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NET VOLUME 1 | ISSUE 6

DENTAL LEARNING A PEER-REVIEWED PUBLICATION

Knowledge for Clinical Practice

Delivering Optimal Results for

Fixed Partial
Dentures
Chris Salierno, DDS and
David R. Avery, AAS, CDT

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Editor Creative Director
permission from the publisher.
FIONA M. COLLINS MICHAEL HUBERT
CE Content Manager Art Director
DENTAL LEARNING MONIQUE TONNESSEN MICHAEL MOLFETTO
500 Craig Road, First Floor, Manalapan, NJ 07726
Delivering Optimal Results for
Fixed Partial Dentures
ABOUT THE AUTHORS
Dr. Salierno received his BS from Muhlenberg College and his DDS from SUNY Stony Brook School of Dental
Medicine. He completed his formal training at Stony Brook Hospital’s General Practice Residency program where
he focused on implant prosthetics. While in dental school, he was the National President of the American Student
Dental Association. Today, he continues his advocacy efforts with the New York State Dental Association and Suf-
folk County Dental Society. Dr. Salierno lectures on his particular areas of interest, including occlusion, dental ma-
terials, prosthodontics, and implant prosthodontics. He enjoys helping audiences integrate the latest research into
everyday practice. In 2005, he returned to his former dental school as an Assistant Clinical Professor. AUTHOR
DISCLO­SURE: Dr. Salierno does not have a leadership position or a commercial interest with DENTSPLY Caulk
or DENTSPLY Prosthetics, the commercial supporters of this course or with products and services discussed in this educational
activity. Dr. Salierno may be reached at drsalierno@gmail.com
Mr. David Avery, CDT, actively teaches undergraduate and post-graduate dental students at the University
of North Carolina, Medical University of South Carolina, Medical College of Georgia, Virginia Common-
wealth University, University of Tennessee, University of Mississippi, Tufts University and University of West
Virginia dental schools. He is also a visiting lecturer at the Carolina’s Medical Center, Wake Forest University,
University of Virginia Hospital, University of Florida, and the McGuire Veterans Administration Hospital in
Richmond, Va., as well as numerous residency programs within the US Armed Forces. He has published in
numerous laboratory and clinical journals and has presented more than 600 scientific programs. He is a board
member of the Dental Technician Alliance of The American College of Prosthodontists. Mr. Avery received his
AAS degree in dental laboratory technology from Durham Technical College in Durham, North Carolina in 1976 and achieved
his Certified Dental Technician status in 1980. AUTHOR DISCLO­SURE: Mr. Avery is a speaker for DENTSPLY International.
Mr. Avery may be reached at davery@drakelab.com
EDUCATIONAL OBJECTIVES ABSTRACT

The overall goal of this article is to provide the reader with infor- Fixed partial dentures require careful consideration
mation on current materials and techniques for the fabrication of a of the materials and treatment protocol that will be
fixed partial denture (FPD). After reading this article, the reader will followed. The successful recording of preparations,
be able to: manufacture of multi-unit restorations, and their
1. List in detail the steps involved in fabrication of an FPD delivery intraorally is aided by astute attention to
2. Describe the impression materials available, considerations in material properties at each of these critical stages.
their selection, and the use of a one-stage or two-stage technique Detailed communication and collaboration with the
3. Review the materials and techniques available for the fabrication laboratory are also required to ensure clinical success
of provisional restorations and the best possible outcomes.
4. List and review the steps involved in the fabrication of full-
contour zirconia CAD/CAM restorations.
SPONSOR/PROVIDER: This is a Dental Learning, LLC continuing education activity. COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from DENTSPLY Caulk and DENTSPLY
Prosthetics. DESIGNATION STATEMENTS: Dental Learning, LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of
continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dental Learning, LLC designates this activity for 2 CE credits.
Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship,
Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2012 - 1/31/2016. Provider ID: #
346890. Dental Learning, LLC is a Dental Board of California CE provider. The California Provider number is RP5062. This course meets the Dental Board of California’s requirements for 2 units of continuing education. EDUCATIONAL
METHODS: This course is a self-instructional journal and web activity. Information shared in this course is based on current information and evidence. REGISTRATION: The cost of this CE course is $29.00 for 2 CE credits. PUBLICA-
TION DATE: September, 2012. EXPIRATION DATE: August, 2015. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, participants must pay the required fee, review the material,
complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education
activity is developed from clinical research and represents the most current information available from evidenced-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived
from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the
field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership
position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course,
Monique Tonnessen, does not have a leadership or commercial interest in any products or services discussed in this educational activity. She can be reached at mtonnessen@dentallearning.net. TARGET AUDIENCE: This course was
written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/REFUND POLICY: Any participant who is not 100% satisfied with this course can request a full refund by contacting Dental Learning, LLC,
in writing. Go Green, Go Online to www.dentallearning.net take your course. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to mtonnessen@dentallearning.net.

DentalLearning.net is an ADA CERP Recognized Provider. ADA CERP is a Approval does not imply acceptance
service of the American Dental Association to assist dental professionals in by a state or provincial board of
identifying quality providers of continuing dental education. ADA CERP does dentistry or AGD endorsement.
not approve or endorse individual courses or instructors, nor does it imply 2/1/2012 - 1/31/2016
acceptance of credit hours by boards of dentistry. DentalLearning.net desig-
nates this activity for 2 continuing education credits. Provider ID: # 346890
AGD Subject Code: 612
 DENTAL LEARNING
Introduction
A
n FPD remains a viable treatment option for patients
who elect to replace missing teeth without receiving
implants. Advances in impression materials, cements,
and provisional and definitive restorations have expanded
the options for clinicians to select a protocol that suits their
preferences. These advances have, however, also increased the
potential for operator and laboratory error. Techniques and
materials may not be interchangeable without consequences,
depending on the materials, and clinicians must be astute in
their cultivation of a protocol and must work in concert with
the laboratory to deliver a predictable restoration for their
patients. The first step is pre-operative diagnostics, followed
by the clinical and laboratory steps required to deliver the
FPD. The value of a diagnostic wax-up in planning fixed re-
storative procedures is well-documented.1,2 Excellent commu-
nication and collaboration with the laboratory is important.
Following preparation of the abutment teeth, subsequent
clinical steps include soft tissue management, the use of a
custom tray for the final impression, provisionalization and
luting of the final FPD. Each of these is important for the final
result and the clinical success of the FPD.
Soft Tissue Management and Impression Taking
The prepared abutment teeth are surrounded by interfer-
ences that can prevent their accurate reproduction. Isola-
tion of the areas of interest is primarily concerned with the
displacement of the gingiva from the prepared margins of
the abutment teeth, which may be achieved through the use
of retraction cord, a compressive cap, or expanding pastes.
Surgical displacement may be accomplished through meth-
ods that include the use of a scalpel, electrosurgery, or a soft
tissue laser. Other adjacent structures, such as buccal mucosa
and the tongue, can be relocated with cotton rolls, gauze,
and saliva evacuator systems. Remaining moisture around
the prepared abutment teeth, such as gingival crevicular
fluid and blood, can be reduced by the application of ferric
sulfate, epinephrine, and other chemical means.
For a traditional impression, a tray is selected to fit the
arch. Double-arch trays or “triple trays” are convention-
ally indicated for one to two units in the same arch when a
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stable, reproducible occlusion is present.3,4 A full-arch tray
is selected for bridges to give the laboratory technician more
information to correctly articulate models and create an ac-
curate plane of occlusion. An impression for an FPD is more
predictably made in a custom tray than a stock tray.5 A cus-
tom tray made from a cured resin is more closely adapted to
the arch than a stock tray and thus requires a smaller, more
uniform amount of impression material.6 There are several
steps occurring in a short period of time during impression
taking that require the clinician’s vigilance. A custom tray re-
lieves the burden of ensuring that the tray has been correctly
seated to capture the entire arch. A contemporary method
of custom tray fabrication utilizes a visible-light-cured
(VLC) custom tray material. The ability to adapt the pliable
material in an uncured state, and to cut back borders prior
to curing, minimizes the finishing time required. The curing
shrinkage is minimal, ensuring a well-adapted result.
Impression Materials
Elastic impression materials should demonstrate excel-
lent dimensional stability, have an adequate working
time, short setting time, and be easy to use with sufficient
flowability. The requirements for impression materials are
addressed by the American National Standards Institute
in collaboration with the American Dental Association.7
Polyvinylsiloxane and polyether impression materials are
common choices for indirect restorative procedures. Their
dimensional stability permits time for transportation to a
dental laboratory, and both materials are suitable for mul-
tiple pours without clinically significant loss of accuracy.8
For restorations with larger numbers of units, a longer
working time is required and can be achieved by cooling
the impression material in the fridge prior to use. Alter-
natively, an impression material with extra working time
should be selected. The clinician’s selection rests upon his/
her comfort with the material’s properties (Table 1).
Impression Techniques
Impressions for indirect restorations follow either a
one-step or two-step protocol. The one-step technique cap-
tures gross and fine detail at the same time. Both polyether
Delivering Optimal Results for
Fixed Partial Dentures
and polyvinylsiloxane impression materials are available in
different viscosities for greater clinician control. The clini-
cian may use a single viscosity impression material, typi-
cally of a medium consistency, for both the tray and tooth
detail. The advantage to this approach is that using only
one material eliminates concerns of a poor mixture of vis-
cosities. Alternatively, the clinician may use two different
viscosities: typically, a heavier body or silicone putty for
the tray and a lighter body for tooth detail. If the manu-
facturer’s instructions for working and setting times for
both materials are followed, distortions such as pulls and
inconsistent mixtures should be eliminated. Note however
that an increase in room temperature reduces the working
time for impression materials. The advantage gained is the
ability of a lighter body material to flow into smaller areas
for greater detail, aided by the compressive strength of the
surrounding heavier body material. Alternatively, the two-
step technique first captures gross detail with silicone putty
in the tray. Typically, a thin film spacer is placed over the
teeth to leave room for impression material in the second
step. Next, the finer tooth detail is captured with a lighter
body impression material.
Provisional Fabrication
A successful provisional restoration for an FPD must
protect the prepared abutment teeth and gingiva, maintain
the three-dimensional relationship between the abutment
teeth and the opposing dentition, and maintain function
Table 1. C
 omparison of common fixed partial denture
impression materials
Polyvinylsiloxane Polyether
Excellent dimensional stability Excellent dimensional stability
Hydrophobic Hydrophilic
More difficult removal after
Easy removal after setting
setting
Fair odor and taste Poor odor and taste
Setting inhibited by latex Setting unaffected by latex
Can be stored wet or dry Must be stored dry
OCTOBER 2012
and esthetics.9 These objectives are similar for single-unit
provisional restorations; however, strength, rigidity, and
ease of use become more critical for multi-unit restora-
tions (Table 2). It is a challenge to fabricate a provisional
restoration efficiently while the patient is in the operatory
and yet still ensure that all of the parameters for success
are met. Fortunately, modern clinicians have a variety of
materials and techniques at their disposal to cultivate a
procedure that is the most predictable in their hands. Op-
tions include chairside and laboratory fabricated provi-
sional FPDs in a variety of materials.
A provisional FPD is intended to last for the duration
of time required to fabricate the final restoration. The
clinician may also elect to have the patient wear the provi-
sional for an additional “trial” period before final impres-
sions are made to evaluate esthetics or occlusal stability,
and/or to allow time for soft tissue healing.
Provisional Materials
The three most prevalent materials used for a provisional
FPD are methyl methacrylate, ethyl methacrylate, and bis-
acryl composite resin. Methyl methacrylate has the longest
track record in dentistry and is still widely used. A powder
and liquid are mixed together to initiate the setting reaction.
Despite its good strength and longevity when set, methyl
methacrylate is known to be problematic during the setting
Table 2. O
 ptimal properties for provisional bridge
restorations
Property of Material Clinical Purpose
Ease of fabrication Reduced chair time
Ability to be relined Ensure marginal fit
Flexural and compressive
Resistant to fracture or distortion
strength
Rigidity Maintain abutment relationship
Biocompatibility Non-irritating to pulp or gingiva
Ability to be polished Resistant to plaque accumulation
Color stability Patient acceptance
5
 DENTAL LEARNING
reaction. The reaction generates significant heat, which may
damage the pulp and gingival tissues.10 Also, the material
shrinks while curing, which may lead to poor marginal
fit.10 If the provisional is removed from the abutment teeth
while setting and is not quickly reinserted, the shrinkage of
the material may distort the provisional’s internal aspects
so that it no longer may be seated on the abutment teeth.
Concerns have also been raised that pulpal and gingival
irritation can result from the presence of free monomer.11
Differences also exist between different versions of the same
chemical material.12 Ethyl methacrylate is also a powder
and liquid mixture but offers better marginal integrity and
less heat generation during setting than methyl methacry-
late. However, these advantages are offset by the poor color
stability and difficulty of use.13 Methyl methacrylate and
ethyl methacrylate acrylic resins may be used chairside using
the direct technique whereby the material sets via self-cure
or autopolymerization. When an indirect technique is used
in the laboratory, both acrylic resins may be heat-processed
for additional strength and color stability (Table 3).14
Recently, bis-acryl composite resin has emerged as
a popular choice for fabrication of a crown and bridge
provisionals. Available in self-mixing cartridges, bis-acryl
exhibits good marginal fit and low heat generation dur-
ing setting.15 Advantages include less heat generation and
shrinkage during polymerization than the methacrylate
acrylic resins. One study showed shrinkage of bis-acryl
resin to be up to 1.7% by volume compared to 6% for
methyl methacrylate.16 As a composite resin, bis-acryl
Table 3. C
 omparison of acrylic and composite resin materials for provisional fabrication
Methyl methacrylate - Advantages
Longer term strength
Ethyl methacrylate - Advantages
Longer term strength
Bis-acryl composite resin - Advantages
Ease of use and repair
Least significant curing exothermia
Least significant curing shrinkage
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material is compatible with bonding materials used for
operative dentistry. Small areas of the provisional in need
of repair or reline may be reliably restored with flow-
able composite resin, which decreases chair time without
sacrificing predictability. Bis-acryl resins may be self-cure,
light-cure, or dual-cure, depending upon the clinician’s
preference. A notable disadvantage of the material is its
decreased strength compared to acrylic resins over time.17
However, indirect fabrication of a bis-acryl composite resin
provisional by a laboratory will improve its strength.18
The most recent material development in the provi-
sional resin category is a unique visible-light-cured hybrid
resin technology. This material provides for excellent wear
rates as well as low solubility and resistance to staining
and color change, and is cleared by the FDA for three
years of clinical use.19 The “wax-like” handling character-
istics of this resin provide the technician with a familiar,
easily adaptable technique that can be utilized to produce
extremely accurate provisional restorations. The low wear
rate and strength are particularly important for long-term
provisional restorations.19
Provisional Cementation
Retention of a provisional restoration is commonly
relegated to the weaker cements such as zinc oxide euge-
nol and zinc oxide non-eugenol, to aid removal when the
permanent restoration is ready for placement. Eugenol is
respected for its bactericidal properties, which can aid in
reducing post-operative sensitivity.20 However, it also acts
Methyl methacrylate - Disadvantages
Most significant curing exothermia
Most significant curing shrinkage
Ethyl methacrylate - Disadvantages
Poor color stability
Bis-acryl composite resin - Disadvantages
Shorter term strength
Expense
Delivering Optimal Results for
Fixed Partial Dentures
as a plasticizer, detrimentally affecting the polymeriza-
tion of acrylic and composite resin.21 Thus, a provisional
that has been previously luted with a eugenol-containing
temporary cement will be difficult to reline or repair. The
added material will be softer than normal and could po-
tentially unsuccessfully adhere to the original provisional.
In addition, eugenol could negatively affect the polym-
erization of a permanent resin cement. As resin cements
grow in popularity, many clinicians prefer to select a tem-
porary cement that does not contain eugenol to avoid such
complications. Zinc oxide non-eugenol cements substitute
organic acids in place of eugenol, which actually makes the
cements stronger.22 If an FPD provisional is expected to be
retained for a long period of time, or if additional reten-
tion is required, a stronger cement such as zinc polycar-
boxylate is often substituted.
Restoration Insertion
Successful luting of the final restoration begins with
successful debridement of the abutment teeth. After the
provisional restoration is removed, debris and provisional
cement remnants are removed to ensure proper definitive
cementation. Some clinicians elect to mechanically debride
the surfaces with an explorer, an air/water syringe spray,
polish with pumice slurry, and/or scale with ultrasonic
instruments. Other clinicians use chemicals such as a dis-
infecting agent to decrease post-operative sensitivity23 and/
or a cleansing agent to remove the smear layer and expose
dentin tubules for improved resin cement bonding.24
Restoration Adjustment
When trying in the final prosthesis it may be necessary
to reshape the occlusal and interproximal porcelain to
achieve harmony with the rest of the dentition. Adjust-
ments with a diamond bur introduce irregularities to the
otherwise smooth, glazed porcelain surface. Remaining
surface roughness may be treated with a series of extra-
oral or intra-oral polishers to achieve the same smoothness
as a glaze finish.25 A smooth finish is desirable because
rough porcelain may injure the opposing dentition26 and
accumulate plaque.27 Special attention must be paid to
OCTOBER 2012
ceramic restorations fabricated from zirconia. Due to
its unique tetragonal, polycrystalline structure, zirconia
increases its volume around a stress-induced crack. This
phenomenon, known as transformation toughening,
contributes to the material’s high flexural strength of up to
1,200 MPa.28 Although some studies have concluded that
adjusting zirconia can actually increase its strength,29 other
studies have pointed out that significant pressure and use
of coarse diamonds can introduce cracks beneath the sur-
face and actually weaken the zirconia.30 To avoid introduc-
ing a critical crack, a light touch with fine diamond burs
under copious air/water spray is advised when adjusting
zirconia.30 If the fitting of a zirconia core or full-contour
zirconia bridge would require that the intaglio surface
be adjusted for proper seating, it is recommended that
the abutment tooth be adjusted instead.31 This is due to
the difficulty of polisher systems in accessing the internal
aspects of a restoration.
Definitive luting agents are selected based upon the
condition of the abutment teeth and the restorative material
used for the prosthesis. Traditional dental cements such as
zinc phosphate and zinc polycarboxylate are mechanically
retentive by flowing into the discrepancy between tooth and
restoration and hardening. This hardening is due to an ionic
reaction and is therefore soluble in the oral environment
over time.32 Resin cements are retentive by serving as an ad-
hesive medium between the tooth and the restoration. Ideally
suited for all-ceramic restorations, which may be capable of
being etched and bonded, resin cements are also used with
metal-ceramic restorations due to their low solubility.
The resin cement bond to the ceramic restoration is
dependent on the nature of the restorative material. Ceram-
ics that contain glass, such as feldspar and lithium disilicate,
may be predictably etched with hydrofluoric acid. Subsequent
treatment of the etched surface with a silane coupling agent
will prepare the glass ceramic for bonding to a resin cement.33
Zirconia’s polycrystalline structure does not contain glass
and therefore cannot form a bond to the resin cement that is
as predictable or as strong as a glass ceramic, despite vari-
ous methods of surface conditioning.34 The manufacturer’s
instructions for a given material must be followed.
7
 DENTAL LEARNING
The resin cement bond to the abutment teeth is
achieved using either a total-etch, self-etch, or self-adhesive
protocol. The total-etch technique begins with chemical re-
moval of the smear layer and hydroxyapatite crystals. The
etch is washed off and a hydrophilic primer and unfilled
bonding resin are applied, which penetrate the exposed
enamel and dentin structures to form a hybrid layer. The
tooth surfaces with exposed hybrid layers are now able to
adhere to the resin cement. Self-etch systems do not com-
pletely remove the smear layer and do not penetrate into
the tooth structure as deeply. The bond is not as strong
as the total-etch technique but there is also a decreased
chance of post-operative sensitivity.35 Self-adhesive systems
incorporate the etch, prime, and bonding elements into
the resin cement itself. These offer the weakest bond of
the resin cement family but are the easiest to use clini-
cally.36 Self-adhesive cements are not recommended for
preparations with insufficient resistance form due to their
poorer bond strengths. However, the overall surface area
of multiple, prepared abutments for an FPD will generally
offer sufficient resistance form for a self-adhesive cement
to be used.
Resin cements are also classified as self-cured, light-
cured, or dual-cured. Light-cure cements are most predict-
able when a translucent ceramic restoration is less than 1.5
mm thick.37 When the thickness of the translucent ceramic
Figure 1. Resin cement bonding protocols
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restoration is greater than 2.5 mm, penetration of a curing
light is unpredictable. In these cases, and for restorations
that do not transmit light, a self-cure or dual-cure resin
cement is recommended. A final category of luting agent
for use with FPD restorations is glass-ionomer and resin-
modified glass ionomer cements. A notable advantage with
this material is the cariostatic release of fluoride from the
cement to the abutment tooth.38 However, the material is
known to expand after cementation, which limits its use to
metal-ceramic and zirconia ceramic restorations.28
Case Study
A 51-year-old male, who was a new patient with no
relevant medical history, presented for replacement of a
fractured porcelain-fused-to-metal FPD spanning teeth #29
to 31 (Fig. 2). His dental history was significant for brux-
ism, as was evidenced by the generalized moderate wear
facets on the dentition. The existing FPD demonstrated
considerable fracturing of porcelain and destruction of
the metal substructure. Tooth #31 had a prior history of
endodontic therapy that had required access through the
occlusal surface of the FPD. This access had been sealed
with a composite resin that now showed signs of marginal
leakage and may also have contributed to the fracturing of
the occlusal porcelain (Fig. 3). The patient was treatment
planned for a full-contour zirconia bridge to prevent future
Figure 2. Preoperative appearance of FPD #29-31, buccal and occlusal
views. Note that the dentition in the same quadrant is A3 while the
opposing dentition is more A2
Delivering Optimal Results for
Fixed Partial Dentures
porcelain fracture associated with his bruxism habit. Pre-
liminary impressions and a bite registration were sent to
the laboratory for the development of a wax-up. The FPD
would be stained to incorporate the shade of the adjacent
teeth in the same quadrant (A3) and the opposing denti-
tion (A2).
At the treatment visit, while waiting for adequate
anesthesia, a pre-operative impression was taken using
a polydimethylsiloxane impression in a stock tray. This
impression was set aside for later use during fabrication of
the provisional bridge. The original bridge was carefully
sectioned and removed so as to preserve remaining tooth
structure. The composite resin filling the endodontic access
on tooth #31 was removed and the remaining four walls
of tooth structure were etched, bonded, and filled with a
Figure 3. Above: Abutment teeth after bridge removal.
Below: The composite resin buildup was replaced by a dual-
cure core buildup material. Note the slightly supragingival
margins left for hygiene access
OCTOBER 2012
dual-cure, fluoride-releasing core buildup material. The
preparations were completed with supragingival margins
to aid hygiene, although had the tooth margins appeared
in the esthetic zone, the margins would have been prepared
equi-gingivally.
A custom tray was fabricated using light-cured materi-
al, for use during taking of the final impression to improve
its accuracy (Fig. 4). A polyvinylsiloxane material was
selected as adequate isolation and moisture control had
been achieved. Application of a surfactant was performed
to optimize flow of the impression material over the tooth
surfaces and around preparation margins. A heavy body
polyvinylsiloxane impression material was mixed into the
custom tray while a light body polyvinylsiloxane impres-
sion material was loaded into a metal syringe. The cord
Figure 4. A custom tray with occlusal stops allows for an even
thickness of impression material to capture necessary detail
Figure 5. Clear margins with flash in the gingival sulcus
9
 DENTAL LEARNING
was removed and the light body material was syringed
into the sulcus, one prepared abutment at a time. After all
surfaces of interest were covered, an air syringe was gently
used to thin the impression material to reduce polymeriza-
tion shrinkage. The full-arch tray of heavy body material
was easily seated because it had been customized for the
patient. After the setting time of five minutes had expired,
the tray and impression material were removed and in-
spected for accuracy. The margins were shown to be fully
captured with additional light body material well into the
gingival sulcus (Fig. 5). The opposing arch was recorded
with a polydimethylsiloxane impression material in a stock
tray. This material demonstrates good dimensional stability
and does not have to be poured in stone before transporta-
tion to the dental laboratory. An interocclusal record was
Figure 6. Bis-acryl provisional material is placed into the
preoperative matrix
Figure 7. After removal of the preoperative matrix from the
mouth, the final curing is accelerated with a curing light
10
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recorded using rigid fast-set polyvinylsiloxane. This form
of polyvinylsiloxane offers less resistance to biting forces
and sets more quickly, reducing the chances for jaw move-
ments to alter the record.
A provisional bridge was fabricated by dispensing a
bis-acryl resin into the pre-operative impression (Fig. 6).
The tray was reseated intraorally and allowed to cure for 90
seconds. After removal, a curing light was held over the pro-
visional bridge for 20 seconds to expedite the curing process
(Fig. 7). This step aids in removal of the provisional bridge
from the pre-operative impression while avoiding distortion
or fracture. The provisional bridge was trimmed with a thin
flame diamond bur and checked intraorally for marginal
integrity and occlusal harmony. An advantage of bis-acryl
resin is its ability to easily bond with composite resin.
Figure 8. The completed provisional bridge. Composite resin
was bonded to the bis-acryl to compensate for the missing
porcelain of the original bridge
Figure 9. Clinical photography of the adjacent teeth with
shade tabs aids in communication of shade
VOLUME 1 | ISSUE 6
Delivering Optimal Results for
Fixed Partial Dentures
Since the original bridge had fractured porcelain, com-
posite resin was added to the provisional bridge to improve
strength, function and esthetics (Fig. 8). A non-eugenol zinc
oxide cement was syringed into the internal surfaces of the
abutments’ restorations and seated. As it was anticipated
that a resin cement would be used for the final case, it was
important to avoid the use of eugenol in the provisional
cement. A sufficient amount of temporary cement was
dispensed and the margins were carefully checked with an
explorer. The impression and bite registration were dis-
infected and sent to the laboratory together with the lab
prescription.
Shade Communication
Numerous digital color communication technologies
have been introduced to the dental profession over the last
15 years. The most impactful device is the digital camera
(Fig. 9). The use of 35 mm digital cameras to communicate
color and characterization between the operatory and den-
tal laboratory has dramatically reduced the most common
reason for disappointment on delivery day—poor color
matching.
Laboratory Technique
Provisional Restoration
A provisional bridge can also be fabricated in the labora-
tory using hybrid resin. The previously developed patient/
Figure 10. Provisional FPD manufactured to illustrate the excellent esthetics that can be achieved
OCTOBER 2012
clinician-approved diagnostic wax-up was first matrixed
with silicone putty. A duplicate cast was minimally prepared
and lubricated with petroleum jelly. An initial application of
enamel shade hybrid resin material was placed into the ma-
trix from the heated syringe, distributed appropriately with
the electric spatula, and allowed to cool. The dentin shade
was then syringed into the matrix and seated on the cast
while it was ensured that the matrix was completely seated.
After the material was allowed to cool for four minutes,
the matrix was carefully removed by first carving carefully
where significant undercuts existed, to prevent damaging the
uncured wax-like material. (Voids from trapped air can be
repaired, if necessary, using the electric spatula.) After the
hybrid resin had cooled, it was carved to develop the desired
final contours and anatomy, after which the occlusal and
interproximal contacts were thoroughly checked. The glaze
was then applied with a disposable brush and cured. Figure
10 shows the excellent results that can be achieved using this
method for a provisional for the same case.
Fabricating the Definitive FPD
All ceramic materials and technologies have exhibited
an exponential development over the previous 20 years for
ceramic indirect restorative advancements. The workhorse
porcelain-fused-to-metal restoration is slowly being replaced
with high-strength CAD/CAM-developed ceramic materials.
Development has moved through leucite-reinforced pressed
11
 DENTAL LEARNING
ceramics to pressed or machined lithium disilicate ceram-
ics. The use of YZ zirconium oxide as a substrate veneered
with stacked ceramics has evolved into monolithic CAD/
CAM-produced restorative systems. In this case, the FPD
was created with full-contour zirconia, utilizing a digitally
optimized fabrication technique. Upon completion of the
master cast fabrication, the casts were articulated in a cen-
tric relation utilizing the provided occlusal registration.
The working cast was scanned and, utilizing the design
software, the margins were identified at 100 times the
actual size, thereby providing a level of accuracy that is
impossible to achieve with traditional die trimming (Figs.
11-12). The virtual cement gap was determined specifically
for each area of the restoration by establishing indepen-
Figure 11. Model in 3 Shape Scanner
Figure 12. Digital identification of margins
12
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dent parameters for margins, axial walls, the occlusal
surface, and line angles. The desired external contours
were transferred from a scan of the approved diagnostic
wax-up (Fig. 13-16). The .stl file was then e-mailed to the
central manufacturing facility for milling of the restora-
tion. Upon receipt of the file, the restoration was milled
from a pre-sintered zirconium oxide disk. Next, the resto-
ration was dipped in the appropriate stain to achieve the
desired dentine shade of the completed restoration. Finally,
the restoration was sintered in an oven at 1600 degrees
Celsius, fusing the zirconia particles and shrinking them
by approximately 30%. The sintering process transforms
the zirconia into a more dense material with high strength.
The restoration was then returned to the laboratory for
Figure 13. Transfer of scanned diagnostic wax-up to master
scan for contour determination
Figure 14. Design from buccal aspect
VOLUME 1 | ISSUE 6
Delivering Optimal Results for
Fixed Partial Dentures
confirmation of internal, occlusal, and interproximal
adaptation. After minimal adjustments were accomplished,
external characterization was applied for appropriate
intra-oral esthetic matching. For optimal results, A-3
Dentine was applied to the areas of wear illustrated on the
buccal cusp tips of teeth #29 and 30 (Fig. 17).
Placement of the FPD
The definitive restoration was tried in to assess marginal
fit, adequate interproximal contact with the distal of tooth
#28, and occlusion. A bitewing radiograph confirmed the
visual inspection that marginal fit had been achieved (Fig.
18). Occlusal and interproximal contacts required no adjust-
ment owing to an accurate impression, bite registration, and
Figure 15. Opposing antagonist determining final occlusion
Figure 16. Resulting design
OCTOBER 2012
meticulous laboratory work. A dual-cure resin cement was
used to retain the FPD. A resin cement will adhere to the
abutment tooth structure for added retention. The patient
was pleased with the improved function and high esthetics of
the final result (Fig. 19). The selected shade was successful in
blending the opposing dentition (shade A2) with the adjacent
dentition (more A3).
Summary
Dentists today have a variety of materials at their disposal
for each step in the fabrication of an FPD. The successful
recording of preparations, manufacture of multi-unit restora-
tions, and their delivery intraorally is aided by astute atten-
tion to material properties at each of these critical stages.
Figure 17. Completed full-contour zirconia fixed partial
denture
Figure 18. Bitewing radiograph during try-in
13
 DENTAL LEARNING
Figure 19. The completed full-contour zirconia bridge intraorally. Note the successful incorporation of shades A2 and A3 to match the
various shades present in the same and opposing quadrants.
References
1. Viana PC, Correia A, Neves M, Kovacs Z, Neugbauer R. Soft Tissue Waxup and Mock-
up as Key Factors in a Treatment Plan: Case Presentation. Eur J Esthet Dent. 2012
Autumn; 7(3):310-23.
2. Garcia LT, Bohnenkamp DM. The use of diagnostic wax-ups in treatment planning.
Compend Contin Educ Dent. 2003 Mar;24(3):210-2, 214.
3. Cox JR. A clinical study comparing marginal and occlusal accuracy of crowns
fabricated from double-arch and complete-arch impressions. Aust Dent J. 2005
Jun;50(2):90-4.
4. Lane DA, Randall RC, Lane NS, Wilson NH. A clinical trial to compare double-arch
and complete-arch impression techniques in the provision of indirect restorations. J
Prosthet Dent. 2003 Feb;89(2):141-5.
5. Gordon GE, Johnson G, Drennon DG. The effect of tray selection on the accuracy of
elastomeric impression materials. J Prosthet Dent 1990;63(1):12-15.
6. Phillips RW. Science of Dental Materials, ed 9. Philadelphia: Saunders, 1991.
7. American National Standards Insitue and American Dental Association. ANSI/ADA
Specification #19: Dental elastomeric impression materials. Chicago, IL: American
Dental Association, Council on Scientific Affairs, 2004.
8. Lee EA. Impression material selection in contemporary fixed prosthodontics: tech-
nique, rationale, and indications. Compend Contin Educ Dent 2005;26(11):780-789.
9. Kaiser DA, Cavazos E Jr. Temporization techniques in fixed prosthodontics. Dent Clin
North Am. 1985;29(2):403-412.
10. Grossman LI. Pulp reaction to the insertion of self-curing acrylic resin filling materi-
als. J Am Dent Assoc 1953;46(3): 265-269.
11. Vahidi F. The provisional restoration. Dent Clin North Am 1987;31(3):363-381.
12. Hernandez EP, Oshida Y, Platt JA, Andres CJ, Barco MT, Brown DT. Mechanical
properties of four methylmethacrylate-based resins for provisional fixed restorations.
Biomed Mater Eng. 2004;14(1):107-22.
13. Christensen G. Making provisional restorations easy, predictable, and economical. J
Am Dent Assoc 2004;135(5):625-627.
14. Galindo D, Soltys JL, Graser GN. Long-term reinforced fixed provisional restorations.
J Prosthet Dent 1998;79(6):698-701.
15. Strassler HE, Anolik C, Frey C. High-strength, aesthetic provisional restorations using
a bis-acryl composite. Dent Today 2007;261(11):128-133. Postgraduate Dental School; Bethesda, MD;26(3):1-5.
16. Lepe X, Bales D, Johnson GH. Retention of provisional crowns fabricated from two
materials with the use of four temporary cements. J Prosthet Dent 1999;81(4):469-
475.
17. Diaz-Arnold AM, Dunne JT, Jones AH. Microhardness of provisional fixed prosth-
odontic materials. J Prosthet Dent 1999;82:525-528.
18. Reinhardt JW, Boyer DB, Stephens NH. Effects of secondary curing on indirect
posterior composite resins. Oper Dent 1994;19(6):217-220.
19. Ewoldsen N, Sundar V, Bennett W, Kanya K, Magyar K. Clinical evaluation of a
visible light-cured indirect composite for long-term provisionalization. J Clin Dent.
2008;19(1):37-41.
20. Pashley EL, Tao L, Pashley DH. Sealing properties of temporary filling materials. J
Prosthet Dent 1988;60(3):292-297. Mar;107(3):170-7. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/22385693.
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21. R osentiel SF, Gegauff AG. Effect of provisional cementing agents of provisional
resins. J Prosthet Dent 1988;59(1):29-33.
22. Olin PS, Rudney JD, Hill EM. Retentive strength of six temporary dental cements.
Quintessence Int 1990;21(3):197-200.
23. Christensen GJ. Disinfection of tooth preparations—why and how? Clin Rep
2009;2(11):2-3.
24. Grasso CA, Caluori DM, Goldstein GR, et al. In vivo evaluation of three cleansing
techniques for prepared abutment teeth. J Prosthet Dent 2002;88(4):437-441.
25. Haywood VB, Heymann HO, Scurria MS. Effects of water, speed, and experimen-
tal instrumentation of finishing and polishing porcelain intra-orally. Dent Mater
1989;5(3):185-188.
26. Wiley MG. Effects of porcelain on occluding surfaces of restored teeth. J Prosthet
Dent 1989;61(2):133-137.
27. Swartz ML, Phillips RW. Comparison of bacterial accumulation on rough and smooth
enamel surfaces. J Periodontol 1957;28(4):304-307.
28. Tinschert J, Zwez D, Marx R, Anusavice KJ. Structural reliability of alumina-, feldspar-,
leucite-, mica-, and zirconia-based ceramics. J Dent 2000;28(7):529-535.
29. Luthhardt RG, Holzhuter MS, Rudolph H, Herold V, et al. CAD/CAM-machining ef-
fects on Y-TZP zirconia. Dent Mater 2004;20(7):655-662.
30. Kosmac T, Oblak C, Jevnikar P, Fundak N et al. The effect of surface grinding and
sandblasting on flexural strength and reliability of Y-TZP zirconia ceramic. Dent
Mater 1999;15(6):426-433.
31. Helvey GA. Finishing zirconia chairside. Inside Dent Tech 2011;2(2):62-65.
32. Swartz ML, Phillips RW, Pareja C, Moore BK. In vitro degradation of cements; a
comparison of three test methods. J Prosthet Dent 1989;62(1):17-23.
33. Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: a review of the literature. J
Prosthet Dent 2003;89(3)268-274.
34. Wegner SM, Kern M. Long-term resin bond strength to zirconia ceramic. J Adhes
Dent 2000;2(2):139-147.
35. Perdigao J, Geraldeli S. Bonding characteristics of self-etching adhesives to intact
versus prepared enamel. J Esthet Restor Dent 2003;15(1):32-42.
36. Weiner RS. Dental cements: a review and update. Gen Dent. 2007;55(4):357-364.
37. Petrich A, VanDercreek J, Kenny K. Clinical updates: dental luting cements. Naval
38. Diaz-Arnold AM, Vargas MA, Haselton DR. Current status of luting agents for fixed
prosthodontics. J Prosth Dent 1999;81(2):139-141.
Webliography
Fasbinder DJ. Clinical performance of chairside CAD/CAM restorations. JADA
2006;137(9 supplement):22S–31S. Available at: http://jada.ada.org/content/137/
suppl_1/22S.abstract?ijkey=24969cbaa0bb04f7453ddfdf45afb2725a09b127&keytype2=
tf_ipsecsha
Raigrodski AJ, Hillstead MB, Meng GK, Chung KH. Survival and complications of
zirconia-based fixed dental prostheses: a systematic review. J Prosthet Dent. 2012
VOLUME 1 | ISSUE 6
Delivering Optimal Results for
Fixed Partial Dentures GO TO WWW.DENTALLEARNING.NET
TO TAKE THIS COURSE AND RECEIVE

CEQuiz
INSTANT VERIFICATION

1. The value of a diagnostic wax-up in planning fixed restorative 9. __________ impression materials possess dimensional stability
procedures is __________. that permits time for transportation to a dental laboratory, and
a. dubious they are suitable for multiple pours without clinically significant
b. well-documented loss of accuracy.
c. negligible a. Alginate
d. none of the above b. Polyether
c. Polyvinylsiloxane
2. The prepared abutment teeth are surrounded by interferences d. b and c
that can prevent their accurate __________.
a. preparation 10. An increase in room temperature __________ for impression
b. bite registration materials.
c. reproduction a. reduces the working time
d. all of the above b. increases the working time
c. increases the setting time
3. __________ may be used to displace the gingiva from the pre- d. b and c
pared margins of the abutment teeth.
a. Retraction cord 11. Electing to have a patient wear the provisional for an additional
b. A compressive cap “trial” period before final impressions are made provides the
c. Expanding pastes option to _________.
d. all of the above a. evaluate esthetics
b. evaluate occlusal stability
4. __________ can be reduced by the application of ferric sulfate. c. allow time for soft tissue healing
a. Gingival crevicular fluid and blood d. all of the above
b. Salivary flow
c. Xerostomia 12. If a methylmethacrylate provisional is removed from the abut-
d. all of the above ment teeth while setting and is not quickly reinserted, the
shrinkage of the material may __________.
5. Double-arch trays or “triple trays” are conventionally indicated a. distort the provisional’s internal aspects
for _________. b. provide for space for the luting agent
a. one to two units in opposing arches c. result in an inability to seat the provisional on the abutment teeth
b. multiple units in opposing arches d. a and c
c. multiple units in the same arch
d. one to two units in the same arch 13. One study showed shrinkage of bis-acryl resin to be up to
__________ by volume compared to __________ for methyl
6. A full-arch tray is selected for bridges to give the laboratory methacrylate.
technician more information to __________. a. 0.7%; 2%
a. correctly articulate models b. 1.2%; 4%
b. properly capture the margins c. 1.7%; 6%
c. create an accurate plane of occlusion d. 2.2%; 8%
d. a and c
14. Visible-light-cured hybrid resin technology for provisional
7. The ability to adapt pliable material in an uncured state restorations offers __________.
and to cut back borders prior to curing a custom tray a. low solubility
minimizes __________. b. a low wear rate
a. tray errors c. resistance to staining
b. the curing time d. all of the above
c. the finishing time
d. none of the above 15. To avoid introducing a critical crack, a light touch with
__________ under copious air/water spray is advised when
8. The two-step technique captures gross and fine detail __________. adjusting zirconia.
a. at the same time a. coarse diamond burs
b. one after the other b. fine diamond burs
c. poorly c. a sanding disk
d. none of the above d. fine tungsten carbide burs

OCTOBER 2012 15
 DENTAL LEARNING www.dentallearning.net

CE QUIZ

16. The use of a __________ on the preparation surfaces can reduce 23. The resin cement bond to abutment teeth is achieved
the hydrophilic properties of a polyvinylsiloxane impression using a __________ protocol.
material. a. total-etch
a. desensitizer b. self-etch
b. surfactant c. self-adhesive
c. tubule occluding agent d. any of the above
d. none of the above
24. Eugenol _________.
17. Zinc oxide non-eugenol cements substitute __________ in a. is respected for its bactericidal properties
place of eugenol. b. can aid in reducing post-operative sensitivity
a. inorganic acids c. acts as a plasticizer
b. organic acids d. all of the above
c. base solutions
d. none of the above 25. _________ offer cariostatic release of fluoride from the cement
to the abutment tooth.
18. Using a scanner and specific design software __________. a. Glass ionomer and resin-modified glass ionomer cements
a. the margins can be identified at 100 times their actual b. Polycarboxylate cements
size c. Zinc phosphate cements
b. enables accuracy that is impossible to achieve with traditional d. all of the above
die trimming
c. helps establish independent parameters for margins, axial 26. Supragingival margins on preparations__________.
walls, the occlusal surface and line angles a. aid hygiene
d. all of the above b. are ideal in the esthetic zone
c. compromise biologic width
19. Using rigid fast-set polyvinylsiloxane for the interocclusal d. none of the above
record __________.
a. results in less resistance to biting forces 27. Using a digital camera __________.
b. results in a faster setting time a. aids communication about color and characterization between
c. reduces the risk of jaw movements, while the record is setting, the operatory and the dental laboratory
that would alter the record b. reduces the occurrence of poor color matching
d. all of the above c. is less effective than a written prescription for color communication
d. a and b
20. Ceramics that contain glass, such as feldspar and lithium
disilicate, may be predictably etched with __________. 28. Glaze can be applied to a laboratory-fabricated hybrid resin
a. phosphoric acid provisional __________.
b. hydrofluoric acid a. after it has cooled
c. acetic acid b. after it has been carved to the desired final contours
d. lactic acid c. with a disposable brush and cured
d. all of the above
21. Zirconia’s polycrystalline structure __________.
a. does not contain glass 29. Definitive luting agents are selected based upon the __________.
b. contains apatite a. condition of the abutment teeth
c. cannot form a bond to the resin cement that is as predictable b. restorative material used for the prosthesis
or as strong as a glass ceramic c. patient’s preference
d. a and c d. a and b

22. Self-etch systems __________. 30. Due to its unique tetragonal, polycrystalline structure, _________
a. do not completely remove the smear layer increases its volume around a stress-induced crack.
b. do not penetrate into the tooth structures as deeply as other a. leucite
adhesive systems b. feldspathic porcelain
c. offer a decreased chance of post=operative sensitivity c. zirconia
d. all of the above d. none of the above

16 VOLUME 1 | ISSUE 6
 DENTAL LEARNING Delivering Optimal Results for
Fixed Partial Dentures
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EDUCATIONAL OBJECTIVES
1. List in detail the steps involved in fabrication of an FPD If you have any questions,
2. Describe the impression materials available, considerations in their selection, and the use of a one-stage please call Dental Learning,
or two-stage technique LLC at 1-888-724-5230.
3. Review the materials and techniques available for the fabrication of provisional restorations
4. List and review the steps involved in the fabrication of full-contour zirconia CAD/CAM restorations

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OCTOBER 2012 17