1
Q
tx options for missing tooth/teeth
A
- no tx/leave spapce
- replace tooth/teeth
- close space (orthodontics)
2
Q
reasons for treating tooth loss (4)
A
- Aesthetics
- Function
- Speech
- Maintenance of dental health
3
Q
tooth replacement options
A
- denture
- bridgework
- implants
4
Q
define bridge
A
“A prosthesis which replaces a missing tooth or teeth and is attached to one or more natural teeth (or implants)”
- “Fixed partial denture” USA*
- Compared with a removable partial denture which replaces soft tissue and bone (bridges do not replace soft tissue usually - limited)
5
Q
2 types of bridgework
A
adhesive
- most common, held by wings on palatal surface
‘conventional’
- held by crowns
6
Q
general indications for bridgework (6)
A
- Function and stability
- Appearance
- Speech
- Psychological reasons
- Systemic disease e.g. epileptics
- Co-operative patient – plaque control, no active disease, motivated
7
Q
4 local indications for bridgework
A
- Big teeth
- Heavily restored teeth (for ‘conventional’ bridge)
- Favourable abutment angulations
- Favourable occlusion
8
Q
6 general contraindications for bridgework
A
- Uncooperative patient
- Medical history contra-indications (e.g. allergies to metals)
- Poor oral hygiene
- High caries rate
- Periodontal disease
- Large pulps esp in primary teeth (conventional bridge
- Turkey teeth
9
Q
8 local contraindications for bridge work
A
- High possibility of further tooth loss within arch
- Prognosis of abutment poor
- Length of span too great
- Ridge form and tissue loss
- Denture tend to be better
- Gingival architecture concern with aesthetics not just tooth loss
- Tilting and rotation of teeth
- Degree of restoration (how much of tooth is left after preparation)
- Periapical status
- Periodontal status (bone loss) – active or advanced
10
Q
abutment
A
a tooth which serves as an attachment for a bridge
11
Q
pontic
A
the artificial tooth which is suspended from the abutement teeth/tooth
12
Q
retainers
A
the extracoronal or intracoronal restorations that are connected to the pontic and cemented to teh prepared abutment teeth
13
Q
connectors
A
component which connects the pontic to the retainer(s)
14
Q
edentulous span
A
space between natural teeth that is to be filled by a bridge
15
Q
saddle
A
area of the edentuolous ridge over which the pontic will lie
16
Q
pier
A
an abutment tooth which stands between and is supporting two pontic - each pontic being attached to a further abutment tooth
17
Q
unit
A
either a retainer or a pontic
e.g. a bridge with two retainers and one pontic = 3 unit bridge
18
Q
2 types of bridge design
A
fixed-fixed
cantilever
19
Q
fixed-fixed bridge
A
This type of bridge has a retainer at each end with a pontic in the middle joined by rigid connectors.
- E.g. (Retainer)-(pontic)-(Retainer)
Can be:
- Adhesive/resin retained
- Conventional
20
Q
cantilever
A
This type of bridge has a retainer (or retainers) at one side of the pontic only
- E.g. (Retainer)-(pontic)
Can be:
- Adhesive/resin retained
- Conventional
21
Q
resin bonded bridgework (RBB) a.k.a
A
- Resin retained bridgework (RRB)
- Adhesive bridgework
- Minimal preparation bridgework
- Maryland bridge
- Resin bonded fixed partial denture (RBFPD)
22
Q
2 options for adhesive cantilever bridges
A
all ceramic adhesive bridge
or
traditional adhesive bridge with metal (CoCr) wing
can be nickel chromium oness too
23
Q
6 advantages of RBB
A
- Minimal or no preparation
- Occlusal contact can be high but tend to resolve in 10-14 days due to DAAL movements
- No anaesthetic needed
- Less costly
- Less surgery time
- Can be used as a provisional restoration
- Hypodontia pt. – long term implant work, but wont want to provide till fully grown 18/19 girls and 20 boys
- Easy and quick to provide in teens and then can give implants when fully grown or when fails and then re-discuss options
- Hypodontia pt. – long term implant work, but wont want to provide till fully grown 18/19 girls and 20 boys
- If fails - usually less destructive than alternatives
24
Q
6 disadv of RBB
A
- Rigorous clinical technique
- Need to be completely dry
- Metal shine-through
- See on 21 – poor cementation or design so metal seen at incisal edge
- Be careful not to overextend retainer
- See on 21 – poor cementation or design so metal seen at incisal edge
- Chipping pocelain
- Can debond
- High chance of it debonding again
- First bond will be best bond
- High chance of it debonding again
- Occlusal interferences – less of issue, DAAL concept
- No trial period possible
25
6 indications for RBB
* Young teeth
* Less destructive
* Good enamel quality
* Large abutment tooth surface area (more bonding area)
* Minimal occlusal load
* Good for single tooth replacement
* Simplify partial denture design
26
6 contraindications for RBB
* Insufficient or poor quality enamel
* Long spans – break, # risk
* Excess soft or hard tissue loss
* Heavy occlusal force e.g. Bruxist
* Poorly aligned, tilted or spaced teeth
* Contact sports?
27
tx planning for RBB bridges
* History
* Establish habits e.g. Bruxism
* Examination
* Clinical
* Dynamic occlusal relationships
* Periodontal
* Radiological
* Caries, periapical pathology check
* Bone level
* Study models
* Mounted on semi-adjustable articulator with facebow registration
* Consider diagnostic wax-ups
28
decision making for RBB bridgework
* Is bridgework appropriate?
* Other options?
* *Consider what you want for final aesthetic outcome first and work how to get there*
* Take care if patient is insistent on bridgework
* Look at:
* Abutment teeth
* Occlusion
* Aesthetics (including soft tissue contour)
* Can patient maintain this complex work?
* Poor OH
29
occlusion considerations for bridgework planning
* Consider opposing dentition
* e.g. Contact points
* Over-eruption of opposing teeth
* Is there a parafunctional habit?
* Bruxism (clenching and/or grinding teeth)
* Look at dynamic occlusal relationships
* Clinically
* Mounted study models
* Consider diagnostic wax-ups
30
direct resin bonded bridgework used when?
* Very useful in emergency situation
* If tooth needs to be extracted immediately
* If tooth has been lost traumatically
31
indirect resin bonded bridgework
can be (3)
* No preparation
* Minimal preparation
* Heavy preparation (Undesirable)
* Dentine bone is poor compared to enamel
32
pontic manufacture for direct resin bonded bridgework
* Pontic manufacture
* Ideally use patient’s own tooth
* Alternatives:
* Acrylic ‘denture’ tooth
* Polycarbonate crown
* Cellulose matrix filled with composite
e.g. Root fracture tooth 11 – not restorable
33
indirect resin bonded bridgework - palatal/lingual coverage (metal)
* Need generous palatal/lingual coverage
* Greater surface area of enamel covered à Greater bond
* Need good quality enamel
* Keep supra-gingival
* Ideal 0.5mm
* Allow pt OH clean around gingiva – prevent caries
* Care with coverage near incisal edge
* Enamel translucent
* Grey shine through
34
cantilever or fixed-fixed?
anterior
generally cantilever design
35
cantilever or fixed-fixed?
posterior
generally fixed-fixed
36
minimal or full prepartion first?
think long term
stick to simplest first before advancing to more destructive
37
Divergent guide paths in anterior mean more likely to use
cantilever designs
## Footnote
longitudinally axis of each tooth different, so occlusal forces directed down slightly differently causing a fixed-fixed restoration to get jutted about and more likely to fall off
38
can abutment teeth have exisitng restorations?
ideally need sound enamel
* Composite
* OK?
* However consider composite replacement prior to preparation if old composite (better bond to new) or roughen with rose head bur
* Amalgam
* Compromised bond to chemically cured composite cement
* Consider replacing
39
preparation for RBB if needed
* 180º ‘wrap-around’ preparation on palatal/lingual surface
* Rests *– can help locate it on position and mechanical retention*
* Rest seats (posterior teeth)
* Cingulum rest (anterior teeth)
* +/- Proximal grooves *(mechanical retention – rare)*
* Supra-gingival **chamfer** finish line ~0.5mm
* Ideally prep should remain in enamel
40
anterior RBB preparation options
* Cantilever design
* No preparation
* Minimal preparation
* Occlusal contact reduction *– on abutment tooth*
* Cingulum undercut removal only *– path of insertion*
* **Chamfer margin (0.5mm supra-gingival)**
* Heavier preparation
* **0.5mm whole palatal surface reduction** (NOTE – metal retainer wing should be 0.7mm thick), settle with time
* Cingulum rest
* +/- Proximal grooves
* **Chamfer margin (0.5mm supra-gingival)**
41
minimal prep for anterior cantilever
* Occlusal contact reduction *– on abutment tooth*
* Cingulum undercut removal only *– path of insertion*
* **Chamfer margin (0.5mm supra-gingival)**
42
heavier prep for anterior cantilever
* **0.5mm whole palatal surface reduction** (NOTE – metal retainer wing should be 0.7mm thick), settle with time
* Cingulum rest
* +/- Proximal grooves
* **Chamfer margin (0.5mm supra-gingival)**
43
posterior RBB preparation options
* No preparation
* Preparation:
* Occlusal rests *– 2mm deep*
* 180º wrap-around with chamfer finish line (0.5mm supra-gingival) *on palatal/lingual surface*
* +/- Proximal grooves
* Can be cantilever or fixed-fixed design
* Increased occlusal force so tend to be better to spread the load over two abutment teeth to help inc longevity
44
temporisation for RBB options
cosider RPD or essix retainer with missing tooth incorporated
if prep remains in enamel - is there any need for a temporary restoration?
* May experience sensitivity – Duraphat toothpaste prescription
If prep into dentine and tooth becomes sensitive:
* Cover with thin layer of dentine bonding agent
Fit bridge as quickly as possible
* Minimise over-eruption and tooth movement (tilting into saddle space)
45
RBB prep remains in enamel temporisation needed
not necessarily
if experience sensitivity - duraphat toothpaste prescription
46
RBB extends into dentine temporisation needed
cover with thin layer of dentine bonding agent
47
temporisation length for RBB
short
fit bridge as quickly as possible - minimise over-eruption and tooth movement (tilting into saddle space)
48
fit surface of retainer
* Cobalt chrome or nickel-chromium alloy (typically)
* Sandblasted surface
* Micro-mechanical retention
* Aluminium Oxide - 50 microns
49
cementation of RBB with
Panavia®21EX
a dual cured composite resin luting cement
50
treatment of retainer for cementation of RBB
Try-in
* Fit and aesthetics
* By hand or can ask lab to make a locating cleat on it – hook on incisal edge of retainer tooth
Chairside micro-etching with 50 micron aluminium oxide particles (sandblast)
* Should have already been done by technician (as per previous slide)
Clean retainer (if contaminated e.g. by unset composite resin used to try in bridge)
* Ultrasonic bath if required
* Use ethanol to ‘degrease’ if required
* Reduces surface tension
Apply chemically (or dual cure) cure composite luting cement just prior to placement of restoration after tooth treatment
51
treatment of tooth of RBB for cementation
* Prophylaxis
* Isolate with dental dam
* Etch tooth: 37% ortho-phosphoric acid (some preparations are 40%)
* Wash & dry
* Apply primer (A and B mixed together) for 30 seconds, about 5 layers
* Air dry for 2 seconds
* No need to cure (unlike for direct composite restorations), self cures
52
final stage of placement in cementation
* Fit retainer (coated with luting cement) to abutment tooth/teeth
* Remove excess cement
* Oxygen inhibitor (Oxyguard II) placed around cement margins for 3 minutes
* Wash off
53
after cementation of RBB
* Check occlusion
* Confirm pontic does not have excessive occlusal forces applied, retaining wings less concern – will adjust with time and DAAL movements
* Demonstrate to patient how to clean around and underneath the bridge
* Superfloss
* Thin and thick bits – feed the thin bit underneath the pontic and thread the thick bit through after whilst sweeping, show then pt demonstrate
* Interdental brushes
54
5 year survival of RBB
80.8%
most likely to fail within first 2 years
55
10 year survival of RBB
80.4%
most likley to fail within first 2 years
BDS4 CDS Operative
flashcards
Decks in class (11)
# Cards
