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BDS4 Restorative > Bridgework > Flashcards

Bridgework Flashcards

1
Q

What are the treatment options for missing teeth?

A
  • no treatment
  • replace tooth
    • bridge
    • implant
    • denture
  • close space
    • orthodontics
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2
Q

What are the 4 reasons for treating tooth loss?

A
  • aesthetics
  • function
  • speech
    • contact between tongue and tooth surface to make noise is restored
  • maintenance of dental health
    • prevention of tilting and over-eruption
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3
Q

What is the definition of a bridge?

A

a prosthesis which replaces a missing tooth or teeth and is attached to one or more natural teeth or implants

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4
Q

What do removable partial dentures replace that bridges do not?

A

soft tissues and bone

  • bridges can have some soft tissue prosthesis included but it is very limited
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5
Q

What are the two main types of bridgework?

A
  • adhesive
  • conventional
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6
Q

What are general indications for bridgework?

A
  • function and stability
  • appearance
  • speech
  • psychological reasons
    • some patients are opposed to RPDs
  • systemic diseases
    • epileptics
      • small RPDs can be inhaled or broken during seizures
  • co-operative patient
    • must be compliant
    • good oral hygiene
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7
Q

What are local indications for bridgework?

A
  • big teeth
    • increased retention
  • heavily restored teeth
    • conventional bridgework
  • favourable abutment angulations
  • favourable occlusion
    • heavy occlusal contacts increase chance of fracture or debonding
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8
Q

What are general contraindications for bridgework?

A
  • uncooperative patient
  • medical history
    • allergies to materials
  • poor oral hygiene
  • high caries risk
  • periodontal disease
  • large pulp
    • conventional bridgework
    • larger pulps in younger teeth
    • can become non-vital during prep
    • RCT would be required
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9
Q

What are local contraindications for bridgework?

A
  • high possibility of further tooth loss within arch
  • poor prognosis of abutment teeth
  • length of span too great
    • bridges can only replace 2-3 teeth
    • ideally as few as possible to reduce flex
  • ridge form and tissue loss
    • if lots lost a denture may be more appropriate
    • aesthetic of gingival architecture
  • tilting and rotation of teeth
    • difficult to attach bridgework
    • occlusion on bridge may be unfavourable
  • degree of restoration
    • must have some remaining tooth tissue
  • periapical status
    • no active endodontic or pulpal disease
    • must be treated first to be considered for an abutment
  • periodontal status
    • no active or advanced periodontal disease
    • teeth likely mobile
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10
Q

What type of ridge form makes bridgework challenging?

A

flat ridge

  • restoration of stippled gingival contour challenging
  • advanced techniques required to re-shape
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11
Q

What is the definition of an abutment tooth?

A

a tooth which serves as an attachment for a bridge

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12
Q

What is the definition of a pontic?

A

an artificial tooth which is suspended from the abutment tooth/teeth

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13
Q

What is the definition of a bridge retainer?

A

the extracoronal or intracoronal restorations that are connected to the pontic and cemented to the prepared abutment teeth

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14
Q

What is the definition of a bridge connector?

A

the component which connects the pontic to the retainer/retainers

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15
Q

What is the definition of a bridge pier?

A

an abutment tooth which stands between and is supporting two pontics with each pontic being attached to a further abutment tooth

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16
Q

What is the definition of a bridge unit?

A

either a retainer or a pontic

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17
Q

In what situations are piers used in bridgework?

A

large bridgework designs

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18
Q

What are the 5 different type of bridge designs?

A
  • fixed-fixed bridge
    • conventional
    • adhesive
  • cantilever bridge
    • conventional
    • adhesive
  • fixed-moveable bridge
  • hybrid bridge
    • fixed retainer and adhesive retainer
  • spring cantilever bridge
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19
Q

What is a fixed-fixed bridge?

A

a bridge with a retainer at each end and a pontic in the middle joined by rigid connectors

  • can be adhesive or conventional
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20
Q

In what scenarios are large span fixed-fixed bridges appropriate?

A
  • class 2 occlusion
    • little occlusal contact
    • less flex experienced
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21
Q

What are other names given to adhesive bridgework?

A
  • resin retained bridgework (RRB)
  • resin bonded bridgework (RBB)
  • minimal preparation bridgework
  • maryland bridge
  • resin bonded fixed partial denture (RBFPD)
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22
Q

What are the most common materials for adhesive cantilever bridges?

A
  • porcelain pontic and metal retainer
    • CoCr or NiCr retainer
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23
Q

What are the advantages of adhesive bridges?

A
  • minimal to no preparation
  • no anaesthetic needed
  • less costly
  • less surgery time
  • can be used as a provisional
    • patient with hypodontia too young for implants
  • less destructive on failure
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24
Q

How are high occlusal contacts resolved when bridgework is placed?

A

Dahl Concept
- high contacts resolve over 10-14 days
- relative axial tooth movement

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25
Q

What are the disadvantages of adhesive bridgework?

A
  • rigorous clinical technique
    • moisture control vital for composite cement
    • contamination with saliva can reduce longevity
  • metal shine through
    • poor design
    • inadequate cementation
    • not kept away from thin incisal edges
  • can debond
    • high chance of repeat debonding
    • first bond is best bond
    • pontic most likely to chip
  • occlusal interferences
    • occlusion tends to adjust
    • dynamic interferences cause problems
      • mandible hits maxillary bridgework and lateral forces cause deboning
  • no trial period
    • cannot see aesthetics
    • cementation required
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26
Q

What are the indications for adhesive bridgework?

A
  • young teeth
    • less destructive
  • good enamel quality
    • required for a good bond
  • large abutment tooth surface area
  • minimal occlusal load
  • single tooth replacement
  • simplify partial denture design
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27
Q

What are the contraindications for adhesive bridgework?

A
  • insufficient or poor quality enamel
  • long spans
  • excess soft or hard tissue loss
    • flat gingival saddle makes recreation of gingival architecture with papilla challenging
  • heavy occlusal forces
    • e.g. bruxists
  • poorly aligned, tilted or spaced teeth
    • path of insertion and aesthetics challenging
  • contact sports
    • increased trauma to area
    • mouth guard required to protect bridgework
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28
Q

What must be identified in a history for a potential bridgework patient?

A
  • habits
    • bruxism
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29
Q

What must be included in an examination for a potential bridgework patient?

A
  • dynamic occlusal relationships
  • periodontal status
  • radiological examination
    • periapical pathology
    • bone levels
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30
Q

What are study models used for in bridgework treatment planning?

A
  • face bow registration
    • semi-adjustable articulator
  • diagnostic wax ups
    • aesthetics
    • potential interference
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31
Q

What factors are considered in the decision making process for bridgework?

A
  • abutment teeth
    • prognosis
  • occlusion
  • aesthetics
    • work backwards from desired final aesthetic result
  • other treatment options
    • implants
    • dentures
  • patient preference
    • cautious of insistent patients
    • manage expectations and explain pros and cons
  • patient compliance
    • bridgework requires maintenance
    • patient must be motivated
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32
Q

How can occlusion impact on decision making surrounding bridgework?

A
  • opposing dentition
    • heavy contact points
    • overeruption
  • parafunctional habit
    • bruxism
      • clenching/grinding
  • dynamic occlusal relationships
    • clinically
    • mounted study models
    • consider diagnostic wax ups
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33
Q

What is direct resin retained bridgework?

A

a bridge made chairside while the patient is present

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34
Q

When is direct resin retained bridgework used?

A
  • emergency situation
  • patient doesn’t want to be left with an edentulous space
  • teeth need extracted immediately
  • tooth has been lost traumatically
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35
Q

What is indirect resin retained bridgework?

A

bridgework made in laboratory from impressions taken then prosthesis cemented in at a second appointment

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36
Q

What are the three different preparation types for indirect resin retained bridgework?

A
  • no preparation
    • resin bonded
  • minimal preparation
    • resin bonded
  • heavy preparation
    • conventional
    • undesirable
    • exposes dentine which has a poorer bond strength than enamel
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37
Q

What is used as a pontic for direct resin retained bridgework?

A
  • ideally patients own tooth
    • if tooth lost from trauma
  • acrylic denture tooth
  • polycarbonate crown
  • cellulose matrix filled with composite
38
Q

What is the process for using a patient’s own tooth for a direct resin retained bridge?

A
  • tooth deemed unrestorable
  • root cut off crown and pulpal tissues removed
    • barbed broaches used
  • pulp chamber filled with composite
  • contact points on pontic tooth and adjacent teeth etched, primed and bonded
  • composite used to attach pontic tooth
39
Q

What are the advantages and disadvantages of direct resin retained bridges?

A
  • advantages
    • tooth is in situ
    • treatment options can be discussed
  • disadvantages
    • aesthetics poor
40
Q

What palatal/lingual coverage is required for indirect adhesive bridgework?

A
  • generous palatal/lingual coverage
    • greater surface area = greater bond
  • good quality enamel
  • supra-gingival coverage
    • ideally by 0.5mm
    • allows for cleans ability of gingival margin
    • reduced risk of periodontal disease
  • reduced coverage at incisal edge
    • enamel is more translucent
    • avoids grey shine through
41
Q

How far away from the gingival margin should resin bonded bridge retainers be kept?

A

0.5mm

42
Q

Where can fixed-fixed resin bonded bridges be used?

A
  • patients with previous orthodontic treatment
    • hold teeth in place
  • lower teeth
43
Q

Where are fixed-fixed resin bonded bridges rarely used and why?

A
  • anteriorly
    • divergent guidance applied to teeth
    • longitudinal axis of the teeth vary along the arch
    • one of the retainers debonds
    • space allows for bacterial ingress
    • caries develop
44
Q

What type of bridge design is most common anteriorly?

A

cantilever

45
Q

What type of bridge is most common posteriorly?

A

fixed-fixed

  • debonding is more obvious and can be dealt with
  • spreads the greater occlusal forces over two teeth
    • increases longevity of bridge
46
Q

How must restorations in abutment teeth be considered before bridgework can be considered?

A
  • ideally sound enamel is present
    • usually restorations will be present
  • composite restorations
    • are acceptable
    • consider replacement prior to preparation
    • better bond to newer composite
    • can roughen existing composite with a Rosemead bur to increase retention
  • amalgam restorations
    • compromised bond to chemically fired composite cement
    • consider replacing with composite
47
Q

Describe the possible aspects of preparation of an abutment tooth for a resin bonded bridge

A
  • 180 degree wrap-around preparation
    • palatal/lingual surface
  • rests
    • rest seats for posterior teeth
    • cingulum rests for anterior teeth
    • increase mechanical retention
    • less common due to modern resin cements
    • useful for location during cementation
  • proximal grooves
    • increase mechanical retention
    • less common due to modern resin cements
    • vertical cuts towards interproximal surfaces
    • rarely used
  • supra-gingival chamfer finish line
    • approximately 0.5mm above gingival margin
    • chamfer bur
  • enamel only prep
48
Q

Describe minimal preparation of an anterior tooth for a resin bonded bridge

A
  • occlusal contact reduction
    • where heavy occlusal contact is suspected
  • cingulum undercut removal
    • aids path of insertion
  • chamfer margin
    • 0.5mm supra-gingival
49
Q

Describe heave prep of an anterior tooth for a resin bonded bridge

A
  • 0.5mm palatal reduction
    • retainer will be 0.7mm thick
      • adjusts due to Dahl Concept
  • cingulum rest
  • possibly proximal grooves
  • chamfer margin
    • 0.5mm supra-gingival
50
Q

Describe preparation of a posterior tooth for a resin bonded bridge

A
  • occlusal rest seats
    • 2mm depth
    • incorporated into surface anatomy of teeth
  • 180 degree wrap-around
    • palatal/lingual surface
  • chamfer finish line
    • 0.5mm supra gingival
  • proximal grooves
    • middle of palatal/lingual aspect
    • not usually required
51
Q

What are the options for temporisation during the laboratory phase for an indirect resin bonded bridge?

A
  • no temporisation
    • if prep remains only in enamel
    • recommend sensitive toothpaste
  • RPD
    • some can tolerate for short period of time
  • dentine bonding agent
    • if prep enters dentine
    • can reduce sensitivity
  • Essix retainer
    • clear retainer with missing tooth incorporated
52
Q

Why should bridges be placed as quickly as possible?

A
  • minimised over-eruption and tooth movement
53
Q

How are metal wing retainers sand-blasted and why is this carried out?

A
  • aluminium oxide particles fired at CoCr or NiCr
    • 50 micron diameter
  • creates small indentations on fitting surface
    • resin cements flows in and sets
    • increased mechanical retention
54
Q

Describe the cementation process of resin bonded bridgework

A
  • try in
    • secure with small amount of composite
    • assessment of aesthetics and fit
    • locating cleat over incisal edge
  • sandblasting
    • should have been performed by lab
  • clean retainer
    • ultrasonic bath if needed
    • ethanol to degrease
    • may require further sandblasting
  • apply chemically or dual cure composite luting cement
    • ideally dual cure (Panavia 21)
  • abutment tooth
    • prophylaxis
    • isolation with dental dam
    • etch with 37% phosphoric acid
    • wash and dry
    • apply primer for 30 seconds
    • air dry for 2 seconds
  • fit bridge retainer coated with luting cement to abutment tooth
    • remove excess cement
  • oxygen inhibitor (oxyguard II) placed around margins for 3 minutes
    • wash off
55
Q

How many layers of Panavia 21 primer should be applied to an abutment tooth before cementation?

A

5 layers over 30 seconds

56
Q

Describe what must be performed post-cementation

A
  • check occlusion
    • static and dynamic
    • confirm pontic does not have occlusal forces applied
    • heavy contacts on pontic should be adjusted
  • demonstrate cleaning to patient
    • underneath and around bridgework
    • feed thin part of superfloss under pontic and pull thick part under
    • can also use interdental brushes
57
Q

What are the advantages of fixed-fixed bridge designs?

A
  • robust
    • crowns as retainers
  • maximum retention and strength
    • not reliant on adhesive retention
    • mechanical retention and bond present
  • abutment teeth are splinted together
    • long standing but stable perio cases
    • increases stability
  • longer spans possible
  • laboratory construction straightforward
58
Q

What are the disadvantages of fixed-fixed bridge designs?

A
  • preparation difficult
    • parallel preparations difficult
  • preparation must be minimally tapered
    • difficult when trying to make parallel
    • aiming for 5-7 degree taper
    • more than 10 degrees eliminates single path of insertion
  • common path of insertion for abutments
    • increases retention
  • removal of tissue
    • danger to pulp
    • particularly heavy prep for all ceramic
    • tooth can become non-vital
59
Q

What is the ideal taper for an abutment preparation for a fixed-fixed bridge?

A

5-7 degrees

60
Q

What are the advantages of conventional cantilever bridges?

A
  • conservative design
    • only one crown prep required
  • laboratory construction straightforward
  • do not need to ensure parallel guide planes
61
Q

What are the disadvantages of conventional cantilever bridges?

A
  • short span only
    • less successful in longer spans
  • rigid to avoid distortion
    • rigidity increases fracture risk
    • common in porcelain when flex isn’t possible
  • mesial cantilever preferred
    • most posterior teeth occlude first
62
Q

Why is a mesial cantilever preferred?

A
  • most posterior teeth occlude first
  • distal cantilever likely to have a heavy contact
  • see saw effect with restoration coming off
63
Q

When can distal cantilevers be considered?

A

when a patient is missing all posterior teeth, with only 1-4 present. distal cantilever can be placed on 4s to replace 5s, patient must be aware of risks

64
Q

What is a fixed moveable bridge?

A
  • bridge with two components
    • crown retainer
    • crown retainer and pontic
  • retainer is separate to retainer and pontic
    • two paths of insertion
  • components slot together
    • some element of flex
65
Q

When could a fixed moveable bridge be used?

A
  • when abutment teeth are not parallel
    • alternative to heavy preparations
66
Q

What are the advantaged of a conventional fixed moveable bridge?

A
  • preparations don’t require a common path of insertion
  • each preparation is retentive independent of the others
  • more conservative of tooth tissue
    • don’t need to remove excess to make parallel
  • allows minor tooth movement
  • may be cemented in two parts
67
Q

What are the disadvantages of a conventional fixed-moveable bridge?

A
  • length of span limited
    • can only replace one tooth
    • due to increased flex
  • laboratory construction more complicated
    • may need a longer lab time
  • possible difficulty in cleaning
    • beneath moveable joint
    • small gap where plaque can accumulate
    • patient must have excellent oral hygiene
      • increased risk of caries and perio
  • cannot construct provisional bridge
68
Q

What is a hybrid bridge?

A

bridge with one conventional retainer and one adhesive retainer

69
Q

When are hybrid bridges used?

A
  • rarely used
    • conventional cantilever is sufficient
  • adhesive retainer likely to debond
  • conventional retainer is robust
    • unlikely to detect debonding and micro leakage
70
Q

What is a spring cantilever bridge?

A

pontic attached to the end of a metal arm that runs across the palate to a rigid connector on the palatal side of a retainer

71
Q

When are spring cantilever bridges used?

A
  • not re-prescribed
    • resin bonded bridge from adjacent tooth instead
  • aim to be more conservative to anterior tooth tissue
  • useful if spacing present between upper incisors, adjacent teeth are unrestored and a posterior tooth would be a suitable abutment
  • only for upper incisors
  • difficult to clean beneath palatal connector and may irritate palatal mucosa
    • have to flex arm to clean underlying mucosa
    • increased risk of candidal infections
  • difficult to control movement of pontic due to springiness of metal arm and displacement of palatal soft tissues
    • can move a lot
    • pinging arm can become habitual
72
Q

What is involved in the evaluation of an abutment tooth?

A
  • must be able to withstand forces previously directed to the missing tooth/teeth
  • supporting tissues should he healthy and free of inflammation
    • no periapical or periodontal disease
  • crown to root ration
    • length of tooth coronal to alveolar crest compared to length of root embedded in bone
      • optimal ration is 2:3
      • minimum ratio is 1:1
  • angulation/rotation of abutment
  • root configuration
    • multiple, larger roots can withstand greater forces
  • surface area and quality of enamel
    • enamel provides a superior bond to dentine
    • enamel defects reduce bonding potential
    • increased surface area increases bond
  • risk of pulpal damage
    • especially must consider for conventional bridgework
  • quality of endodontics
    • option to re-RCT
    • must have confidence in the RCT before placing bridgework
    • reduce risk of periapical infection to prevent having to remove bridge
  • core
    • removal of core to re-build
    • composite core most common
    • can consider crown lengthening surgery
73
Q

What occlusal information is required before determining whether bridgework is appropriate?

A
  • guidance present
    • canine guidance
    • group function
  • incisal classification
  • reduced interocclusal space
    • over erupted opposing teeth
  • parafunctional habits
    • bruxism
      • wear facets
      • attrition
74
Q

What are the 5 sections that must be considered when designing and planning bridges?

A
  • type of preparation
    • aim to conserve as much tooth tissue as possible
    • where robust bridgework is required, conventional may be necessary
  • abutment evaluation
    • pulpal status
    • periodontal status
    • previous RCT
  • cleansibility
    - patient’s oral hygiene
  • aesthetics
    - consider limitations of bridgework
    - lower high patient expectations
  • material
    • what is most suitable for the patient
75
Q

What are the 5 details of bridge design that must be included in the lab prescription?

A
  • selected abutment teeth
    • must consider longevity of abutments
  • selected retainer
    • no prep
    • minimal prep
    • regular prep
    • conventional prep
  • selected pontic and connector
    • sanitary/wash-through
    • dome/bullet/torpedo
    • modified ridge lap
    • total ridge lap
    • ovate
  • planned occlusion
  • prescribed material
76
Q

What are the 5 different types of pontic?

A
  • sanitary/wash-through
  • dome/bullet/torpedo
  • modified ridge lap
  • total ridge lap
  • ovate
77
Q

What are the considerations when choosing a pontic design?

A
  • cleansibility
    • smooth, well polished or glazed surface
      • plaque should not easily adhere
    • no surface joins of materials
      • occlusal forces can cause shearing
    • smooth and cleansable embrasure space
      • plaque and food should not be trapped
    • easy to clean and brush around
  • appearance
    • anterior should look as much like a tooth as possible
      • aesthetic zone
    • aesthetics of posterior can be compromised
      • functional zone
  • strength
    • material thickness increased for longer spans
      - greater forces applied to larger pontics
78
Q

Describe the different surfaces of a pontic

A
  • occlusal surface
    • resembles tooth it is replacing
    • narrow if possible to enable cleaning
    • sufficient occlusal contact
  • approximate surface
    • connector must be 2mmx2mm for sufficient strength
    • embrasure space can be reduced if highly aesthetic
      • more challenging to clean
  • buccal and lingual surfaces
  • ridge surface
    • fitting surface
79
Q

What are the minimum dimensions for a connector between a retainer and a pontic?

A

2mm x 2mm

80
Q

Describe the features of a wash-through pontic

A
  • hygienic/sanitary
  • no contact with soft tissues of overlying ridge form
  • functional rather than aesthetic
  • easy to clean as fluids can pass through
81
Q

Describe the features of a dome shaped pontic

A
  • torpedo/bullet
  • lower incisor, lower premolar and upper molar
  • acceptable if occlusal 2/3 of buccal surface visible
    • upper 2/3 of pontic look like tooth
    • apical 1/3 is narrowed to aid cleansibility
82
Q

Describe the features of a modified ridge lap pontic

A
  • buccal surface looks like a tooth
  • lingual surface cut away
  • line contact with buccal aspect of ridge
  • problems with food packing on lingual aspect of ridge
83
Q

Describe the features of a ridge lap pontic

A
  • saddle
  • greatest contact with soft tissue
  • can be cleansible if carefully designed
  • less food packing than modified ridge lap
  • must not displace tissue or cause tissue blanching
  • highly motivated patient to prevent plaque build up
84
Q

Describe the features of an ovate pontic

A
  • presses on the ridge
  • can mould and shape gingivae
  • difficult to clean so only in highly motivated patients
  • increased risk of inflammation to ridge
  • very good aesthetic result
  • may require prescription of Essix retainer with tooth to mould gingivae initially
85
Q

What are the different options of materials for conventional bridges?

A
  • all metal
    • gold
      • excellent properties
      • not tooth coloured
    • nickel/cobalt chrome
    • stainless steel
  • metal ceramic
    • good strength and aesthetics
  • all ceramic
    • good option but higher fracture rate
    • modern all ceramic bridges starting to rival all metal
    • zirconia
      • LAVA, Procera
      • strongest, reasonable aesthetics
    • lithium disilicate
      • Emax
      • highly aesthetic
  • ceromeric
    • not typically used now
    • porcelain/composite hybrid
      • composite to withstand occlusal forces
      • porcelain for aesthetics
    • BelleGlass, Vectris, Targis Vectris
86
Q

Where can all metal bridges be used?

A
  • most common in lower posterior area
  • subjected to high occlusal forces
  • aesthetic demand is low
  • gold is particularly malleable
87
Q

Where can metal ceramic bridges be used?

A
  • most commonly used bridge in the UK
  • can be used anywhere in the mouth
  • metal substructure provides robustness
  • ceramic provides aesthetics
88
Q

Where can all ceramic bridges be used?

A
  • LAVA 3M ESPE
    • 3-4 unit fixed bridge
      • maximum span
    • milled zirconium oxide frame
    • feldspathic porcelain overlying
    • can be used anywhere in the mouth
      • withstand occlusal forces
      • good aesthetics
    • similar reduction to MCC
      • less destructive preparation
      • better mechanical properties of material
  • Zirconia
    • preparations on casts scanned
    • multilayered or ultra translucent multilayer
    • milled
    • can have layer of feldspathic porcelain overlying
89
Q

What are implant retained bridges?

A
  • large span bridges
  • screw or cement retained
  • screw retained
    • access holes on palatal aspect
    • screwdriver screws bridge into implant
    • PTFE tape or cotton wool fill hole
    • hole covered with composite
  • cement retained
    • abutment on implant
    • bridge cemented to this
90
Q

Describe the entire process of conventional bridgework

A
  • mounted study models
  • diagnostic wax up and custom impression tray
    • not required for all cases
  • request construction of vacuum formed stent from lab
    • allows reduction to be checked during preparation
    • allows for construction of provisional bridge
  • select shade
  • pre-op putty impression if no laboratory made stent
  • occlusal/incisal reduction
  • separation of teeth
  • parallelism of surfaces achieved
    • mesial surfaces
    • distal surfaces
    • labial surfaces
  • consider retentive features
    • for short clinical crown height or over tapering
    • slots or grooves
  • construct provisional bridge
  • make impression and occlusal registration
  • temporarily cement provisional bridge
  • demonstrate cleaning with superfluous
  • write prescription for technician
91
Q

Why is parallelism important?

A

BDS4 Restorative (3 decks)

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