Herbert T. Shillingburg, Jr, DDS David Ross Boyd Professor Emeritus Department of Fixed Prosthodontics University of Oklahoma College of Dentistry Oklahoma City, Oklahoma with David A. Sather, DDS Edwin L. Wilson, Jr, DDS, MEd Joseph R. Cain, DDS, MS Donald L. Mitchell, DDS, MS Luis J. Blanco, DMD, MS James C. Kessler, DDS Illustrations by Suzan E. Stone Quintessence Publishing Co, Inc Chicago, Berlin, Tokyo, London, Paris, Milan, Barcelona, Istanbul, Moscow, New Delhi, Prague, São Paulo, and Warsaw Cover design based on a photograph of Monument Valley on the Navajo Reservation in northern Arizona taken at sunrise by Dr Herbert T. Shillingburg, Jr. Contents Dedication vii Authors viii Preface ix Acknowledgments x 1 An Introduction to Fixed Prosthodontics 1 2 Fundamentals of Occlusion 13 3 Articulators 27 4 Interocclusal Records 35 5 Articulation of Casts 45 6 Treatment Planning for Single-Tooth Restorations 71 7 Treatment Planning for the Replacement of Missing Teeth 81 8 Fixed Partial Denture and Implant Con!gurations 99 9 Principles of Tooth Preparations 131 10 Preparations for Full Coverage Crowns 149 11 Preparations for Partial Coverage Crowns 165 12 Preparations for Intracoronal Restorations 193 13 Preparations for Severely Debilitated Teeth 203 14 Preparations for Periodontally Weakened Teeth 229 15 Provisional Restorations 241 16 Fluid Control and Soft Tissue Management 269 291 17 Impressions 325 18 Working Casts and Dies 343 19 Wax Patterns 363 20 Investing and Casting 383 21 Cementation and Bonding 413 22 Esthetic Considerations 425 23 All-Ceramic Restorations 447 24 Metal-Ceramic Restorations 471 25 Pontics and Edentulous Ridges 493 26 Solder Joints and Other Connectors 517 27 Restoration of Osseointegrated Dental Implants 531 28 Single-Tooth Implant Restoration 543 29 Multiple-Tooth Implant Restoration Index 555 Dedication In Memoriam Constance Murphy Shillingburg 1938–2008 This book is dedicated to the loving memory of Constance surgeries later in life, she was the most optimistic person I Murphy Shillingburg. We met at the University of New Mex- ever met. ico at the beginning of her freshman year in 1956. We were She accompanied me on 29 trips outside the United States. married 4 years later, 1 week after she graduated. During At !rst she came along because she loved to travel, and I my !rst 2 years in dental school, I made 13 trips, totaling didn’t enjoy the trips nearly as much without her. However, over 22,000 miles, from Los Angeles to Albuquerque. She I very quickly learned that my hosts and audiences were en- shared all of the triumphs and disappointments of my last 2 chanted by her. They enjoyed her as much or more than they years in dental school. It was not my career; it was our career. did me, and she used what she learned on those trips in her She supported me in all that I did. She didn’t question my teaching. She died 3 weeks after we celebrated our 48th leaving practice to start a career in academics or our mov- wedding anniversary. There is a song on the most recent ing from California to Oklahoma. We had three daughters Glen Campbell album, Ghost on the Canvas, that sums it up along the way. Although she had three open-heart surgeries perfectly: “There’s no me…without you.” in her teens because of rheumatic fever and then two cancer vii Authors Luis J. Blanco, DMD, MS David A. Sather, DDS Professor and Chair Associate Professor Department of Fixed Prosthodontics Department of Fixed Prosthodontics University of Oklahoma College of Dentistry University of Oklahoma College of Dentistry Oklahoma City, Oklahoma Oklahoma City, Oklahoma Joseph R. Cain, DDS, MS Herbert T. Shillingburg, Jr, DDS Professor Emeritus David Ross Boyd Professor Emeritus Department of Removable Prosthodontics Department of Fixed Prosthodontics University of Oklahoma College of Dentistry University of Oklahoma College of Dentistry Oklahoma City, Oklahoma Oklahoma City, Oklahoma James C. Kessler, DDS Edwin L. Wilson, Jr, DDS, MEd Director of Education Professor Emeritus L. D. Pankey Institute Department of Occlusion Key Biscayne, Florida University of Oklahoma College of Dentistry Oklahoma City, Oklahoma Donald L. Mitchell, DDS, MS Professor Emeritus Department of Oral Implantology University of Oklahoma College of Dentistry Oklahoma City, Oklahoma viii Preface Fixed prosthodontics is the art and science of restoring dam- An attempt has been made to provide a sound work- aged teeth with cast metal, metal-ceramic, or all-ceramic ing background in the various facets of !xed prosthodon- restorations and of replacing missing teeth with !xed pros- tic therapy. Current information has been added to cover theses using metal-ceramic arti!cial teeth (pontics) or metal- the increased use of new cements, new packaging and dis- ceramic crowns over implants. Successfully treating a patient pensing equipment for the use of impression materials, and by means of !xed prosthodontics requires a thoughtful com- changes in the management of soft tissues for impression bination of many aspects of dental treatment: patient edu- making. New articulators, facebows, and concepts of occlu- cation and the prevention of further dental disease, sound sion needed attention, along with precise ways of making diagnosis, periodontal therapy, operative skills, occlusal con- removable dies. The usage of periodontally weakened teeth sider ations, and, sometimes, placement of removable com- requires different designs for preparations of teeth with ex- plete or partial prostheses and endodontic treatment. posed root morphology or molars that have lost a root. Restorations in this !eld of dentistry can be the !nest ser- Different ways of handling edentulous ridges with defects vice rendered for dental patients or the worst disservice per- have given the dentist better control of the functional and petrated upon them. The path taken depends upon one’s cosmetic outcome. No longer are metal or ceramics needed knowledge of sound biologic and mechanical principles, the to somehow mask the loss of bone and soft tissue. The big- growth of manipulative skills to implement the treatment gest change in the replacement of missing teeth, of course, plan, and the development of a critical eye and judgement is the widespread use of endosseous implants, which make it for assessing detail. possible to replace teeth without damaging adjacent sound As in all !elds of the healing arts, there has been tremen- teeth. dous change in this area of dentistry in recent years. Im- The increased emphasis on cosmetic restorations has ne- proved materials, instruments, and techniques have made it cessitated expanding the chapters on those types of resto- possible for today’s operator with average skills to provide rations. The design of resin-bonded !xed partial dentures a service whose quality is on a par with that provided only has been moved to the chapters on partial coverage restora- by the most gifted dentist of years gone by. This is possible, tions. There are some uses for that type of restoration, but however, only if the dentist has a thorough background in the indications are far more limited than they were thought the principles of restorative dentistry and an intimate knowl- to be a few years ago. edge of the techniques required. Updated references document the rationale for using ma- This book was designed to serve as an introduction to the terials and techniques and familiarize the reader with the lit- area of restorative dentistry dealing with !xed partial dentures erature in the various aspects of !xed prosthodontics. If and cast metal, metal-ceramic, and all-ceramic restorations. more background information on speci!c topics is desired, It should provide the background knowledge needed by the several books are recommended: For detailed treatment of novice as well as serve as a refresher for the practitioner or dental materials, refer to Kenneth J. Anusavice’s Phillip’s Sci- graduate student. ence of Dental Materials, Eleventh Edition (Saunders, 2003) To provide the needed background for formulating ratio- or William J. O’Brien’s Dental Materials and Their Selection, nal judgments in the clinical environment, there are chapters Fourth Edition (Quintessence, 2008). For an in-depth study of dealing with the fundamentals of treatment planning, occlu- occlusion, see Jeffrey P. Okeson’s Management of Temporo- sion, and tooth preparation. In addition, sections of other mandibular Disorders and Occlusion, Sixth Edition (Mosby, chapters are devoted to the fundamentals of the respective 2007). The topic of tooth preparations is discussed in detail subjects. Speci!c techniques and instruments are discussed in Fundamentals of Tooth Preparations (Quintessence, 1987) because dentists and dental technicians must deal with them by Herbert T. Shillingburg et al. For detailed coverage of oc- in their daily work. clusal morphology used in waxing restorations, consult the Alternative techniques are given when there are multiple Guide to Occlusal Waxing (Quintessence, 1984) by Herbert techniques widely used in the profession. Frequently, how- T. Shillingburg et al. Books of particular interest in the area of ever, only one technique is presented. Cognizance is given to ceramics include W. Patrick Naylor’s Introduction to Metal the fact that there is usually more than one acceptable way Ceramic Technology (Quintessence, 2009) and Christoph of accomplishing a particular task. However, in the limited Hämmerle et al’s Dental Ceramics: Essential Aspects for time available in the undergraduate dental curriculum, there Clinical Practice (Quintessence, 2009). is usually time for the mastery of only one basic technique for accomplishing each of the various types of treatment. —Herbert T. Shillingburg, Jr, DDS ix Acknowledgments No book is the work of just its authors. It is dif!cult to say Lee Holmstead, Brasseler USA, for his assistance with the which ideas are our own and which are an amalgam of those illustrations of the diamonds and carbide burs. with whom we have associated.