provide a distinct smooth chamfer of about 1.5 mm width. 3% 4educe the proximoaxial and linguoaxials surfaces with the diamond held parallel to the intended path of withdrawal of the restoration. These walls should converge slightly from cervical to incisal. A taper of proximately 0 degrees is recommended. :n anterior teeth, a lingual concavity is prepared for adequate clearance for the restorative material. Typically, ! mm is required if centric contacts in the completed restoration are to be located on metal. ?hen contact is porcelain, additional reduction will be necessary. *or anterior teeth, usually only i groove is placed, in the center of the lingual surface. 4% $a e a lingual alignment groove by positioning the diamond parallel to the cervical plane of labial reduction. ?hen the round tipped diamond of appropriate si;e and shape is aligned properly, it will be almost halfway submerged into tooth structure. 7arry the axial reduction from the groove along the lingual surface into the proximalE maintain the originally selected alignment of the diamond at all the times. B. As the lingual chamfer is developed, extend it buccally into the proximal to blend with the interproximal shoulder placed earlier. The proximal flange that resulted from the shoulder preparation can be used as a reference for =udging alignment of the rotary instrument. The interproximal margin should not be inadvertently placed too far gingivally and thereby infringe on the attachment apparatus. It must follow the soft tissue contour. After preparation of the cingulum wall, one or more depth grooves are placed in the lingual surface. These are approximately ! mm deep. 5% Ase a football-shaped diamond to reduce the lingual surface of anterior teeth. It is helpful to stop when half this reduction has been completed to
19
evaluate clearance in the intercuspal position and all excursions. The remaining intact tooth structure can serve as a reference. Finishing. The margin must provide distinct resistance to vertical displacement of an explorer tip, and it must be smooth and continuous circumferentially. 8A properly finished margin should feel li e smooth glass slab.9 All other line angles should be rounded, and the completed preparation should have a satin finish free from obvious diamond scratch mar s. Tissue displacement is particularly helpful when finishing subgingival margins. +ometimes this step is postponed until =ust before impression ma ing after tissue displacement. 67% *inish the margins with diamonds, hand instruments, or carbides. All internal line angles should be radiused to facilitate the impression-ma ing and die-pouring steps. The finishing steps for the facial margin depend on the design of margin chosen. A porcelain labial margin requires proper support for the porcelain. A shoulder with a 21-degree cavosurface angle is recommended. This type of shoulder can also be used for a crown with a conventional metal collar and offers the advantage of allowing the collar to be ept narrow. "owever, there is then the ris of leaving unsupported enamel. *or this reason, the margin is often beveled or sloped to create a more obtuse cavosurface angle. A flat-ended diamond in a low-speed hand-piece creates the 21-degree shoulder. Any unsupported enamel must be removed subsequently by careful planning with a sharp chisel. 7are must also be ta en to orient the rotary instrument as it moves around the tooth if inadvertent undercuts are to be avoided. ?hen a metal-collar design of ceramic restoration is planned, the need for a 21-degree shoulder is less critical. A sloping shoulder has been advocated to ensure the elimination of unsupported enamel and to minimi;e marginal gap width. +uch a shoulder 8cavosurface angle of about !#1 degrees9 can be accomplished with a flatended diamond by changing its alignment, paying particular attention to the
20
configuration of the tooth structure cervical to the margin. Alternatively, a hatchet can be used to plane the margin to the correct angulation. Again, be careful to avoid undercutting the axial wall of the preparation where it meets the shoulder during finishing. A shoulder-bevel margin is most effectively achieved with a flame-shaped carbide bur or hand instrument, depending on the length of bevel required. /enerally a short bevel with a cavosurface of !'5 degrees is advocated, although longer bevels have been recommended for improved marginal fit. The chamfer and bevel should be continuous with each other. Tissue displacement before subgingival bevels is recommended. 66% After a satisfactory facial margin is obtained, round all line angles and point angles. A fine grit diamond at low speed is used for this. 5lend all surfaces together and remove any sharp transition. ALL-CE$AMIC C$O,N! The all-ceramic crown differs from other cemented veneer restorations because it is not cast in gold or some other metal. It is capable of producing the best cosmetic effect of all dental restorations. "owever, since it is made entirely of ceramic, a brittle substance, it is more susceptible to fracture. The development of dental porcelain reinforced with alumina in the !201s created renewed interest in the restoration. )icor cast glass ceramic, "i-ceram, Inceram, and I-+ 3mpress restorations have maintained the interest of the profession over the past decade. -reparations for this type of crown should be left as long as possible to give maximum support to the porcelain. An over shortened preparation will create stress concentrations in the labiogingival area of the crown, which can produce a characteristic @half-moon@ fracture in the labiogingival area of the restoration. A shoulder of uniform width 8approximately ! mm9 is used as a gingival finish line to provide a flat seat to resist forces directed from the incisal. The incisal edge is flat and placed at a slight inclination toward the
21
linguogingival to meet forces on the incisal edge and prevent shearing. *inally, all sharp angles of the preparation should be slightly rounded to reduce the danger of fracture caused by points of stress concentration. The position of the tooth in the arch, factors relating to occlusion, and morphologic features of the tooth all should be weighed when an all-ceramic crown is considered for a restoration. All-ceramic crowns are best suited for use on incisors. If they are used on other teeth, patients should now that there is an increased ris of fracture. Ase of the all-ceramic crown should be avoided on teeth with an edge-toedge occlusion that will produce stress in the incisal area of the restoration. It li ewise should not be used when the opposing teeth occlude on the cervical fifth of the lingual surface. Tension will be produced, and a @half-moon@ fracture is li ely to occur. Teeth with short cervical crowns also are poor ris s for all-ceramic crowns because they do not have enough preparation length to support the lingual and incisal surfaces of the restoration. Armamentari*m !. "andpiece #. *lat-end tapered diamond '. +mall wheel diamond (. "!5B-1!# radial fissure bur 5. 4+-! binangle chisel )epth-orientation grooves are placed on the labial and > incisal surfaces with the flat-end tapered diamond before any reduction is done. ?ithout grooves it is impossible to accurately gauge the depth of reduction done on the labial surface. The grooves are !.# to !.( mm deep on the labial and #.1 mm deep on the incisal. Three labial grooves are cut with the diamond held parallel to the gingival one-third of the labial surface. A second set of two grooves is made parallel to the incisal two-thirds of the uncut labial surface. The labial
22
surface of an all-ceramic preparation is done in two planes to achieve adequate clearance for good esthetics without encroaching on the pulp. Incisal reduction is done with the flat-end tapered diamond so that it will be possible for instruments to reach the finish line area of the preparation in subsequent steps. *rom !.5 to #.1 mm of tooth structure is remove. The tooth structure remaining between the depth orientations grooves on the incisal portion of the labial surface is planed away. The gingival portion the labial surface is reduced with the flat-end tapered diamond to a depth of !.# to !.( mm. This reduction extends around the labioproximal line angles and fades out on the lingual aspects of the proximal surfaces. The end of the flatend tapered diamond bur form the shoulder finish line, while the axial reduction done with the sides of the diamond. The shoulder should be a minimum of !.1 mm wide. ,ingual reduction is done with the small wheel diamond, being careful not over reduce the =unction between the cingulum and lingual wall. :ver shortening the lingual \ will reduce the retention of the preparation. 4eduction of the lingual axial surface is done with flat-end tapered diamond. The wall should form a minimum taper with the gingival portion of the Iabial wall. The radial shoulder is at least !.1 mm wide should be a smooth continuation of the labial and proximal radial shoulders. All-ceramic crowns made over shoulder finish lines exhibit greater strength than that made over chamfers. All of the axial walls should be smoothed with an "!5B-1!# radial fissure bur, accentuating the shoulder at the same time. All sharp angles should be rounded over at this time. The 4+-! modified binangle chisel is used to smooth the shoulder removing any loose enamel rods at the cavosurface angle. 7are must be ta en not to create undercuts in axial walls where they =oin the shoulder.
23
ANTE$IO$ TH$EE-8 A$TE$ C$O,N! )emands for the avoidance of any display of metal, coupled with the ease of preparing a tooth for a metal-ceramic crown, have led to the near total demise of the anterior three-quarter crown. Ansightly, unnecessary displays of metal in poor examples of this restoration made it unpopular with both the public and the profession. ?hen a partial veneer is used, it is usually a pin-modified three-quarter crown in which metal coverage is minimi;ed by using pins. "owever, well-executed standard three-quarter crowns on a maxillary incisor or canine need not show much metal. It can be used as a retainer for shortspan fixed partial dentures on restoration- and caries-free abutments. ?ellaligned, thic , square anterior teeth with a large faciolingual bul structure are the best candidates for three-quarter crowns. Two factors must be controlled successfully to produce a restoration with a minimal display of metal< (1) path of insertion and groove placement, and (2) placement and instrumentation of extensions. The path of insertion of an anterior three-quarter crown parallels the incisal one-half to two-thirds of the labial surface, not the long axis of the tooth. This gives the grooves a slight lingual inclination, placing their bases more apically and labially, and ma ing the grooves longer. If the grooves incline labially, the fabioincisal comers are over cut, displaying metal. The bases of the grooves then move lingually, becoming shorter and less retentive. -roximal extensions are done with thin diamonds or hand instruments with a lingual approach to minimi;e the display of metal. Ase of a large instrument or a labial approach will result in overextension and an unsightly display of metal. Armamentarium !. "andpiece #. +mall round diamond of tooth
24
'. +mall wheel diamond (. ,ong needle diamond 5. Torpedo diamond 0. Torpedo bur D. .o. !02,bur B. .o, !D1,bur 2. *lame diamond !1. *lame bur !!. 3namel hatchet A small wheel diamond is used to create a concave lingual reduction incisal to the cingulum. It is necessary to create 1.D mm or more clearance with opposing teeth. To ensure adequate reduction, depth-orientation cuts are made on the lingual surface with a small round diamond whose head has a diameter !.( mm larger than its shaft- 5uried in enamel to the shaft, the diamond penetrates 1.D mm. 4eduction is done to the depth of the orientation cuts. The lingual reduction of a canine is done in two planes, with a slight ridge extending incisogingivally down the middle of the lingual surface. :n incisors, the entire surface is smoothly concave. The =unction between the cingulum and the lingual wall must not be over reduced. If excessive tooth structure is removed, the lingual wall will be too short to provide retention, Incisal reduction is done with the small wheel diamond. It parallels the inclination of the uncut incisal edge and barely brea s through the labioincisal fine angle. .ear the =unction between the incisal edge and the lingual surface, it is about 1.D mm deep- on a canine, the natural mesial and distal inclines of the incisal edge are followed. :n an incisor, a flat plane is cut from mesial to distal.
25
The lingual axial wall is reduced with a torpedo diamond, creating a chamfer finish line at the same time. The diamond is ept parallel with the incisal twothirds of the labial surface to initiate the path of insertion of the preparation. The vertical lingual wall is essential to retention. If cingulum is short, wall length can be increased with a dual beveled shoulder that moves the wall farther into tooth. A '.1-mm-deep pinhole can be placed in the cingulum to compensate for a very short lingual wall. This common variation of the anterior three-quarter crown frequently used on abutments for fixed partial denture -roximal reduction is started with a long needle diamond. The instrument comes from the lingual, to minimi;e the display of metal later. An up and down motion is used, with care not to nic the ad=acent tooth or lean the diamond too far into the center of the prepare tooth. The labial proximal extensions are completedE a contact with the ad=acent tooth should be barely bro en with an enamel hatchet, not with the diamond. I The axial reduction is completed and the finish line is accentuated with a torpedo diamond. To prevent binding between the prepared proximal axial wall and the ad=acent tooth, it may be necessary to use a flame diamond before the torpedo diamond. The axial surface and chamfer are then planed with the torpedo carbide I The grooves are placed as far labially as possible with out undermining the labial enamel plate. To implement groove placement, outlines of the grooves are drawn on the lingual incisal area of the preparation. 7utting a !.1-mmdeep GtemplateH within the penciled outline using a no. !D1, bur begins the first groove. The groove is extended gingivally in increments to its full length. A novice may want to use a no. !02, bur initially to allow ad=ustment of the groove without over cutting it. The second groove is cut parallel with the first, ending both =ust short of the chamfer. 4emember that grooves in an anterior three-quarter crown
26
preparation parallel the incisal one-half to two-thirds of the facial surface, unli e those in a posterior tooth, which parallel the long axis of the tooth. 5oxes may be substituted for grooves if there exist proximal restorations or caries. 5oxes must be narrow to be resistant, because the lingual wall of a box shortens as it moves lingually. :n the facial aspect of each groove, a flare is starts at the gingival end with the thin tip of a flame diamond. It is finished with the flame bur to ma e a smooth flare and a sharp, definite finish line. If a very minimal extension is desired, a wide enamel chisel should be used instead. Asing a no. !D1, bur. the grooves are connected with an incisal offset, staying a uniform distance from the incisal edge, The offset is a definite step on the sloping lingual surface, placed near the opposite occlusal contact. The metal that occupies the space reinforces the margin. :n a canine it forms a F, but on an incisor it is a straight line. The angles between the incisal edge and the upright wall of the offset and between the incisal reduction and each flare are rounded. A 1.5-mm-wide bevel is placed on the labioincisal finish line using a no. !D1, bur. This can also be done with a flame diamond and bur, but finishing is still done with a bur to create the sharpest finish line. The bevel is perpendicular to the path of insertion along the mesial incline. A contra bevel can be placed on the distal incline, where esthetic considerations are not as critical. A contra bevel should never be used on an incisor. 7onservative extension and careful finishing of the gold incisal margin will cause light to be reflected downward, ma ing the incisal edges appear dar rather than metallic to the viewer. As a result, it will blend in with the dar bac ground of the oral cavity.
27
PIN-MODI#IED TH$EE-8 A$TE$ C$O,N! There are situations calling for a partial veneer crown that will not permit the use of a @classic@ preparation design. The pin-modified three-quarter crown is an esthetic modification that has long been considered the retainer of choice on unblemished teeth used as fixed partial denture abutments in esthetically critical areas. Although resin-bonded retainers gained popularity in such situations in the !2B1s, the pin-modified three-quarter crown is still an excellent retainer for short-span fixed partial dentures. The pin-modified three-quarter crown preserves the facial surface and one proximal surface. ?ith minimal sub gingival margins, it is periodontally preferable to a full crown. An unsightly display of metal is avoided without resorting to a destructive full veneer metal-ceramic restoration. The pinmodified three-quarter crown is good for repairing incisors and canines with severe lingual abrasion. It should not be used on teeth with caries or restorations, on surfaces that are not to be covered, or in mouths with extensive caries. Although this restoration design is conservative in the amount of enamel that is untouched, a variety of factors could place the pinholes near or even in the pulp. Therefore, pin-modified three-quarter crowns should not be used on teeth that are small, thin, possessed of large pulps, or malpositioned. Ans illed dentists should not use them. -ins are li ely to produce less retention, and pin-retained castings are less retentive than standard three-quarter crowns. "owever, the greater the number, depth, or diameter of pins, the greater the retention. The pinmodified three-quarter crown is an old restoration that was revived in the !201s by the development of small twist drills to ma e pinholes and nylon bristles to accurately reproduce them. -inholes are usually made with a 1.0-mm drill. .ylon bristles, #5 to 51 microns smaller in diameter than the drill, are placed in the pinholes because
28
the pinholes are too small to be reproduced by impression material. Impression material surrounds the pin and incorporates it into the impression. ?hen the impression is poured, the nylon bristles protruding from it reproduce the pinholes. +errated pins produce more retention than smooth pins, so serrated iridioplatinum pins #5 to 51 microns smaller than the pinholes in the stone cast are used in the wax pattern. The resulting pins in the casting are 51 to !11 microns smaller than the original pinholes in the preparation. -ins should be #.1 to '.1 mm long. Adequate pin length is essential to retention, and short pins will cause the failure of a conservative fixed partial denture. These are very destructive failures, because the pinholes become channels for oral fluids and microorganisms to penetrate deep into the tooth. 7onsiderable damage may occur before a loose retainer is detected. If adequate pinhole depth is not possible, a different retainer design should be used. Armamentari*m !. "eadpieces #. +mall round diamond '. +mall wheel diamond (. ,ong needle diamond 5. Torpedo diamond 0. Torpedo bur 1. .o. !02, bur B. .o. !D1,bur 2. *lame diamond !1. *lame bur !!. 3namel hatchet !#. .o. !&# round bur !'. 1.0-mm drill.
29
!(. .ylon bristles 7oncave reduction of the lingual aspect of the tooth is done with a small wheel diamond to produce a minimum clearance of 1.D mm with ad=acent teeth. )epth-orientation cuts can be made using a small round diamond with a head diameter !.( mm greater than its shaft diameter. It is sun into enamel down to the shaft to ma e a cut approximately 1.D mm deep. 3xcessive shortening of the vertical wall of the cingulum should be avoided. A lingual incisal bevel paralleling the uncut surface of the incisal edge is also prepared with the wheel diamond. This bevel is approximately !.5 mm wide, but it may vary on teeth with unusually thic or thin incisal edges. It should stop lingual to the labioincisal line angle to prevent a display of metal. Asing a torpedo diamond, the lingual axial wall is reduced to parallel the incisal two-thirds of the labial surface, simultaneously forming a chamfer finish line. 7are should be ta en not to extend too far labially into the lingual proximal embrasure on the proximal surface opposite the retentive feature. The finish line must be far enough lingual to the proximal contact so that the restoration margin can be finished by the dentist and cleaned by the patient. If the cingulum is short, a beveled shoulder should be used to move the lingual wall toward the center of the tooth, ma ing it longer. The torpedo diamond is used to continue the axial reduction to its most facial extension near the labioproximal line angle. The reduction is diminished at the finish line. The location of this finish line is critical. If it is not far enough facial, it can cause an undersi;ed, wea connector, and a margin that would be impossible to finish properly. The axial reduction and the chamfer finish line should be smoothed with a torpedo carbide bur. The primary axial retention&resistance features, two grooves, are placed next to the edentulous space. If the proximal surface is carious or has been restored previously, a box form is used. The box is too destructive to use routinely on unblemished proximal surfaces. Iishimoto et al demonstrated
30
that two grooves are equal to a box on a premolar. :n an anterior tooth, they are probably superior. +ince the lingual surface slopes linguogingivally, moving the lingual wall a slight distance lingually shortens it and decreases resistance. 5y using two grooves, there will be two lingual walls. The wall of the more facially positioned groove will be longer and more resistant than the single, shorter lingual wall of a box. The facial groove is placed with a no. !D1, bur. An inexperienced dentist may want to start the grooves with a no. !02, bur to avoid over cutting. +hallow pilot grooves are made and chec ed for location and direction. Then a no. !D1, bur is sun into the trac of the trial groove to the full diameter of the bur. The lingual groove is placed next. -aralleling it with the first. A third, much shorter groove is placed on the opposite side of the cingulum near the vertical finish line on that surface. This groove enhances the restoration resistance slightly, and it accommodates a bul of metal to reinforce the margin. -roximal flares are formed with a flame diamond. *or the flare to draw, it must be wider incisally than it is gingivally. It nearly eliminates the facial wall of the groove at its incisal end. A slight flare is placed on the mesial groove. The distal and mesial flares are reinstrumented with a matching flame carbide bur. 7are should be ta en not to round over the finish line. A flat ledge or countersin is cut in the incisal corner opposite the site of the proximal grooves using a no. !D1, bur. It must be gingival to the incisal edge, in dentin, and lingual to the finish line. A ledge is also placed in the middle of the cingulum. These flat areas on the sloping lingual surface provide easy starts for precise pinhole placement, and they create space for a reinforcing bul of metal at the base of the pins. The no. !D1, bur is used to connect the incisal edge and the facial most proximal groove with an incisal offset A F-shaped trough is cut along the side
31
of the lingual surface from the incisal ledge to the short cingulum groove. The metal in the trough will reinforce the linguoproximal margin of the restoration. A shallow depression to begin a pinhole in the center of each ledge is made using a no. !&# round bur. To initiate the first pinhole, a low-speed contraangle 1.0-mm 81.1#(-inch9 drill is carefully aligned with the grooves. The handpiece is started before touching the tooth and should not be stopped while the drill is in the pinhole, as it will snap off. ?hen the first pinhole is approximately '.1 mm deep, the handpiece is withdrawn and a nylon bristle is placed in the pinhole. Asing the bristle and grooves as guides, a '.1-mmdeep pinhole is made in the other ledge. The angle between the facial wall of the offset and the incisal edge of uncut tooth structure is beveled. 7are should be ta en not to extend this bevel too far facially, as metal will show. A finishing bevel is placed on the functional area of the incisal edge using a flame diamond. 7are is ta en to prevent an unnecessary display of metal, but it may be necessary to extend the bevel on the distal incline of the incisal edge of a canine onto the labial surface. This is not li ely to be unacceptable cosmetically, since it is usually hidden from view. This should not be done on an incisor. The incisal bevel is blended into the flare and the bevel is redefined on the marginal ridge next to the incisocingulum trough. The areas =ust described are smoothed with flame bur. Acute angles between the lingual and proximal surfaces are blunted, and any sharp corners at the incisal ends of the grooves are eliminated.
32
# NDAMENTAL! O# OCCL !ION
33
# NDAMENTAL! O# OCCL !ION

In restorative treatment, the goal is to create occlusal contacts in posterior teeth that stabili;e, instead of creating deflective contacts that may destabili;e, the mandibular position. The occlusion in a restoration should be made in harmony with the optimum condylar position, centric relation: an anteriorly, superiorly braced position along the articular eminence of the glenoid fossa, with the articular disc interposed between the condyle and eminence. Anfortunately, the occlusion of teeth is frequently overloo ed or ta en for granted in providing restorative dental treatment for patients. This may be due in part to the fact that the symptoms of occlusal disease are often hidden from the practitioner not trained to recogni;e them or to appreciate their significance. The long-term successful restoration of a mouth with cast metal or ceramic restorations is dependent upon the maintenance of occlusal harmony. This position of the condyles in the glenoid fossae has been discussed and debated for years. It is used in dentistry as a repeatable reference position for mounting casts in an articulator. Ideally, that condylar position is also coincident with maximum intercuspation of the teeth. The bone of the glenoid fossa is thin in its most superior aspect and is not suited to be a stress-bearing area. "owever, the slope of the eminence in the articular aspect of the fossa is composed of thic cortical bone that is capable of bearing stress. The articular disc is biconcave, is devoid of nerves and blood vessels in the central area, and is toughJmuch li e a piece of shoe leather. It has a few muscle fibers attached in the anterior aspect from the superior head of the lateral pterygoid muscle. The disc is attached to the condyle on its medial and lateral aspects and should be interposed between the condyle and articular eminence as function occurs. The condyle is not spherical, but has an
34
irregular, elliptical shape. This shape helps to distribute stress throughout the temporomandibular =oint rather than concentrating it in a small area. $any methods have been used to guide the mandible into an @ideal@ position. 3arlier concepts of centric relation involved the most posterior condylar position in the fossa. The condyle was sometimes forcefully manipulated into the rearmost, uppermost, and midmost position within the glenoid fossa, called the "RUM" position, using chin point guidance. "owever, when the condyle is retruded, it may not be seated onto the central area of the articular disc. Instead it may be on the highly vascular and innervated retrodiscal tissues 8the bilaminar zone} posterior to the disc. This can occur if the hori;ontal fibers of the temporomandibular ligament have been unduly traumati;ed so that they no longer support the condyle in a more anterior, physiologic position. It is presently thought that rather than being a physiologic position, it is frequently an abnormal, forced position, which could create unnecessary strain in the temporomandibular =oint. In this circumstance, the disc is displaced anteriorly, and clic ing of the =oint is frequently observed as the patient opens and closes. The more recent concept describes a physiologic position regarding musculos eletal relationships of the structures. It is not a forced position, but is gently guided by the operator using the bilateral method or by allowing natural muscle action to place the condyle in a physiologically unstrained position. Man&ib*lar Mo)ement $andibular movement can be bro en down into a series of motions that occur around three axes< !. Horizontal axis. This movement, in the sagittal plane, happens when the mandible in centric relation ma es a purely rotational opening and closing border movement around the trans erse !orizontal axis, which extends through both condyles. 35
#. "ertical axis. This movement occurs in the hori;ontal plane when the mandible moves into a lateral excursion. The center for this rotation is a vertical axis extending through the rotating or wor ing-side condyle. '. #a$ittal axis. ?hen the mandible moves to one side, the condyle on the side opposite from the moves downward simultaneously. ?hen viewed in the frontal plane, this produces a downward arc on the side opposite the direction of movement, rotating about an anteroposterior 8sagittal9 axis passing through the other condyle. Farious mandibular movements are composed of motions occurring concurrently about one or more of the axes. The up and down motion of the mandible is a combination of two movements. A purely @hinge@ movement occurs as the result of the condyles rotating in the lower compartments of the temporomandibular =oints within a !1- to !'-degree arc, which creates a #1to #5-mm separation of the anterior teeth. This phenomenon was the basis for the @terminal hinge axis@ theory in the early !2#1s by $c7ollum. Iohno verified the presence of a transverse hori;ontal axis, which he termed the @ inematic axis.@ There is also some gliding movement in the upper compartment of the =oint if the mandible drops down farther. Then the axis of rotation shifts to the area of the mandibular foramen, as the condyles translate forward and downward while continuing to rotate. ?hen the mandible slides forward so that the maxillary and mandibular anterior teeth are in an end-to-end relationship, it is in a %rotr&si e position. Ideally, the anterior segment of the mandible will travel a path guided by con tacts between the anterior teeth, with complete disocclusion of the posterior teeth. $andibular movement to one side will place it in a wor'in$, or laterotrusive, relationship on that side and a nonwor'in$, or mediotrusive, relationship on the opposite sideE e.g., if the mandible is moved to the left, the left side is the wor ing side, and the right side is the nonwor ing side. In this type of
36
movement, the condyle on the nonwor ing side will arc forward and medially. $eanwhile, the condyle on the wor ing side will shift laterally and usually slightly posteriorly. 5ennett first described the bodily shift of the mandible in the direction of the wor ing side. The angle formed in the hori;ontal plane between the pathway of the nonwor ing condyle, the man(ib&lar lateral translation, and the sagittal plane, is called the )ennett an$le. The presence of an immediate or early lateral translation, or side shift, has been reported in B0K of the condyles studied. In addition to confirming the predominant presence of the early lateral translation, ,undeen and ?irth, using a mechanical apparatus, showed its median dimension to be approximately !.1 mm with a maximum of '.1 mm. "obo and $ochi;u i, using an electronic measuring device, found a lower mean value of 1.( mm for the immediate lateral translation, with a high of #.0 mm. *ollowing the immediate lateral translation, there is a further gradual shifting of the mandible, %ro$ressi e lateral translation, which occurs at a rate proportional to the forward movement of the nonwor ing condyle. At one time this was nown as @progressive side shift@ or @5ennett side shift.@ ,undeen and ?irth found slight variation in the direction of the progressive lateral translation or 5ennett angle, with a mean value of D.5 degrees. "obo and $ochi;u i found a much greater variation, ranging from !.5 to '0 degrees, with a mean value of !#.B decrees. T9e Determinants o: Man&ib*lar Mo)ement The two condyles and the contacting teeth are analogous to the three legs of an inverted tripod suspended from the cranium. The determinants of the movements of that tripod are, posteriorly, the right and left temporomandibular =ointsE anteriorly, the teeth of the maxillary and mandibular archesE and overall, the neuromuscular system.
37
The
dentist
has
no
control
over
the
posterior
determinants,
the
temporomandibular =ointsE they are unchangeable. "owever, they influence the movements of the mandible, and of the teeth, by the paths that the condyles must travel when the mandible is moved by the muscles of mastication. The measurement and reproduction of those condylar movements is the basis for the use of articulators. The anterior determinant, the teeth, provides guidance to the mandible in several ways. The posterior teeth provide the vertical stops for mandibular closure. They also guide the mandible into the position of maximum intercuspation, which may or may not correspond with the optimum position of the condyles in the glenoid fossae. The anterior teeth 8canine to canine9 help to guide the mandible in right and left lateral excursive movements and in protrusive movements. Anterior teeth are especially suited for guidance by virtue of< !. 7anines having the longest, strongest roots in their respective arches #. The load being reduced by distance from the fulcrum 87lass III lever9 '. The proprioceptive threshold and concomitant reflexes reducing the load. )entists have direct control over the tooth determinant by orthodontic movement of teeth< restoration of the anterior lingual or posterior occlusal surfacesE and equilibration, or selective grinding, of any teeth that are not in a harmonious relationship. Intercuspal position and anterior guidance can be altered, for better or for worse, by any of these means. The closer a tooth is located to a determinant, the more that it will be influenced by that determinant. A tooth placed near the anterior region will be influenced greatly by anterior guidance and less by the temporomandibular =oint. A tooth in the posterior region will be influenced partially by the =oints and partially by the anterior guidance. The neuromuscular system, through proprioceptive nerve endings in the periodontium, muscles, and %oints, monitors the position of the mandible and
38
its paths of movement. Through reflex action, it will program the most nearly physiologic paths of movement possible under the set of circumstances present. )entists have indirect control over this determinant. -rocedures done to the teeth may be reflected in the response of the neuromuscular system. :ne of the ob=ectives of restorative dentistry is to place the teeth in harmony with the temporomandibular %oints. This will result in minimum stress on the teeth and %oints, with only a minimum effort expended by the neuromuscular system to produce mandibular movements. ?hen the teeth are not in harmony with the =oints and with the movements of the mandible, interference is said to exist. cclusal Interferences Interferences are undesirable occlusal contacts that may produce mandibular deviation during closure to maximum intercuspation or may hinder smooth passage to and from the intercuspal position. There are four types of occlusal interferences< !. 7entric #. ?or ing '. .onwor ing (. -rotrusive The centric interference is a premature contact that occurs when the mandible closes with the condyles in their optimum position in the glenoid fossae. It will cause deflection of the mandible in a posterior, anterior, and&or lateral direction. A wor ing interference may occur when there is contact between the maxillary and mandibular posterior teeth on the same side of the arches as the direction in which the mandible has move. If that contact is heavy enough to disocclude anterior teeth, it is an interference.
39
A nonwor ing interference is an occlusal contact between maxillary and mandibular teeth on the side of the arches opposite the direction in which the mandible has moved in a lateral excursion. The nonwor ing interference is of a particularly destructive nature. The potential for damaging the masticatory apparatus has been attributed to changes in the mandibular leverage, the placement of forces outside the long axes of the teeth, and disruption of normal muscle function. The protrusive interference is a premature contact occurring between the mesial aspects of mandibular posterior teeth and the distal aspects of maxillary posterior teeth. The proximity of the teeth to the muscles and the oblique vector of the forces ma e contacts between opposing posterior teeth during protrusion potentially destructive, as well as interfere with the patient>s ability to incise properly. !ormal "ersus Pathologic cclusion
In only slightly more than !1K of the population is there complete harmony between the teeth and the temporomandibular %oints. This finding is based on a concept of centric relation in which the mandible is in the most retruded position. ?ith the present concept of the condyles being in the most superoanterior position with the disc interposed, the results could be different. .onetheless, in a ma=ority of the population, the position of maximum intercuspation causes the mandible to be deflected away from its optimum position. In the absence of symptoms, this can be considered physiologic, or normal. Therefore, in the normal occlusion there will be a reflex function of the neuromuscular system, producing mandibular movement that avoids premature contacts. This guides the mandible into a position of maximum intercuspation with the condyle in a less than optimal position. The result will be either some hypertonicity of nearby muscles or trauma to the
40
temporomandibular =oint, but it is usually well within most people>s physiologic capacity to adapt and will not cause discomfort. "owever, the patient>s ability to adapt may be influenced by the effects of psychic stress and emotional tensions on the central nervous system. 5y lowering the threshold, frequently parafunctional =aw activity such as clenching or bruxing occurs, and a normal occlusion can become a pathologic one. +imple muscle hypertonicity may give way to muscle fatigue and spasm, with chronic headaches and locali;ed muscle tenderness, or temporomandibular =oint dysfunction may occur. -athologic occlusion can also manifest itself in the physical signs of trauma and destruction. "eavy facets of wear on occlusal surfaces fractured cusps, and tooth mobility often are the result of occlusal disharmony. There is no evidence that occlusal trauma will produce a primary periodontal lesion. "owever, when occlusal trauma is present, there will be more severe periodontal brea down in response to local factors than there would be if only the local factors were present. "abit patterns may develop in response to occlusal disharmony and emotional stress. 5ruxism and clenching, the cyclic rubbing together of opposing occlusal surfaces, will produce even greater tooth destruction and muscle dysfunction. ?hen the acute discomfort of a patient with a pathologic occlusion has been relieved, changes that will prevent the recurrence of symptoms must be effected in the occlusal scheme. 7are must also be ta en when providing occlusal restorations for a patient without symptoms. The dentist must not produce an iatrogenic pathologic occlusion, In the placement of restorations, the dentist must strive to produce for the patient an occlusion that is as nearly optimum as his or her s ills and the patient>s oral condition will permit. The optimum occlusion is one that requires
41
a minimum of adaptation by the patient. : eson has described the criteria for such an occlusion< In closure, the condyles are in the most superoanterior position against the discs on the posterior slopes of the eminences of the glenoid fossae. The posterior teeth are in solid and even contact, and the anterior teeth are in slightly lighter contact, !. :cclusal forces are in the long axes of the teeth. #. In lateral excursions of the mandible, wor ing-side contacts 8preferably on this canines9 disocclude or separate the nonwor ing teeth instantly '. In protrusive excursions, anterior tooth contacts will disocclude the posterior teeth. (. In an upright posture, posterior teeth contact more heavily than do anterior teeth. Organi;ation o: t9e Occl*sion The collective arrangement of the teeth in function is quite important and has been sub=ected to a great deal of analysis and discussion over the years. There are three recogni;ed concepts that describe the manner in which teeth should and should not contact in the various functional and excursive positions of the mandible. They are bilateral balanced occlusion, unilateral balanced occlusion, and mutually protected occlusion. +ilateral +alance& Occl*sion 5ilateral balanced occlusion is based on the wor of von +pee and $onson. It is a concept that is not used as frequently today as it has been in the past. It is largely a prosthodontic concept, which dictates that a maximum number of teeth should contact in all excursive positions of the mandible. This is particularly useful in complete denture construction, in which contact on the
42
nonwor ing side is important to prevent tipping of the denture. +ubsequently, the concept was applied to natural teeth in complete occlusal rehabilitation. An attempt was made to reduce the load on individual teeth by sharing the stress among as many teeth as possible. It was soon discovered, however, that this was a very difficult type of arrangement to achieve. As a result of the multiple tooth contacts that occurred as the mandible moved through its various excursions, there was excessive frictional wear on the teeth. nilateral +alance& Occl*sion Anilateral balanced occlusion, which is also commonly nown as $ro&% *&nction, is a widely accepted and used method of tooth arrangement in restorative dental procedures today. This concept had its origin in the wor of +chuyler and others who began to observe the destructive nature of tooth contact on the nonwor ing side. They concluded that inasmuch as cross-arch balance was not necessary in natural teeth, it would be best to eliminate all tooth contact on the nonwor ing side. Therefore, unilateral balanced occlusion calls for all teeth on the wor ing side to be in contact during a lateral excursion. :n the other hand, teeth on the nonwor ing side are contoured to be free of any contact. The group function of the teeth on the wor ing side distributes the occlusal load. The absence of contact on the nonwor ing side prevents those teeth from being sub=ected to the destructive, obliquely directed forces found in nonwor ing interferences. It also saves the centric holding cusps, i.e., the mandibular buccal cusps and the maxillary lingual cusps, from excessive wear. The obvious advantage is the maintenance of the occlusion. The functionally generated path technique, originally described by $eyer, is used for producing restorations in unilateral balanced occlusionE $ann and -an ey have adapted it for use in complete mouth occlusal reconstruction.
43
M*t*ally Protecte& Occl*sion $utually protected occlusion is also nown as canine-protected occlusion or @organic@ occlusion. It had its origin in the wor of )>Amico, +tuart, +tallard and +tuart, and ,ucia and the members of the /nathological +ociety. They observed that in many mouths with, healthy periodontium and minimum wear, the teeth were arranged so that the overlap of the anterior teeth prevented the posterior teeth from ma ing any contact on either the wor ing or the nonwor ing sides during mandibular excursions. This separation from occlusion was termed disocclusion. According to this concept of occlusion, the anterior teeth bear the entire load and the posterior teeth are disoccluded in any excursive position of the mandible. The desired result is an absence of frictional wear. The position of maximum intercuspation coincides with the optimal condylar position of the mandible. All posterior teeth are in contact with the forces being directed along their long axes. The anterior teeth either contact lightly or are very slightly out of contact 8approximately #5 microns9, relieving them of the obliquely directed forces that would be the result of anterior tooth contact. As a result of the anterior teeth protecting the posterior teeth in all mandibular excursions and the posterior teeth protecting the anterior teeth at the intercuspal position, this type of occlusion came to be nown as a mutually protected occlusion. This arrangement of the occlusion is probably the most widely accepted because of its ease of fabrication and greater tolerance by patients. "owever, to reconstruct a mouth with a mutually protected occlusion, it is necessary to have anterior teeth that are periodontally healthy. In the presence of anterior bone loss or missing canines, the mouth should probably be restored to group function 8unilateral balance9. The added support of the posterior teeth on the wor ing +ide will distribute the load that the anterior teeth may not be able to bear. The use of a mutually protected occlusion is
44
also dependent upon the orthodontic relationship of the opposing arches. In either a 7lass II or a 7lass III mal-occlusion 8Angle9, the mandible cannot be guided by the anterior teeth. A mutually protected occlusion cannot be used in a situation of reverse occlusion, or cross bite, in which the maxillary and mandibular buccal cusps interfere with each other in a wor ing-side excursion. E::ects o: Anatomic Determinants The anatomic determinants of mandibular movement, i.e., condylar and anterior guidance, have a strong influence on the occlusal surface morphology of the teeth being restored. There is a relationship between the numerous factors, such as immediate lateral translation, condylar inclination, and even disc flexibility, and on the cusp height, cusp location, and groove direction that are acceptable in the restoration. It is beyond the scope of this text to discuss all of the nearly 51 rules that have been written on the sub=ect of determinants. Those, which have the greatest effect on morphology, should be considered. Molar Disoccl*sion ?hen sub=ects with normal occlusions perform repeated lateral mandibular movements, they will not trace the same path on electronic recordings, presumably because of the flexible nature of the articular disc. The measured deviation averages 1.# mm in centric relation, 1.' mm in wor ing, and 1.B mm in both protrusive and non-wor ing movements. To avoid occlusal interferences and non-axially directed forces on molars during eccentric mandibular movements, molar disocclusion must equal or surpass these observed deviations in mandibular movement. "ealthy natural occlusions exhibit clearances that will accommodate these aberrations. $easurements of disocclusions from the mesiobuccal cusp tips
45
of mandibular first molars in asymptomatic test sub=ects with good occlusions showed separations averaging 1.5 mm in wor ing, !.1 mm in nonwor ing, and !.! mm in protrusive movements. Therefore, one of the treatment goals in placing occlusal restorations should be to produce a posterior occlusion with buffer space that equals or surpasses the deviations resulting from natural variations found in the temporomandibular =oint. Con&ylar (*i&ance 7hief among those aspects of condylar guidance that will have an impact on the occlusal surface of posterior teeth are the protrusive condylar path inclination and mandibular lateral translation. The inclination of the condylar path during protrusive movement can vary from steep to shallow in different patients. It forms an average angle of '1.( degrees with the hori;ontal reference plane 8(' mm above the maxillary central incisor edge9. If the protrusive inclination is steep, the cusp height may be longer. "owever, if the inclination is shallow, the cusp height must be shorter. Immediate mandibular lateral translation is the lateral shift during initial lateral movement. If immediate lateral translation is great, then the cusp height must be shorter. ?ith minimal immediate translation, the cusp height may be made longer. The condylar path, particularly the lateral translation, affects ridge and groove directions. The effects are observed on the occlusal surface of a mandibular molar and premolar with the paths traced by the lingual cusps of the respective opposing maxillary teeth. The wor ing path is traced on the mandibular tooth in a lingual direction, and the nonwor ing path is in a distobuccal direction. The nearer the tooth is to the wor ing-side condyle anteroposteriorly, the smaller the angle between the wor ing and nonwor ing paths. The farther the tooth is placed from the wor ing-side condyle, the
46
greater the angle between the wor ing and nonwor ing condyles. ?hen immediate lateral translation is increased, the angle also becomes more oblique. Anterior (*i&ance )uring protrusive movement of the mandible, the incisal edges of mandibular anterior teeth move forward and downward along the lingual concavities of the maxillary anterior teeth. The trac of the incisal edges from maximum intercuspation to edge-to-edge occlusion is termed the protrusive incisal path. The angle formed by the protrusive incisal path and the hori;ontal reference plane is the protrusive incisal path inclination, which ranges from 51 to D1 degrees. ?hile conventionally regarded as independent factors, there is evidence to suggest that condylar inclination and anterior guidance are lin ed, or dependent factors. In a healthy occlusion, the anterior guidance is approximately 5 to !1 degrees steeper than the condylar path in the sagittal plane. Therefore, when the mandible moves protrusively, the anterior teeth guide the mandible downward to create disocclusion, or separation, between the maxillary and mandibular posterior teeth. The same phenomenon should occur during lateral mandibular excursions. The lingual surface of a maxillary anterior tooth has both a concave aspect and a convexity, or cingulum. The mandibular incisal edges should contact the maxillary lingual surfaces at the transition from the concavity to the convexity in the centric relation position. The concavity represents a uniform shape in all sub=ects. Anterior guidance, which is lin ed to the combination of vertical and hori;ontal overlap of the anterior teeth, can affect occlusal surface morphology of the posterior teeth. The greater the vertical overlap of the anterior teeth, the longer the posterior cusp height maybe. ?hen the vertical overlap is less, the posterior cusp height must be shorter. The greater the hori;ontal overlap of
47
the anterior teeth, the shorter the cusp height must be. ?ith a decreased hori;ontal overlap, the posterior cusp height may be longer. 5y increasing anterior guidance to compensate for inadequate condylar guidance it is possible to increase the cusp height. If the protrusive condylar inclination is shallow, requiring short posterior cusps, the cusps may be lengthened by ma ing the anterior guidance steeper. In li e manner, increasing anterior guidance will permit the lengthening of cusps that would otherwise have to be shorter in the presence of a pronounced immediate lateral translation. ##L$SAL %R&A%'&!% ?hen a patient exhibits signs and symptoms that appear correlated to occlusal interferences occlusal treatment should be considered. +uch treatment can include tooth movement through orthodontics, elimination of deflective occlusal contacts through selective reshaping of the occlusal surfaces of teeth, or the restoration and replacement of missing teeth resulting in more favorable distribution of occlusal force. The ob=ectives of occlusal treatment are as follows< !. To direct the occlusal forces along the long axes of the teeth #. To attain simultaneous contact of all teeth in centric relation '. To eliminate any occlusal contact on inclined planes to enhance the positional stability of the teeth (. To have centric relation coincide with the maximum intercuspation position 5. To arrive at the occlusal scheme selected for the patient 8e.g., unilateral balanced versus mutually protected9 In the short term, these ob=ectives can be accomplished with a removable occlusal device fabricated from clear acrylic resin that overlays the occlusal surfaces of one arch. :n a more permanent basis, this can be accomplished through selective occlusal reshaping, tooth movement, the placement of
48
restorations, or a combination of these. )efinitive occlusal treatment involves accurate manipulation of the mandible, particularly in centric relation. 5ecause the patient may resist such manipulation as a result of protective muscular reflexes, some type of deprogramming device may be needed 8e.g., an occlusal device9. OCCL !AL DE"ICE THE$AP< :cclusal devices 8sometimes referred to as occl&sal s%lints, occl&sal a%%liances, or ort!otics) are extensively used in the management of T$ disorders and 5ruxism. In controlled clinical trials, they have effectively controlled myofascial pain 8i.e., the patient>s perceived positive changes as a result of the device therapy9. "owever, no clear hypothesis about the mechanism of action has been proved, and none of the various hypotheses 8repositioning of condyle and&or the articular dis , reduction in masticatory muscle activity, modification of @harmful@ oral behavior, and changes in the patient>s occlusion9 has been consistently supported by scientific studies. :cclusal devices are particularly helpful in determining whether a proposed change in a patient>s occlusal scheme will be tolerated. The proposed scheme is created in an acrylic resin overlay, which allows testing of the scheme through reversible means, although at a slightly increased vertical dimension. If a patient responds favorably to an occlusal device, the response to restorative treatment should be positive as well. Thus, occlusal device therapy can serve as an important diagnostic procedure before initiation of fixed prosthodontic treatment. The device can be made for either maxillary or mandibular teeth. +ome clinicians express a preference for one or the other and cite advantagesE however, both maxillary and mandibular devices have proved satisfactory.
49
#A+$ICATION O# DE"ICE There are several satisfactory methods for ma ing an occlusal device. :ne made from heat-polymeri;ed acrylic resin will have the advantage of durability, but auto-polymeri;ing resin used alone or in con=unction with a vacuumformed matrix can serve equally well. (irect Procedure "ac**m-#orme& Matri' !. Adapt a sheet of clear thermoplastic resin to a diagnostic cast using a vacuum-forming machine. "ard resin 8! mm thic 9 is suitable. 5e sure that excessive undercuts have been bloc ed out. Trim the excess resins so all the facial soft tissues are exposed. :n the facial surfaces of the teeth, the device must be ept well clear of the gingival margins. :n the lingual surface of maxillary devices, the matrix should cover the anterior third of the hard palate for rigidity. #. Try in the matrix for fit and stability. Add a small amount of autopolymeri;ing acrylic resin in the incisal region. /uide the mandible into 74 using the bimanual manipulation technique. "inge the mandible to ma e shallow indentations in the resin. '. Add more resin to the incisor and canine regions and guide the patient to retrusive, protrusive, and lateral closures in the soft resin. Allow the resin to polymeri;e. .:T3< The resin should be allowed to polymeri;e on the cast or with the appliance in place in the mouth. :therwise, the heat generated by polymeri;ation may distort the thermoplastic matrix. (. ?ith the help of mar ing ribbon, ad=ust the resin to give smoothE even contacts during protrusive and lateral excursions as well as a definite occlusal stop for each incisor in centric relation. 7onfine protrusive contacts to the incisors and lateral contacts to the laterotrusive canines. All posterior contacts should be relieved at this stage.
50
5. "ave the patient wear the device for a few minutes in the office. 4epeated protrusive and lateral movements will overcome most problems in =aw manipulation. :ccasionally it will be necessary for the patient to wear the device overnight before the acquired protective muscle patterns are overcome. .:T3< In such cases, if posterior tooth eruption is to be avoided, the patient must be seen again within #( to (B hours. 0. Add autopolymeri;ing acrylic resin to the posterior region of the device and guide the patient into centric relation. "old 74 until the acrylic resin has polymeri;ed. D. 4emove the device and examine the impressions of the opposing arch in the resin. -olymeri;ation can be accelerated by placing the device on the cast in warm water in a pressure pot. B. -lace pencil mar s in the depressions formed by the opposing centric cusps. If a cusp registration is missing, new resin can be added and the device reseated. 2. 4emove excess resin with a bur or wheel to leave only the pencil mar s. All other contacts must be eliminated if posterior disocclusion is to be achieved, !1. 7hec the device in the mouth for 74 contacts, mar ing them with a ribbon. 4elieve heavy contacts by continued ad=ustment until each centric cusp has an even mar . !!. Identify protrusive and lateral excursions using different-colored tape. Ad=ust excursive contacts as necessary, being careful no9 to remove the centric cusp stops. !#. +mooth and polish the device, again being careful not to alter the functional surface. !'. After a period of satisfactory use, the device can be duplicated in heatpolymeri;ed rest using a standard denture reline technique
51
In&irect Proce&*re
sing A*topolymeri;ing Acrylic $esin
Accurately mounted diagnostic casts are essential for this procedure. A relatively small mounting error can lead to considerable loss of time at try-in. -articular attention must be given to occlusal defects or interfering soft tissue pro=ections on the casts, which could cause errors during mounting. !. 5e sure that the device is made at the same vertical dimension of occlusion as the 74 record. This will reduce mounting errors derived from using an arbitrary facebow. #. *it the articulator with a mechanical incisal guidance table initially set flat. '. ,ower the incisal guide pin until there is approximately ! mm of clearance between the posterior teeth. This should be the same vertical dimension of occlusion as the one at which the 74 record was made. (. )epending on the type of articulator used, it may be necessary to reposition the incisal guide table after step '. 5. 7hec the clearance between opposing casts during protrusive movement of the articulator. ?here this is less than ! mm, increase it by tilting the incisal guidance table. 0. 4aise the platform wings of the incisal guidance table so there is at least ! mm of clearance in all-lateral excursions . It may be necessary to raise the incisal pin occasionally to ensure adequate clearance. D.$ar the height of contour of each tooth on the cast and bloc out undercuts with wax.
52
$E!TO$ATION O# ENDODONTICALL< T$EATED TEETH
53
$E!TO$ATION O# ENDODONTICALL< T$EATED TEETH History Attempts to restore pulpless teeth using posts and cores have been reported for more than #11 years In !D(D - -ierre fauchard - $axillary anterior teeth for anchorage when restoring single multiple units In !BB1, 4ichmond 7rown 8Luoted by Tamarin A"9 was introduced threaded tube in the canal which held a screw placed through the crown. ,ater simplified to eliminate the tube and ma e the dowel by unthreaded an integral part of final restoration or crown. In !205 /reen ?ald - *abrication of cast gold post and core. In !2D# - +tandlee etal - Tapered smooth sided posts. In !2DB - 7aptain and +tandlee - -arapost system 8most retentive of all post systems9. In !2DD - Iahin and *ishnan - Amalgam and composite resin as core build up materials. In !2B1 .ayyar and ?alton described amalgam core, or coronal radicular restoration rather than placing a post. In !2BD ,ui -introduced composite post In !2B2 - Iwiat ows i and /eller - 7linical application of glass ceramic posts and cores to improve esthetic. In !221 - )uret - 7arbon *ibre post 87--ost9 In !221 - Iern and Inode - -osts and cores made up of glass infiltrated aluminum oxide ceramic 8Inceram9 In !22# - 4ibbond - 4ibbond 4ibbon - 7old gas plasma treated polyethylene woven fiber ribbon. In !22( - +andhaus and -asche --refabricated ;irconia ceramic endodontic posts.
54
The same year - +andhaus and -asche - Mirconia ceramic for fabrication of core buildup and post in one piece. In !225 - $onobloc technique - *abrication of post and core and crown as a single component made out of glass ceramic material 8I-+ empress9 In !225- 4odigues *ilho - .i-7r castpost with macro retentive on the wax cast pattern surface E::ect o: En&o&ontics on t9e toot9 !. #. '. ,oss of tooth structure Altered physical characteristics Altered esthetic characteristics of the residual tooth
Loss of %ooth structure )ecreased strength because of loss of coronal tooth structure 3ndodontic procedure - 5K reduction in tooth stiffness $:) preparation - 01K reduction in tooth stiffness ,oss of structural integrity by endodontic access into the pulp chamber *racture of under minded cusps or tooth structure under normal functional forces Altered Ph)sical #haracteristics !(K reduction in strength and toughness of tooth due to changes in 7ollagen cross-lin ed and dehydration of dentin. $axillary teeth are stronger than madibular teeth ,oss of structural integrity, loss of moisture and loss of dentin toughness special care in restoration of pulpless tooth.
55
Altered &sthetic #haracteristics Altered dentin - $odifies light refraction through the tooth - modifies its appearance )ar ening of non-vital anterior teeth Ca*ses o: Discoloration Inadequate endodontic cleaning and shaping of coronal areas )egradation of vital tissue left in the pulp horns. $edicaments 4emnants of root canal filling material 4etain a translucent, natural appearance by careful control of procedures and materials *ASI# # 'P !&!%S !. #. '. )owel 7ore 7oronal restoration f (o,el
Ideal Pro+erties
!. +imple, safe, versatile, reliable in clinical use #. $aximum protection of the root '. Adequate retention within the root (. $aximum retention of the core and crown 5. $aximum protection of the crown 0. -leasing esthetic when indicated D. "igh radiographic visibility B. 4etrievability 2. 5io 7ompatibility !1. 5e made of bio-inert materials to resist corrosion and other forms of deterioration in the mouth
56
!!. 4esist loosening and displacement by occlusal and other functional forces P S% #LASSIFI#A%I ! I. A. 5. II. A. 5. $etallic posts 8+tainless +teel&5rass&..i-7r&Titanium & gold9 .on metallic posts 8composite & ceramics9 7ustom- made posts -re fabricated posts
III.
A. 5.
+tiff *lexible 3sthetic .on-esthetic Active -assive
IF. F.
A. 5. A. 5.
Principle :or t9e *se o: post= cores > copings !.-ost +election 4::T $:4-":,:/N 43$AI./ 7:4:.A, T::T" +T4A7TA43 :77,A+A, *:473+ #.4oot +election '.-ost 3mbedment )epth (./utta -ercha 4emoval 5.7hannel -reparation 0.-ost Installation
57
An endodontically treated tooth can resume full function and serve satisfactorily as an abutment for a fixed or removable partial denture. "owever, special techniques are needed to restore such a tooth. Asually a considerable amount of tooth structure has been lost because of caries, endodontic treatment, and the placement of previous restorations. The loss of tooth structure ma es retention of subsequent restorations more problematic and increases the li elihood of fracture during functional loading. Two factors influence the choice of techniqueE the type of teeth i.e. whether it is an incisor, canine, premolar, or molar and the amount of remaining coronal tooth structure. The latter is probably the most important indicator when determining the prognosis. 5efore restoration, existing endodontically treated teeth needed to be assessed carefully for the< /ood apical seal .o sensitivity to pressure .o exudates .o fistula .o apical sensitivity .o active inflammation.
Inadequate root fillings should be retreated. If doubt remains, the tooth should be observed until there is definite evidence of success or failure. ?ith the two-step approach of fabricating a separate crown over a post and core, achieving a satisfactory marginal fit is easier because the expansion rate of the two castings can be controlled individually. The two-step approach further permits fabrication of a replacement crown. -ost considerations -ost length
58
A post that is too short will fail, whereas one that is too long may damage the seal of the root canal fill or ris root perforation if the apical third is curved or tapered. Ideally, the post should be as long as possible without =eopardi;ing the apical seal or the strength or integrity of the remaining root structure. $ost endodontic texts advocate maintaining a 5-mm apical seal. "owever, if a post is shorter than the coronal height of the clinical crown of the tooth, the prognosis is considered unfavorable, because stress is distributed over a smaller surface area, thereby increasing the probability of radicular fracture. A short root and a tall clinical crown present the clinician with the dilemma of having to compromise the mechanics, under such circumstances, a minimum apical seal of ' mm is considered acceptable. -ost diameter Increasing the post diameter in an attempt to increase retention is not recommended because it may unnecessarily wea en the remaining root. :verall prognosis is good when post diameter does not exceed one third of the cross-sectional diameter of the root. -ost-surface texture A serrated or roughened post is more retentive than a smooth one, and controlled grooving of the post and root canal considerably increases the retention of a tapered post. If a dowel is used its extension into the root must at least equal the length of the crown for optimum stress distribution and maximum retention, or the dowel should be two-thirds the length of the root, whichever is greater. A minimum length of (.1mm of gutta-percha, and more if possible should remain at the apex to prevent dislodgment and subsequent lea age. *errule
59
3xtension of the axial wall of the crown apical to the missing tooth structure provides what is nown, as a *err&le. There is evidence that preserving as much coronal tooth structure as possible will enhance prognosis, it is less clear whether the prognosis will improve by creating a ferrule in an extensively damaged tooth. +orensen and 3ngleman to provide a ferrule effect, enhancing fracture resistance by B1K, found having !.1mm of vertical tooth wall between the margin of the core and the shoulder of the preparation. If a crown on a premolar that is to serve, as an abutment cannot cover a minimum of !.1mm of vertical axial wall, the tooth should be extracted. 3ndodontically treated teeth should not be used as abutments for distal extension removable partial dentures. A pulp less molar with a moderately damaged clinical crown can be built up with an amalgam or composite resin core prior to placement of an artificial crown. If there is one sound cusp, the core may be retained by gross extension of the amalgam into the pulpal chamber alone, or in con=unction with pins, peripheral slots, or dentinal wells 8amalgam pins9. The core and its attachment8s9 are made separately from the final restoration. The crown is then fabricated and cemented over the core =ust as a restoration would be placed over a preparation done in tooth structure. This two-unit system offers several advantages over a one-piece dowel crown. The marginal adaptation and fit of the restoration are independent of any dowel that must be used. The restoration can be replaced in future if required. -refabricated dowel with amalgam or resin core -refabricated dowels with amalgam or composite resin cores are the most commonly used dowel cores today. Iits for prefabricated dowels utili;e special reamers or drills for canal preparations that are the same si;e and configuration as the dowels. Through the use of one of these systems, it is possible to complete the entire procedure in a single appointment.
60
Amalgam provides greater strength, Iovari
et al, found that 0DK of the
amalgam cores tested in an in vitro study survived !,111,111 cycles of D5-lb loading, while only !DK of the composite resin cores survived. In that it studies, all of the glass ionomer cores had failed within the first ##1,111 cycles. 7omposite resin remains popular because it is easily placed, polymeri;ing in minutes and allowing wor progress almost immediately. )owels can be made of stainless steel, titanium, brass, or a chromiumcontaining alloy. The preferred materials in light of current nowledge of galvanism and corrosion are titanium, high platinum, and cobalt-chromiummolybdenum alloys. The least desirable are brass and chromium-nic el steel. -refabricated dowels are made in both parallel-sided and tapered configurations. )owel systems can be classified by their mechanism of retention< passive 8cemented9 or active 8threaded9. The threaded dowels are more retentive than the cemented, but they also produced more stress in the tooth. Armamentarium !. "andpiece #. *lat-end tapered diamond '. +mall wheel diamond (. *lame diamond 5. .o.!D!, bur 0. .o.( round bur D. 3ndodontic condenser B. +et of six -eeso reamers 2. )owel it, including dowel, special reamer, pin8s9, and drill. !1. 7ement spatula and glass slab. !!. Amalgam on the core preparation to
61
!#. 7opper band and wedges !'. 7apsule8s9 and amalgamator !(. 7arrier !5. 7ondenser !0. 7arver8s9 !D. 7omposite resin !B. 7rown form 8clear or polycarbonate9 !2. 4esin it #1. -lastic filling instrument -reparing the coronal tooth structure begins the preparation for a dowel core. 4emove existing restorations, caries, bases, and thin or unsupported walls of tooth structure. -reserve as much coronal tooth structure as possible, to enable the axial walls of the crown to externally brace the tooth. $easure a -eeso reamer against a radiograph of the tooth being restored to determine the length to which the instrument will be inserted into the canal. +lide a silicone rubber endodontic stop onto the shan of the reamer, aligning it with a landmar such as the incisal edge of the ad=acent tooth to insure insertion of the instrument to the proper depth in the tooth. 5egin the dowel space preparation by first removing gutta-percha in the canal with a hot endodontic condenser. +tart enlarging the canal with the largest -eeso reamer or /ates /lidden drill that will fit into the canal. 5egin with safety-tipped instruments that will follow the path of least resistance, the gutta-percha in the canal. ?ith a series of successively larger reamers, enlarge the canal to diameter slightly smaller than that of the specific instrument required for the system being used. 7onventional drills used without any prior enlargement of the canal are more prone to stray from the original canal pathway than either -eeso reamers or /ates /lidden drills.
62
In the area of greatest bul between the canal and the periphery of the tooth, drill one or two 1.0mm pin holes to a depth of #.1 mm. -lace the pins in these holes to provide anti-rotational resistance against forces transmitted from the incisal edge of the crown to the core under it. $a e a thin mix of cement, and coat the dowel with it. Introduce cement into the dowel space with a plastic instrument. Ase a lentulo spiral to insure that the walls of the canal are completely coated with cement. 4etention can be increased by as much as 21K if a lentulo spiral is used. -ush the dowel slowly to place, allowing the excess cement to escape. "old the dowel in place with finger pressure until initial set occurs. cement from around the dowel head and pins. If amalgam will be used for the core, select a copper band of correct diameter to fit the tooth and festoon the gingival end to follow the gingival contours. If the core is to be composite resin, a copper band can be used, but it is easier and faster to use a crown form. A clear crown form permits the use of lightactivated resin, while a polycarbonate form can be used with autopolymeri;ing resin. If a polycarbonate crown form is used, place a separating medium in it. *ill it with light-bodied impression material and blow out the excess with an air syringe, leaving a thin film lining the walls of the crown. Then fill the crown form with resin and hold it is position over the protruding dowel until the resin core material has polymeri;ed. 4emove the matrix and shape the core with diamonds and burs to the form of a crown preparation. 5e sure that the gingival finish line is on tooth structure. *abricate a provisional restoration and ma e the impression for the crown. 7ustom cast dowel cores -refabricated noble-metal dowels have been combined with wax cores. )irect wax patterns have been fabricated using either a fissure bur or a paper clip as Then remove excess
63
reinforcement. A direct technique can be used to fabricate a dowel-core pattern from acrylic resin. The direct acrylic dowel-core technique can be used for teeth with single or multiple roots. The direct method for fabrication of a dowel core is accomplished in three steps< 7anal preparation 4esin pattern fabrication *inishing and cementation of the dowel core.
Armamentarium !. "andpiece #. *lat-end tapered diamond '. +mall wheel diamond (. *lame diamond 5. .o.!D!, bur 0. .o.( round bur D. 3ndodontic condenser B. +et of six -eeso reamers 2. +traight handpiece !1. 7oarse garnet disc on a $oore mandrel !!. *ine sandpaper disc on a $oore mandrel !#. ,arge green stone !'. 5urlew wheel on mandrel !(. !(-gauge solid plastic sprue !5. )appen dish !0. 7ement spatula !D. 7otton pellets !B. -etrolatum !2. 4esin monomer and polymer
64
#1. $edicine dropper #!. I--A plastic filling instrument. ##. 7anal preparation The preparation for the final restoration is roughly approximated. *or an anterior tooth, the final restoration will probably be a metal-ceramic crown. Axial reduction and incisal reduction of #.1 mm is accomplished with a flatted tapered diamond. ,abial reduction should be !.1 to !.# mm deep axially. ,ingual reduction is done with a small wheel diamond. All caries, bases, and previous restoration are removed, and the remaining tooth structure is evaluated to determine that which is sound enough to be incorporated into the final preparation. The tooth is now ready for preparation of the canal. The instruments of choice for removing the gutta-percha and enlarging the canal are -eeso reamers. They are available in sets of six graduated si;es ranging from 1.D to !.Dmm in diameter, with non-cutting tips that follow the path of least resistance. 5egin the removal of gutta-percha with a hot endodontic condenser. $easure as a -eeso reamer as will fit in the obturated canal against a radiograph of the tooth being restored to determine the length to which the reamer will be inserted into the canal. +lide a small square of rubber dam material to the place on the reamer that will correspond with the landmar when the reamer is inserted to the proper depth in the canal. -lace the reamer in the tooth to the predetermined depth and expose a radiograph to chec the accuracy of the length. 7ontinue enlarging the canal with the graduated si;es of reamers until reaching the si;e that has been decided upon for that tooth. The si;e of reamer used will depend upon the diameter of the tooth. As a general rule, it will be no greater than one-third the diameter of the root at the cementoenamel =unction, and there should be a
65
minimum thic ness of !.1mm of tooth structure around the dowel around the dowel at midroot and beyond. After the canal has been prepared for the dowel, use a no.!D1 bur to ma e a eyway, or groove, in the orifice of the canal. -lace it in the area of the tooth where there is greatest bul . The eyway should be cut to the depth of the diameter of the bur 8approx. 1.0-mm9. :n a premolar, the second canal serves the same anti-rotational function. If there is supragingival tooth structure, use a flame diamond to place a contra bevel around the external periphery of the preparation. 4esin pattern fabrication Trim a !(-gauge solid plastic sprue so that it will slide easily into the canal to the apical end of the dowel preparation. It must not bind in the canal. 7ut a small notch on the facial portion of the occlusal end of the plastic sprue to aid in orienting the dowel-core pattern when it is reseated in subsequent steps. In a dappen dish, mix acrylic resin monomer and polymer to a runny consistency. ,ubricate the canal with petrolatum on a small piece of cotton on a -eeso reamer. *ill the orifice of the canal as full as possible with acrylic resin applied with an I--A plastic filling instrument. 7oat the sprue with monomer and seat it completely in the canal. ?hen the acrylic resin has become tough and doughty, pump the pattern in and out to insure that it will not loc into any undercuts in the canal. As the resin polymeri;es, remove the dowel from the canal and ma e sure that it extends to the apical end of the prepared canal. If there are any voids, they can be filled with a soft, dead wax, such as utility wax. 4einsert the dowel into the canal and move it up and down to insure that it can be withdrawn easily at a later time. After the resin in the dowel portion has polymeri;ed, relubricate the canal and reseat the dowel. $a e a second mix of acrylic resin and place it around the exposed sprue to provide the bul from which to fashion a preparation for the
66
final restoration. ?hile the resin is polymeri;ing, the coronal portion can be roughly molded on the facial and lingual aspects by holding it between the thumb and forefinger. The core can be roughly shaped in the hand with green stones and coarse garnet discs. The preparation for the final restoration is completed with the dowel-core pattern in place. ?ipe the dowel-core pattern with an alcohol sponge to remove any residual lubricant that could displace investment or promote bubble formation. 3ither could result in metal pro=ections that would interfere with complete seating of the cast metal dowel core. Finishing and cementation of the do,el core The dowel-core pattern is sprued on the incisal or occlusal end. Add !.1 to #.11 cc of extra water to 51g of investment, and do not use a liner in the ring. These measures will result in a slightly smaller dowel core that should have less tendency to bind in the canal. The invested pattern should remain in the burnout oven for '1 minutes longer to insure complete elimination of the resin. After the casting is removed from the investment, it is pic led and the sprue is cut off. 7hec the fit of the dowel core in the tooth by seating it with light pressure. If it binds in the canal or will not seat completely, air abrade the dowel and reinsert it in the canal. 4elieve any shiny spots. The core portion of the casting should be polished to a satin finish with a 5urlew wheel. 7ut a groove on the side of the dowel from apical end to contrabevel to provide an escape vent for cement. $ix the cement and insert some of it in the canal with a lentulo spiral. +lowly insert the dowel core into the canal so that the excess cement may escape, allowing the dowel core to seat completely. Touch up the preparation for the final restoration, and ma e the impression for it. The crown will be cemented at a subsequent appointment.
67
7ast dowel cores can be used on premolars. $andibular premolars with a single root require no variations in procedure from dowel cores for anterior teeth. :n maxillary premolars with two canals, one canal is employed for the dowel preparation, and a stabili;ing eyway is placed in the other. 7ast dowel-cores are very rarely done on molars, because they have divergent canals that require elaborate, interloc ing multipiece castings.
68
PONTIC!
69
PONTIC!
-ontic is a component that replaces the missing tooth, restores function and appearance compatible with continued oral health. and comfort. The pontic is attached to the retainer by a rigid connector such as a shoulder =oint. +ome special cases require a non-rigid connector such as ey and eyway or telescopic retainers. The design is dictated by function, esthetics, ease of cleaning, patient comfort and maintenance of healthy tissue over the edentulous ridge. The success or failure of a bridge depends largely upon the design of the pontic. 4equirements of a pontic 4estore function -rovide esthetics 5e biologically acceptable -ermit effective oral hygiene -reserve underlying residual mucosa. The design of a pontic consists of constructing a substitute tooth that favorably compare in form, function and appearance with the tooth it replaces. The ideal pontic form as +tein and 3issman et al outlined are <Posterior +ontic s9o*l& 9a)e? +urfaces smooth, well finished and convex in all directions -in point, pressure free tissue contact on the buccal slopes of the ridge :cclusal table in functional harmony with the opposing teeth. The contours confluent with those of the ad=acent teeth. The overall buccal surface length equal to that of the ad=acent abutments or pontics.
70
Anterior +ontic s9o*l& 9a)e? +mooth, properly finished and convex on all surfaces -in-point pressure free contact on the labial mucosa 3mergence profile and pontic length harmonious with ad=acent pontics or abutment teeth too maximi;e esthetics. ,ingual contours confluent with ad=acent teeth or pontics. Est9etic Consi&erations? The main problem in replacing missing teeth with a fixed prosthesis is achieving a natural appearance. .o matter how well the biologic and mechanical factors have been utili;ed during fabrication, because for the patient it is the esthetics part which is more important. An esthetically successful pontic will replicate the form, contour, gingival margins, incisal edge, gingival and incisal embrasures and color of the ad=acent teeth. This cannot be done by merely copying the original tooth. To achieve this the anterior tooth should deceive observers into believing they are seeing a natural tooth. *or his to occur we should consider about the light and shade, optical illusion, proportion and balance. Occl*sal :orces? 4educing the buccolingual width of the pontic by as much as '1K has long been suggested as a means of lessening occlusal forces on and hence the loading of abutment teeth. This has got very little scientific basis. In fact narrowing the occlusal table may actually impede or even preclude the development of a harmonious and stable occlusal relationship.
71
Mec9anical Consi&erations? If insufficient attention is given to the mechanical principles, the prognosis is compromised. Available pontic materials<$etal -orcelain fused to metal Acrylic resin veneered pontics. -re-fabricated pontics Pontic Material? Any material, which is chosen to fabricate a pontic, should provide good esthetic results where needed, biocompatibility, rigidity and strength to withstand the occlusal forces and desired longevity. /la;ed porcelain is considered to be the most biocompatible of all the available pontic materials. ?ell-polished gold is less prone to corrosion and is smoother and less retentive of plaque. Although gla;ed porcelain loo s very smooth, microscopically its surface contains many voids. .evertheless highly gla;ed porcelain is easier to clean. Any material used for pontic should be highly polished and smooth. The actual configuration of the axial contours of the pontic is a function of two variables. a. The location of the crests of the resorbed alveolar ridge. b. ?idth and desired configuration of the occlusal table or incisal edge. Pontic $i&ge $elations9ip ? The most popular concept since its inception in !2!B is the hygienic or sanitary type where there is a minimum of '-mm clearance between the tissue and the pontic. This permits easier plaque control by allowing gau;e strips and other cleansing devices to be passed under the pontic and
72
cleaned. The disadvantage of this design is food particles tend to become trapped leading to tongue habits that are annoying to the patient. This is contraindicated if vertical space is limited and where esthetics is of prime concern and indicated where esthetics is not of primary concern where esthetics is of prime concern eg. $axillary anterior pontics, the lingual surface is made convex and the embrasures are exaggerated to facilitate cleaning. The facial surfaces are shaped to simulate the natural appearance. :cclusion, *unction And "ygiene 7onsidering these aspect pontics can be classified as A - $ucosal contact 5 - .on $ucosal contact .ormally where the tissue contact occurs, the gingival surface of a pontic is inaccessible for cleaning with a toothbrush, so other oral hygiene methods should be used. The pontic is these areas mush be convex and smoothly finished otherwise plaque accumulation may ta e place. A pontic with a concave fitting surface which overlaps the residual ridge on both the sides is called a saddle type of pontic, this is avoided as it is not easily cleansable. An egg-shaped or bullet shaped pontic is probably easiest for the patient to eep clean. It should be made as convex as possible, with only one point of contact at the center of ridge. This design is recommended, thereby developing a positive ridge contact. 5ut this design is no longer used because of the ulceration that results inevitably unless flossing is meticulously carried out by the patient. (ental +la-ue. The chief cause of ridge irritation is the toxins that are released from the plaque, which accumulates between the gingival surface of the pontic and the residual ridge, causing tissue inflammation and calculus formation.
73
To enhance plaque control, the patient must be taught to perform efficient oral hygiene techniques with particular emphasis on cleansing the gingival surface of the pontic. The shape of the gingival surface, its relation with the ridge and the materials used in its fabrication will influence the success. (ingi)al !*r:ace O: T9e Pontic? ?hen esthetic is a main concern in the anterior region of the mouth, the pontic should contact the gingival tissue on the labial or buccal aspect to give an appearance of Oemerging from the tissueP to ma e it loo more natural. Therefore special attention must be paid to the gingival surface of the pontic to prevent tissue impingement and ulceration where this contact occurs. In posterior areas or less visible area more attention should be paid to cleansability. Pontic Design Consi&erations? *iologic consideration? The biologic principles of pontic design pertain to a -ontic ridge contact b 4emoval of dental plaque c )irection of occlusal forces. Ridge contact: -ressure free contact between the pontic and the underlying tissues are indicated to prevent inflammation and ulceration of the soft tissues. The tissue contact should be entirely passive. This passive contact should occur exclusively on eratini;ed attached tissue. -reviously in order to improve the appearance of pontic ridge relationship there was a system of scraping the ridge area on the wor ing cast. +pecial care must be ta en in studying where shadows fall around the natural teeth particularly around the gingival margin.
74
Pro+ortion: 3sthetics depends largely on proportion. *alance: The concept of balance including the location of the midline is of particular importance. Pontic a++earance: It is not possible to obtain a correctly si;ed pontic simply by duplicating the original tooth. 4idge resorption will ma e such a tooth loo too long in the cervical region. CONCL !ION :f particular importance to long term success with pontics are designed that allows easy plaque control. This means minimi;ing tissue contact by maximi;ing the convexity of the gingival surface of the pontic. +pecial consideration is also needed to create a design that combines ease of maintenance with natural appearance and adequate mechanical strength. ?hen appropriate design has been selected .it must be accurately conveyed to the dental technician so the chances of disappointment and failure will be remote.
75
#L ID CONT$OL AND TI!! E MANA(EMENT
76
#L ID CONT$OL AND TI!! E MANA(EMENT Tissue management in fixed prosthodontics is one of the critical phases. *ull coverage preparations often require subgingival margins because of caries, existing restorations, esthetics, and additional retention. #L ID CONT$OL This is necessary for patientPs comfort, clear visibility, and removal of saliva and the water introduced by the operator. )uring the tooth preparation it is necessary to remove large amounts of water produced by the hand piece and to control the tongue to prevent accidental in=ury. )uring cementation procedure or during impressions fluid control is necessary. Met9o&s o: :l*i& control? !. 4ubber dam #. "igh volume vacuum '. +aliva e=ectors 1/ Rubber (am : This is the most effective of all isolation devices used in restorative dentistry. It has a limited direct application in the area of cast restorations. It can be used in preparation of inlays and onlays, cementation, for use during elastomeric impressions the rubber darn must be lubricated and removal or avoidance of the clamp is necessary and another important aspect during elastomeric impressions is that the rubber should not be made of latex material.
77
0/ 1igh "olume "accum . It is an extremely useful device during tooth preparation and is effectively utili;ed with the help of an assistant. It is not practical during impression and cementation stages. 2/ Saliva &3ectors. Its main advantage is that it can be used without an assistant. In case of maxillary etch it is placed in the corner of the mouth opposite the quadrant being operated. In mandibular arch it can be used by using some extra tips li e < +wedopter Faccum tip Facuum e=ector S,edo+ter. *or isolation and evacuation of the mandibular arch, this metal saliva e=ector with attached tongue deflector can be used. It is most effective when it is used with the patient in a nearly upright position. It is excellent for an operator without assistant. +rawbac's: Access to lingual surfaces of mandibular teeth is limited. 5ecause the device is made of metal, care must be exercised to avoid bruising the tissues of the floor of the mouth. +election of an oversi;ed deflector should be avoided, since it could cut into the palate above or trigger a gag reflex. "acuum e3ector. Tongue control and high volume evacuator are combined with a bite bloc in this evacuator device. "ere the tongue deflectors are made of plastic so there is very little danger of in=ury from tissue impingement. This is excellent for
78
tooth preparation but during impressions it may desiccate the tissues. This also bloc s the lingual access. Antisilogogus . In some patients no mechanical device is effective in producing a dry enough field for impressions or cementation. )rugs such as $ethantheline bromide 85anthine9 or -ropanthalene bromide 8-ro banthine9 can be used to control salivary flow. These are gastrointestinal anticholinergics that act on the smooth muscles of the gastrointestinal, urinary, and bilary tracts. ,ontrain(ications: "istory of hypersensitivity to drugs, glaucoma, asthma, congestive heart failure and in lactating females. These drugs should be used cautiously. They produce a dry mouth and bitter after taste which are unpleasant, and the patient may experience drowsiness and blurred vision. Asually 51 mg of 5anthine or !5 mg of -robanthine is given one hour before the appointment. TI!! E MANA(EMENT (ingi)al retraction? It is essential that the gingival tissues be healthy and free of inflammation before any cast restorations are started. 5ecause the marginal fit of the restoration, is essential in preventing recurrent caries and gingival irritation, the finish line must be reproduced in the impressions. This can be complicated by the fact that some of the preparation lines may be at or below the crest of the free gingiva. To ensure adequate reproduction of the entire preparation the gingival finish line must be exposed by enlarging the gingival sulcus temporarily. This can be accomplished by !. $echanical #. $echanical- chemical
79
'. +urgical- electrosurgery, gingitage 1/ 'echanical. This must be carefully performed to minimi;e trauma. :versi;ed copper bands are contoured to gingiva and restricted towards the cavity margins when gently seated over the tooth. A compound or a resin plug is placed on the top and is vented for excess impression material to flow. A loop of floss is threaded through the vent to ease the band removal. +ince ginigival retraction can be accomplished using other means with limited trauma to the tissues this has got a limited use.
0/ 'echanical 4 #hemical. This is the routinely used method for gingival retraction. This consists of cords impregnated with chemicals that placed into the gingival sulcus beneath the tooth margins. The cord physically pushes the gingiva away from the finish line and the combination of chemical action and pressure pac ing helps to control the seepage of fluids from the walls of the gingival sulcus. A variety of medicaments are used with these cords. -in$i al retraction materials s!o&l( satis*. certain criterion: !. It must be effective, it must result in sufficient lateral and vertical displacement, adequate tissue shrin age, control of hemorrhage and fluid seepage. #. Ase of this material should not cause irreversible tissue damage '. Ase of this material should not produce potential systemic effects. 7onsiderations should be given to potential reaction from local anesthetics, medication ta en for medical purposes, endogenous secretions, and cardiovascular condition. The medicaments used or have been suggested for
80
retractions are epinephrine, ;inc chloride, alum, aluminum sulfate, aluminum chloride. $e)ie. O: Literat*re ? 4amadan studied in dogs the length of time the sulcus remained open and the width of the sulcus with plain, !&!111 epinephrine, BK epinephrine, !11K alum. "e concluded that all but the untreated were effective. $o bel and $ohammed found that !1K and 1/0 aluminum chloride resulted in severe tissue destruction and 5K was satisfactory. /ennaro et, al. +tudied in humans to compare the histologic response to plain ,rd, chords impregnated with potassium aluminum sulfate, hemodent and BK racemic epinephrine. .o practical difference was demonstrated. *rom the above studies, alum, aluminum sulfate, aluminum chloride can be used without any reaction. 3pinephrine is also effective but has systemic effects. 1%ine%!rine: $aximal dose- 1.# mg in an healthy adult Impregnated cords contain 1.# to ! mg of racemic epinephrine per inch of the cord. -ossible cumulative effects of epinephrine from cord combined with epinephrine from other sources have to be considered. $anipulation of gingival tissue during retraction can cause an increase in blood pressure suggesting the influence of endogenous epinephrine. -el;ner et, al.. reported a human study involving gingival retraction with (K and BK epinephrine with plain chord and found that blood pressure was elevated and was highest when BK epinephrine was used. 7o-relating data on the use of epinephrine as a medicament in gingival retraction is not clear.
81
Proce&*re o: retraction The operating area must be dry. The retraction cord is drawn from the dispenser with a sterile cotton plier approximately # inches long and is cut off. "olding the cord between the thumb and forefinger of each hand twist the ends to produce a tightly wound chord, form it into a A loop and place it around the prepared tooth. +tart pushing it gently into the sulcus in the interproximal area with a chord pac er instrument, once the chord is tuc ed in on one side use the instrument to secure it on the interproximal area. next the chord is tuc ed in the lingual areaE the tip of the instrument should be inclined slightly towards the area where the chord has already been placed. If the instrument is directed totally in an apical direction the chord will rebound off the gingiva and roll out of the sulcus. 7ontinue around the lingual area, firmly securing the chord where it was lightly tuc ed before. 7ut off the length of the chord protruding from the mesial sulcus as nearly as possible to the interdental papilla. 7ontinue pac ing the chord around the facial. surface. -ac all but #-' mm of the chord in the last, this will help in easy removal. Tissue retraction must be done firmly but gently. If there is a slight hemorrhage, it can be controlled by the use of homeostatic agent. 4etraction chord can be moistened prior to the placement with an hemostatic agent and then pac ed or it can also be placed dry but during removal it is moistened and then only it is removed otherwise it can cause in=ury to the delicate sulcular epithelium. Types of retraction chords are nitted cords or braided cords. .ewer type of cord is called as stayput, it contains a copper wire over which the chord is woven. Techniques of gingival retraction advocated are double retraction, retraction cord placed before the preparation and the regularly used single retraction.
82
!*rgery? 1/ Gingitage. In this technique, special diamond stones remove the sulcus epithelium as the margins are finished beneath the crest of the gingiva. )c Fitre et, al.. in !2B5 has demonstrated successful exposure through gingitage and also healing of the tissues comparable to electrosurgery. 0/ &lectrosurger). There are some situations in which the gingiva cannot be successfully handled by retraction. The use of electro-surgery has been recommended for enlargement of the gingival sulcus and control of hemorrhage to facilitate the ma ing of an impression. It uses high frequency electrical current of !.1 $"; or more to produce controlled tissue destruction to achieve a surgical result. ) Arsonval is credited for demonstrating this, in !B2! he demonstrated that electricity at high frequency will pass through a body without producing a shoc and producing instead an increase in the internal temperature of the tissue. This discovery was eventually used for development of electrosurgery 8radiosurgery9. An electrosurgery unit is a high frequency oscillometer or a radio transmitter, which uses a vacuum tube, or a transmitter for this purpose. It generates heat in a way that is similar to the concept of diathermy machine or a microwave oven. 7urrent flows from a small electrode that produces a high current density and a rapid temperature rise at its point of contact with the tissues. The cutting electrode remains cold. The ones used are< An-rectified current -artially rectified current *ully rectified current
83
*or the patients safety it is important the circuit should have a ground electrode. It is contraindicated in patients with cardiac pacema ers. It is used for< /ingival sulcus enlargement 4emoval of edentulous cuffs 7rown lengthening. 2ec!ni3&e: 5efore any electrosurgical procedure is done the anesthetic action is verified. A drop of pleasant smelling oil is usually placed on the lip to mas the odor emanating from the mouth during the procedure. (ingi)al s*lc*s enlargement? 5efore any tissue is removed, it is important to assess the width of the band of attached gingiva. 3lectrosurgery is a surgical procedure, it cannot restore lost gingiva. To enlarge the gingival sulcus for impression ma ing, a straight or =-shaped electrode is selected. It is used with the wire parallel with the long axis of the tooth so that tissue is removed from the inner wall of the sulcus. If the electrode is maintained in this direction the loss of gingival height will be about 1. !-mm. 7lean tissue debris off the electrode tip after each stro e with a cotton pellet dipped in hydrogen peroxide.
84
P$O"I!IONAL $E!TO$ATION!
85
P$O"I!IONAL $E!TO$ATION!
)uring fixed partial dentures treatment it is important that the prepared tooth or teeth be protected and the patient be ept confortable while a cast restoration is being fabricated. This is achieved by way of provisional restorations. $e@*irements o: pro)isional restorations An optimum provisional restoration must satisfy many interrelated factors, which can be classified as< I9 a9 )iolo$ic %rotection< -ulp protection< The provisional must seal the prepared tooth surface
from the oral environment, thereby preventing any sensitivity and irritation to the pulp. Therefore the margins should be well adapted. b9 -eriodontal health< The plaque accumulation should be prevented by having a good marginal fit of the provisional proper contour and smooth surface c9 :cclusal compatibility and tooth position< The provisional must have and maintain good contact with ad=acent and opposing teeth. If this is not given properly, it could result in supra eruption or hori;ontal movement of the prepared teeth. d9 -revention of enamel fracture< The provisional should protect the remaining tooth structure after tooth preparation from damage. This is especially true in cases of partial coverage designs. 3ven a small chip of enamel would render the final restoration useless. II9 Mec!anical re3&irements: a9 *unction< The greatest stresses are induced on the provisional during mastication. Though an acrylic provision has !&#1th the strength of metal
86
ceramic alloys they are expected to resist fracture. This can best be achieved by increasing the thic ness of the connectors as compared to the definitive prosthesis. Also the depth and sharpness of the embrasures is reduced, this reduces the stress concentration associated with sharp internal line angles. b9 )isplacement< )isplacement should be avoided of the provision of irritation to pulp and tooth movement are to be avoided. )isplacement is best prevented by proper tooth preparation and ma ing a closely adopted provisional. c9 4euse< :ften provisionals have to be removed to be reused. Thus during this procedure they should not get damaged. III9 1st!etic re3&irements: The provisional restorations, particularly for incisors, canines and sometimes premolars should have good esthetics to a certain extent. Though it is not possible to restore the exact dour, shape, translucency and texture. The provisional often serves as a guide to achieve optimal esthetics in the final restorations. Materials *se& :or :abricating pro)isional restorations < $any materials have been used over the years to ma e satisfactory provisional restorations. There are two general categories under which the provisional restorative materials can be put, namely< !9 7ustom< +elf cure acrylic resins #9 -reformed< A variety of performed crowns are available commerciallyE i9 -olycarbonate crowns ii9 7ellulose acetate crowns. iii9 Aluminum and tin silver iv9 .ic el-chromium
87
6A i% C*stom ma&e acrylic cro.ns? Armamentarium . !9 )iagnostic cast #9 Atility wax '9 ?ax spatula (9 Luadrant impression 59 Alginate 09 4ubber bowl and spatula D9 B9 29 !!9 !#9 Luic set plaster 5rush +eparating medium +traight hand piece +and paper and carborandum disc
!19 Acrylic monomer and polymer
!'9 -olishing wheel and pumice. Procedure. !. 5efore tooth preparation, an impression is made using alginate of the arch and poured with plastic to get a diagnostic cast. If the tooth to be restored has any defects, these are to be rectified using utility wax. #9 .ow tooth preparation is carried out following which an impression is made using a sectional tray of the preparation with alginate. Luic setting plaster is poured to get a cast. The cast is neatly trimmed and ept aside. '9 An over impression is made of the diagnosticQ cast which was previously immersed for five minutes in water, using alginate. :n setting of the alginate the over impression is removed. The sectional cast earlier obtained of the prepared tooth is now tried into the over impression to ensure its complete seating.
88
(9
7oat the cast with separating medium. Tooth coloured acrylic is mixed
and is placed in the over impression completely covering the crown area of the tooth for which the provisional is being made. 59 +eat the cast into the over impression ma ing sure the cast is properly aligned. :nce cast has been firmly seated, it is held in placed with a large rubber band. The over impression with the cast is placed in a bowl of hot water for five minutes. 09 After acrylic has polymeri;ed, remove the rubber band and separate the cast from the impression. The acrylic restoration got may be difficult to remove easily, brea the tooth off the cast with a nife. 4emove plaster from the inside of the temperature crown with a sharp nife. D9 A carborandum dis is now used to trim the excess acrylic from the temporary restoration. The restoration is sand papered and polished. ii% C*stom acrylic temporary bri&ge< The acrylic temporary bridge is made in the same way as a custom acrylic temporary crown. "ere a denture tooth or teeth of a suitable si;e is placed in the edentulous space on the diagnostic cast. The embrasure are filled with putty and then an over impression is made of the cast. After tooth preparation, a sectional impression is made of the teeth and a cast is poured. Acrylic is poured into the over impression and the cast is seated into the over impression. It is held in placed with rubbed bands till the acrylic has polymeri;ed completely. It is then separated from the cast, excess acrylic is trimmed off and the pontic area is trimmed to widen the embrasure and to remove the saddle. The restoration is sandpapered and polished.
89
/A i% Anterior polycarbonate cro.n? After the tooth preparation has been completed, an alginate impression is made of the prepared tooth and a cast is poured. Asing the mold guide provided in the it, select a crown with proper mesiodistal si;e for the prepared tooth. 4emove the correspond si;ed crown from the it and place it on the prepared tooth on the cast. Asing a pencil mar on the gingival portion of the labial surface the required length using the ad=acent tooth as a guide. :nce this is done, use a stone to grind to crown to the desired length. Try te crown on the cast again. .ow paint separating medium on the cast with a brush, mix self cure resin in a deepen dish and place in it the crown form. +eat the crown onto the cast and place it in a bowl of hot water. :nce polymeri;ation is completed, the crown is separated from the cast. 3xcess acrylic is trimmed away from the margins. -lace the crown now in the mouth on the prepared tooth to chec for fit and occlusion. -erformed anatomic metal crown< A measuring gauge which measures in a !mm range is 2-!1mm, !1-! !mm, and !!-!#mm, is used to measure the mesio-distal width of the crown space. An appropriate shell is selected based on these measurements. The crown is tried on the tooth to evaluate the marginal ridge of the crown and the ad=acent tooth. +cissors are used to cut the crown at the gingival margin equal to the margin ridge discrepancy. Any rough area or irregularities in the margin are smoothed with a sand paper disc. The crown is the contoured to produce a slightly convex contour occlusal to the margin, this also causes the margin to constrict. Cro.n cementation< The primary function of a luting agent is to provide seal, preventing marginal lea age and hence pulpal irritation. Ideal properties of a provisional luting agent are<
90
!9 #9 '9 (9 59
+eal against lea age of oral fluid +trength consistent with intentional removal 7hemical compatibility with provisional 7onvenience of dispensing and mixing 3ase of eliminating excess
09 Adequate wor ing time and short setting time. $aterials available Mn:3 cement seems to be the most satisfactory. Minc phosphate, /lass ionomer and polycarboxylate are not recommended because of their high strength, thereby ma ing intentional removal difficult. Mn:3 is much wea er cement and provides easy removal. "owever free eugenol acts as a plastici;er of methyl methacrylate and has been shown to reduce surface hardness and strength. Armamentarium -rovisional luting cement $ixing pad -lastic filling instrument -etrolatum )ental floss
- 7ement spatula
- 3xplorer
-rocedure ,ubricate the extend surface of the provisional with petrolatum. This $ix the luting agent to desired consistency and apply small in ma es the removal of excess cement easy. quantities. Avoid filling the crown as it prolongs cleanup.
91
- +eat the restoration and allow the cement to set. - 7arefully remove excess with an explorer and dental floss. .ote< - 7ement remnants left in the sulcus have an irritating effect on the gingiva and may cause periodontal inflammation with bone loss. "ence sulcus must be carefully chec ed and irrigated with air-water syringe.
92
LA+O$ATO$< P$OCED $E!
93
LA+O$ATO$< P$OCED $E!

BMo*l& preparation to :inis9A
Casting tec9ni@*e 9a)e been *se& since ancient times to con)ert .a' pattern to cast metal% P9ilbrooC :irst &escribe t9e lost .a' met9o& in 6D54% Taggart introduced this technique of fabricating cast metal crowns from lost wax method to the dental professional in !210. Thus arriving at a completed casting after fabrication of wax pattern involves three steps. Investing 5urn out 7asting Terminologies Investing < +urrounding the wax pattern with a material that can accurately duplicate its shape and anatomic features. +prue former < The sprue former is a diameter pen or tube made of wax plastic or metal. :ne end of the sprue former attached to the wax pattern and other end to the crucible former. 7rucible former < 7onical rubber base to which one end of the sprue former is attached. After the investment is hardened the crucible former is removed from the ring living a funnel shape entrance to the mold. 5urn out < 4emoval of the wax pattern so that a mold is created into which the molten alloy can be placed. +prue < The channel left by the sprue former following burn out is the sprue. 7asting < Introducing the molten alloy into the previously prepared mold. Investments used for the fabrication dental castings are generally of # types depending on the melting range of the alloy and individual preference.
94
/ypsum bonded investments < :lder type traditionally used for conventional gold alloys. They are used for alloys whose melting temperature is below !1B1o7 8!2D5o*9. -hosphate bonded investments < )esigned for alloys used for metal ceramic restoration. Classi:ication o: &ental casting alloy Alloy types by function In !2#D, the 5ureau of standards established gold castings alloy Type I through IF, according to dental function. In !201, the metal ceramic alloys emerged and they were subsequently added. Type I < 8+oft9 +mall inlays R easily burnished and sub=ect to very slight stresses. Type II < 8$edium9 Inlays sub=ect to moderate stress. Thic crowns, abutments, pontic and full crowns. Type III < 8"ard9 Inlays sub=ect to high stresses, thin three quarter crowns, thin cast bac ings, abutments, pontics, full crowns and denture bases and short span fixed partial dentures. Type III < Alloys usually can be age hardened. Type IF < 83xtra hard9 inlays sub=ect to very high stresses, denture base bars and clasps, partial denture frame wor s and long span fixed partial dentures. This type can be aged hardened. +hrin age compensation *or crowns, therefore, it is necessary to compensate for the solidification shrin age of the specific alloy used by expanding the mold enough to at least equal to shrin age. There are four mechanisms that can play a role in producing an expanded mold < +etting expansion of the investment three quarter
95
"ygroscopic expansion ?ax pattern expansion Thermal expansion +etting expansion < +etting expansion of the investment occurs as a result of normal crystal growth. The expansion probably is enhanced by silica particles in the investment interfering with the forming crystaline structure of the gypsum, causing it to expand outward. The expansion, in air, normally is about 1.(K. "ygroscopic expansion < "ygroscopic expansion may be employed to augment normal expansion. That maximum expansion could be achieved by immersing an investment-filled ring in a !11 o* 8'Bo79. The water in which the investment is immersed replaces the water used by the hydration process. "ygroscopic expansion ranges from !.#K to #.#K. In a lined, rigid, metal ring, the expansion attributed to hygroscopic expansion is more li ely due to expansion of the wax pattern caused by the elevated temperature of the water in which the pattern has been immersed. ?ax pattern expansion < 3xpansion of the wax pattern while the investment is still fluid occurs when the wax is warmed above the temperature at which it was formed. The heat may come from the chemical reaction of the investment or from a warm water bath in which the ring is immersed. The lowtemperature burnout technique employs a combination of wax pattern expansion and thermal expansion of the mold. After the investment-filled ring is removed from a !11o* 8'Bo79 water bath, the ring is heated to only 211 o* 8(B#o79 before casting to produce the additional expansion needed.
96
Thermal expansion < Thermal expansion of the investment occurs when the investment is heated in the burnout oven. "eating of the mold also serves to eliminate the wax pattern and to prevent the alloy from solidifying before it completely fills the mold. The high-temperature burnout technique relies primarily on thermal expansion of the mold. (yps*m +on&e& In)estments The gypsum bonded investments are used with type I, type II and type III gold alloys. Compositions - hemihydrate R binder R '1-'5K. Luart;&cristobalite R refractory material R 01-05K. 7oloring matter R modifiers 7arbon&powdered copper R reducing agent. Armamentari*m #11cc vaccum spat bowl and lid. Facuum tubing Facu-u-vestor 4ubber crucible former 7asting ring 8'#mm diameter9 -lastic water measure +patula -IT waxing instrument 8no.! and no.(9 7otton pliers 5unsen burner $atches +tic y wax +prue formers 8hollow plastics9 51g investment.
97
*our inch 8!1cm9 strip of cellulose ring line +prue former attachment The sprue former is a small diameter pin&tube made of wax, A !1-guage 8#.0mm diameter9 sprue former can be used on most patterns, while the !# gauge on #mm diameter is used on small premolars patterns. :ne end of the sprue former is attached to the wax pattern and the other end to the crucible former 8a conical rubber base9. After the investment has hardened the crucible former is removed from the ring leaving a funnel shaped entrance to the mold. The channel left by the sprue former following burnout is the GsprueH an ingot for the gold that will be forced into the mold. A sprue former as large as possible should be used on each pattern. If the sprue is too thin&too long, the gold may solidify in the sprue before it does in the larger cavity formed by the wax pattern. If this happens molten gold cannot be drawn from the 43+34F:I4 8O5ATT:.P9 as the casting solidifies as Gshrin spotH porosity will occur in the bul iest part of the casting. The sprue former should be attached to the wax pattern at its point of greatest bul , avoiding centric occlusal contacts. It is attached at an angle to allow the incoming alloy 8gold9 to flow freely to all portions of the mold. If the sprue is directed at right angles to the wall of the mold, a G"ot +potH may be created at that point. This will eep the alloy ad=acent to it molten after the rest of the casting has solidified causing G+uc -5ac H porosity. A hollow plastic sprue former is selected and placed inside the crucible former and casting ring for measurement. The sprue former must be =ust long enough so that the highest point on the wax pattern will be 0.11 mm from the end of the ring. If the pattern is too close to the end of the ring, the molten alloy may blast through the investment during casting. If it is too far, gases may not escape rapidly enough to permit complete filling of the mold with the
98
alloy. The sprue former is removed from the crucible former and shortened with a sharp nife is required. If the hole in the crucible former is too large to firmly grasp the sprue former, of the hole is filled with soft wax. Asing a -IT .o.! instrument, a small head of stic y wax is dropped onto the proposed site of attachment on the pattern. The sprue former is placed into the molten head of stic y wax. If the wax is hot enough, a small amount of wax will be drawn into the human of the sprue by capillary action. This creates a strong union between sprue former and pattern, provided there is no movement as the wax hardens. +tic y wax is melted, around the sprue former R wax pattern =unction with a -IT .o.! to provide a smooth condition for molten alloy. The wax pattern is not exposed to prolonged heating during the procedure. :ver bul ing the sprue former attachment has to be avoided as this will increase the ris of G+hrin +potH porosity and also ma es the removal of the sprue from the casting difficult. 7onstriction of the sprue former at its attachment to the wax pattern should not be present. )uring the time period between removal of the wax pattern from the die and hardening of the investment, deformation will occur as stresses in the wax are released. To minimi;e this time, all the armamentarium must be at hand, the ring liner should be in place and the water should be measured out before the pattern in removed. To remove the wax pattern from the die, it is lightly grasped on the proximal surfaces with the thumb and fore finger of the left hand, being careful not to exert any pressure on the sprue former. The die is held between the thumb and forefinger of the right hand and squee;ed together. This squee;ing action by the right hand will exert gentle pressure against the tips of the fingers of the left hand and will usually lift the pattern from the die.
99
)irect pulling action exerted with the left had should never be attempted. 3xcept in the situation described below removal of the pattern by sprue former is also not indicated. )ifficulty can be encountered in removing an inlay pattern from the die, since there is usually exerting distortion forces on the sprue former. In this situation, the sprue should parallel the path of insertion of the restoration to prevent torquing of the pattern with attendant distortion of its margins 8a small loop of gold ;ephyr wire with turned up ends can be heated and embedded into the occlusal surface of the wax pattern and used as a handle for removal with cotton pliers9. To produce uniform expansion, the pattern should be surrounded on all sides with investment that is an uniform in thic ness as possible. The closer to the center of the ring that the pattern is placed the greater will be the expansion. ?ith the pliers the sprue former is pushed down into the soft wax in the top of the crucible former until the top of the pattern in 0.1mm below the end of the ring. To provide adequate bul of gold during solidification the sprue itself should be no longer than 0.11mm, it can be shorter. To correct any discrepancy in length soft wax is added onto the sprue former thus lengthening the crucible former and shortening the exposed sprue former. All the wax around the base of the sprue former is smoothened. Investing procedure *or a single crown&on lay. A $etal 7asting 4ing with an outside diameter of '#mm is used. A resilient liner is placed on the inside of the ring to provide a buffer to pliable material against which the investment can expand to enlarge the mold. If there is no room for expansion outward, the expansion forces will be exerted inwards towards the mold, resulting in distortion of the casting. The
100
layer of soft material between the investment and the wall of the ring also permits easier removal of the investment and casting from the ring later. +plit--lastic casting ring is an alternative method which offers no resistance to the setting expansion. The plastic rings removed before the invested pattern in placed into the oven. This technique allows easier escape of gas from the mold during casting, but the mold is more vulnerable to crac ing. *or many years Asbestos was used to line casting rings, this however is presently not used because of its carcinogenic properties. 7eramic -aper and 7ellulose -aper < are now used as substitutes for asbestos. "owever ceramic paper is also found to be ha;ardous as it contains fibers in the si;e range li ely to cause lung cancer in rats. 7eramic material )oes not readily absorb water 7ellulose material )oes absorb water and thus becomes thic er and more compressible vacuum 7ellulose liners burns out before the casting is made, allowing unrestricted thermal expansion. 3asy escape of gases from the mold during castings. "owever this deprives the investment of support by the ring, and may result in crac ing of the investment and fins on the castings. The manufacturers recommend that approximately 'mm of ring at each end be left unlined so that the investment will be partially supported by direct contact with the ring after the liner has burned out. A dry strip of cellulose liner which is approximately 2.5 cm long is placed into a '#mm diameter casting ring, carefully adapting the strip to the walls of the ring with no overlap. except under
101
The ring is dipped in water to wet the liner and then excess water is sha en off. The water in the liner aids in < Adding a degree of hydroscopic expansion to the setting expansion. 5ut it also decreases -<? ratio which intrun will reduce the thermal expansion of the investment. As a result, the net expansion with a dry liner will be slightly greater than with a wet liner. "owever because the effect of a dry liner depends on its volume relative to that of the investment, which varies with the diameter of the ring, a )A$- ,I.34 is preferred for the sa e of consistency. The ring is rotated firmly onto the crucible former being careful to avoid snapping movements or contact of the wax pattern with the ring. Air bubbles in the investing material ad=acent to the wax pattern will result in modules on the casting. Amongst the 5 commonly employed methods of investing as reported by %:".+:.. Facuum mixing produced the best results with open&vacuum pouring. The procedure for investing pattern for a single tooth restoration to the cast in type II or type III gold with vacuum mixing vacuum pour technique is as follows < The assembled ring and crucible former is placed into the hole at the tope of the vac-n-spat investor. The lid is held by the spindle with the paddle towards the operator and the inlay ring towards the bottom. The aperture through which the investment will flow into the ring is observed to ma e sure that internal portion of the wax pattern is visible. :ne end of the clear plastic vacuum tubing is connected to the vacuum outlet on the Fac-A-vestor. The metal connector on the other end of the tubing is inserted into the hole in the lid of the Fac-A-spat. The Fac-A-vestor is turned on briefly. The recommended amount of room temperature water is ta en in
102
the bowl. The ?<- ratio is carefully measured as this has a critical effect on the expansion. A pac age of investment is added to the bowl and mixed with a hand held spatula until all of the investment has become wet. The lid is placed on the bowl ma ing sure that it is firmly sealed. The Fac-A-vestor is turned on and the spindle of the lid of the Fac-A-spat is inserted into the smaller of the # drive chuc s on the bottom of the unit. -ower spatulation is done for '1 seconds. The time of spatulation is measured precisely since the length of spatulation can affect expansion of the investment. :ver spatulation will increase thermal expansion. +pindle is removed from the drive chuc . The Fac-A-vestors is not turned off at this point and also the vacuum is not disconnected. The drive nut of the Fac-A-spat is palced on the vibrator nob. It is made sure the shaft is hori;ontal and the casting ring is in the lowest position on the circumference of the lid. The Fac-A-spat is held in this position for a few seconds until the investment has run to the lower side of the bowl. The Fac-A-+pat is inverted slowly until the shaft points straight down, eeping the drive nut in contact with the vibrator. It should ta e slightly less than '1 seconds to transverse the 21 arch from the hori;ontal to the vertical position. The drive nut from the vibrator vacuum hose is disconnected. The casting ring and crucible former are then removed from the Fac-A-+pat ring. If a high temperature 8!,#11o*, 051o79 burn out technique will be used, the casting ring and crucible are placed into a humidor and it is let to set at room temperature. If a low temperature 8211 o*, (B1o79 burnout technique is to be used, the ring is immersed in !11o* 8'Bo79 water bath to produce expansion nob is removed eeping the Fac-A-+pat
inverted. ?hile it is still in this position the vacuum pump is turned off and the
103
of the wax pattern. The investment is allowed to set for a minimum of '1 minutes. The ring is left in the humidor until it is ready for burn out and casting. The bowl, lid and paddle are cleaned before the investment hardnes on them. 7asting armamentarium for type II and III gold alloys 7asting ring with invested pattern *urnace 7entrifugal casting machine with crucible /as-air blow pipe, matches 7asting alloy, casting flux, casting tongs Tooth brush 3xplorer %el pac -orcelain casserole dish -lastic coated forceps 5unsen burner +*rno*t 5urnout prepares the mold for the molten alloy and allows thermal expansion to occur. If thermal expansion alone is to provide the compensation expansion a high temperature technique 8!,#11 o*, 051o79 is employed. If a !11o water bath 8hygroscopic technique9 was used to expand wax pattern, a lower temperature 8211 o7, (11o79 can be utili;ed. "eating must be gradual to allow them to escape without crac ing the mold. The crucible former is carefully separated from the ring. The cater and the bottom of the ring are chec ed for any small strips of investment and removed as they could contaminated the casting later. The casting ring is placed with the crater down into a 8011 o*, '!5o79 oven and left for '1 minutes. 5y burning out in an inverted position, much of the wax will
104
run out of the mold as it is melted. 7arrying any loose chips of investment with it. The ring, with casting tongs is transferred to a hotter furnace 8211 o*, (B#o79 or 8!,#11o*, 051o79 depending on the technique used for ! hour. As an alternative, the ring can be placed in a cold oven and heated slowly to the casting temperature. The ring should be set crater up about !1 minutes before the casting is made. This allows oxygen to contact the internal area of the mold to ensure complete wax residue elimination. 7asting for type II and III gold alloys .o more than '1 seconds should elapse between the time the ring is removed from the oven and molten alloy is centrifuged into the mold. Any undue delay will cause heat loss and resultant mold contraction. The crucible is placed in its brac et on the arm of the casting machine. The counterweight of the casting machine is grasped with the right hand and wound ' times in a cloc wise direction. The pin is raised from the base of the machine in front of the crucible assembly. The right hand is slowly released until the pin rests against the arm, preventing it from unwinding. The casting alloys is placed in the crucible. The gas-air blowpipe is lit and the red gas and green air nobs are ad=usted to produce a conical flame. The !st cone-mixing ;one Is a cool, colourless ;one in which partial combustion ta es place. Around this area is combustion ;one, greenish blue area in which partial combustion ta es place. This is an oxidi;ing ;one. .ext is reducing ;one This is the dim blue tip of the flame. This is the hottest area in the flame. Is the only part of the flame used to heat the casting alloy. 5eyond this is another oxidi;ing ;one in which final combustion between the gas and surrounding air occurs. .either of oxidi;ing ;ones should be used for heating. They are not as hot as the reducing ;one, and if the alloy comes in contact with them, copper
105
and other non-noble metals will be oxidi;ed, changing the properties of the alloy. This can result in reduced strength and altered solidification shrin age. ,ocating the reducing ;one has to be practiced by directing the flame against the crucible to form a glowing hot area. The flame is moved closer, slowly. ?hen it is too close a central dar spot will be formed by the cooler combustion ;one. The torch is now withdrawn until the dar spot =ust disappears. This will be the ideal distance the torch should be from the gold. In order to maintain the original composition of the alloy. A small amount of *lux should be sprin led onto the warmed metal. 5orax, which is used for this purpose helps to exclude oxygen from the surface of the alloy and dissolve any oxides that are formed. O4educing fluxP, which contains carbon in addition to borax can also be used. "eating the gold is continued until it balls up. As it approaches the casting temperature, the gold will become straw yellow in colour. It will wiggle easily in the crucible when it is lapped and will follow the flame if it is moved slightly. If the reducing ;one has been used properly the molten gold will appear mirror li e and shiny. Ieeping the flame on gold the casting ring is removed from the oven with casting tongs and carefully the ring is placed in the cradle. The platform on which the crucible rests against the ring and cradle are gently slide ma ing sure it fits snugly so that the ring will not rool when the arm is released. The blow pipe is held in one hand and a gentle cloc wise pressure is applied on the counter weight with the other hand until the pin drops. The weight is giggled slightly to see that the gold moves freely. The weight is released allowing the machine to spin. To insure maximum fluidity of the gold, the torch is not lifted out of position until the arm of the casting
106
machine has been released. The centrifuge has to be allowed to slow to a stop by itself. CLEANIN( THE CA!TIN( After the gold buttoning has lost its glow the casting ring is removed with the tongs and it is thrust into a pan of cold water. *or a casting of firmly in a, small ring, this casting should occur about 5 minutes after casting achieve the best grain strength. If it is quenched while it is too hot, the gold will be softer and wea er. If it is allowed to bench cool completely, the grain structure will be too large. An additional advantage of quenching is the disintegration of the hot investment when it contacts the cold water. The ring is removed from the cold water and the investment and the casting are pushed out of the ring. As much as the investment is bro en off by hand&with an old instrument and then the casting and button are scrubbed with a stiff brush. The casting should appear smooth with a dull, dar oxide layer. The oxide layer and any remaining particles of investment are removed by lightly sand blasting all the surfaces with 51 m abrasives, ta ing care not be abrade the thin margins. A process called G-ic lingH has also been used widely for cleaning the gold castings. This involves soa ing the casting in a hot acid solution for several minutes. %el -a being a much safer and less corrosive pic ling agent than the formerly uses sulfuric or the hydrochloric acid. A porcelain casserole dish is used to contain the pic ling solution and plastic covered pliers are used to introduced and remove the casting from the solution. $etal instruments must not come into contact with gold in strong solution as 3lectro )eposition may occur on the surface of the casting. :nly gold casting may be cleaned by pic ling.
107
5ecause of the health and environmental ha;ards associated with pic ling solution air abrasion with small particle si;e abrasives is the preferred means of cleaning the castings. -hosphate bonded investments -hosphate bonded investments are much stronger and with stand much higher temperatures than do gypsum bonded investments. They are used for investing and casting alloys with higher melting temperatures eg < +ilver palladium /old palladium .ic el R chromium To obtain sufficient expansion for crowns of these alloys, the mold must be heated to !,(11o* 8D01o79 or higher, temperatures that would cause decomposition of the calcium sulfate in a gypsum binder with the resultant release of contaminating sulfur into the mold. The powder contains phosphate of magnesium and amonium, grophite 8carbon9 and large silica particles while the special provided with these investments contains an aqueous suspension of colloid silica. 7arbon R free phosphate investments are available for use with base alloys that are made brittle in the presence of carbon. $agnesium phosphate reacts with primary ammonium phosphate to produce magnesium ammonium phosphate. ?hich gives the investment its strength at room temperature. At high temperature, silicophosphates are formed, they give the investment its great strength. 3xpansion can be varied by the proportions of silica sol and water. $ore silica sol and less water S more expansion. ,ess silica sol and more water S less expansion. The usual proportion is three parts silica sol liquid to one part distilled water. Investing armamentarium for phosphate bonded investments #11ml Fac-A-+pat bowl and lid.
108
Facuum tubing. 4ubber crucible former. 7asting ring. -lastic water measure. +patula. -IT 8thomas9 waxing instrument 8no.! and no.(9 7otton pliers. 5unsen burner and matches +tic y wax +prue formers 8hollow plastic&wax9 :ne pac age 01g of ceramic gold investment +pecial liquid +trip of liner 2.5cm long +mall camels hair brush In)esting .it9 p9osp9ate bon&e& materials A !1-guage 8#.0mm9 plastic sprue former is sttached to the incisal position of the single crown wax pattern with stic y wax using -IT no.! instrument to melt and blend the =unction. If there is a broad expanse of paper thin wax between the sprue and the margin then it is bridge with a narrow strip 81.5mm9 that of wax that will serve as a internal sprue. This will provide a channel through which the molten alloy can flow more readily to reproduce the margin. The resulting ridge can be easily trimmed bac to the desired thic ness after the casting is made. The pattern is carefully removed from the die and the sprue former is grasped with cotton pliers. The sprue former is seated into the soft wax in the center of the crucible former. The sprue formers length should be ad=usted so that the pattern will be 0mm from the end of the ring when it is in place.
109
The crucible former is built up with wax if necessary so that no more than 0mm of the sprue former will be exposed. -osterior patterns are sprued on the tip of the cusp with the greatest bul . An !B gauge 81.B mm9 diameter wax sprue former should connected the other cusp tip with the base of the crucible former. The tip of this cusp should be lower than the point of entry of the main sprue. A layer of dry cellulose line is adapted to the inside of the ring. The ring is then briefly immmersed in a bowl of water to moisten the liner. The ring, crucible former and Fac-A-spat lid are assembled 2.5 R of liquid is placed in the Fac-A-+pat bowl and the 01g pac age of ceramic gold investment is added to it. The vacuum tubing is connected and mechanically spatualated under a vacuum for approximately !5 seconds. The vacuum is then disconnected and the ring is removed from the lid. This type of investment possesses poor surface wetting characteristics. 5ecause of this the problem of trapping bubbles during investing is even greater than with gypsum investments. 3ither vacuum&open investing can be used. Allowing the investment to set in a pressure will further reduce the si;e and number of air bubbles. If there are small restricted areas in the interior of a wax pattern, then the investment has to be brushed into the pattern with a small brush. The ring is then placed over the crucible former and the investment is gently poured down on one side of the ring with vibration and the pattern is gradually filled from the bottom. :nce the pattern is covered, the ring can be filled with minimum of vibration. There should be an excess of investment above the end of the ring so that the hardened gla;e can be easily ground away on a model trimmer. The wax pattern for metal ceramics. *ixed partial dentures are invested and casted as one unit whenever possible because of the problems encountered in soldering the alloys used for this type of restorations. In these situations the
110
wax pattern should be fabricated on a one piece die in which the dies of the individual abutments preparations has not been separated. The wax pattern for an fixed partial denture should be invested in a large ring 8round&oval9 with a diameter of approximately 0.'cm to produce the most accurate casting. *or lower fusing gold alloy casting, sprue formers run directly from crucible former to wax pattern to provide rapid turbulence free access of the metal of the mold during casting. -atterns for metal ceramic fixed partial dentures, however, must be sprued by an indirect method because the alloy used fuse and solidify at must higher temperature. 5ecause the ambient air is much colder than the molten metal, the exposed button is li ely to solidify while the metal at the center of the ring is still liquid. Thus the button cannot serve as a reservoir to prevent shrin spot porosity instead a bul y hori;ontal runner bar is placed between crucible former and pattern. A piece of B gauge hollow plastic sprue former material is placed hori;ontally into the sprue former networ to form a manifold between the crucible former and the wax pattern. 5oth the ends of the hollow tube has to be plugged with wax to avoid the formation of thin pro=ections of investment than might brea off in the mold. As the alloy ma es its way through the feeder sprues, runner and manifold sprues, the temperatures of the surroundings investment is elevated. The metal farthest form the manifold the margins, and the surface of the button exposed to ambient room temperature will cool first while the feeder bar is still fluid and can serve as a reservoir for solidification contraction in the fixed partial denture. The runner bar also helps to stabili;e the pattern against distortion during investing. It equali;es the flow of metal so that all parts of the mold will be filled evenly and simultaneously during casting.
111
The pattern is placed in a vertical position on the hori;ontal centrifugal casting machine to insure that all parts of the mold can fill simultaneously. To facilitate proper orientation a wax dot can be placed on the crucible former. This will leave an imprint on the surface of the investment which can seen when the ring is placed in the casting machine. As an alternative, # dots can be scribed on the outside of the ring, one directly opposite the other. These dots should be aligned with the axis of the pattern before investing. /old palladium alloys 7asting armamentarium 7asting ring with invested wax pattern *urnace 7entrifugal casting machine with quart; 7olored safety glasses /as-oxygen touch $atches $etal ceramic alloy 7asting tongs ,ab nife Tooth brush 3xplorer Casting base metal alloys +pecial gold-palladium alloys are used for metal ceramic restorations and where greater strength than that provided by type III gold required. After the investment has set for ! hour on the bench top, the excess investment beyond the end of the ring is ground&scrapped away. This will allow the smooth, dense surface layer and allow gases to escape more readily from the mold during casting.
112
The crucible former is then removed and the ring is placed in 011o*&'!5o7 oven. After '1 minutes is low heat oven the ring is placed in a !'11o*&D1(o7 oven for no longer than ! hour. 5ecause of the higher melting temperature of the metal ceramic alloy, the gas air blow pipe is inadequate&A single oropice, gas-oxygen torch should be used. A quart; crucible is preferred to clay crucible. .o flux has to be used for metal ceramic alloys as R it may upset the balance of the alloy and interfere with bonding later on. The torch is turned on and the flame is ad=usted to ma e the inner cone 1.#5 R 1.5 inch long 80-!# mm long9. The crucible is preheated and then the alloy is placed in the crucible. Alloy is heated until it liquefies. It goes through ( stages < 4ed :range ?hite 8dull9 ?hite 8mirror li e9 :nce the gold is orange, the ring is transferred from the furnace to the cradle of the casting machine. It has to be made sure that the mold of the frame wor is vertical 8one of the dots on the ring in top position9. The gold is further heated as it becomes white, a light fog&scum forms on the surface. As soon as the scum disappears and metal is shiny, the machine is released and cast. The ring is bench cooled to room temperature 8metal ceramic alloy should not be quenched9. ?hen it has cooled, the casting is removed and remnants of investment material is cleaned off. The casting is then washed in water and sand blasted lightly. $etal ceramic alloys are never pic led.
113
7asting base metral alloys The high-fusing alloys used for this has a high degree of shrin age on cooling. To achieve the necessary expansion, the invested pattern is placed in a water bath at !11o*&'B1o7 for ! hour for best results for night curing of investment before proceeding with burn out is done. The ring is placed in cold oven and the temperature is raised upto B!5 o7 & !511o* in approximately ! hour. Heat soaCing ? is allowed at this temperature for approximately # hours to eliminate all traces of carbon. The quart; crucible is then preheated in an oven. The casting machine is wound giving it one or two extra winds to compensate for much lighter density of the base metal alloys. The quart; crucible is removed from the oven with casting tongs and placed in the brac et on the casting machine. $etal ingot is then placed in the crucible. -rotective gaggles have to be worn for casting. The flame is ad=usted to ma e the inner cones approximately 1.5 inch 8!#mm9 long.t he alloy is heated evenly by moving the torch around to cover all ingots. The casting is done immediately to avoid overheating. The casting is then removed and the investment remnants cleaned off. $etal is cleaned with air abrasion using 51 m alumina. .o pic ling is done for base metal alloys. CONCL !ION *or substructure design for metal ceramic restorations, the restoration are waxed to anatomic contours and then it is 7ut 5ac in the area to be veneered. This will allow for even porcelain thic ness and also will have
114
superior mechanical properties in the completed restoration and a standardi;ed shade matching. 4egardless of which technique is employed, a precise routine for investing burning out and casting must be adhered to in order to achieve consistent results. ?henever failure occurs all technical steps and materials used need to carefully reevaluated. +ome common casting defects and their causes ,arge module < Air trapped during investing. $ultiple random modules < Inadequate vacuum during mixing. $odules on the under side only < -rolonged vibration after pouring. +hrin spot porosity < +prue attachment too bul y sprue too long&thin button too small. 4andom porosity < )irt in wax pattern loose particles of in investment. *ins < )ropped ring, rapid heating, liner flush with end of ring, excessive casting force. +hort rounded margins with rounded button < Alloy not hot enough&insufficient casting force. +hort rounded margins with sharp button < -attern too far from the end of the ring. 5lac rough casting < 5rea down of investment from excessive heat. Jo9nson= A% T9e e::ect o: :i)e in)esting tec9ni@*es on air b*bble entrapment an& casting no&*les=. Int % -rosthodont, !22#, 5 < (#(-(''. *ive different investing techniques were used to invest lost-wax castling patterns. MATE$IAL! AND METHOD! A standardi;ed maxillary molar crown preparation was constructed in brass. Asing the brass master die, identical silicone rubber moulds were
115
constructured. *our dental investments - two gypsum-bonded investments 87ristobalite and 5eauty-7ast, ?hipe-$ix 7orp, louisville, Iy9 and two phosphate-bonded investments 87eramigold, whip-$ix 7orpE )eguvest-+oft, )egussa, *ran furt, /ermany9 were then poured into the moulds, using the five different investing techniques. A vibrating time of '1 seconds and a setting time of ! hour were used for the four investments. A ! hour setting time was used as a standard inasmuch as this time most nearly approximately usual practice. 3ach of the four investments used was invested !1 times per investing technique, five times using a surface-tension reducer and five times without, for a total of two hundred test pieces. The five investing techniques used are listed as follows < -ower spatulation under vacuum, investment in air, placement into a pressure bath 8(1 psi for '1 minutes9. "and mixing, air investment, placement into a vacuum chamber. $ixing and investment under the same vacuum. "and mixing, investment in air. Facuum mixing, investment in air. All the investments for techniques, !, ', and 5 were mixed and invested using a combination unit drawing '1 inches or D01mm of mercury of vacuum. Technique # and ( were mixed in a bowl for the same time as recommended for mechanical mixing. The combination unit was used with a drive speed of (#5 rpm for techniques ! and 5 and !D#5 rpm for technique '. )ental castings were also produced to compare the number of air bubbles on the surface of the investment samples with the number of cast noddules&air bubbles found inside the fitting surfaces of the castings. The castings were made using a yellow-gold alloy.
116
$E! LT! Technique ! gave the best results with only !2 air bubbles. Techniques 5 had (2 air bubbles, technique ' had 00 air bubbles, technique ( had !1( air bubbles, and technique # had #1D air bubbles. Technique ! produced 5(K fewer bubbles. Technique # produced 5K fewer bubbles. Technique ( produced (K fewer bubbles. Technique ' produced ##K fewer bubbles when no +T4 agent was used. CONCL !ION The technique of mechanically mixing investments under vacuum, pouring them into the casting ring and around the pattern under vibration, in air, and sub=ecting the unset investment to (1 psi of air pressure !9 produced fewer air bubbles&cast nodules than did the other techniques investigated. Facuum mixing of investments is more effective than is hand mixing in eliminating air bubbles. A reduction in cast nodules was seen in all investing techniques when an +T4 agent was used.
117
COLO $ !CIENCE
118
COLO $ !CIENCE
7olour was recogni;ed as a '-dimensional entity as early as the !' th 7enturyE a graphic depiction of a '-) colour sphere has survived to this date. In !000, +ir Isaac .ewton observed that white light passing through a prism divided into an orderly pattern of colours now termed the O+pectrumP. "e also discovered that these colours would reproduce white light when passed bac through the prism proving that all spectral colours were in the original beam. PE$CEPTION O# COLO $ ,ight from an ob=ect enters the eye and acts on receptors in the retina i.e., rods and cones. Impulses from these are passed to the optical center of the brain, where an interpretation is made. +hade selection is very sub=ective R different individuals will have different interpretations of the same stimulus. T9e eye ? Ander low lighting conditions, only the rods are used i.e. scotopic vision. These receptors allow an interpretation of the brightness, but not the colour of ob=ects to be made. They are most sensitive to blue-green ob=ects. 7olour vision is dependent on the cones, which are active under higher lighting conditions i.e. photopic vision. The change from photopic to scotopic vision is called (ar' a(a%tation and ta es about (1 minutes. Colo*r a&aptation ? 7olour vision decreases rapidly as an ob=ect is observed. The original colour appears to become less and less saturated until it appears almost gray. +imultaneously, the chroma, intensity, of complementary colours appears greater. This phenomenon explains the suggestion that shade selection can be enhanced if operator walls are painted pale blue i.e. complementary to yellow, or that a pale gray-blue surface should be glanced at periodically while viewing colour choices.
119
Metamerism ? Two colours that appear to be a match under a given lighting condition but have different spectral reflectance are called metamers and the phenomenon is nown as metamerism. A sample that appears to match under the operatory light, for example, may no longer be satisfactory in day-light. The problem of metamerism can be avoided by selecting a shade and confirming it under different lighting conditions 8e.g., natural daylight and fluorescent light9. #l*orescence ? *luorescent materials, such as tooth enamel, re-emit radiant energy at a lower frequence than it is absorbed. *or example, ultraviolet radiation is re-emitted as visible light. In theory, a mismatch can occur if the dental restoration has different fluoresence than the natural tooth. Opalescence ? .atural teeth, particular at their incisal edges, exhibit a lightscattering effect. This is similar to the bluish-white bac ground seen in opal gemstones this explains the term opalescence. Colo*r blin&ness ? )efects in colour vision affect about BK of the male population and less of the female population. )ifferent types exist, such as achromatism i.e. complete lac of hue sensitivity, dichromatism e.g. sensitivity to only two primary hues R either red or green, and anomalous trichromatism i.e. sensitivity to all three hues with deficiency or abnormality of one of the three primary pigments in the retinal cones. Lig9t an& colo*r? ?ithout light, colour does not exist. An ob=ect that we perceive as a certain colour absorbs all light waves corresponding with other colours and reflects only those waves that we interpret as that ob=ects colour. An understanding of the nature of light and how the eye perceives and brain interprets light as colour is important for successful esthetic restorations particularly when metal ceramic or all ceramic restorations are being made. *or eg., an ob=ect that absorbs blue and green light and reflects red appears red. The apprent colour of an ob=ect is influenced by factors such as, Its physical properties.
120
The nature of the incident light to which it is exposed. The relationship to other coloured ob=ects. The sub=ective assessment of the observer. Description o: lig9t ? +cientifically light is described as, visible
electromagnetic energy whose wave length is measured in nanometer 8nm9&billianths of meter. The eye is sensitive only to visible part of the electromagnetic spectrum, a narrow band with wavelength of 'B1-D51nm. At the shorter wavelengths lies AF, x-rays at the longer wave lengths are infrared, microwaves and TF and radio transmission. 8*ality o: lig9t ? The most common light source in dental offices are Incandescent and *lourescent, matter of which are pure white light. )ay light is often used as the standard against which other light sources are compared, however tooth shades should never be selected in direct sunlight. .orthern day light around the moon hour on a bright day is considered ideal because there is a harmonious balance of the full visible spectrum. ?henever circumstances dictate the use of artificial light for shade selection, 7olour 7orrected *luorescent ,ighting is recommended because it approaches the necessary type of balance. Another light source reference standard is 7olour Temperature, which is related to the colour of a standard blac body when heated. Description o: colo*r ? %ust as solid body can be described by ' dimension of physical form 8i.e.9 length, width and depth, colour has ' primary dimensions, these however depends on the colour system used # such systems are <
121
$unsell colour order system. 7ielab colour system. $unsell colour order system < This is the most popular method of describing colour. The three attributes of colour in this system are hue, chroma, value. H&e : "ue is defined as the particular variety of a colour, shade or tint. The shorter the wavelength, the closer the hue will be to the violet portion of the spectrumE the longer the wavelength, the closer it will be to the red portion. In the $unsell colour system, hues are divided into !1 gradations< yellow, yellow-red, red, red-purple, purple, purple-blue, blue, blue-green, green, and green-yellow. These are arranged in a wheel. 3ach gradation is subdividedE for example, red can be written !4, #4, '4TT24, !14, followed by !N4, #N4, 'N4T..2N4, !1N4, followed by !N, #N, 'N, and so on. "ue sensitivity < After 5 seconds of staring at a tooth or shade guide, the eye accommodates and become biased. If one stares at any colour for longer 5 seconds then stares away at a white surface, or closes onePs eyes, the image appears but in the complementary hue. This phenomenon now as the O"ue sensitivityP. It adversely effects shade selection. ,!roma : 7hroma is defined as the intensity of a "ue. The terms saturation and chroma are used interchangeably in the dental literatureE both mean the strength of a given "ue or the concentration of pigment. A simple way to visuali;e differences in chroma is to imagine a buc et of water. ?hen one drop of in is added, a solution of low chroma results. Adding a second drop of in increases the chroma, and so on, until a solution is obtained that is almost all in and consequently of high chroma. In the munsell colour system, maximum chroma depends on the particular hue but can range from !1 to !(. Achromati shades have a chroma near 1. "al&e : Falue is defined as the relative lightness or dar ness of a colour or the brightness of an ob=ect. The brightness of any ob=ect is a direct consequence of the amount of light energy the ob=ect reflects or transmits.
122
,ight energy is measured in photos, and it is possible for ob=ects of different hues to reflect the same number of photons and thus have the same brightness or value. A common example is the difficulty experienced in trying to tell a green from a blue ob=ect in a blac and white photograph. In the $unsell method of describing colour, value is divided into !1 gradations, with 1 being blac and !1 being white. .atural teeth range is value from 5.5 to B.5. 7ielab colour system < )etermined by the commission international de IP3dairage in !2DB. In both $unsell and the lab colour order systems, the location in the colour space of a particular shade is defined by ' co-ordinates value, hue and chroma R $unsell ,6, a6, b6. Falue and ,6 are proportionate to each other and represent lightness&dar ness blac &white character of colour. 7olours with high value&,6 8such as tooth colours9 are located rear the top of the colour space. The chromatic&non-blac &white characteristics of a colour are represented in the $unsell system by hue and chroma and in 7I3,A5 by a6 and b6. In each system, these # co-ordinates define the location of colour on a plane of given lightness. In $unsell, the colour is identified by one polar coordinate 8"ue9 and one linear&cartesian co-ordinate 8chroma9. In 7I3,A5, both co-ordinates a6 and b6 are 7artesian 8*or an anology, consider how a house in the city may be described. :ne could say that one lived a distance of !!.B5 miles 8linear co-ordinate9 in a .orth-.orth ?est disection 8polar co-ordinate9 from down town. This is analogons is describing colour in $unsell system. The identical location can also be located as being !1.0 miles north and 5.' miles west of down town 8# 7artesian co-ordinates9. This is analogous to describing a colour in 7I3,A5 system. They represent the same location in space. "owever unli e $unsell, the 7I3,A5 co-ordinates define the colour space in approximately uniform steps of human colour perception.
123
,6 < ,6 is lightness variable proportional to value in the $unsell system. It describes the a chromatic character of the colour. a6, b6 < The a6, b6 co-ordinates describe the chromatic characteristics of the colour. Although they do not correlate directly with $unsellPs "ue and chroma. They can be converted by numerical parameters. The a6 co-ordinates corresponds to the red-purple&blue green axis in the $unsell colour space. A positive a6 relates to a predominantly red-purple colourE whereas a negative a6 denotes a colour that is more blue-green. +imilarly, the b6 coordinates corresponds to the yellow-purple&blue axis. 7olour measuring instruments !9 colour selection for dental restorative materials is generally done visually by matching a shade sample, #9 in industry, electronic colour measuring equipment is used. This equipment consists of spectrophotometers that measure light reflectance at wavelength intervals over the visible spectrum and colourimeters that provide direct colour co-ordinate specifications without mathematical manipulation. This is accomplished by sampling light reflected from an ob=ect through ' colour filters that simulate the response of colour receptors in the eye. These instruments have been used extensively in dental research. +hade guides 5ecause shade matching is sub=ective, consistency is difficult to achieve. "ence shade guioles are used in choosing the colour for a restoration. +hade selection can be improved by a ceramics. The colours of shade guides, from a given manufacturer, vary from guide to guide. The porcelain or the guide is not necessarily the same as the porcelain nowledge of the principles of light and colour, and of the techniques involved in dental
124
used for the restoration. The guides do not duplicate the manner in which porcelain restoration must be constructed. In an early publication +proull 8!2D'9 listed prime requirements of a shade guide as < !9 a logical arrangement in colour space, #9 an adequate distribution in colour space. /eneral principles .o matter which system of shade selection is employed there should be general adherence to certain principles. The patient should be viewed at eye level so that the most colour-sensitive part of the retina will be used. +hade comparison should be made under different lighting conditions. .ormally the patient is ta en to a window and the colour is confirmed in natural daylight after initial selection under incandescent and fluorescent lighting. The teeth to be matched should be clean. If necessary, strain should be removed by prophylaxis. +hade comparisons should be made at the start of a patient visit. Teeth increases in value when they are dry, particularly if rubber dam has been used. The dentist should be aware of eye fatigue, particularly if very bright fibre-optic illumination has been used. 5rightly coloured clothing should be draped and lipstic operatory wall should not be brightly coloured. +hade comparisons should be made quic ly with the colour samples placed under the tip directly next to the tooth being matched. This will ensure thaat the bac ground of the tooth and the shade sample are the same. The eye should be rested by focusing on a grey-blue surface immediately before a comparison because this balances all the colour sensors of the retina and resensiti;es the eye to yellow colour of the tooth. +hade selection sequence removed. The
125
The shade should always be matched prior to preparation of the tooth to be restored. .ot only can teeth become dehydrated and change colour during preparation but the debris generated in the form of enamel, metal and cement grindings can coat everything in the mouth. The patient is as ed to remove all distractions before attempting to match a shade. ,ipstic , in particular should be removed. $a ing sure that the teeth are clean and unstained before attempting to match a shade. A quic rubber cup and paste prophylaxis in the area of the mouth, where the shade is to be matched is done. The patient in an upright position with the mouth at the operators eyePs level. The operator has to be positioned between the patient and a light source. :bservations should be made quic ly 85 seconds or less9 to avoid fatiguing the cones in the retina. The shade should be matched by value, chroma and here in that order. The entire shade guide is quic ly scanned, selecting the tabs that are worst matched !st and eliminating them. 5y process of elimination this will leave very few tabs that are the closest matches. They are then moistened as they are used. If a decision can not be made between # tabs. They are placed on either side of the tooth being matched. If no tab will permit a good match, then the gingival portions of the shade tabs have to be matched with the gingival area of the tooth. Then the matching process is completed by comparing the incisal segments of those tabs which most nearly match with the incisal portion of the tooth. Initially the shade is selected using a colour-corrected light 8colour rendering index of go or greater9, then the process is repeated under atleast one other light source to minimi;e OmetamerismP. +ince value is the most important dimension of colour when selecting porcelain shades. The tabs have to be viewed through half closed eyes. Although this
126
decreases the ability to discriminate colour, it increases the ability to match value. )eveloping colour translucency and characteri;ations within the porcelain will create a more life li e restoration than simply applying extrinsic colourants after porcelain is fired. A drawing of the facial surface of the tooth has to be made on the patients chart and different shades are indicated if more than one is selected for different parts of the tooth. It is a good idea whenever possible to send the shade tab, cast including the contralateral tooth, and a photograph to the dental laboratory. 5efore putting the shade guide away it has to be disinfected. Autodrawing or other processing involving heat should be avoided as parts of most shade guides are made of plastic. An ideal shade guide In the $unsell system the relationship of any of the colour chips to the ships surrounding it is instantly nown by geographic location. If the achromatic axis is to the left, any colour chip to the right will be more saturated in colour 8i.e.9 have a higher chroma. Any chip above will be higher in value, and any chip below will be lower in value, chips on the same level will be equal in value. "ue changes are predictable from the location ahead of or behind the chip on the hue circle. A loo at the colour space of natural teeth as determined by spectrophotometric analysis will help in designing the ideal shade guide. The ey is the orderly arrangement according to hue, value and chroma. The approach used with such a guide would enable the user to swiftly arrive at the closest colour match available with the assurance that the correct tab has been chosen.
127
The user would first determine the value of the tooth to be matched. 5y squinting, stimulating the rods and not the cones, the value level of the tooth can be ascertained with some degree of accuracy. .ext a tentative hue is chosen if cuspids are present, their stronger chroma usually offers a good due to the here of the remaining teeth. The chroma that loo s most compatible with the tooth to be matched is then identified. If differences are still evident, the user would probe in '-) space to determine if better match is available. se o: e'isting s9a&e g*i&es 8an approach with the ideali;ed shade guide9 < In any colour matching procedure, the dimension of colour must be analy;ed before appropriate action can be ta en. I&enti:ying t9e 9*e ? If the guide is arranged by colour families the hue can be identified. The cuspeds are many times the best due to the correct hue. The higher the chroma, the easier it is to identify the hue. I&enti:ying t9e )al*e ? The most noticeable and ob=ectionable difference to the patient will be difference in value. This dimension of colour however is the easiest to determine. 5y squinting, switching to scotopic rod vision, the optic system will show differences in value without the overlaying confusion of hue and chroma. I&enti:ying t9e c9roma ? Falue differences are most ob=ectionable and must be identified. 5ut chroma differences can also be deadly. The rule of survival in this choice is to choose a shade that is higher in value and wea er in chroma than the tooth to be matched. 7lar , 5rue, 3. Toot9 colo*r selection. %A)A, !2''E #1, !105-!1D'. P*rpose ? To apply colour science to the dental profession. Material an& met9o&s ? Authors experience and nowledge. $es*lts ? 7olour has three dimensions, hue, brilliance, and saturation. "ue relates the colour to the spectrum. 5rilliance gives the property of lightness
128
and dar ness with blac being ;ero and white being maximum. +aturation has to do with the strength of hue seen in the colour. .eutral gray is ;ero in the saturation scale. The basic colour of teeth may be considered yellow-gray and have modifications in each dimensions of colour with saturation being the principal modifier. The gingival areas are the most saturated because the yellow is stronger. The saturation decreases as you go more incisally. 5rilliance differences are also found in the same teeth. The incisal areas are dar er than the gingival areas. The thinner portions are dar er because they permit more transmission of light. The hue differs in the same teeth also. ?hen the hue of a shade guide tooth differs from a natural tooth it must be a redder or greener yellow than that of the natural tooth. 7lar classifies tooth colour into three groups. Nellow, which comprise B1K, reddishyellow, and greenishyellow. To classify tooth colour 7lar found there to be !2 brilliances steps for each degree of saturation, !1 saturation steps and ' hue steps ma ing a total of 5'# different colours for teeth. "owever each tooth has different colours in the gingival and incisal areas therefore giving clar D1' shade guide teeth colours to account for. To help dentist select the correct shade clar devised a 01 tooth shade guide that could accommodate all D1' colours. There are several factors to consider in selecting a shade. *irst is the position of the patient relative to the dentist and the source of illumination. .ext is the quality or colour of the illuminating light. )aylight of proper colour is preferable because it is diffused light. ?hite light is of average quality and the most suitable for colour wor in dentistry. The best source for white light is an overcast s y near the middle of the day. After selecting the proper colour the best colour results can be secured when the labial wall of the finished crown is at least ! mm thic . The cement used will affect the colour and should be ta en into consideration.
129
Concl*sion ? To successfully select and reproduce tooth colour a clear conception of the three dimensional nature of colour is necessary. 7lar , 5. Colo*r matc9ing in &entistry= %A)A, !2''E #1, !105. "istorical perspective for tooth colour selection -rimary colours < red, yellow, green, blue 7olour dimensions < "ue R quality of colour as it relates to the spectrumE boundaries established between the reddest yellow and greenest yellow. 5rilliance R property of lightness and dar nessE scale begins as blac as ;ero and extends to white as a maximumE boundaries established between the lightest and dar est colours. +aturation R strength of the hueE boundaries established between the strongest yellow and neutral gray. 7olour selection. Illumination R white light is most suitable for colour wor E best source< overcast s y near the middle of the day. 7haracteri;ation R solid colours ma e artificial teeth loo falseE nature of the finish. 7ementation R translucent vs grey cements. -reston %. and 5ergen, +.*. Colo*r science an& &ental art 7.F. $osby, +t. ,ouis, !2B1, 7hap.'. This is a chapter on white light and itPs following properties < Additive colour mixing $ixing of coloured lights to yield white light is termed Gadditive colourH. This phenomenon applies only to light R not to pigment systems. 7yan, yellow and magenta are additive secondary hues. All three primary colours combined, white light is generated.
130
7ombinations of a primary colour and its opposing secondary colour are nown as Ocomplementary coloursP. +ubtractive colour mixing ?hite light passed through a filter, some wavelengths are absorbed and therefore subtracted from the spectral content of the light that originally entered the filter. +ubtractive system is the converse of the additive colour system. Three primary hues of subtractive colour mixing are 7yan, magenta, and yellow. ?hen all three subtractive primary coloures are mixed, all light is absorbed and blac in the result. -resswood, 4./. Est9etics an& color ? Percei)ing t9e problem% )7.A, !2DDE #!, B#'-B#2. 4eview article < +ymposium on ceramics Lualities of colour "ue < the true colour. 7hroma < the saturation of the colour. Falue < the intensity or brightness of the colour. 7olour matching +hade matching should be done by as many pairs of eyes as possible. ?omen generally have a higher acuity for colour selection than men. +hades should not be selected electively or affirmatively, but rather by elimination. !*mmary ? The only consistent way to achieve acceptable esthetic results is to < ,imit the number of perceiving eyes that are used in the decernment of colour and esthetic value. 3nsure that the restoration is started and completed in the same physical environment 8dentist, light source, and bac ground colour or effect9.
131

Evaluation of Patient in FPD

Загружено:

Сведения о документе

Исходное описание:

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Evaluation of Patient in FPD

Загружено:

Авторское право:

Доступные форматы

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

A.T34I:4 74:?.+< *A,, C -A4TIA,

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

# NDAMENTAL! O# OCCL !ION

FIXED PARTIAL DENTURES

# NDAMENTAL! O# OCCL !ION

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

sing A*topolymeri;ing Acrylic $esin

FIXED PARTIAL DENTURES

$E!TO$ATION O# ENDODONTICALL< T$EATED TEETH

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES

FIXED PARTIAL DENTURES