C H A P T E R 3 1
Postoperative Care
After placement and cementation of a fixed dental pros- agent that may have been overlooked previously and that thesis (FDP), patient treatment continues with a care- all aspects of the occlusion remain satisfactory. fully structured sequence of postoperative appointments Radiolucent cements should be avoided because designed to monitor the patient’s dental health (Fig. detecting excess luting agent radiographically is impos- 31-1), ensure meticulous plaque control habits, identify sible if that material is effectively radiolucent. With luting any incipient disease, and introduce any corrective agents of greater radiopacity, excess cement is spotted treatment that may be needed before irreversible future more easily on routine radiographs; therefore, the dentist damage occurs. should choose a luting agent that is as radiopaque as Patients should be instructed in special plaque-control possible. In practice, luting agents are available in a measures, especially around pontics and connectors, and wide range of radiopacities.4-6 Figure 31-5 summarizes the use of special oral hygiene aids such as floss threaders data from these studies. (Fig. 31-2). If pontics are properly designed (see Chapter The presence of fremitus (see Chapter 1), or “pol- 20), floss can be looped through the embrasure spaces on ished” facets, on the occluding surfaces of cast restora- each side, and the loop can be pulled tightly against the tions at the postcementation appointment should prompt convex pontic tissue surface. A sliding motion is then a careful reassessment and correction of the occlusion. If used to remove dental plaque (Fig. 31-3). Flossing under any minor shift in tooth position has occurred, some pontics is essential for improving prosthesis longevity. occlusal adjustment may be necessary. If so, the patient When dental floss is used, the mucosa beneath pontics is rescheduled to visit the following week to confirm that remains healthy; without its use, mild or moderate no further correction is needed. inflammation results.1 Tissue response has been shown to be independent of the pontic material.2 Recall examinations are especially important for PERIODIC RECALL patients with extensive restorations and should be carried out by the dentist. Responsibility for follow-up care Patients with cast restorations should attend recall visits should not be delegated to auxiliary personnel (although at least every 6 months. If recall is less frequent, recurrent good cooperation with a dental hygienist is beneficial caries or the development of periodontal disease may go for success). undetected. Patients who have been provided with exten- Detecting disease around an FDP can be extremely sive FDPs (Fig. 31-6) need more frequent recall appoint- difficult at a stage when corrective treatment is still rela- ments, particularly when advanced periodontal disease is tively simple. For instance, partial dissolution of the present. The restorative dentist or the periodontist can luting agent may be difficult to diagnose with a subgin- coordinate these appointments. To ensure treatment con- gival margin. Caries is often detected only after irrevers- tinuity, it is imperative to establish in advance who will ible pulp involvement has resulted. Caries under a crown assume primary responsibility for coordinating recall is more difficult to detect radiographically, although appointments. bitewing images provide some interproximal informa- tion. Follow-up studies on patients with FDPs reveal that History and General Examination identifying risk factors and predicting the development of caries in any particular patient are complicated. The patient’s medical history should be reviewed and However, there is no indication that caries is more likely updated at least annually. The patient should be exam- to occur in association with prostheses than on unre- ined according to the principles introduced in Chapter 1. stored teeth.3 Particular attention is paid to the soft tissues because If caries is overlooked, disease may rapidly progress to early signs of oral cancer may be detected at a recall the point at which the fabrication of a new prosthesis appointment. becomes inevitable or, even worse, tooth loss results. Oral Hygiene, Diet, and Saliva POSTCEMENTATION APPOINTMENTS Patients tend to become somewhat less diligent in their plaque control efforts when the active phase of their To enable the dentist to monitor the function and comfort treatment is completed. The dentist should look carefully of the prosthesis and to verify that the patient has mas- for any signs of deterioration in oral hygiene and assess tered proper plaque control (Fig. 31-4), an appointment the general effectiveness of plaque control at every recall is generally scheduled within a week to 10 days after the with an objective index (Fig. 31-7). Deficiencies must cementation of an FDP. The dentist should check care- be identified early, and corrective therapy should be fully that the gingival sulcus is clear of any residual luting initiated. The dentist should ask about changes in diet, 792 31 Postoperative Care 793
FIGURE 31-4 ■ Postcementation monitoring of plaque control is necessary around recently cemented restorations. In this FIGURE 31-1 ■ Treatment after placement of multiple restora- patient, poor oral hygiene has led to gingival inflammation tions. To ensure tissue health and long-term success, proper (arrows). oral hygiene is mandatory.
Saliva plays an important role in caries development. Patients with xerostomia can rapidly develop extensive carious lesions.7 Diagnosing the cause of reduced saliva is imperative; the origin is often a drug side effect.8 Patients with dry mouth should be on a more frequent recall schedule (e.g., every 3 months), and fluoride varnish may be applied. A protocol of a chlorhexidine 0.12% 10-mL rinse for 1 minute daily for one week each month, in combination with xylitol gum or candies and high- fluoride toothpaste, has been advocated.9
Dental Caries Dental caries (Fig. 31-8) is the most common cause of failure of a cast restoration.10-13 Detection can be very difficult,14 particularly where complete coverage is used. FIGURE 31-2 ■ Oral hygiene aids designed to maintain partial At each appointment, the teeth should be thoroughly fixed dental prostheses. dried and visually inspected (Fig. 31-9). The explorer must be used very carefully when early enamel lesions are assessed because a heavy-handed examination may damage the fragile demineralized enamel matrix. An intact enamel matrix is essential for procedures that induce remineralization15 (e.g., improved plaque control, dietary changes, topical fluoride applications). Conservative treatment of caries at the cavosurface margin is especially problematic. The lesion can spread rapidly, particularly if the restoration has a suboptimal marginal fit. Use of a small restoration made with amalgam, composite resin, or glass ionomer sometimes corrects the problem (Fig. 31-10). If the cast restoration is supported by an amalgam or composite resin core, the extent of the caries may be difficult to determine. When there is doubt that all carious dentin has been removed, replacing the entire restoration is recommended. FIGURE 31-3 ■ The patient should be instructed in the use of floss to clean partial fixed dental prostheses. Root Caries Caries of exposed root surfaces (Fig. 31-11) can be a severe problem in patients older than 50 (the age group particularly increased sugar consumption or “fad” diets. of patients who most commonly seek fixed prosthodontic Excessive weight loss or gain should also be investigated. care).16-18 In the classic Vipeholm study,19 root caries For instance, a patient who has recently stopped smoking accounted for more than 50% of new lesions in patients may start ingesting large amounts of candy, which can in that age group. Root caries incidence increased con- result in an increase in dental caries. siderably with age.20 In the caries examination from phase 794 PART IV Clinical Procedures: Section 2
Radiopacity Luting Agents
mm/Al/4 mm 15
Glass Zinc Resins ionomers Polycarboxylates phosphates 12
Study: Akerboom et al
Resin ionomer El-Mowafy et al 9 Matsumara
Enamel 6
Increasing radiopacity Dentin
3
0 Tulux Estilux G-Cera Durelon GC Elite All-Bond Fuji Bond GC Carbo Dicor MGC 3M Indirect Ketac-Cem Clearfil Inlay Duo Cement Shofu Carbo Mirage Bond Dual Cement Vitrebond LC Porcelite Dual Shofu HY-Bond GI Shofu HY-Bond ZP Getz Zinc Phosphate FIGURE 31-5 ■ Radiopacity of luting agents. In three in vitro studies,4-6 investigators compared the radiographic appearance of various luting agents with that of aluminum. The data were normalized to account for different specimen thicknesses used by the investiga- tors. Excess luting agent is more difficult to detect if materials have lower radiopacity values. In addition, margin gaps and recurrent caries are more difficult to diagnose.
or caused by medication or radiation treatment has been implicated in the origin of rampant caries.23-25 Other factors include the patient’s economic status, diet, oral hygiene, and ethnic background.26 Only a most vigorous effort on the part of the dentist and patient leads to resolution of the problem. Prevention is focused on diet counseling and fluoride treatment. Treatment often requires the placement of large cervical glass ionomer or amalgam restorations that wrap around the periphery of previously placed cast restorations. Such restorations are difficult to place. However, in view of the constraints, they are a preferred alternative to compre- hensive re-treatment with elaborate FDPs.
Periodontal Disease FIGURE 31-6 ■ Patients who have received extensive treatment of this nature require frequent follow-up care. Unfortunately, periodontal disease often occurs after placement of FDPs,27 especially where the cavosurface margin has been placed subgingivally28-30 or if the pros- 1 of the Third National Health and Nutrition Examina- thesis is overcontoured.31 Inflammation is more severe tion Survey, root caries affected 22.5% of the dentate with poorly fitting restorations32 (Fig. 31-12), but even population.21 Root caries seems to be associated with “perfect” margins have been associated with perio individual dental plaque scores and high counts of sali- dontitis.33 At recall appointments, the dentist should be vary Streptococcus mutans.22 Xerostomia that is age-related particularly alert for sulcular hemorrhage, furcation 31 Postoperative Care 795
Plaque control record Previous index Present index
A
Name Date
Plaque control record Previous index Present index
FIGURE 31-9 ■ Drying the teeth facilitates assessment of the margin integrity of a cemented prosthesis. B
Name Date FIGURE 31-7 ■ A, Plaque control record filled out at the first appointment for teaching proper oral hygiene measures. B, Plaque control record after four sessions of instruction. This patient’s plaque level is such that definitive treatment can begin. This level of plaque control needs to be maintained during the postoperative phase of treatment. (Modified from Goldman HM, Cohen DW: Periodontal therapy, 5th ed. St. Louis, Mosby, 1973.)
FIGURE 31-10 ■ Occasionally, cervical glass ionomer or amalgam restorations (arrows) can extend the useful life of a previously placed cast restoration and postpone complicated replacement of the prosthesis.
FIGURE 31-8 ■ Undetected caries beneath this partial fixed dental FIGURE 31-11 ■ Extensive root caries beneath a cemented partial prosthesis resulted in serious complications. fixed dental prosthesis. (Courtesy Dr. J. Keene.) involvement, and calculus formation as early signs of asked about any noxious habits such as bruxism. An exam- periodontal disease. Improperly contoured restorations ination of the occlusal surfaces may reveal abnormal wear should be recontoured or replaced. facets (Fig. 31-13). In particular, the canines should be inspected because wear in this area soon leads to other Occlusal Dysfunction excursive interferences. If parafunctional activity is a cause of tooth wear, the progression of facet formation At each recall appointment, the patient is examined for often begins on the canines. In a slightly more advanced signs of occlusal dysfunction. The patient should be state of wear, additional facets can be observed on the 796 PART IV Clinical Procedures: Section 2
A B
C D
E F
FIGURE 31-12 ■ Periodontal failure resulting from defective fixed dental prostheses. A, Inadequate margins and contour. B, Appear- ance before surgery. C, Flap reflected. D, Appearance after surgical recontouring. E, Radiograph of new cast restorations. F, Replace- ment restorations. (Courtesy Dr. C.L. Politis.)
be periodically remade (Fig. 31-14) and compared with previous records so that any occlusal changes can be monitored and corrective treatment initiated. A small number of patients may not have responded well to previous occlusal treatment or may resume parafunctional activity some time after completion of the active phase of fixed prosthodontic treatment. Although resolving the underlying cause is preferable, prescribing a night guard is occasionally helpful (Fig. 31-15). Its design is identical to that of the occlusal device described in Chapter 4 for treating neuromuscular symptoms resulting from malocclusion. However, the device is worn only at night. If the patient primarily clenches, the dentist should consider a slightly flatter anterior ramp than is FIGURE 31-13 ■ If a cast restoration is not designed according to ordinarily incorporated in the conventional device. neuromuscular and temporomandibular controls, extensive wear can result after a relatively short time. Pulp and Periapical Health incisor teeth, after which excursive interfering contacts At the recall appointment, the patient may describe one result in wear facets on the posterior teeth. Abnormal or more episodes of pain during the previous months. tooth mobility is investigated, as is muscle and joint pain. This could indicate the loss of vitality of an abutment A standardized muscle-and-joint palpation technique (see tooth and should be investigated. Appropriate corrective Chapter 1) is helpful. Articulated diagnostic casts should measures can then be made. 31 Postoperative Care 797
B
A
C
D E
F G,H
FIGURE 31-14 ■ Posttreatment occlusal analysis. A, Diagnostic casts should be articulated periodically. B and C, Nonworking wear facets on the maxillary molar correspond with wear on the premolar, canine, and lateral incisor. D and E, Mandibular excursion corresponding to the observed wear patterns. F and G, After marking, the newly detected interferences can be easily removed. H, The adjusted surfaces are polished.
A B
FIGURE 31-15 ■ A and B, It may be essential to prescribe an occlusal device after extensive fixed prosthodontic treatment has been provided, especially if occlusal porcelain is used or the patient has a bruxism habit. 798 PART IV Clinical Procedures: Section 2
One advantage of partial-coverage restorations is that be shielded from further fracture when a small chip is pulp health can be monitored with an electric pulp tester promptly rounded off and the occlusion adjusted imme- (Fig. 31-16), although the vitality of any tooth with a diately after it is first noticed. All-ceramic crowns are complete crown can still be assessed by thermal means. subject to fracture, which often necessitates their replace- Correlating the histologic condition of a pulp directly ment (Fig. 31-18). Postponement of corrective treatment with the patient’s response to pulp testing is difficult.34 can be especially costly, necessitating a remake of a Therefore, such results should be combined with other complex prosthesis that could have been saved with clinical data that result from careful patient history docu- prompt attention. mentation and examination. Consultation with an endo- dontist is often advisable (Fig. 31-17). Radiographs Pain provide useful information about the presence of periapi- cal pathosis. Teeth with fixed restorations should be A patient presenting with pain should be asked about its reviewed radiographically every few years. The use of a location, character, severity, timing, and onset. Factors standardized technique enables the dentist to make an that precipitate, relieve, or change the pain should be objective comparison with previous films. Although the investigated, and appropriate treatment measures should incidence of periapical disease in association with FDPs be initiated (see Chapter 3). is high in some studies,35,36 it is low in others.30,37,38 Although most oral pain is of pulpal origin, such an origin should never be assumed. A detailed investigation is always recommended. In difficult or questionable situ- EMERGENCY APPOINTMENTS ations, the diagnosis should be confirmed by an appropri- ate specialist. On occasion, patients have an emergency between routine If the patient has several endodontically treated teeth recall visits. With carefully planned and executed treat- that have been restored with posts and cores and with ment, however, these should be rare (although problems FDPs, the possibility of root fracture should be consid- can still develop even with the best treatment). Patients ered, especially for teeth that were internally weakened should be taught to notice small changes in their oral as a result of endodontic treatment in conjunction with health and to report them without delay. For instance, oversized posts of suboptimal length. If a fracture has the porcelain veneer of a metal-ceramic restoration may occurred, the tooth is almost invariably lost, which can
A B
FIGURE 31-16 ■ A and B, Partial-coverage restorations offer the advantage of convenient vitality assessment with an electric pulp tester.
A B,C
FIGURE 31-17 ■ Endodontic treatment after crown cementation. A, Symptomatic maxillary molar with a metal-ceramic crown. B, Access cavity prepared through the crown. C, Endodontic therapy in progress. (Courtesy Dr. D.A. Miller.) 31 Postoperative Care 799 significantly complicate follow-up treatment, especially if supported by several abutment teeth. The patient may it involves an abutment tooth for an FDP (Fig. 31-19). have noticed a bad taste or smell rather than detecting Fracture of a tooth that has not been endodontically movement. treated can be confirmed by sequential loading of indi- Unless appropriate instrumentation is available, vidual cusps (Fig. 31-20). Pain on release, the neural removing the prosthesis intact for recementation is often signal for which is transmitted by Aδ fibers, can be indica- difficult or impossible. The more recently developed tive of radicular fracture. Sophisticated electronic testing devices shown in Figures 31-22 to 31-24 have been suc- to determine whether teeth have been fractured has also cessful, but they are expensive. The devices shown in been reported.39 Figure 31-25 are less reliable and can be quite intimidat- ing and uncomfortable for the patient. On occasion, a Loose Abutment Retainer direct pull with hemostat forceps or special crown- removal forceps (Trial Crown Remover, Hu-Friedy Mfg. Looseness of a retainer (Fig. 31-21) may not be easily perceived by the patient, especially if it is part of an FDP
FIGURE 31-20 ■ A tooth Sleuth can be used to selectively load FIGURE 31-18 ■ Clinical example of a fracture in an all-ceramic individual cusps of teeth that are suspected of having a radicular restoration. (Courtesy Dr. D. Ketteman.) fracture. Pain on release is indicative of fracture.
A B
C D
FIGURE 31-19 ■ A, Longitudinal root fracture of an abutment tooth for a partial removable dental prosthesis necessitated removal of the abutment tooth. B and C, Longitudinal fracture with resulting periodontal defect. D, Fracture is clearly visible after removal. (Courtesy Dr. D.A. Miller.) 800 PART IV Clinical Procedures: Section 2
A B
C D
FIGURE 31-21 ■ A, Severe tooth destruction may result when looseness of a retainer goes undetected. B, Looseness of one retainer is occasionally observed directly (arrow) when force is exerted in an occlusal direction. Water is then applied to the cervical area (C), and the diagnosis is confirmed if bubbles appear (arrow) when pressure is exerted (D).
A B
C
FIGURE 31-22 ■ CORONAflex crown remover. This is an air-driven device that connects to standard dental handpiece hoses via KaVo’s MULTIflex coupler. The crown remover delivers a controlled low-amplitude impact at its tip. The device works well on partial fixed dental prostheses (FDPs) and is well tolerated by patients. A, The kit includes calipers, loops to thread under FDP connectors that attach to a holder, and an adhesive clamp to obtain purchase on single crowns. The goal is to deliver the impact in the long axis of the abutment tooth. B, The loop is threaded under the connector. The tip of the crown remover is placed on the bar, and the impact is activated by releasing the index finger from the air valve. C, The adhesive clamp is attached with autopolymerizing resin used to remove a single crown. (A and C, Courtesy KaVo Dental, Charlotte, North Carolina.) 31 Postoperative Care 801
A B
C D
E F
G H
FIGURE 31-23 ■ The Metalift Crown and Bridge Removal System (Classic Practice Resources, Inc.). A, Five-unit partial fixed dental prosthesis (FDP) supporting a partial removable dental prosthesis. The anterior abutment (right mandibular central incisor) is loose; the posterior abutments (both right mandibular premolars) are firmly cemented. B, To obtain access to the metal on each abutment, a diamond is used to drill through the porcelain. C, The metal is penetrated with a No. 1 round bur to create a pilot channel in each abutment. D, The special drill is inserted into the pilot hole. E, The holes should just penetrate the metal, as indicated by the visible cement. F, The Metalift instrument is threaded into both crowns, breaking the cement seal. The partial FDP is removed (G), and if the abutments are satisfactory, as seen here (H), it can be recemented for further service. The manufacturer supplies threaded keys that can be used to seal the occlusal holes. To facilitate recovery, they can also be incorporated in crowns before cementation. (Courtesy Dr. R.D. Westerman.) 802 PART IV Clinical Procedures: Section 2
A B
FIGURE 31-24 ■ Removal devices. A, GC Pliers. This device has specially rasped finish with small sharp pins and is designed to grip a crown or partial fixed dental prosthesis and to deliver a removal force along the long axis. Grip can be enhanced with emery powder. B, Easy Pneumatic Crown and Bridge Remover II. With this device, compressed air is used to deliver a controlled, adjust- able force to remove the restoration. (A, Courtesy GC America, Inc., Alsip, Illinois. B, Courtesy Dent Corp Research and Development, White Plains, New York.)
A B
FIGURE 31-25 ■ Crown removers. A, Back-action. B, Spring-activated. (A, Courtesy Henry Schein Inc., Melville, New York. B, Courtesy Peerless International Inc., North Easton, Massachusetts.)
A B
FIGURE 31-26 ■ Richwil Crown and Bridge Remover (Almore International, Inc., Portland, Oregon). This adhesive resin tablet is sof- tened in warm water for 1 to 2 minutes, and the patient is instructed to close into it (A); the manufacturer recommends tying a length of floss to the tablet to prevent aspiration. The resin is cooled with water. A sharp opening action should remove the crown (B). Care is needed to avoid removing a restoration in the opposing jaw.
Co.) succeeds. (Metal-ceramic crowns should first be certain situations42 (Fig. 31-26). When trying to remove coated with autopolymerizing acrylic resin to prevent a definitively cemented prosthesis, the dentist must use chipping or cracking.) Applying the tip of an ultrasonic great caution. Unless force is applied in the path of with- scaler to the restoration is recommended because pro- drawal, an abutment tooth may fracture and be lost. longed ultrasonic vibration can decrease crown reten- Looseness of a retainer usually indicates inadequate tion.40 A procedure for removing crowns and FDPs with tooth preparation, poor cementation technique, or caries. a strongly adhesive resin41 has been used successfully in In this situation, the tooth requires repreparation and a 31 Postoperative Care 803 new prosthesis. Sectioning the prosthesis rather than periodontal ligament may draw attention away from the attempting to remove it intact is often the best procedure location of the actual problem. If the abutment teeth have (Fig. 31-27). good bone support and minimal mobility, fractures of connectors can be very difficult to detect clinically. Fractured Connector Wedges can sometimes be positioned to separate the individual FDP components enough to confirm the An improperly fabricated connector may fracture under correct diagnosis. functional loading (Fig. 31-28). Depending on the design and location of the FDP, the degree of pain may vary. Fractured Porcelain Veneer Because the load is no longer shared between the abut- ment teeth, extra force is typically transmitted to the Mechanical failure of a metal-ceramic restoration abutment tooth, and discomfort from overloading the (Fig. 31-29) is not uncommon. It is usually related to
A B
C D
E F
G H
FIGURE 31-27 ■ Removal of an existing crown by sectioning. A, This cantilevered partial fixed dental prosthesis had to be replaced for esthetic and periodontal reasons. B, The restoration is carefully sectioned, with the initial cut through the ceramic just to the metal. It is easiest to do this on the facial and incisal surfaces. C, The goal is to cut through the metal just to the cement and follow the cement toward the gingival margin. The gingiva is displaced with an instrument (D), and the crown is carefully sectioned to the gingival margin (E). F, A suitable instrument (e.g., a cement spatula or sterilized screwdriver) is placed in the cut and gently rotated to force the halves of the crown apart. It may be necessary to section part of the lingual surface to facilitate this step. G, The abut- ment. Additional incisal reduction was necessary; the notch in the incisal edge is of no concern. H, Removed prosthesis. Continued 804 PART IV Clinical Procedures: Section 2
J I
L
K
FIGURE 31-27, cont’d ■ I, A cut has been made through the mesiobuccal and occlusal surfaces of the defective metal-ceramic crown. An elevator is used to bend the crown open, initially from the buccal surface (J), and then the occlusal aspect (K). Note that gauze is used to capture any metal-ceramic shards that may chip off. L, On removal of the crown, the residual tooth structure can be assessed for further modification. (A-H, Courtesy Dr. D.H. Ward.)
A B
FIGURE 31-28 ■ A, The soldered connector (arrow) of a four-unit partial fixed dental prosthesis fractured during function. B, The soldering gap was too narrow; as a result, the connector was incomplete, which eventually caused the clinical failure. The long lever arm, which consisted of the two “cantilevered” pontics that resulted after fracture, caused the pulpal irritation to arise.
faults in framework design, improper laboratory proce- dures, excessive occlusal function, or trauma (e.g., an automobile or sports accident). All-ceramic crowns are also susceptible to fracture after extended use (Fig. 31-30). If the porcelain has fractured on an otherwise satisfac- tory multiunit prosthesis, an attempt at repair rather than a remake may be justified to save the patient additional discomfort, time, and expense. When the fractured porcelain is not missing and there is little or no functional loading on the fracture site, it can some- FIGURE 31-29 ■ The incisal edge of the maxillary lateral incisor times be bonded in place with a porcelain repair system metal-ceramic pontic has fractured. (Fig. 31-31) with the use of silane coupling agents or 31 Postoperative Care 805
A A
B
B
FIGURE 31-31 ■ On occasion, repairing a fractured metal-ceramic C veneer is more advantageous than replacing the entire fixed dental prosthesis. A, Fractured central incisor pontic of an extensive prostheses. B, The porcelain surface has been etched; a resin repair system has been used.
FIGURE 31-30 ■ A, In this monolithic zirconia molar crown, a crack extended from the central fossa to the mesiolingual surface. B, The lingual surfaces of veneered zirconia crowns on both central incisors exhibit cracking. These crowns had been RE-TREATMENT in service for approximately 7 years before failure occurred. C, Fractures in pressed lithium-disilicate crowns. (A to C, Cour- FDPs do not last forever; however, with good plaque tesy Dr. D. Ketteman.) removal, patient motivation, and average or above- average resistance to disease, a well-designed and well- fabricated restoration can provide many years of service. With poor care and neglect, even the “perfect” prosthesis 4-methacryloxyethyl-trimellitic anhydride (4-META) to or restoration can fail rapidly (Fig. 31-33). Because promote bonding with acrylic or composite resin.43-46 of exceptional host resistance, long-term success is Unfortunately, the strength of joints made this way seems sometimes possible with obviously defective restorations to diminish with changes in temperature47 and with pro- (Fig. 31-34). longed water storage.48 Benefits from such repair are con- Nevertheless, at some stage, the decision about sidered temporary, but it may be preferable to periodically re-treatment must be made. Much depends on whether perform a repair than to dismantle and remake a complex the re-treatment is part of an ongoing program of com- FDP. In other circumstances, the fractured area may be prehensive care or whether the existing prosthesis has repaired with composite resin retained by means of been subjected to years of neglect. mechanical undercuts in the metal framework.49 The use of a silane coupling agent is also recommended for these Planned Re-treatment repairs. A metal-ceramic restoration made to fit over the frac- At the original treatment planning stage, the need for tured original sometimes provides a more permanent future re-treatment should be considered. This consid- repair. This technique is appropriate when the pontic eration may need to be general rather than specific rather than an abutment retainer has fractured. A little because of difficulties in accurately predicting the pattern ingenuity is needed to produce a suitable design.50,51 The of future dental disease. On occasion, however, a pros- most common difficulty encountered when such a repair thesis is designed to accommodate the eventual failure of is attempted is weakening of the connectors during the a doubtful abutment (Fig. 31-35). With a little foresight, preparation, with the associated risk of subsequent pros- survey contours can already be incorporated in the retain- thesis fracture (Fig. 31-32). ers of an FDP to accommodate a future partial removable 806 PART IV Clinical Procedures: Section 2
A B
C D,E
F G,H
I J,K
L M,N
O P
FIGURE 31-32 ■ Repair of a fractured metal-ceramic pontic. A, Pretreatment appearance. B, The ceramic veneer is removed with diamond rotary instruments. C, Appearance after porcelain removal. D, Special impression tray. E, Pinholes are placed in the sub- structure. F, Cast of the substructure. G and H, Waxed overlay. Note the plastic pins used (H). I, Cast overlay. J, Facial view. K, Proximal view. L, Facial view after the porcelain application. M, Lingual view after firing (cast relieved). N, Appearance after cementation. O and P, The finished repair. (Courtesy Dr. A.G. Gegauff.) 31 Postoperative Care 807 dental prosthesis in the event of loss of a terminal abut- TREATMENT PRESENTATIONS ment. Similarly, accommodations can be made for future occlusal rests by intentionally increasing occlusal reduc- Several treatment results are presented, including tion during tooth preparation and using metal occlusal follow-up documentation as appropriate, in some cases surfaces. Furthermore, proximal boxes can be incorpo- over many years. The treatments demonstrate successful rated to achieve extra metal thickness if it is anticipated treatment approaches that are consistent with the princi- that a nonrigid (dovetail) rest could simplify future ples discussed throughout this text. re-treatment (see Fig. 31-35). • Treatment I (Fig. 31-36): simple cast restorations When tooth preparations are conservative, when • Treatment II (Fig. 31-37): single cast restorations preparation margins are supragingival, and when compli- • Treatment III (Fig. 31-38): simple partial FDPs cated FDP designs are avoided, subsequent re-treatment • Treatment IV (Fig. 31-39): full-mouth rehabilita- and replacement of failed work can be performed in a tion with FDPs and removable prostheses predictable manner, provided that plaque control and • Treatment V (Fig. 31-40): extensive fixed prostho- follow-up care are maintained. dontic treatment The key to successful fixed prosthodontic treatment • Treatment VI (Fig. 31-41): extensive fixed and planning (see Chapter 3) lies in anticipating potential removable prosthodontic treatment areas of future failure. Ideally, the design of a prosthesis • Treatment VII (Fig. 31-42): anticipation of future should incorporate an escape mechanism to allow simple needs and convenient alteration to accommodate future treat- • Treatment VIII (Fig. 31-43): long-term evaluation ment needs. of comprehensive rehabilitation with FDPs and removable dental prostheses Neglect • Treatment IX (Fig. 31-44): long-term evaluation of comprehensive rehabilitation with FDPs An extensive FDP that has been neglected is much more • Treatment X (Fig. 31-45): long-term evaluation of difficult to treat. Considerable expertise is needed to perform comprehensive rehabilitation of a periodontally the lengthy and demanding procedures successfully. Spe- compromised dentition cialized treatment is almost always necessary and usually • Treatment XI (Fig. 31-46): long-term evaluation of includes controlling mobility of the abutment teeth, improv- FDPs ing support for removable appliances in the edentulous area, and creating a more favorable load distribution. SUMMARY
Well-organized and efficient postoperative care is the chief mechanism for ensuring optimal longevity and success in fixed prosthodontics. A restoration that is cemented and then forgotten or ignored is likely to fail, regardless of how skillfully it was designed, created, and placed. Restored teeth require more assiduous plaque removal and maintenance than do healthy unrestored teeth, and, similarly, an FDP requires additional care and attention. Common complications after completion of the active phase of treatment include caries, periodontal failure, endodontic failure, loose retainers, porcelain fracture, 52,53 FIGURE 31-33 ■ Osseous defects (arrows) occurred within 2 years and root fracture. If possible, the dentist should of the placement of this partial fixed dental prosthesis. (Courtesy anticipate the long-term prognosis and treatment needs Dr. J. Keene.) Text continued on p. 827
A B
FIGURE 31-34 ■ A, A “saddle” pontic should not be fabricated because it makes plaque control impossible. This particular partial fixed dental prosthesis, however, served for 35 years. B, Despite poor pontic design, there are no significant signs of ulceration. This example illustrates the variability of tissue response as a result of differences in host resistance. 808 PART IV Clinical Procedures: Section 2
A B
C D
E F
FIGURE 31-35 ■ Anticipation of future needs. A, Appearance 4 years after the restoration of an arch with periodontally compromised teeth. Three intracoronal rests (arrows) were fabricated to support a partial removable dental prosthesis (RDP). B, An additional rest (arrow) was included as a nonrigid connector for splinting the prostheses in the maxillary left quadrant. This rest is parallel to the others, and so it is available (if needed) for future support of a modified or new RDP. C, The lingual wall of the premolar incorporates the appropriate survey contour (arrow) to accommodate such a prosthesis. D, The RDP in place. Note the third intracoronal rest (arrow). E and F, External and internal views of the RDP. This was cast in type IV gold, which allows the relatively easy addition of a new minor connector with conventional soldering techniques. 31 Postoperative Care 809
A B
C D
FIGURE 31-36 ■ Simple cast restorations (treatment I): a complete cast crown and an inlay used to restore the first molars. A, Wax patterns. B, Castings seated and adjusted for clinical evaluation. C, Cemented restorations. D, This two-surface intracoronal cast restoration served for 66 years. 810 PART IV Clinical Procedures: Section 2
A B
C D
E F
G
FIGURE 31-37 ■ Single cast restorations (treatment II) reestablish canine guidance and functional occlusion. A, Extensive anterior wear caused by prolonged parafunctional activity that resulted from malocclusion. B, Anterior pinledges are waxed concurrently with the molar castings. C, Anterior guidance and posterior occlusion are reestablished. Castings seated and adjusted (D) and at clinical evaluation (E). F, A normal canine-to-canine relationship has been reestablished. G, Working-side excursion. 31 Postoperative Care 811
A B
C D
FIGURE 31-38 ■ Simple partial fixed dental prostheses (FDPs; treatment III). Long-term follow-up: These small FDPs remain service- able after 7 and 13 years. A and B, Appearance at 7-year follow-up. C and D, Appearance at 13-year follow-up. 812 PART IV Clinical Procedures: Section 2
A B,C
D E,F
G
H I
J
FIGURE 31-39 ■ Full-mouth rehabilitation with fixed, implant-supported, and removable partial prosthodontics (treatment IV). Before treatment (A to E): Note the reverse smile line and discrepancy in the maxillary central incisor gingival tissue levels. The maxillary first molars had furcation involvement and poor prognosis as a result of periodontal bone loss. A and B, Occlusal views. C, Frontal view. D and E, Right and left views in maximum intercuspation. During treatment: F, Diagnostic waxing. G, Dental implants were placed to restore the mandibular arch and to provide retention and support for a maxillary partial removable dental prosthesis (RDP). H, The gingival tissue levels were corrected with periodontal surgery. I and J, Anterior teeth were prepared for fixed restorations. 31 Postoperative Care 813
K L
M N
O P
FIGURE 31-39, cont’d ■ After treatment: Occlusal views of maxillary arch without (K) and with (L) partial RDP. M, Occlusal view of restored mandibular arch. Views in maximum intercuspation: right (N) and left (O) mirror views and frontal view (P). (Courtesy Dr. B.A. Purcell.) 814 PART IV Clinical Procedures: Section 2
A B
C D
E F
FIGURE 31-40 ■ Extensive fixed prosthodontic treatment (treatment V): teeth with advanced periodontal disease restored with fixed dental prostheses. A, Initial presentation. The patient required extraction of the right maxillary incisor and surgical correction of the periodontal defects. B, Maxillary teeth prepared for metal-ceramic restorations. C, Reversible hydrocolloid impression. D, Interim restorations. E, Definitive casts. F, Anatomic contour wax patterns. 31 Postoperative Care 815
G H
I J
K L
M N
O
FIGURE 31-40, cont’d ■ G, Patterns cut back for porcelain application. H, Patterns with sprues inserted. I, Appearance of metal frame- work at evaluation. J, Opaque porcelain applied. K, Appearance of porcelain at bisque stage. L, Centric contacts are on metal. M, Finished restorations before cementation. The extensive prosthesis is segmented with intracoronal rests. N and O, Cemented prostheses. (Courtesy Dr. M.T. Padilla.) 816 PART IV Clinical Procedures: Section 2
A B,C
D E,F
G H,I
J
FIGURE 31-41 ■ Extensive fixed and removable prosthodontic treatment (treatment VI). The patient presented with missing maxillary anterior teeth (A) and missing mandibular posterior teeth (B). There was a significant slide from centric relation to maximum inter- cuspation. The patient was treated with a combination of fixed and removable prostheses. C, Maxillary teeth were prepared, and foundation restorations were placed. D and E, Maxillary teeth waxed to anatomic contour. F and G, Completed fixed restorations. H, Definitive cast for mandibular partial removable dental prosthesis (RDP) framework before duplication. A rotational path of place- ment was used to engage mesial undercuts in second molars. I, Completed mandibular RDP. Amalgam stops were placed in the first molars to prevent premature wear of the denture teeth. J, Appearance at completion of treatment. 31 Postoperative Care 817
K L
M N
O
FIGURE 31-41, cont’d ■ K to O, Appearance 13 years after treatment. (Courtesy Dr. J.A. Holloway.) 818 PART IV Clinical Procedures: Section 2
A B
C D
E F
G H
FIGURE 31-42 ■ Anticipation of future needs (treatment VII). Appearance of maxillary teeth (A) and mandibular teeth (B) before treat- ment. Appearance at bisque bake: buccal views (C and D) and labial view (E). F, Occlusal view before clinical evaluation. G, Occlusal view at clinical evaluation. Note the location of the occlusal rests to anticipate various future partial removable dental prosthesis designs. An intracoronal rest (dovetail) was incorporated in the left lateral incisor. It is filled with composite resin, which is easily removed if the need arises. H, Appearance at completion of treatment. 31 Postoperative Care 819
A B,C
D E
F G,H
I J
FIGURE 31-43 ■ Long-term evaluation of comprehensive rehabilitation with fixed and removable dental prostheses (treatment VIII). The patient presented with multiple failing restorations and severely compromised function. A to E, Preoperative photographs. F to J, Posttreatment photographs. Where possible, I-bars were used to minimize clasp visibility. Also note the extensive use of metal occlusal surfaces. When prostheses are designed for dentitions with compromised crown-to-root ratios, the occlusion and anterior guidance components must be adjusted precisely. Continued K L,M
N O
P Q
R
S
FIGURE 31-43, cont’d ■ K to Q, Seventeen-year follow-up photographs. Note that the maxillary canine was lost and the existing retainer was modified into a pontic through the addition of composite resin. Additional endodontic treatment was needed as time passed. R, Preoperative radiographs. S, Postoperative radiographs. 31 Postoperative Care 821
T
U
FIGURE 31-43, cont’d ■ T, Eight-year postoperative radiographs. U, Seventeen-year postoperative radiographs. A fixed dental prosthe- sis (FDP) was fabricated, replacing the missing tooth #3 with teeth #5, #4, and #2 as abutments. The teeth were prepared with minimal taper, and the castings exhibited good retention. After 10 years, the FDP failed when tooth #2 became dislodged, possibly as a result of the additional loading by the removable dental prosthesis (RDP). Tooth #2 and the pontic were removed, endodontic treatment was performed, a new crown was fabricated, and the #3 pontic was incorporated in a new RDP. Tooth #6 was lost as a result of internal resorption and caries. Initially, the tooth was discolored, but the lesion was inactive, and the attempt to save it failed after 8 years. Its guarded prognosis was discussed as a significant risk factor before treatment initiation. This suggests that teeth with a guarded prognosis can be maintained if attention is paid to the principles of casting adaptation and occlusion. 822 PART IV Clinical Procedures: Section 2
A B,C
D E
F G,H
I J
FIGURE 31-44 ■ Long-term follow-up after comprehensive treatment with fixed dental prostheses (FDPs) of the patient in Fig. 31-42 (treatment IX). A to E, Preoperative photographs. F to J, Postoperative photographs. 31 Postoperative Care 823
K
L
FIGURE 31-44, cont’d ■ K, Preoperative radiographs. L, Fourteen-year postoperative radiographs. If the FDPs have been designed care- fully and the patient is cooperative and maintains excellent plaque control, FDPs can withstand the test of time. Today, these pros- theses continue to provide excellent esthetics and function after more than 16 years of service. Note that no intervention was performed for the impacted canine. Initially, the patient presented with only posterior guidance on the left and right first molars. A gingival graft was performed on the left side before the fixed prosthodontic treatment. Fourteen years later, all teeth were stable without any clinically significant mobility, and the anterior guidance components exhibited no visible faceting. No significant change occurred in bone levels, whereas apparent radiographic bone densities appeared slightly increased. Meticulous attention to precise adjustment of the occlusion, especially the anterior guidance component, contributed to the long-term success of this treatment. The 14-year postoperative radiographs showed no signs of occlusal trauma. Also, note that three endodontically treated molars had very large access cavities. Such teeth had a guarded prognosis and were prone to fracture, but no fractures had occurred. Again, this suggests the importance of precise and optimal load distribution at the time of initial treatment and during periodic follow-up appointments. Recall visits were scheduled every 6 months. 824 PART IV Clinical Procedures: Section 2
A B
C D
E F
FIGURE 31-45 ■ Comprehensive rehabilitation of severely periodontally compromised dentition (treatment X). A to C, Preoperative photographs. D to F, Fourteen-year postoperative photographs. In the initial discussion of an extensive treatment plan with a patient with a severely compromised dentition, the many risks and possibilities of failure must be fully understood by all parties. This extremely complex rehabilitation continues to serve well today. A meticulous design and frequent recall appointments, combined with outstanding home care, enabled this patient to enjoy improved function 14 years later. Throughout the follow-up, the patient was seen at 1-month and periodic 3-month recall appointments, depending on pocket charting and patient motivation. At the 14-year evaluation, tooth #4 had no attached gingiva and little bone support, but no pocket formation. Initially, it was expected that this tooth would be the first to be lost. In conjunction with loss of tooth #1, this would have necessitated a partial removable dental prosthesis or implant-supported fixed dental prosthesis. Occlusal rests, undercuts, and guide planes had been incorporated in the initial prosthesis to anticipate such failure. After more than 14 years, the prostheses continued to serve satisfactorily. The anterior guidance component was starting to show some wear. Throughout the recall period, wherever posterior tooth contact was observed in excursive movements, they were eliminated as part of ongoing occlusal adjustment. Meticulous management of load distribution contributed to the long-term success of this very complex rehabilitation. 31 Postoperative Care 825
G
H
FIGURE 31-45, cont’d ■ G, Preoperative radiographs. H, Fourteen-year postoperative radiographs. This patient was referred initially for complete maxillary and mandibular denture fabrication. Before prosthodontic treatment, the periodontal condition was treated. Treatment included a modified Widman flap, performed throughout both arches. A root resection was performed for tooth #14, and tooth #30 was hemisected, which resulted in two premolar-like restorations. Use of the severely tilted tooth #17 as a single abut- ment to support a very long span posed a substantial risk to the long-term success of this treatment, and the tooth’s future loss was anticipated in the design of the prostheses. Another risk was posed by the root structure of tooth #1, with a small, fused root. This tooth was lost after 14 years as a result of a periodontal defect that progressed along a vertical groove in the fused root. 826 PART IV Clinical Procedures: Section 2
A B,C
D E
F G,H
I J
FIGURE 31-46 ■ Long-term evaluation of fixed dental prostheses (FDPs; treatment XI). A to E, Preoperative photographs. F to J, Eighteen-year posttreatment photographs. Three simple FDPs, combining conventional and metal-ceramic prostheses with post- soldered connectors, continue to serve 18 years after initial placement. Complications over the years included the reshaping of some restorations to correct occlusal discrepancies and the endodontic treatment of tooth #19 through the prosthesis (the access cavity was restored with amalgam). The patient presented with congenitally missing teeth #4 and #12. The maxillary canine was left in the premolar position for use as an abutment with posterior disocclusion resulting from guidance on the canine-shaped pontic. This is not ideal from the perspective of force distribution; however, the canine root successfully withstood the loading over time. Risk factors initially discussed with the patient included uncertainty regarding the effect of the crown-to-root ratios on the long-term prognosis. At the time of prosthetic treatment, more than 25 years before these pictures were taken, osseous integration was not the reliable treatment modality that it is today. The patient declined a removable prosthesis as an alternative to FDPs. A pinledge retainer was used on the small lateral incisor. Over time, not only was this esthetically effective, but it contributed to long-term maintenance of its periodontal health. Similarly, a pinledge was used on the left mandibular canine, a far more conservative option than a metal-ceramic restoration. If instead metal-ceramic retainers had been used, additional treatment needs and possibly the loss of the lateral incisor may have eventually resulted. Teeth #18, #19, and #3 were treated endodontically; cast posts and cores were used. Also, note that tooth #8 has served well over time. The conservative access cavity was restored, and the favorable posi- tion in the arch results in favorable loading. Recall appointments for the patient were scheduled at 6-month intervals throughout the evaluation period. 31 Postoperative Care 827
K
L
FIGURE 31-46, cont’d ■ K, Preoperative radiographs. L, Eighteen-year postoperative radiographs.
of the patient and attempt to design the treatment plan 11. Libby G, et al: Longevity of fixed partial dentures. J Prosthet Dent accordingly. On occasion, FDPs can be designed so that 78:127, 1997. future re-treatment can be anticipated and simplified. 12. Sundh B, Odman P: A study of fixed prosthodontics performed at a university clinic 18 years after insertion. Int J Prosthodont 10:513, However, it is impossible, even for the most experienced 1997. and talented clinicians, to anticipate every contingency 13. Priest GF: Failure rates of restorations for single-tooth replace- and complication. The patient must understand the limi- ment. Int J Prosthodont 9:38, 1996. tations of fixed prosthodontics before treatment begins. 14. Bauer JG, et al: The reliability of diagnosing root caries using oral examinations. J Dent Educ 52:622, 1988. 15. Silverstone LM: Remineralization phenomena. Caries Res 11(Suppl REFERENCES 1):59, 1977. 1. Tolboe H, et al: Influence of oral hygiene on the mucosal condi- 16. Gordon SR: Older adults: demographics and need for quality care. tions beneath bridge pontics. Scand J Dent Res 95:475, 1987. J Prosthet Dent 61:737, 1989. 2. Tolboe H, et al: Influence of pontic material on alveolar mucosal 17. Hellyer PH, et al: Root caries in older people attending a general conditions. Scand J Dent Res 96:442, 1988. dental practice in East Sussex. Br Dent J 169:201, 1990. 3. Ericson G, et al: Cross-sectional study of patients fitted with fixed 18. Guivante-Nabet C, et al: Active and inactive caries lesions in a partial dentures with special reference to the caries situation. Scand selected elderly institutionalised French population. Int Dent J J Dent Res 98:8, 1990. 48:111, 1998. 4. Akerboom HB, et al: Radiopacity of posterior composite resins, 19. Gustafsson BE, et al: The Vipeholm Dental Caries Study: the effect composite resin luting cements, and glass ionomer lining cements. of different levels of carbohydrate intake on caries activity in 436 J Prosthet Dent 70:351, 1993. individuals observed for 5 years. Acta Odontol Scand 11:232, 5. Matsumura H, et al: Radiopacity of dental cements. Am J Dent 1954. 6:43, 1993. 20. Fure S: Five-year incidence of caries, salivary and microbial condi- 6. el-Mowafy OM, Benmergui C: Radiopacity of resin-based inlay tions in 60-, 70- and 80-year-old Swedish individuals. Caries Res luting cements. Oper Dent 19:11, 1994. 32:166, 1998. 7. Gibson G: Identifying and treating xerostomia in restorative 21. Winn DM, et al: Coronal and root caries in the dentition of adults patients. J Esthet Dent 10:253, 1998. in the United States, 1988-1991. J Dent Res 75(Spec. No.):642, 8. Keene JJ Jr, et al: Antidepressant use in psychiatry and medicine: 1996. importance in dental practice. J Am Dent Assoc 134:71, 2003. 22. Reiker J, et al: A cross-sectional study into the prevalence of root 9. Jenson L, et al: Clinical protocols for caries management by risk caries in periodontal maintenance patients. J Clin Periodont 26:26, assessment. CDA J 35:714, 2007. 1999. 10. Walton JN, et al: A survey of crown and fixed partial denture fail- 23. Younger H, et al: Relationship among stimulated whole, glandular ures: length of service and reasons for replacement. J Prosthet Dent salivary flow rates, and root caries prevalence in an elderly popula- 56:416, 1986. tion: a preliminary study. Spec Care Dentist 18:156, 1998. 828 PART IV Clinical Procedures: Section 2
24. Powell LV, et al: Factors associated with caries incidence in an elderly 39. Sheets CG, et al: An in vitro comparison of quantitative percussion population. Community Dent Oral Epidemiol 26:170, 1998. diagnostics with a standard technique for determining the presence 25. Sorensen JA: A rationale for comparison of plaque-retaining prop- of cracks in natural teeth. J Prosthet Dent 112:267, 2014. erties of crown systems. J Prosthet Dent 62:264, 1989. 40. Parreira FR, et al: Cast prosthesis removal using ultrasonics and a 26. Alexander AG: Periodontal aspects of conservative dentistry. Br thermoplastic resin adhesive. J Endod 20:141, 1994. Dent J 125:111, 1968. 41. Robbins JW: Intraoral repair of the fractured porcelain restoration. 27. Valderhaug J: Gingival reaction to fixed prostheses. J Dent Res Oper Dent 23:203, 1998. 50:74, 1971. 42. Chung KH, Hwang YC: Bonding strengths of porcelain repair 28. Reichen-Graden S, Lang NP: Periodontal and pulpal conditions of systems with various surface treatments. J Prosthet Dent 78:267, abutment teeth. Status after four to eight years following the incor- 1997. poration of fixed reconstructions. Schweiz Monatsschr Zahnmed 43. Kupiec KA, et al: Evaluation of porcelain surface treatments and 99:1381, 1989. agents for composite-to-porcelain repair. J Prosthet Dent 76:119, 29. Wagman SS: The role of coronal contour in gingival health. 1996. J Prosthet Dent 37:280, 1977. 44. Pameijer CH, et al: Repairing fractured porcelain: how surface 30. Mojon P, et al: Relationship between prosthodontic status, caries, preparation affects shear force resistance. J Am Dent Assoc 127:203, and periodontal disease in a geriatric population. Int J Prosthodont 1996. 8:564, 1995. 45. Nowlin TP, et al: Evaluation of the bonding of three porcelain 31. Rantanen T: A control study of crowns and bridges on root canal repair systems. J Prosthet Dent 46:516, 1981. filled teeth. Suom Hammaslaak Toim 66:275, 1970. 46. Gregory WA, et al: Composite resin repair of porcelain using dif- 32. Abou-Rass M: The stressed pulp condition: an endodontic- ferent bonding materials. Oper Dent 13:114, 1988. restorative diagnostic concept. J Prosthet Dent 48:264, 1982. 47. Barreto MT, Bottaro BF: A practical approach to porcelain repair. 33. Saunders WP, Saunders EM: Prevalence of periradicular periodon- J Prosthet Dent 48:349, 1982. titis associated with crowned teeth in an adult Scottish subpopula- 48. Welsh SL, Schwab JT: Repair technique for porcelain-fused-to- tion. Br Dent J 185:137, 1998. metal restorations. J Prosthet Dent 38:61, 1977. 34. Karlsson S: A clinical evaluation of fixed bridges, 10 years following 49. Miller TH, Thayer KE: Intraoral repair of fixed partial dentures. insertion. J Oral Rehabil 13:423, 1986. J Prosthet Dent 25:382, 1971. 35. Eckerbom M, et al: Prevalence of apical periodontitis, crowned 50. Cardoso AC, Spinelli Filho P: Clinical and laboratory techniques teeth and teeth with posts in a Swedish population. Endod Dent for repair of fractured porcelain in fixed prostheses: a case report. Traumatol 7:214, 1991. Quintessence Int 25:835, 1994. 36. Valderhaug J, et al: Assessment of the periapical and clinical status 51. Westerman RD: A new paradigm for the construction and service of crowned teeth over 25 years. J Dent 25:97, 1997. of fixed prosthodontics. Dent Today 18:62, 1999. 37. Olin PS: Effect of prolonged ultrasonic instrumentation on the 52. Goodacre CJ, et al: Clinical complications in fixed prosthodontics. retention of cemented cast crowns. J Prosthet Dent 64:563, 1990. J Prosthet Dent 90:31, 2003. 38. Oliva RA: Clinical evaluation of a new crown and fixed partial 53. Goodacre CJ, et al: Clinical complications with implants and denture remover. J Prosthet Dent 44:267, 1980. implant prostheses. J Prosthet Dent 90:121, 2003.
STUDY QUESTIONS
1. What should be included in a typical posttreatment 3. How can advanced root caries be satisfactorily assessment once the previously rendered treatment resolved? has been completed? When and how often should the patient be reexamined? Provide examples of variables 4. How is looseness of a retainer confirmed? Once this that influence this frequency. has been confirmed, how is the FDP removed?
2. What are typical complications for short-term post 5. Give three examples of treatment planning in which cementation? How can they be avoided? Once they future failure is taken into consideration. have been identified, how can they be resolved?