1. Fixed Prosthodontics
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2. Introduction
Fixed prosthodontics is the specialized area of dentistry devoted to the replacement of missing teeth with cast prostheses that are permanently cemented in place.
Fixed prosthodontics is also known as “crown and bridge.”
Fixed prosthetics require good home care by the patient.
The supportive tissues must be healthy, because they will be supporting the bridge.
A prosthodontist is a dentist with an additional 3 years of specialized training.
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3. Indications for Fixed Prosthodontics
One or two adjacent teeth are missing in the same arch.
The supportive tissues are healthy.
Suitable abutment teeth are present.
The patient is in good health and wants the prosthesis placed.
The patient has the skills and motivation to maintain good oral hygiene.
Fixed prosthodontics is also known as “crown and bridge.”
Fixed prosthetics require good home care by the patient.
The supportive tissues must be healthy, because they will be supporting the bridge.
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4. Contraindications for Fixed Prosthodontics
The supportive tissues are diseased or missing.
Suitable abutment teeth are not present.
The patient is in poor health.
The patient is not motivated to have the prosthesis placed.
The patient has poor oral hygiene habits.
The patient cannot afford the treatment.
Would a patient with severe periodontal disease be good candidates for fixed prostheses? Why or why not?
If suitable abutment teeth are not present, what is another option for the patient? (Removable prosthesis or implants.)
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5. Cast Restorations Also known as indirect restorations
They are fabricated outside the patient’s mouth, in a dental laboratory. Made from materials like gold alloys, composite and porcelain and then cemented back into the prepared cavity of the teeth.
Would a patient with severe periodontal disease be good candidates for fixed prostheses? Why or why not?
If suitable abutment teeth are not present, what is another option for the patient? (Removable prosthesis or implants.)
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6. Types of Fixed Prosthesis
Inlay
Covers a portion of the occlusal and proximal surface
Onlay
Covers proximal surfaces and most or all of the occlusal surface
Porcelain veneers
Thin shell-like covering placed to improve the appearance of anterior teeth.
Full crown
Completely covers the anatomic crown of an individual tooth A porcelain jacket crown is a very thin metal shell covered by layers of porcelain to resemble the shading and translucence of the enamel of a natural tooth.
Three-quarter crown
Covers the anatomic crown of a tooth except for the facial portion
Cast restorations are also known as indirect restorations.
They are fabricated outside the patient’s mouth, in a dental laboratory.
Where is the proximal surface?
Why can’t veneers be placed on posterior teeth? 6

7. What type of restoration is this?
An inlay involves the proximal surface and only a portion of the occlusal surface.
Inlay
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8. What type of restoration is this?
An inlay involves the proximal surface and only a portion of the occlusal surface.
¾ Gold Crown
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9. What type of restoration is this?
An onlay involves the proximal surface and most or all of the occlusal surface.
Cusp tips are involved.
Onlay
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10. What has changed from A to B
What has changed from A to B? What prosthesis is placed to improve cosmetics? A B
Veneers are placed to cover defects such as hypocalcification and intrinsic stains.
What is an intrinsic stain? (A stain that comes from the inside.)
An opaquer may be used to block out any underlying color or structural defects.
The cement used for veneers may also be shaded to enhance the color match.
What is the best lighting for shade selection?
Defects from A are hypocalcification and intrinsic stain
Porcelain veneers are bonded to improve esthetics
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11. What type of prosthesis is shown here?
Which anterior tooth might this be? (Canine.)
The metal “ring” is healthier for the gum tissue because it is not as “bulky” as the porcelain fused to metal.
Porcelain fused to metal full crown
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12. Types of Multiple Tooth Restorations
Fixed bridge - A prosthesis for missing teeth within the same arch. A fixed bridge contains a series of two or more units and is cemented permanently in place.
Winglike extensions of the resin-bonded bridge are bonded onto the lingual surfaces of the teeth adjacent to the missing tooth.
Splint
A prosthesis where multiple crowns are tied together for support without any pontics
Resin-bonded bridge
Also known as a Maryland bridge, with winglike extensions coming from the proximal sides
Combination conventional and Maryland bridge
A porcelain jacket crown is a very thin metal shell covered by layers of porcelain to resemble the shading and translucence of the enamel of a natural tooth.
A fixed bridge contains a series of two or more units and is cemented permanently in place.
Winglike extensions of the resin-bonded bridge are bonded onto the lingual surfaces of the teeth adjacent to the missing tooth.
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13. What type of prosthesis is here?
How many units are involved in this bridge?
What are the components of the bridge? (Two pontics, two abutments.)
Which teeth are being replaced?
Conventional four unit porcelain fused to metal bridge
Teeth included:
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14. What type of prosthesis is pictured here?
Resin bonded bridge/ Maryland bridge
This is an example of a Maryland bridge.
Wings are bonded onto the lingual surfaces of the adjacent teeth.
Would a Maryland bridge be placed on the posterior teeth? Why or why not?
Which tooth is replaced? #8
Which teeth are the abutments?
#7 & #9
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15. Overview of a Fixed Prosthodontic Procedure
Shade selection
A shade guide contains samples of all available shades used to match the natural tooth color.
Moisture helps achieve a more accurate match.
Use natural sunlight.
Record the shade on the patient record and on the laboratory prescription.
Preliminary impressions for provisional
Tooth preparation
The tooth is prepared for the cast restoration to slide into place and to be able to withstand the forces of occlusion.
Rotary instruments are used to reduce the height and contour of the tooth.
Shade selection should be performed before anesthetic is administered.
Unfortunately, there are times when the initial shade selection does not match at the final appointment. Reselection of a shade must be done.
Some dental labs have the patient come to the lab for a custom shade.
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16. Overview of a Fixed Prosthodontic Procedure
Retention aids
These provide additional support for the crown if the tooth is extensively decayed or fractured or has been endodontically treated.
Core buildup
Pin retention - Pins are placed before the core buildup.
Post-and-core- can only be used on teeth that have been endodontically treated.
Pins are placed before the core buildup.
Post-and-core can only be used on teeth that have been endodontically treated.
A cast post is made from an acrylic pattern and fabricated by a dental lab technician.
Not all teeth require pin retention for a core buildup.
What material is used for a core buildup?
What is a prefabricated post made of? (Titanium and titanium alloys.)
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17. Retention Aids What is a "core"?
Teeth sometimes have large portions missing due to decay, fracture, loss of and root canal treatment, with the creation of an access cavity.
Core placement refers to a procedure where a dentist replaces missing tooth structure in preparation for making a dental crown. Replacing these missing portions creates the optimal foundation for the new restoration.
A core can be made out of any type of permanent dental restorative material. Examples would be dental amalgam (metal filling material), dental composite (tooth bonding) or dental cements.
Pins are placed before the core buildup.
Post-and-core can only be used on teeth that have been endodontically treated.
A cast post is made from an acrylic pattern and fabricated by a dental lab technician.
Not all teeth require pin retention for a core buildup.
What material is used for a core buildup?
What is a prefabricated post made of? (Titanium and titanium alloys.)
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18. Retention Aids Why are dental cores needed?
A crown's stability depends on the amount of tooth structure that extends into its interior of the tooth. If very little tooth structure occupies this space, the crown can be easily dislodged.
By "building up" the tooth with a core (rebuilding the tooth so it is closer to its original dimensions), the dentist can increase the stability of the crown, and therefore maximize its long-term chances for success.
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19. Retention Aids What is a "post and core"?
The difference between a dental core and a post and core is that , a dental post is used to help to anchor the core to the tooth.While a dental core can be used for any tooth, a post and core can only be made for a tooth that has had root canal treatment.
Is a post always needed?
As a rule of thumb, if more than half of a tooth's crown portion has been lost, a post is needed to assist in anchoring the core to the tooth. If more than half still remains, a core by itself will probably suffice.
Posts don't strengthen teeth.
in decades past there was a misconception that metallic dental posts played a role in strengthening the teeth in which they were placed.
What is the purpose of a post? support the core
What is the purpose of a core? retain the crown
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20. Overview of a Fixed Prosthodontic Procedure
Gingival retraction and tissue management
Gingival retraction cords come in a variety of sizes (thicknesses). They are available twisted, untwisted, and braided.
Impregnated cords contain a vasoconstrictor.
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21. Gingival Retraction and Tissue Management
Purpose: to temporarily displace sulcular tissues to widen sulcus so that impression material may flow into that area to capture all parts of the tooth preparation.
When: after majority of preparation has been completed and before final impression is taken
Types: 1. Gingival retraction cord- cord is placed in the sulcus forcing the tissues away from the tooth (non impregnated
2. Chemically impregnated cords- the chemical, causes contraction of tissues as well as mechanically moving tissues with cord
3. Surgical retraction- excessive tissue removed with surgical knife or electrosurgery unit
4. Expa-syl- a viscous paste designed to be injected in the sulcus. (Aluminum Chloride)
Gingival retraction cords come in a variety of sizes (thicknesses). They are available twisted, untwisted, and braided.
Impregnated cords contain a vasoconstrictor.
What is a vasoconstrictor?
What medical conditions would contraindicate the use of impregnated retraction cord?
A hemostatic solution is used to control bleeding.
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22. Gingival Retraction
Gingival retraction cords come in a variety of sizes (thicknesses). They are available twisted, untwisted, and braided.
Impregnated cords contain a vasoconstrictor.
What is a vasoconstrictor?
What medical conditions would contraindicate the use of impregnated retraction cord?
A hemostatic solution is used to control bleeding.
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23. Gingival Retraction – Cord Types
Retraction cords displace gingival tissue mechanically; they also can have a chemical action when impregnated with astringents and vasoconstrictors that cause tissue contraction and hemostasis.
Types
Plain
Twisted
Braided
Different thickness (00,0,1,2 & 7,8,9,10- lower # thinner the material)
Stay-put- cord with thin copper wire inside
Non-impregnated
Impregnated with some astringent or vasoconstrictor to reduce bleeding
Gingival retraction cords come in a variety of sizes (thicknesses). They are available twisted, untwisted, and braided.
Impregnated cords contain a vasoconstrictor.
What is a vasoconstrictor?
What medical conditions would contraindicate the use of impregnated retraction cord?
A hemostatic solution is used to control bleeding.
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24. Gingival Retraction -Cord
What is a vasoconstrictor?
A vasoactive agent that constricts blood vessels–eg, epinephrine, norepinephrine which help control bleeding.
The epinephrine also constricts the blood supply to adjacent tissue, thereby permitting the impression to be secured without contamination by bleeding.
What medical conditions would contraindicate the use of impregnated retraction cord?
Cardiac issues, High Blood Pressure, Pregnancy.
Epinephrine impregnated cord can cause elevated heart rate,blood pressure (especially if placed into bleeding tissues).
Gingival retraction cords come in a variety of sizes (thicknesses). They are available twisted, untwisted, and braided.
Impregnated cords contain a vasoconstrictor.
What is a vasoconstrictor?
What medical conditions would contraindicate the use of impregnated retraction cord?
A hemostatic solution is used to control bleeding.
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25. Cord packing instrument Retraction cord Scissors
Equipment Needed
Basic setup
Cotton rolls
Cord packing instrument
Retraction cord
Scissors
Hemostatic agent (if needed)
Gingival retraction cords come in a variety of sizes (thicknesses). They are available twisted, untwisted, and braided.
Impregnated cords contain a vasoconstrictor.
What is a vasoconstrictor?
What medical conditions would contraindicate the use of impregnated retraction cord?
A hemostatic solution is used to control bleeding.
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26. Steps
Cut a 1 to 1 ½ inches in length (determine length by circumference of preparation)
Use the cotton pliers to form a loose loop of the cord, have a tail on one side
Slip it over the tooth, have tail positioned on facial or lingual
Using the cord-packing instrument and working in clockwise direction, pack the cord gently into the sulcus
Overlap the cord where it meets
Leave cord in place at least 5 minutes
Remove cord just before impression
Moisten area, to prevent bleeding
Grasp the end the cord by the tail, and remove counterclockwise
Dry and isolate for the final impression
Gingival retraction cords come in a variety of sizes (thicknesses). They are available twisted, untwisted, and braided.
Impregnated cords contain a vasoconstrictor.
What is a vasoconstrictor?
What medical conditions would contraindicate the use of impregnated retraction cord?
A hemostatic solution is used to control bleeding.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 26

27. Overview of a Fixed Prosthodontic Procedure
Final impression - The final impression must be accurate to prevent the dental laboratory technicians from fabricating the restoration according to an inaccurate impression (which will require additional appointments for the patient).
Elastomeric impression materials are used to create an extremely accurate impression.
Light-bodied material is mixed and applied around the prepared tooth.
Heavy-bodied material is mixed and loaded into a tray to be seated on the quadrant or arch.
The final impression must be accurate to prevent the dental laboratory technicians from fabricating the restoration according to an inaccurate impression (which will require additional appointments for the patient).
Always ask the dentist which type of elastomeric material will be used for the final impression. Dentists usually use one to three types of material (one or two for crown and bridge impressions and one for denture impressions).
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28. Laboratory Prescription
The laboratory prescription is a detailed and precise written order from the dentist to the laboratory technician bearing the description of the restoration to be fabricated.
Lab slips may be filled out by the dental assistant.
Always have the dentist check the slip before sending it out to the dental laboratory.
The slip should be filled out completely.
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29. Overview of a Fixed Prosthodontic Procedure
Bite registration
Provides the laboratory technician with a reproduction of a patient’s bite and opposing arch registration for designing the anatomic structures of the fixed prosthetic
Types:
Baseplate wax
Polyvinylsiloxane
Why is it necessary to obtain a bite registration?
To show the dental laboratory technicians the relationship between the arches.
Why is it necessary to obtain a bite registration? (To show the dental laboratory technicians the relationship between the arches.)
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30. Overview of a Fixed Prosthodontic Procedure
Provisional coverage
Used for patient comfort from tooth preparation to final cementation of the fixed prosthetic
Criteria:
Tight contacts
Proper occlusion
Smooth margins
Covered margins
Purposes:
Reduces sensitivity and discomfort
Maintains function and aesthetics
Protects the margins
Prevents shifting
The temporary is made to last long enough for the dental laboratory technicians to fabricate the permanent restoration.
Good contact and occlusion are important in the fabrication of a provisional restoration.
What might happen if the provisional temporary does not have good contact with the adjacent teeth? (Drifting.)
What are the postoperative instructions for care of the provisional temporary?
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31. Delivery
When the casting (prosthesis) has been fitted and is acceptable, the dentist cements the casting.
Permanent cementation
Temporary cementation
The shade should be checked before cementation.
The cement is placed on the inside of the restoration and transferred to the dentist for placement.
What types of cement are used?
Why would the restoration be cemented temporarily?
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32. Home-Care Instructions for the Patient with a Fixed Prosthesis
Good home care is essential to the maintenance of a fixed prosthesis.
A fixed prosthesis and its supporting tissues must be brushed carefully every day.
A bridge threader is used to thread dental floss under the pontic and into the sulcus at both abutments of a bridge.
If any prosthesis feels loose or any area is packing food the patients needs to return immediately to have area evaluated
Avoid very sticky, gummy foods that could break the seal of cement
Fixed prosthetics must be taken care of just as normal teeth are.
If symptoms do not subside, the patient should be instructed to contact the office immediately.
Is it normal for a patient to experience slight temperature sensitivity after the crown has been placed?
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33. Temporary cementation
Supplies:
Basic setup
Spoon excavator
Plastic instrument
Cement spatula
Cotton rolls, gauze
Floss
Articulating holder and paper
Saliva ejector
Cement/ mixing pad
Petroleum jelly/ glycerin (optional)
Chlorhexidine gluconate scrub (disinfecting)(optional)

34. Temporary cementation steps
Dry temp. inside and out
Apply petroleum jelly/glycerin to external edges of crown to help with removal of excess cement
Set crown aside; clean and isolate tooth with cotton rolls
Dispense cement, mix and load (lightly coat internal surface)
Gently seat crown over crown preparation
Have patient close to check occlusion
If occlusion is good have patient hold closed with cotton roll

35. Temporary cementation
If occlusion feels high, have patient bite on cotton roll firmly then remove cotton roll and check bite again
If it still feels high remove crown and remove some of the cement
Start again with checking bite
If better then have patient close with cotton roll and wait a couple of minutes to start trimming excess cement

36. Temporary cementation
Use an explorer or scaler to remove any excess cement
Floss/ use floss threaders between proximal surfaces (don’t pop out; pull out at gum line)
Give post-operative instructions