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Thursday, October 13, 2022

 


• Expensive

• Limited shade selection

• Marginal fit is not good

• Less stain resistance

Classification of provisional restoration

On the basis of method of fabrication

(i) Prefabricated restoration

(ii) Custom-made restoration: Mainly made by direct technique or the

indirect technique or combination of both

On the basis of fabrication technique

(i) Direct technique

(ii) Indirect technique

(iii) Indirect–direct technique

On the basis of material used to fabricate

provisional restoration

(i) Resin-based autopolymerizing and dual-cure resins (e.g. PMMA,

poly(ethyl methacrylate), bis-glycidyl methacrylate resins, bis-acryl

resin composites, VLC resins)

(ii) Metal-based (e.g. aluminium, stainless steel, tin–silver, nickel–

chromium)

On the basis of time duration

(i) Short-term temporary: For smaller time duration less than 2 weeks

(e.g. single crown, short-span bridges)

(ii) Long-term temporary: Longer time duration (between 2 weeks and

few months). This type includes periodontally compromised teeth,

in full mouth rehabilitation cases.

Custom-made provisional restoration

The custom-made provisional restorations are made by direct or

indirect technique or combination of both. Custom matrix is formed

to create the proximal and occlusal contours of the provisional

restoration. These are preferred for fabrication of multiple unit or

complex interim restorations. Usually, an elastomeric or alginate

overimpression is made on the diagnostic cast or in the mouth before

tooth preparation. This overimpression can then be used to fabricate

the provisional restoration. Elastomeric impression material provides

better stability than alginate, but because of the cost factor alginate is

most commonly used. Another method is to form a template on the

diagnostic cast with clear thermoplastic vacuum-formed resin

material. This template is filled with resin and applied on the

prepared teeth/tooth or check cast of the prepared teeth. Templates

are very stable and good acceptable provisional restoration is

fabricated by this method.

A thin oversized, shell crown or bridge can be fabricated by

autopolymerizing resin through sprinkle-on method on the diagnostic

cast. This shell can also be heat cured in the laboratory. This shell is

loaded with resin and placed on the prepared tooth or cast of the

prepared tooth. Provisional restoration made can then be shaped to fit

the prepared tooth.

Techniques used for fabrication of provisional

restorations

A number of techniques are available for fabricating provisional

restorations. The external contours of the provisional restoration are

formed by a matrix and the internal adaptation is formed by either

direct technique or the indirect technique.

Matrix

A matrix is always required to form the external contours of the

provisional restoration. Matrix can be custom-made or prefabricated.

The prefabricated or preformed matrix is usually used for single unit

restoration. The internal adaptation is done with direct technique or

indirect technique.

Direct technique

It is indicated for single crowns and short-span bridges. In this

technique, the matrix of choice is tried over the prepared teeth. The

matrix is formed from the preoperated diagnostic cast with preferred

material. After tooth preparation, the matrix is seated in the patient

mouth to check its fit. The prepared tooth is then isolated and

Vaseline is applied gently over the tooth surface. Next, the selected

material is mixed according to the manufacturer’s instructions and

loaded into the matrix. This loaded matrix is gently seated onto the

prepared tooth and allowed to set. The matrix should be moved in

and out in order to prevent interlocking of the resin onto the prepared

tooth. After the material has reached the rubbery stage, the

provisional restoration is carefully teased out and reseated several

times, till the polymerization is completed. The area needs to be

continuously flushed with water during the completion of this

procedure. This technique is not preferred these days because it has a

number of disadvantages.

Advantages

• Less time is consumed.

• Less material is consumed, as intermediate impression, etc. are

avoided.

Disadvantages

• There is a high chance of pulpal damage due to chemical irritation

of free monomer.

• Exothermic reaction of resin may damage the pulp.

• There are chances of resin interlocking onto the prepared tooth.

• There is poor marginal integrity.

Indirect technique

A sectional impression is made with elastomeric impression material

of the diagnostic cast or diagnostic wax-up to make the matrix. After

completion of tooth preparation, impression with preferred material is

made and is poured with dental plaster or stone. The matrix is then

tried on the cast to check its fit. The cast is coated with a separating

medium. Once the fit is satisfactory, the resin of choice is mixed

following the manufacturer’s instruction and is loaded onto the

matrix. The loaded matrix is placed on the cast and allowed to

polymerize. The matrix should be firmly seated onto the cast and can

be stabilized by elastic bands. The cast–matrix assembly can be placed

in warm water in a pressure pot to increase its density and strength.

Advantages

• The material used does not polymerize in the mouth.

• The prepared tooth is not exposed to exothermic reaction of the

resin.

• There is no chemical irritation due to the free monomer onto the

pulp.

• It can be used even in cases with complex fixed partial designs with

multiple units.

• Undercuts, if any, can be blocked on the cast for easy removal or

placement of the temporary bridge.

• Marginal fit is more accurate than the direct technique.

• It results in increased patient comfort.

Disadvantages

• This technique is time-consuming.

• More material is required in the technique.

• It may require reline in the margin intraorally.

Indirect–direct technique

This technique combines both the above-mentioned techniques to

provide an accurately fitting provisional restoration. A thin shell in

the form of matrix is fabricated on the diagnostic cast. This thin shell

is tried on the prepared tooth and the appropriate resin material

(preferably light cure) is mixed and relined intraorally. After

polymerization, the provisional restoration is finished and polished in

the laboratory (Fig. 27-1).

FIGURE 27-1 Matrix is relined and cured using light-cure

resin.

Advantages

• It provides best marginal accuracy.

• It is least damaging to the pulp.

Disadvantages

• More time is needed for this technique.

• Laboratory help is needed.

Commonly available prefabricated crowns

Prefabricated or preformed crowns are available in variety of tooth

shapes and sizes and different materials. Their use is limited mostly to

the single crowns, as it is difficult to fabricate pontic for fixed partial

dentures. These crowns mostly require relining with

autopolymerizing resin or light-cure resin to achieve best fit and

accurate marginal adaptation.

Preformed or prefabricated crowns can be classified into the

following two groups on the basis of type of material used:

(i) Resin-based crowns (e.g. cellulose acetate, polycarbonate)

(ii) Metal-based anatomical crowns (e.g. aluminium, silver–tin, nickel–

chromium)

Polycarbonate crowns (fig. 27-2)

• These are indicated for anterior single crown.

FIGURE 27-2 Polycarbonate crowns of different shapes,

sizes and shades.

Advantages

• These are made of highly colour-stable resin.

• Aesthetics are similar to ceramic crown.

• These are supplied for use in the anterior incisors, canines and

premolar region only.

Disadvantages

• It is supplied only in one shade and requires a particular shade

relining resin to modify its shade.

• It may require extensive reshaping and recontouring to get a proper

shape.

• It may have sharp ledges or overhangs, if not contoured properly.

Cellulose acetate

• It is often supplied as thin shells (0.2–0.3 mm) which act as matrix.

• It is available in various tooth shapes and sizes.

• It can be used in both anterior and posterior regions.

• Particular shade resin is loaded into the matrix and placed onto the

prepared tooth and allowed to polymerize.

• This thin shell does not bond to the resin chemically and

mechanically and, therefore, can be easily removed.

• The final provisional crown is then shaped, finished and polished.

Preformed or prefabricated anatomical metal

crown

Prefabricated anatomical metal crowns are mostly indicated in the

posterior region which requires immediate coverage of the crown like

in cases of fractured molar tooth.

Aluminium and Tin–silver

• It is used in the posterior regions only.

• It is supplied in the form of both anatomical crowns and nonanatomical

cylindrical shells.

• Nonanatomical cylindrical shells are inexpensive but require

elaborate modification to achieve an acceptable fit.

• Anatomical crowns are mostly preferred.

• Preformed crowns should be modified outside on the swaging block

and not inside the patient mouth.

• In any case, the patient should be allowed to bite on unmodified

preformed crown.

• This may even lead to fracture of the natural tooth.

• Although the crowns are more ductile and can easily be contoured

onto the tooth.

• Overhanging margin may irritate the gingiva.

Nickel–chromium (fig. 27-3)

• It is rigid, more durable and has high strength.

• It is indicated for damaged deciduous dentition and sometimes for

permanent tooth.

• The crowns are adapted using contouring and crimping pliers.

• These usually cannot be relined with resin material.

• These are luted with high-strength luting cement.

• It is usually used as long-term provisional restoration.

• Disadvantage: These are difficult to adapt and often do not produce

good occlusal contact.

FIGURE 27-3 Nickel–chromium anatomic crowns.

Limitations of provisional restoration

Provisional restoration is fabricated to function for short duration of

time. It satisfies the functional and aesthetic requirement till the time

the definitive prosthesis is fabricated. However, it has limitations too.

Some of the limitations are:

• Lack of strength: Provisional restorations fracture in long-span

bridges can occur.

• It has poor marginal adaptation.

• Colour instability: This can occur, if the provisional restorations are

placed for longer duration.

• Poor wear properties: Resin wears in the proximal contact area and

may result in drifting of the teeth.

• Detectable odour emission: As the resins are porous, bad odour is

sometimes reported.

• Inadequate bonding characteristics: Eugenol-based cements are

incompatible with methyl methacrylate resins, as these interfere in

their polymerization.

Key Facts

• Indirect technique is preferred over direct technique to fabricate

provisional restoration for its accuracy and protection of pulp, in

case acrylic resin is used.

• Prefabricated polycarbonate crowns are used on prepared single

anterior tooth.

• Bis-acryl composite resin should not be used in long-span bridges,

as these are brittle in nature.

CHAPTER

28

Occlusion relationship

CHAPTER OUTLINE

Introduction, 393

Different Concepts of Occlusion in Fixed Prosthodontics, 393

Bilateral Balanced Occlusion, 394

Unilateral Balanced Occlusion or Group

Function, 394

Canine-Guided Occlusion or Mutually Protected

Occlusion or Organic Occlusion, 395

Functionally Generated Pathway, 396

Definition, 396

Requirements before Using this Technique, 396

Advantages, 396

Technique, 397

Role of Diagnostic Wax-Up, 397

Role of Articulators in Fixed

Prosthodontics, 397

Pros and Cons of Semi-Adjustable Articulators in Fixed Partial

Denture, 398

Pros of Semi-Adjustable Articulators, 398

Cons of the Semi-Adjustable Articulators, 398

Fully Adjustable Articulators and their Utility in FPD with Multiple

Abutments, 398

Pathological Occlusion, 398

Definition, 398

Splints, 399

Definition, 399

Purpose of Splinting, 399

Different Splints Used in Fixed

Prosthodontics, 399

Myofascial Pain Dysfunction Syndrome, 400

Occlusal Therapy in Fixed Prosthodontics, 400

Aims of Occlusal Therapy, 400

Introduction

The maintenance of occlusal harmony is one of the most important

factors in determining the long-term success of fixed restorations. It is

important to understand different concepts of occlusion in fixed

prosthodontics in order to diagnose and treat occlusal disharmonies.

Different concepts of occlusion in fixed

prosthodontics

There are three concepts or schemes of occlusion which are commonly

used in fixed restorations. These concepts are bilateral balanced

occlusion, unilateral balanced occlusion and mutually protected

occlusion.

Concepts of occlusion

1. Bilateral balanced occlusion

2. Unilateral balanced occlusion or group function

3. Mutually protected occlusion

These are described in brief below.

Bilateral balanced occlusion

• Balanced occlusion is bilateral, simultaneous contact of all the teeth in

maximum intercuspation and during all eccentric movements of the

mandible.

• This type of occlusion is ideal for fabrication of complete dentures, as

it improves the stability of dentures.

• This occlusal scheme helps to distribute lateral forces throughout

the teeth and condyles during mastication.

• It has both cross-tooth and cross-arch balance (Fig. 28-1).

• Balanced occlusion is based on three classic theories of occlusion:

Bonwill’s three points of occlusal balance, Spee’s curve of Spee and

Monson’s spherical theory of occlusion.

• At the start of the century, this type of occlusion was used in the

treatment of dentulous and edentulous patients.

• It was widely used by B.B. McCollum and E.R. Granger but was

criticized by H. Stallard and C.E. Stuart.

• Occlusal surface wears due to excessive contact area; it is thought to

be the key cause of failure.

• It is extremely difficult to find a balanced occlusion in the natural

dentition. It may be found in the cases of advanced attrition.

FIGURE 28-1 Bilateral balanced occlusion.

Unilateral balanced occlusion or group

function

• Clyde Schuyler (1929) advocated the group function occlusion.

• This type of occlusion occurs with all the teeth contacting only on

the working side with no contact on the balancing side (Fig. 28-2).

• This occlusion has been frequently observed in natural dentition.

FIGURE 28-2 Unilateral balanced occlusion or group

function. Simultaneous contact occurs on the canine and

posterior teeth on the working side during lateral movement.

H.L. Beyron (1969) listed the characteristics of this type of occlusion:

• Teeth should receive stress along their long axis.

• Total stress should be distributed among the tooth segment in

lateral movement.

• No interferences occur from closure into intercuspal position.

• Keep proper interocclusal clearance.

• Teeth contact in lateral movement without interferences.

Characteristics of group function occlusion

The characteristics of group function occlusion include:

• Theory of long centric: Long centric is a 0.5–0.75 mm free space

between maximum intercuspation and centric relation position

without changing vertical dimension of occlusion.

• It follows concept of all working side teeth sharing lateral pressures

during lateral movements.

• It follows concept of nonworking side teeth free from contacts

during lateral movements.

• Group function does not have harmful effects as seen with a

balanced occlusion and is not difficult to fabricate.

• Group function has been advocated by Mann and L.D. Pankey for

full mouth restorations.

• The functionally generated path technique described by F.S.

Meyer is based on group function.

Canine-guided occlusion or mutually

protected occlusion or organic

occlusion

• This concept originated from the work of A. D’Amico, C.E. Stuart,

H. Stallard, C.E. Stuart and V.O. Lucia.

• This is one of the most widely used occlusal schemes because of ease

of fabrication and greater acceptability by the patient.

Definition

‘An occlusal scheme in which the anterior teeth disengage the posterior teeth

in all mandibular excursive movements, and the posterior teeth prevent

excessive contact of the anterior teeth in maximum intercuspation’. (GPT 8th

Ed)

• It is found in patients with good periodontal health and minimal

wear such that anterior teeth prevented the posterior teeth from

making any contact during mandibular excursions on the working

or the nonworking sides (Fig. 28-3).

• This separation from occlusion is also called disocclusion.

• According to GPT, disocclusion is defined as ‘separation of opposing

teeth during eccentric movements of the mandible’.

• In the position of maximum intercuspation, the posterior teeth

occlude with the forces being directed along the long axis of the

teeth and the anterior teeth have minimal or no contact.

• Thus, the anterior teeth protect the posterior teeth and the posterior

teeth protect the anterior teeth from the obliquely directed forces.

• This type of occlusion is, therefore, known as the mutually protected

occlusion and is advocated for full mouth rehabilitation provided the

teeth are periodontally healthy.

• In cases where there is anterior bone loss or missing canines, group

function should be the occlusion scheme of choice for restoration of

the mouth.

• The mutually protected occlusion cannot be used in class II, class III

or crossbite cases, where the mandible cannot be guided by the

anterior teeth.

FIGURE 28-3 Canine-guided occlusion.

Various movements of mandible

Mandibular movement occurring in all excursions is a complex threedimensional movement. It is made possible by the simultaneous

movements of both the TMJs. There are two types of movement

occurring in the TMJ, namely, rotational and translational.

Rotational movement: Movement of body about an axis

Translational movement: Movement of all the points in the body with

same velocity and direction

Movement of the mandible occurs around three axes:

1. Horizontal axis: Movement occurs in a sagittal plane when

mandible makes a purely rotational opening and closing movement

around the terminal hinge axis passing through both the condyles.

This type of movement is called a hinge movement. This type of

movement occurs till about 20–25 mm of separation in the anterior

teeth and beyond it translatory movement occurs.

2. Vertical axis: Movement occurs in horizontal plane when the jaw

moves laterally to one side. Condyle moving to one side is called the

working side condyle and the opposing condyle is called the

nonworking side or balancing condyle. The working side condyle

moves anteriorly out of the terminal hinge position and the balancing

condyle rotates around the terminal hinge position. This bodily shift

of the working side condyle is called the Bennett movement.

3. Sagittal axis: Movement occurs in the frontal plane when the

mandible moves laterally. The nonworking or balancing condyle

moves down and medially, whereas the working condyle rotates

around the sagittal axis perpendicular to this plane.

U. Posselt (1957) first described the extremes of the mandibular

movements and called them border movements.

Factors affecting mandibular movements are:

• TMJ

• Teeth

• Neuromuscular coordination

• Ligaments and muscles

Determinants of mandibular movement (also see chapter 5)

Anterior determinants: Teeth are the anterior determinants which guide

the mandible in various excursive movements. Anterior teeth

provide the incisal guidance, i.e. the overjet and overbite.

Posterior determinants: It is the condylar guidance which is influenced

by the slope of articular eminence.

Functionally generated pathway

Definition

Functionally generated path is defined as ‘registration of the paths of

movement of the occlusal surfaces of teeth or occlusion rims of one dental

arch in plastic or other media attached to the teeth or occlusal rims of the

opposing arch’. (GPT 8th Ed)

• This technique was first described by F.S. Meyer (1934).

• In this technique, a soft plastic material, such as wax, is used to

carve the pathways travelled by opposing cusps on lateral excusive

movements of the mandible.

• This record of static and dynamic occlusion is made in the patient’s

mouth and reduces the role of articulator as a simple hinge

instrument.

• This technique is indicated for single-tooth restorations only.

Requirements before using this technique

• It is used for single restorations.

• There should be no posterior interferences.

• There should be no missing or damaged opposing teeth.

Advantages

• Technique is simple, if well versed.

• It is time saving.

• It is inexpensive.

Technique

• Soft plastic material such as wax or pattern resin is adapted over the

prepared tooth.

• The patient is asked to bite in intercuspal position and move the jaw

in all excursive movements.

• The cusp tips carve grooves on the wax which represent the border

movements of the mandible in three dimensions.

• This impression is then cast in the mouth by painting plaster or

stone using brush.

• This stone functional core is then used to fabricate posterior tooth

restorations.

• The cast is then mounted in the laboratory and used in conjugation

with the normal opposing model.

• This functional core indicates not only the cusp tips of the opposing

teeth in intercuspal position but also where these move relative to

the proposed crown. This is a static record of the patient’s dynamic

movement.

Role of diagnostic wax-up

Diagnostic wax-up is a process in which correctly mounted and then

equilibrated casts are modified by application of wax, so as to mockup the final definitive prosthesis. The diagnostic wax-up is a very

important diagnostic tool which should be fabricated by the

technician under the guidance of clinician.

The features of diagnostic wax-up are:

• It is a valuable guide to the treatment objective for both the clinician

and technician.

• It provides information related to the occlusal scheme which is to be

generated.

• It provides the patient with an opportunity to visualize the outcome

of the treatment.

• It provides the template for provisional restorations.

• It provides information about the need for crown lengthening and

orthodontic tooth movement.

• It acts as a guide for optimum crown preparation.

• It helps in creating an occlusal plane.

Role of articulators in fixed prosthodontics

An articulator is a mechanical device which represents the TMJ and

simulates some or all the mandibular movements. The main principle

of articulator is to replicate the movements of TMJ as closely as

possible.

• It maintains casts at an established vertical height and centric

relation and simulates the mandibular movements as closely as

possible.

• These are classified on the basis of accuracy in reproducing

mandibular border movements.

• These can be nonadjustable, semi-adjustable and fully adjustable

articulators.

Uses

• The upper and lower casts are attached to the articulator to study

the functional and parafunctional relation between the teeth for

diagnosis, occlusal rehabilitation and equilibration.

• These are also used to accurately fabricate fixed and removable

prosthesis which are in harmony with various mandibular

movements.

• Articulator is used to establish occlusion in maxillofacial prosthesis

and for fabrication of occlusal splints.

• It is used for functional analysis of occlusion.

• It is used for full mouth rehabilitation.

• No articulator can reproduce the mandibular movements exactly.

Selection of the articulator depends on the complexity of restorative

need required by the patient.

Pros and cons of semi-adjustable

articulators in fixed partial denture

Pros of semi-adjustable articulators

• For most routine fixed prosthodontic procedures, the semiadjustable articulators are sufficient to provide valuable diagnostic

information.

• Use of this instrument does not require more time or expertise.

• These are capable of accepting lateral and protrusive records.

• Arcon-type semi-adjustable articulators are usually used in fixed

prosthodontics.

• Use of this articulator reduces adjustments during try-in and

insertion stages.

• This articulator has same spatial dimension as the condyle to the

teeth and, therefore, the discrepancies between the radius of

movement of articulator and the arc of tooth closure are minimal.

• One advantage of this articulator over nonadjustable is that it can be

adapted to the patient’s specific condylar movements.

• This type of articulator is used for fabrication of single crowns and

fixed partial dentures (FPDs).

• Arbitrary facebows are used with semi-adjustable articulators.

• Some articulators can allow adjustments to condylar inclinations

and progressive or immediate side shift.

Cons of the semi-adjustable articulators

• Intercondylar distance is not fully adjustable, as it can be adjusted to

small, medium or large configurations in some instruments.

• All the border movements are not reproducible.

• Some articulators reproduce the condylar path as a straight line

rather than a curved path.

• These are more time-consuming and more expensive than the

nonadjustable articulators.

Fully adjustable articulators and their

utility in FPD with multiple abutments

Fully adjustable articulators are considered to be the most accurate

instruments which are capable of accepting three-dimensional

dynamic registrations.

• These can reproduce an entire range of border movements of the

patient mandible.

• Accuracy and reproduction are highly dependent on the skill of the

clinician.

• Here, pantographic tracings are used to record the border

movements in the form of series of tracings.

• The intercondylar distance is completely adjustable.

• Kinematic facebow is used to locate true hinge axis.

• The ability of the articulator to track irregular pathways of the

mandible allows for fabrication of restorations of multiple

abutments. This is especially useful in full mouth rehabilitation

cases.

• Correct use of this articulator can reduce the chairside time during

try-in and insertion of the prosthesis.

• Although not required in general practice, their use become more

sensible when complex prosthesis are fabricated, especially in cases

where atypical mandibular movement exists.

Pathological occlusion

Definition

Pathological occlusion is defined as ‘an occlusal relationship capable of

producing pathologic changes in the stomatognathic system’. (GPT 8th Ed)

In pathological occlusion, disharmony between the teeth and the

TMJ exists resulting in signs and symptoms that require treatment or

intervention. The stomatognathic system consists of teeth,

periodontium, muscles and the TMJ. In a pathological occlusion, one

or more aspect of the system is affected.

In pathologic occlusion, the common signs and symptoms noticed

are:

• The teeth may show hypermobility, open contacts or abnormal

wear.

• Parafunctional habits, such as bruxism or clenching, may show

abnormal tooth wear, cuspal fracture or chipping of the incisal

surfaces.

• There could be trauma from normal occlusion when the periodontal

status of the teeth is compromised.

• Acute or chronic muscular pain on palpation may indicate habits

related to psychic tension, such as bruxism or clenching.

• Chronic muscular fatigue can lead to muscular spasm or pain.

• Pain, clicking sound or popping sound in the TMJ can indicate

temporomandibular disorder.

• Clicking of the joints may indicate internal derangement of the

joints.

The acute signs and symptoms of the patient should be addressed

first and should be relieved. It is important to select an occlusal

scheme which prevents the recurrence of the signs and symptoms of

the pathological occlusion. An optimum occlusion should be provided

so that the patient requires minimum adaptation to the new occlusal

scheme.

Splints

Definition

‘A rigid or flexible material used to protect, immobilize, or restrict motion in

a part’. (GPT 8th Ed)

Purpose of splinting

• Mobility is reduced drastically.

• Forces are distributed to a number of teeth.

• Food impaction is prevented and proximal contacts are stabilized.

• Migration and overeruption is prevented.

• Discomfort or pain is eliminated.

• Appearance may be improved.

Splints can be of two types, namely, temporary splints and permanent

splints.

Different splints used in fixed prosthodontics

Night guard

• It is used in management of bruxism and clenching.

• It is made over the occlusal surfaces of the teeth with heat-cured

acrylic resin.

• It can be fabricated for one or both the jaws depending on the

availability of freeway space.

• Most commonly, it is fabricated in the upper jaw.

• If it is used in one jaw, the occlusal contact of the opposing jaw is

adjusted, so that there is smooth maximal contact in gliding

movements.

• The acrylic resin should extend just below the height of contour for

ease of insertion and removal and retention.

Occlusal splint

• It is used in management of TMJ disorders and bruxism.

• It has been found to be effective in controlling myofascial pain.

• The patient is given a new occlusal scheme made in acrylic resin

overlay.

• The patient is asked to wear the splint for certain duration of time.

• If the patient adapts well and becomes comfortable over a period of

time, the proposed restorative treatment is likely to be successful.

• It is an important diagnostic procedure before treating cases

requiring full mouth rehabilitation.

Cast metal resin-bonded FPDs or maryland

bridges

• It is used with intact or very slight alteration of enamel.

• This type of prosthesis is functional, aesthetic, reversible and

economical.

• It consists of a metal frame bonded with resin cement to the tooth

structure.

• Although more successful in the anterior region, it can also be used

for posterior teeth.

Myofascial pain dysfunction syndrome

Myofacial pain is a type of regional muscular pain which is

characterized by localized areas of firm, hypersensitive muscular

bands of tissues called the trigger points.

Causes: Local and systemic factors, such as trauma,

hypervitaminosis, viral infection, muscle fatigue and emotional stress.

Signs and symptoms of myofascial pain dysfunction syndrome

(MPDS) are:

• Unilateral dull pain in the ear/periauricular area which radiates to

the angle of mandible, temporal area. Pain is relatively constant and

usually reported as worse in the morning.

• Tenderness over the neck of the mandible in region distal to the

tuberosity. Area of tenderness is presumed to be the spasm area of

masticatory muscles.

• Clicking or popping sound over TMJ. If only this symptom is

present, the patient is not included in MPDS.

• Limited jaw movement: Fourth cardinal symptom of MPDS. It is

characterized by the inability to open the mouth widely or there is

deviation while opening the mouth.

Occlusal therapy in fixed

prosthodontics

One of the primary objectives of restorative dentistry is to restore and

replace teeth in harmony with TMJs. If the teeth are not in harmony

with the joints and mandibular movements, it is understood that there

is some occlusal interference.

Occlusal interference can occur in the following:

• In centric contact

• On the working side when mandible makes lateral

excursion.

• On the nonworking side when mandible makes

lateral excursion.

• In protrusive contact

• When occlusal interference occurs, occlusal therapy

should be considered.

Aims of occlusal therapy

• To direct the occlusal forces along the long axis of the teeth

• To have centric relation coincide with maximum intercuspation

• To have simultaneous contact of the teeth in centric relation

• In protrusive contact, there should be disocclusion of the posterior

teeth

• To attain the occlusal scheme selected for the patient (canine guided

or group function)

• Physiological plane of occlusion

• A functional incisal guidance, i.e. proper overjet and overbite of the

anterior teeth

• An aesthetic and phonetic relationship of anterior teeth

Occlusal therapy can include treatment, such as orthodontic

treatment for tooth movement, selective grinding or restoration or

replacement of missing teeth. Proper diagnostic aids are very useful in

providing proper occlusal treatment. Diagnostic wax-up on the

mounted diagnostic casts at established vertical dimension is the

fundamental guide for providing a suitable restorative treatment.

Key Facts

• Group function is characterized by contact of all teeth on the

working side and no contact on the balancing side during lateral

excursions.

• Maximum limit of transverse hinge axis movement is 18–22 mm.

• In natural occlusion, the centric relation position is located 0.5–1.0

mm posterior to the centric occlusion position.

• The point at which the maximum opening of the jaws occurs

without translation movement of the condyle is called terminal

hinge axis position.

• Mutually protected occlusion or canine-guided occlusion is

characterized by posterior teeth protecting the anterior teeth in

intercuspal position and anterior teeth protecting the posterior teeth

in all mandibular excursions.

• Arcon articulators are preferred for fixed prosthodontics because of

accuracy and ease during occlusal waxing.

• Pantographic tracings are used with fully adjustable articulators.

• Functionally generated path technique was first advocated by F.S.

Meyer.

• The most important factor in the success of the artificial crown is

restoration of proper occlusion.

CHAPTER

29

Laboratory procedures in fixed

prosthodontics

CHAPTER OUTLINE

Introduction, 402

Dies and Various Materials Used for Making Dies, 402

Requirements of a Die Used in Fixed

Prosthesis, 402

Materials Used for Fabricating a Die, 403

Various Die Systems, 403

Alloy and Historical Perspective of Dental Casting Alloy, 406

Definition, 406

Historical Perspective of Dental Casting

Alloys, 406

History of Dental Casting Alloys, 406

Classification of Dental Casting Alloys and

Critical Evaluation of Precious, Semiprecious

and Nonprecious Alloys in Prosthodontics, 407

Casting Techniques for Casting of Base Metal

Alloy and Titanium, 408

Casting Defects and their Remedies, 409

Investment Materials Used in Fixed

Prosthodontics, 411

Shade Selection for the Patient Requiring FPD, 412

Characteristics of Colour, 412

Procedure of Shade Selection, 413

Dentist–Technician Inter-Relationship—Important Key to Success in

Fixed Partial Denture, 413

Guidelines for Dentist, 413

Guidelines for Technician, 413

Introduction

Accurately fitting casting is important for successful fixed prosthesis.

To obtain precisely fitting casting, knowledge of various laboratory

procedures involved in fixed prosthodontics is critical. The

procedures are briefly explained in this chapter.

Dies and various materials used for

making dies

A die is defined as ‘the positive reproduction of the form of a prepared tooth

in any suitable substance’. (GPT 8th Ed)

Requirements of a die used in fixed prosthesis

• It should reproduce the prepared tooth accurately.

• Prepared surfaces and unprepared surfaces should be recorded

accurately.

• It should be easily mounted onto the articulator.

• It should be resistant to abrasion.

• It should have adequate strength.

• It should reproduce details accurately.

• It should be easily wetted by wax.

• It should not stick with wax and should be available in colour

contrasting to the wax.

Materials used for fabricating a die

Gypsum products

• Type IV and type V gypsum products are usually used as die

materials.

• These are capable of reproducing a 20-micron wide line according to

American Dental Association (ADA) (specification no. 19).

• They have poor resistance to abrasion which is overcome by using

gypsum hardeners (e.g. colloidal silica).

• The surface of the die can also be impregnated with low-viscosity

resin such as cyanoacrylate.

Resin

• The resins that are commonly used as die materials are epoxy resins

and polyurethane.

• Epoxy resins are cured at room temperature and are dimensionally

stable.

• It has very good abrasion resistance.

• It has higher strength.

Disadvantages

• It is more expensive than die stone.

• It undergoes some shrinkage during polymerization.

• Prosthesis fabricated on resin dies fits more tightly.

• It is not compatible with materials such as polysulphides and

hydrocolloids.

• It is a time-consuming, complex procedure.

Electroplated dies

• Electroplated dies are used to provide good abrasion resistance and

high strength.

• It involves the deposition of a coat of pure silver or graphite.

• A layer of pure metal is deposited on the impression and is

supported by die stone.

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