CROWNS, FIXED BRIDGES AND DENTAL IMPLANTS GUIDELINES

THE BRITISH SOCIETY FOR RESTORATIVE DENTISTRY INTRODUCTION Standards in healthcare are of fundamental importance. Evidence-based dentistry, audit and peer review are essential components of effective clinical practice.

To assist with these processes, the These guidelines should not WHY IS IT THAT BSRD perceives a need for guidelines be considered prescriptive or on acceptable levels of care in didactic. Obviously, there will be restorative dentistry. Some guidance circumstances, encountered during is already available from our sister patient management, when the TEETH DECAY? organisations, the British Endodontic “ideal” treatment may not be Society, the British Society of possible nor the outcome optimal. and The British In addition, new techniques and YOU DON’T ALWAYS HAVE TO GO Society of , within materials will become available their spheres of interest. which will bring about change. This document is intended to act However, it is the Society’s belief TO THE DOCTOR’S TO HAVE HOLES as a stimulus to members of the that these standards can and Society and to the profession to seek should be the goal during attainable targets for quality in fixed management of the majority of IN YOUR ARM STOPPED UP DO YOU? prosthodontics. It is hoped that this clinical cases. document from the Society will assist in the pursuit and maintenance of IT’S A FLAW IN THE DESIGN. high standards of clinical practice.

Originally published in 1993, updated in 2007 and 2013. ALAN BENNETT

2 crowns, fixed bridges and implants GUIDELINES crowns, fixed bridges and implants GUIDELINES 3 INDICATIONS ALTERNATIVES TO DEFINITION OF A THE RATIONALE The decision to provide a or fixed whether tooth or implant - supported depends on many factors, including: FIXED BRIDGE • The motivation and aspirations of In all situations, the clinical CROWNS AND Any dental that is luted, implant abutments that FOR THE USE OF: the patient. advantages and long-term benefits screwed or mechanically attached or furnish the primary support for • The oral and general health of of crowns and fixed bridges should otherwise securely retained to natural the dental prosthesis. CROWNS: FIXED BRIDGES: the patient. justify such treatment and outweigh teeth, tooth roots, and/or dental their disadvantages. They should only • To restore the form, function and • To replace one or more teeth of Tooth-supported bridges require the • The condition of the remaining The Glossary of Prosthodontic Terms J Prosthet Dent 2005; 94: 10-92 FIXED PROSTHESES appearance of teeth which are badly functional or cosmetic importance availability of sufficient abutments of be undertaken in those situations teeth and tooth tissues, the in which such advanced restorative broken down, worn or fractured to the patient. appropriate quality and prognosis. periodontal condition and oral Modern dentistry offers many For example, in the management Aspects of the provision of implant- care will clearly contribute to the oral to the extent that simpler forms of Either in the absence of adjacent hygiene maintenance. opportunities to provide direct and of the worn dentition, particularly based restorative dentistry are similar • More rarely, to prevent tooth restorations are contraindicated or suitable teeth or when they would health and welfare of the patient. indirect restorations which satisfy that damaged by erosive substances, to those for teeth whilst others movement and improve occlusal • Analysis of the benefits, have been found to fail in clinical not benefit from restoration, implant- The replacement of failed crowns aesthetic and functional requirements the use of full coverage crowns has require different considerations and stability. disadvantages and long-term service. supported prostheses should be and bridges and the teeth or of patients without the need for little to commend it as the first option skills. These guidelines will refer to consequences of providing a crown considered. Dental implants offer implants which support them should significant, if any, tooth preparation. for treatment. implant-supported crowns and fixed • To improve the form and appearance or fixed prosthesis. of unsightly teeth which cannot the benefit of being able to facilitate be conditional on an understanding Vital bleaching, composite resins, Dental implants may frequently be prostheses as necessary. • Complications which limit the be managed by more conservative tooth replacement without the of the aetiology and successful ceramic and resin- the treatment of choice when The development of adhesive likelihood of clinical success. preventive management of the cosmetic procedures. need to involve teeth adjacent to retained bridges frequently have major missing teeth are to be replaced. techniques and the predictability of the edentulous area. Where implant • The skill and experience of the cause(s) of failure. • To reduce the risk of fractures roles in any treatment plan. The biological cost to the patient is dental implants reduce the need for placement and restoration are clinician. occurring in extensively restored teeth Where teeth are minimally or low when sufficient bone is available the removal of sound tissue as part of complicated and the use of tooth- including endodontically treated moderately restored at the time of to house them. restorative treatment. supported fixed bridgework is contra- posterior teeth. presentation, adhesive restorations indicated the use of removable partial are generally most appropriate. • More rarely, to alter significantly the prostheses will require evaluation by shape, size and inclination of teeth for both the and the patient. cosmetic and functional purposes. • To restore a .

4 crowns, fixed bridges and implants GUIDELINES crowns, fixed bridges and implants GUIDELINES 5 AIMS • To determine the patient’s Patients with medical conditions may The clinical examination may be Other forms of special test Many clinical situations benefit from requirements and expectations and still be treated with implants following supported by special tests, which may include: the involvement of additional dental to gain an informed opinion of the advice from their physician. may include: • Dietary analyses. specialists or those with particular patient’s suitability for treatment skills. Such involvement should take • To complete a comprehensive clinical • Sensibility testing of teeth. • The use of diagnostic and provisional involving the use of crowns or fixed place prior to the establishment of examination which will include a • Radiographic examinations. appliances. prostheses. review of the clinical performance a treatment plan and may increase • Analyses of study casts mounted in • Direct observations of occlusal and • To obtain a history, which includes and mode of failure of any existing the options available to the patient. a semi-adjustable articulator in an masticatory function. details of all previous conditions and restorations. This will require a Implant-based treatment may be appropriate jaw relationship experiences of relevance including diagnosis of existing disease and an • Long-term monitoring against base- provided either by a single competent information pertaining to any assessment of the processes that • Assessments of the patient’s line study casts. operator or by a team lead by a adverse reactions to treatment, the have resulted in the need to provide response to initial instruction in Diagnoses may take time to establish prosthodontist and including a surgeon. administration of drugs and the use restorations and prostheses. oral hygiene procedures. and require the use of additional The need for inter-disciplinary provision of materials. • To analyse the effectiveness of special tests including dental and restoration of implants is based on • A medical history is mandatory for the patient’s control of their own investigations to stabilise or determine the complexity of the case and the skill all patients. Treatment involving the dental disease. a prognosis for one or more teeth. and wishes of the dentist providing the provision of dental implants should Any case considered to be beyond a restorative care. It is important that the additionally include questioning clinician’s capabilities and experience whole dental team is knowledgeable regarding the following recognised should be referred for further about dental implants. Training of risk factors: assessment, advice and possibly dental nurses, technicians and reception staff is mandatory. • Osteoporosis. treatment. • Bisphosphonate therapy. • Uncontrolled diabetes. • Smoking. • Radiotherapy.

6ASSESSMENT crowns, fixed bridges and implants GUIDELINES crowns, fixed bridges and implants GUIDELINES 7 AIMS DESIGN CONSENT CLINICAL RECORDS PREPARATORY • To establish the diagnoses, The design for tooth-supported The choice of material(s) should: • Has protocols to allow single Before finally agreeing to a It is important to obtain written In common with all other MANAGEMENT related clinical findings and fixed bridges should: • Allow the realisation of patients’ stage surgery, two stage surgery, particular treatment strategy, informed consent for all forms of documentation related to the Preparatory management TREATMENT treatment alternatives, together immediate placement, immediate • Be as simple and conservative cosmetic expectations, but not patients should be made aware of fixed prosthodontic treatment: this patient, clinical records detailing should, where indicated, include with the patient, and to loading, cemented or screw- as possible, yet sufficient to necessitate preparations the implications, possible sequelae should include a clear understanding the provision of crowns and bridges demonstrable completion of: determine the nature and most retained restorations. satisfy physical and mechanical involving excessive removal of and anticipated life-expectancy of of the financial cost of treatment. should be complete, unambiguous appropriate sequence of events, • Relief of pain, extraction of requirements. sound tooth tissue. • Has a universal implant for all the work and other options for Consent may only be obtained and prepared in a legible form. PLANNING which should result in the bone types. hopeless teeth, control of • Avoid where possible using • Facilitate optimal tissue response. their continuing care. following a full discussion of the successful achievement of agreed carious lesions and any necessary multiple, linked abutments. • Allows ease of use with proposed treatment with the patient. treatment objectives. • Take account of: In addition, patients must preliminary occlusal adjustment. • Consider the use of dental implants rationalised components. • To devise a realistic management • The materials and tissues forming understand and accept that the as an alternative to • Has low start-up costs. • Non-surgical periodontal therapy. strategy which should: opposing and adjacent contacts. success of the treatment will tooth-supported fixed prostheses. • Is affordable for the patient. • Assessment of the patient’s • Control and prevent further • Technical considerations. be highly dependent on their • Enhance occlusal relationships and response to initial treatment. active disease. • Be limited to those which satisfy the subsequent commitment to function, yet minimise adverse Treatment planning is relevant standards. oral health care maintenance. • Investigation of individual teeth and • Be efficient and effective yet loading. facilitated by: involving only minimal operative This constitutes an essential part the placement of cores. • Encourage optimal tissue response • Having demonstration models intervention. Implant-supported crowns and of the process of obtaining • Definitive endodontic treatment. and facilitate effective oral fixed bridges should use an and illustrated case histories to informed consent from the patient • Satisfy the patient’s expectations hygiene maintenance. Particular • Assessment for dental implants implant system which: discuss with patients. prior to treatment. and requirements. if part of the treatment strategy. attention needs to be paid to the • The use of study casts to rehearse • Is supported by a good All treatment plans should be kept • Result in optimal outcomes and maintenance of embrasure spaces preparations, and for the These require particular evidence base. under continual review throughout long-term benefits. to facilitate oral hygiene. purposes of diagnostic wax-ups. consideration to optimise the final • Has good company support for • Involve minimum psychological • Be realistic in terms of being The use of diagnostic wax-ups all stages of patient management. prosthetic result. training, product availability and a Contingency treatment options trauma. attainable clinically with an or “try-ins” for both tooth and • Any necessary orthodontic guarantee of long-term supply. should form part of the overall • Facilitate any further treatment, acceptable prognosis. implant-supported prostheses is treatment. • Fulfils national and international which may be required. highly beneficial in all cases and strategy for patient care. standards. is nearly always essential for • Any necessary surgical periodontal • Take account of long-term While not always essential, • Is made of appropriate material and optimal treatment. treatment maintenance preoperative photographic records has suitable shape and • Liaison with the technician who • Definitive occlusal adjustment or • To decide on the design and may assist in the provision of surface configuration. will construct the crown or equilibration if required. material(s) to be used in the treatment and form part of a • Provides a variety of implant lengths prosthesis. construction of the crown or base-line record. • Placement of dental implants if part and diameters. fixed bridge. • Effective audit and peer review of the treatment plan. • Provides a variety of abutments. processes. • Has an internal connection for abutments.

8 crowns, fixed bridges and implants GUIDELINES crowns, fixed bridges and implants GUIDELINES 9 SPACE REQUIREMENTS THE NUMBER AND SURGICAL PROTOCOLS FOR SINGLE VERSUS IMMEDIATE PLACEMENT IMMEDIATE LOADING HEALING TIMES CEMENTED OR SCREW- FOR DENTAL IMPLANTS POSITION OF IMPLANTS IMPLANT PLACEMENT TWO-STAGE SURGERY In this type of treatment the dental • The temporary crown or Healing times refer to the time that RETAINED RESTORATIONS • There should be adequate inter- • Anatomical structures may The number and position of implants • The placement of dental implants is • The surgical flap will be influenced There is no evidence of improved implant is placed immediately into prosthesis is attached to the the implant needs to osseointegrate The decision on whether to provide dental and inter-occlusal space prevent the simple placement of is influenced by the type of prosthesis under constant development. The by the extent of surgery, the outcomes between single and two the tooth socket following dental implant immediately after in the jawbone. a restoration that is cemented or for an implant restoration. dental implants in the posterior provided, the quantity and quality main aim of these developments anatomical structures and the stage surgical treatments. Single extraction. surgical placement of the implant. • With developments in implant screw-retained depends on the • There should be sufficient space maxilla and posterior mandible. of bone and the occlusal loads is to reduce treatment times experience of the operator. Larger stage surgery is convenient for • The bone should be healthy with no • It can be employed for a single design and surface configuration following factors: for the implant to be placed in • Bone concavities or thin ridges expected. For edentulous patients and improve patient care. It is flaps will be needed to identify the patients and reduces treatment evidence of peri-radicular infection tooth, multiple tooth spans or a these are under constant review. • Appearance. the following may be a guide: important for the clinician to follow mental or inferior dental nerve and times. A two-stage procedure, or pathology. full arch. the bone without compromising may compromise implant • A safe healing time in the mandible • Security of fixation. adjacent structures. placement. Fixed bridge protocols produced by companies, during sinus lift procedures. whereby the implant is buried and • It is helpful if there is at least 5mm • It is important that good primary would be two to three months and or experienced teachers in the field subsequently uncovered after an • Serviceability or future • Where implants are placed • The effects of gross resorption • “Flapless” surgery involves of apical bone to the tooth socket stability of the dental implant three to four months in the maxilla. Maxilla – 6 implants of implantology. appropriate healing time should maintenance. between teeth or adjacent to following tooth extraction and perforation of the mucosa at the to allow for good (primary) implant stability is achieved. • If there are complications Mandible – 4 implants be considered under the following • Space. each other there should be the presence of flabby ridges • Drilling procedures should follow implant site only, followed by the stability on placement. • Occlusal loading must be with implant treatment it is circumstances: sufficient space to allow normal make implant placement Overdenture standard protocols. Initial stability is bone osteotomy and subsequent • This technique is more difficult for controlled. recommended that the healing A screw-retained prosthesis may important for osseointegration implant placement. The morbidity is • Where the temporary prosthesis have a visible screw access hole soft tissue contours around them. more difficult. Maxilla – 4 implants multi-rooted teeth. • This treatment can be successful times should be lengthened to occur. low and surgical time reduced. For is a denture. but it provides the most secure Implants should be fully covered • Care must also be taken with Mandible – 2 implants in the anterior mandible. to allow a better chance of this technique to be successful good retention and simplifies any future by the bone. Where there is implant placement if there • A surgical guide (template or stent) • Where bone augmentation has osseointegration. • The implants should be placed at bone volume needs to be present or • Longer spans or full arch maintenance. The angulation of insufficient bone augmentation is a large incisive canal or is necessary for planning, surgical been carried out. regular intervals and correspond careful placement carried out with a restorations require multiple the implant may prevent the use of procedures should be considered. submandibular fossa. placement and the prosthodontic • Where there is poor initial stability to the correct tooth positions. CAD-CAM produced surgical drilling stable implants. screw-retention of the restoration. stages to help with design of the of the dental implant. • It is not necessary to use an superstructure. The guide helps guide based on a CT scan. implant for every missing tooth with the positioning, spacing and • Preservation of the gingivae or if long and stable implants can angulation of single or multiple attached mucosa is important for be placed. implants in the surgical field. the final functional and aesthetic result. Soft tissue surgery, possibly involving free or pedicle grafts, may facilitate the prosthodontic stages.

DENTAL10 crowns, fixed bridges and implants IMPLANTS GUIDELINES crowns, fixed bridges and implants GUIDELINES 11 Shade determination should A written and diagrammatic Principal considerations: Decisions regarding the form and involve consideration of the hue, prescription will facilitate the transfer • Conservation of tooth tissue. dimension of preparations should chroma and value for the body, of information between the dentist and take account of: • Control of the path of insertion. cervical and incisal portions of the the technician. • Tooth morphology and anatomy. proposed crown and bridge. This • Optimal retention and resistance Where appropriate, the patient and, • The quantity and location of should involve: form. whenever possible, the technician who remaining tooth tissue responsible for • Appropriate clearance in • Use of a neutral colour environment. will construct the restorations should the retention of existing restorations and articulation. • A shade guide familiar to the participate in the completion of the including cores. prescription of colour and • The removal of adequate tooth technician and appropriate for the • Occlusal relationships and function. tooth-coloured materials to be used. form. Clinical photographs may be tissue to allow the manufacture of value in assisting a technician of restorations with appropriate • The need for realignment. • Assessments under different lighting who is unable to examine the contours and aesthetics. • Relationships with adjacent teeth and conditions. patient in person. Electronic colour • The retention of basic occlusal and soft tissues. • An initial rapid scan of the guide determination using scanning devices axio-occlusal form. • The material(s) to be used. against the teeth to be restored, may be helpful but an appreciation of • The need for well-defined margins of • Considerations of long-term sequelae. followed by short duration (<5s) their limitations is required. assessments of the suitability of appropriate design, wherever possible • Aesthetic requirements. Where teeth are to be replaced, the use possible shades. on supragingival, sound tooth tissue. of a diagnostic wax-up is beneficial and If pulp vitality/integrity of the tooth • Damage limitation through the use of • Time (l5-30s) spent between may be used to construct a provisional is likely to be put in jeopardy by the atraumatic techniques. assessments looking at a blue prosthesis to facilitate patient and extent of the preparation required, background colour to minimise the dentist understanding of the final form All preparations should be planned then additional preparatory influence of negative after-images. of the restoration prior to beginning taking account of access and with treatment involving orthodontic Shade determination is best completed definitive prosthodontic treatment. reference to radiographs and realignment or elective root canal pre-operatively to minimise errors In the case of implant-supported study casts. therapy may be indicated. Specific related to eye fatigue, dehydration restorations and some tooth supported The equipment for tooth preparation consent must be sought prior to of teeth and apparent shifts in shade fixed prostheses, the contours of the should be well maintained and elective root canal therapy. following the removal of tooth tissues. provisional restoration may be used to include an appropriate range of When it is intended to remove a finite Details of features such as areas of develop soft tissue form adjacent to the instrumentation. amount of tooth tissue a guide or opacity and translucency, cracks and crown or fixed prosthesis. preoperative index is a valuable aid to any special staining effects required avoid excessive preparation. should be recorded as part of the shade determination.

DETERMINATION OF COLOUR

AND FORM OF RESTORATIONS TOOTH PREPARATIONS crowns, fixed bridges and implants GUIDELINES 13 MASTER IMPRESSIONS OPPOSING ARCH The purpose of occlusal registration MATERIALS TECHNIQUE PRINCIPAL MANDIBULAR FUNCTIONAL is to allow opposing casts to be POSITIONS RELATIONSHIPS PURPOSE MATERIALS IMPRESSION TRAYS TECHNIQUE IMPRESSIONS related accurately either in a cast The material selected to record occlusal • The patient should be instructed and registrations should: rehearsed in the desired position of To obtain an accurate, dimensionally- • Impression materials should be Whether custom-made or of the stock • The impression must allow Impressions of the opposing arch are relator or an articulator. When adopting a conformative Correct functional relationships are of the mandible. approach (i.e. the crown or bridge is considerable importance to the clinical stable, fully-supported impression of selected to meet the specific variety, impression trays should: accurate relations to be established critical to the success of crown and A formal registration may not be • Readily and accurately record detail of bridgework. While such impressions the occlusal and axio-occlusal tooth • The registration material or device to be in harmony with existing jaw success of crown and bridgework. To the prepared teeth, any dental implants requirements of individual • Have sufficient extension to support between casts within the dental required if a small number of teeth may generally be successfully surfaces. should be positioned or applied as relationships), the intercuspal position facilitate correct functional relationships, and associated soft tissues. situations on the basis of their an impression of all structures to be laboratory and provide sufficient is being restored and there are completed using alginate, great care is appropriate. (ICP) / centric occlusion (CO) should registration procedures should include a physical properties and handling recorded. information in respect of occlusal sufficient remaining contacts • Exhibit limited flow following be recorded. facebow transfer. Lateral and protrusive characteristics. form, function and relationships. required to avoid the introduction of between the unprepared teeth to application. • The registration material should • Be sufficiently rigid in use. significant errors in their use. registrations are often recommended, • The impression material(s) used • Soft tissue management and allow the technician to establish • Have a working time sufficient to not impede or prevent complete When a reorganised approach has • Incorporate occlusal stops but in the dentate patient confer little should conform to relevant moisture control must be effective Impressions of the opposing arch adequately the intercuspal position allow correct positioning of the mandibular closure. been planned, it is advantageous if and, where indicated, features benefit where there is reasonable standards. but atraumatic. should be handled, decontaminated, (ICP) or centric occlusion (CO). mandible, yet exhibit an abrupt • Positioning of the mandible should be the change in the jaw relationship appropriate to aid the retention of protected and stored with the same has been made prior to making the anterior guidance. Appropriate records • In the set state, all impression • Impression materials must be Sufficient information informing the transition to the solid state. completed within the working time of impressions. care adopted for master impressions. tooth preparations such that ICP / to allow the duplication of the anterior materials must be able to used in strict accordance with technician which teeth make contact • Be dimensionally stable and capable the registration material. • Have appropriate features to allow CO and the Retruded Axis Position guidance may be helpful for the withstand effective decontamination manufacturer’s instructions. in the patient’s mouth on mandibular of being adjusted without distortion • Only reproducible and definable the use of any necessary impression (RAP) / (CR) coincide. restoration of anterior teeth: this is procedures. closure will facilitate this. when set or in the solid state. positions of the mandible should copings for dental implants. Completed impressions should be: This makes the recording of jaw particularly the case where multiple In situations where patients have lost be recorded. restorations are planned. • Have a robust handle, preferably • Washed thoroughly. relationships easier. posterior occlusal support, it may • Following the set of the registration integral. • Inspected carefully. The use a functionally-generated only be possible to make an occlusal material, the positioning of the path (FGP) technique can create an • Be capable of withstanding • Subjected to an effective registration by using wax occlusion mandible should be verified and, if inter-occlusal record of assistance autoclave sterilisation if designed decontamination procedure. rims. However, the limitations of these required, the registration refined. in providing information about the for re-use. • Identified. for fixed prosthodontic work should • The technique adopted for relationship of antagonist teeth to • Protected and stored in an be recognised. the removal, cleaning and posterior preparations on mandibular appropriate manner ready for decontamination, identification and closure and mandibular excursions. transit to the dental laboratory in a storage of registrations should not The accuracy of inter-occlusal records way which will preclude damage, result in the introduction of any should be confirmed by the dentist distortion or contamination. significant errors. and technician. The use of shimstock • The accuracy of the inter-occlusal foil, a split-cast technique or copings record should be verified by both the are all techniques which may assist in dentist and technician. achieving accuracy in relating working casts. However, the quality of the inter- occlusal record remains paramount.

OCCLUSAL REGISTRATION

IMPRESSIONS14 crowns, fixed bridges and implants GUIDELINES FOR WORKING CASTS crowns, fixed bridges and implants GUIDELINES 15 PURPOSE QUALITIES TECHNIQUE Temporary restorations: Provisional Restorations: There is much to commend a replica During the fabrication and To restore, protect and maintain the Temporary restorations may also be technique for the fabrication of placement of provisional crown position of prepared teeth between used to test form and function and provisional crown and bridgework and bridgework care is required appointments and until the develop soft tissue contours adjacent in situations in which tooth form to ensure: placement of the final restoration. to the restoration: these are more and function should remain • Occlusal accuracy. unchanged. However, there are a Interim : appropriately termed “provisional • Maintenance of pulpal and restorations”. Provisional crowns and number of methods which may all Interim prostheses may be required periodontal health. bridges should incorporate most of the give acceptable results. Practitioners to maintain form and function • Good marginal adaptation. qualities of the final restorations which nonetheless need to be aware of the during treatment involving the use will replace them. These should include: advantages and limitations of the Temporary and provisional of dental implants. Tooth-supported method selected. restorations should be cemented • Restoration, or where indicated, prostheses are preferable in this to the teeth with a material that improvements in tooth form and When planning a significant change respect. provides an adequate marginal seal function. in form or function the diagnostic wax-up can be used to produce but has physical properties that • Marginal adaptation and seal. an index for the production of allow removal of the provisional • Minimal tissue response and provisional restorations. This restoration without damage to favourable hygiene features. approach allows the clinician to underlying preparation. Care needs to be taken to ensure assess the patient’s response to a good quality of marginal fit the proposed changes prior to without ledges and an adequate the construction of the definitive reproduction of embrasure space to restorations. facilitate oral hygiene. • Fracture and wear resistance sufficient for anticipated time in clinical service. • Properties which serve to protect the health of the underlying dental tissues. • Functional comfort and control of sensitivity. • Acceptable appearance.

TEMPORARY, PROVISIONAL AND INTERIM

RESTORATIONS IN crowns, fixed bridges and implants GUIDELINES 17 PURPOSE REQUIREMENTS PURPOSE PRINCIPLES To record and communicate precise Laboratory prescriptions should • Details of the teeth and/or • Materials to form margins and To confirm the clinical • Prior to an appointment for try-in details of all aspects of the crown include: implants involved (number/ occlusal contacts. acceptability of completed or the restorations should be carefully and bridgework required. • The clinician’s name, practice notation), the type of crown or • Shades and characterisation. partially completed crowns or inspected, together with the master casts and when available the Laboratory prescriptions are best address and contact telephone/fax prosthesis to be constructed, fixed bridges in terms of: • Surface features and finish. impression of the preparations, to completed together with the number(s) or e-mail address. the design for any • Seating and marginal adaptation. • A description of the occlusal confirm satisfactory completion of the technician. In situations in which this to be subsequently provided/ • Details of the patient: registration(s) provided. • Contacts and relationships with laboratory work. is impractical, misunderstandings replaced and, where appropriate, • Name, initials or reference number. adjacent and opposing teeth. • Assessment of the acceptability of and omissions in prescriptions may information regarding • Miscellaneous clinical • Form. restorations, at the time of try-in, be minimised by effective clinician/ • Age. contingency and long-term observations and specific patient may be facilitated by the use of technician liaison, including the • Sex. planning should be given. requests. • Aesthetic qualities. magnification or radiographs for clinician inspecting various stages • Date and time of recording The use of labelled diagrams • Patient acceptance. • Any relevant photographic records implant-supported restorations. of the laboratory work, notably impressions. together with study casts, available. • Any minor adjustments or further working casts and wax-ups. diagnostic wax-ups and • Pertinent aspects of the social • Date and time for latest return laboratory instructions are generally impressions of temporary or history. of completed laboratory work. best completed while the patient is provisional restorations greatly • Unambiguous statement of type still present. • Summary of the treatment being facilitates communication. Clinical of alloy(s) and other material(s) • If a crown or bridge is considered to be undertaken: photographs may assist the to be used. unsatisfactory at try-in the cause of the • Overall plan. technician in the design of crowns problem should be identified before • A detailed description of the particularly with aspects of form • Stage of treatment. modifying or remaking the item. design features for the crown and surface texture but should not • Present work. • Consideration should be given to or bridge, including directions be relied upon to communicate temporarily cementing crowns and • Subsequent care. regarding: colour accurately. bridges which, for example, alter • Form and function, not vertical face height or change aesthetics forgetting pontics. or occlusal functional relationships despite satisfying immediate criteria for clinical acceptability. • Having patients confirm the comfort and their acceptance of the appearance of crowns and bridges should be considered a routine element of try-in procedures.

LABORATORY PRESCRIPTIONS TRY-IN crowns, fixed bridges and implants GUIDELINES 19 The final placement of tooth- TOOTH-SUPPORTED IMPLANT-SUPPORTED CROWNS FOR ALL RESTORATIONS supported and implant-supported RESTORATIONS AND FIXED PROSTHESES restorations has a number of common elements but also AIM AIM SCREW-RETAINED Before discharging a patient, INITIAL REVIEW PROCEDURE LONG-TERM REVIEW significant differences. following the placement of crowns To cement/bond crowns and bridges The restorations must not be To attach securely crowns and bridges CROWNS AND Purpose • During the initial review, attention Long-term reviews of crowns and To monitor clinical performance and and bridgework, suitable instructions considered to be satisfactory by both allowed to move relative to the considered to be satisfactory by both PROSTHESES: should be paid to patient fixed prostheses should form part of any deterioration in acceptability, should be given regarding immediate To assess the patient’s response to the operator and the patient at the underlying preparation(s) during the the operator and the patient at the satisfaction and comfort. routine recall examinations. These detailed records should be kept of • The final restoration is seated and care, action to be taken in the event of the restorations and to deal with any time of try-in or following a period of critical initial set or polymerisation time of try-in or following a period of examinations should, from time to clinical observations made during retained by a screw, tightened to the post-operative pain or discomfort, and postoperative difficulties, concerns, • Proximal contacts and relationships temporary cementation. of the lute. At this time special temporary use. time, include radiographic examinations reviews of crown and bridgework. manufacturer’s recommended torque. appropriate oral hygiene measures. pain or discomfort which arise after with adjacent and opposing teeth precautions may be required to The luting system should be chosen The final restoration may be screw- placement. should be checked. using intra-oral films. When a dental hygienist or other dental isolate and protect the luting • The screw hole is restored with a with the following in mind: retained or cemented to an abutment Care needs to be taken during long care professional is part of the dental material used. direct restorative material. • Special note should be made of attached to the implant. term review to ensure that the cement team undertaking long term care of • The nature and condition of the • Beneath the direct restoration the initial tissue-response and When set, the excess luting lute remains intact for all tooth- crowns and bridges he/she must be prepared tooth. but separating it from the head the effectiveness of the patient’s material should be removed using supported indirect restorations. This aware of the specific maintenance • The fit-surface finish of the of the retaining screw is a plug of oral hygiene maintenance in instruments and techniques least is of particular importance for fixed issues and potential modes of failure. restorations. intermediary material usually either relationship to the restorations. liable to cause damage. It is of bridges or linked crowns where failure PTFE tape or light-bodied • Where indicated, suitable The preparations should be cleaned, particular importance to ensure of the cement lute may lead to rapid impression material. adjustments should be completed isolated and, where indicated, primed that no excess cement is left in and extensive dental caries. and conditioned as required for the interproximal or subgingival sites. with all altered surfaces being CEMENT-RETAINED Follow-up of implant patients is just cement selected. The luting system refinished. Newly cemented/bonded crowns as important as for those who have should be dispensed, mixed and applied CROWNS AND • Where indicated, further and bridges must be examined with received tooth-supported crown and in strict accordance with manufacturer’s PROSTHESES: instructions and advice should particular regard to: bridgework: radiographs are advisable instructions whilst the operating field be given regarding oral hygiene • Degree of seating. • Small volumes of cement should be one year following treatment to check should be controlled. used to minimise extrusion of excess maintenance. • Proximal contacts and relationships that coronal bone levels have been The final restorations must be fully cement into the surrounding tissues. with adjacent and opposing teeth. maintained. All patients should be seated within the available working • The area overlying the abutment- reviewed at least annually. They should • Occlusal function. time using appropriate techniques retaining screw should be protected be encouraged to return to the provider to overcome the effects of hydraulic Where indicated, suitable by PTFE tape or a plug of impression of the implant treatment if they feel forces. While it is highly desirable adjustments should be material. that there has been any deterioration. to have some excess luting material completed, including refinishing • It is of particular importance to present along the entire margin of of roughened areas. ensure that no excess cement is left the restoration, completely filling the in interproximal or subgingival sites. restoration with cement will impede the seating of crowns and fixed bridges.

FINAL PLACEMENT

20OF crowns, fixed RESTORATIONS bridges and implants GUIDELINES crowns, fixed bridges and implants GUIDELINES 21 The provision of crowns and fixed The Society hopes that these bridges to a high standard is an guidelines are helpful and act as a exacting task for the whole dental practical reminder of the standards CONCLUDING team, clinician, technician, nurse and that we try to achieve. Guidance other support staff, as well as for notes are never complete, and these the patient. Provision of high-quality are no exception. The Society will be crown and bridgework accompanied reviewing this document at regular REMARKS by excellent maintenance can intervals for accuracy and in the light of produce long-term success which is contemporary thinking. Any comments rewarding for both the patient and you may have would be gratefully the dental team. received and should be addressed to the Honorary Secretary of the Society.

Richard Ibbetson Ken Hemmings Ian Harris

This page was last updated October 2013 © British Society for Restorative Dentistry

22 crowns, fixed bridges and implants GUIDELINES crowns, fixed bridges and implants GUIDELINES 23 THE BRITISH SOCIETY FOR RESTORATIVE DENTISTRY

The Chapter House, Bristol Dental Hospital, Lower Maudlin Street, Bristol BS1 2LY 24 crowns, fixed bridges and implants GUIDELINES