We are learning on **Noongar land** THE UNIVERSITY OF WESTERN AUSTRALIA We are learning on **Noongar land** The University of Western Australia **Copyright Notice** Material used in this recording may have been reproduced and communicated to you by or on behalf of **The University of Western Australia** in accordance with section 113P of the *Copyright Act 1968*. Unless stated otherwise, all teaching and learning materials provided to you by the University are protected under the Copyright Act and is for your personal use only. This material must not be shared or distributed without the permission of the University and the copyright owner/s. Material used in this recording may have been reproduced and communicated to you by or on behalf of The University of Western Australia in accordance with section 113P of the *Copyright Act 1968*. Unless stated otherwise, all teaching and learning materials provided to you by the University are protected under the Copyright Act and is for your personal use only. This material must not be shared or distributed without the permission of the University and the copyright owner/s.  Clinical photo: A close-up extraoral view of a patient's mouth showing the upper and lower teeth. The image displays a missing maxillary lateral incisor, with the adjacent central incisor and canine visible. **[F][020Y]** **[mm] : orthogonal / 30.0 /** **20** **30** **40** **50** *[F] [020Y]* *[mm]: orthogonal / 30.0* - 20 - 30 - 40 - 50 **Developmental Changes** 1. Maxilla grows down and forward 2. Resorption of labial bone over maxillary anterior teeth  1. Maxilla grows down and forward 2. Resorption of labial bone over maxillary anterior teeth This schematic lateral cephalometric diagram illustrates maxillary growth patterns, showing a large orange arrow indicating downward and forward displacement of the maxilla. Additionally, red shaded areas on the bone surfaces are marked with plus signs (+) to denote deposition and minus signs (-) to denote resorption, specifically highlighting labial bone resorption over the anterior teeth. # Developmental Changes 3. Teeth extrude and upright   3. Teeth extrude and upright A superimposed lateral cephalometric tracing showing two profiles: a black outline representing age 37 and a red outline representing age 77. The diagram illustrates developmental changes in the craniofacial complex, specifically highlighting that the teeth (shown in the anterior region) have extruded and uprighted over time. This is a line drawing diagram showing a lateral profile of a human skull and mandible, with superimposed outlines in black and red to illustrate growth or structural changes. The outlines depict the cranial base, nasal cavity, maxilla, mandible, and teeth, showing shifts in position between the two states. Developmental Changes 1. Maxilla grows down and forward 2. Resorption of labial bone over maxillary anterior teeth  1. Maxilla grows down and forward 2. Resorption of labial bone over maxillary anterior teeth This is a lateral schematic diagram of a human skull illustrating the direction of maxillary growth and surface bone remodeling. A large red arrow points forward, while orange shaded areas on the maxilla are marked with plus signs (+) to indicate bone deposition and minus signs (-) along the labial surfaces to indicate resorption. # Developmental Changes ## 3. Teeth extrude and upright FIG. 4-25 Growth changes in adults. A, Changes in a male from age 37 (**black**) to age 77 (**red**). Note that both the maxilla and mandible grew forward, and the nose grew considerably. B, Growth changes in a woman between age 34 (**black**) and 83 (**red**). Note that both jaws grew forward and somewhat downward, and that the nasal structure enlarged. (From Behrents RG: A treatise on the continuum of growth in the aging craniofacial skeleton. Ann Arbor, 1984. University)   3. Teeth extrude and upright **Fig. 4-25 — Growth changes in adults** - **A:** Changes in a male from age 37 (black) to age 77 (red). Note that both the maxilla and mandible grew forward, and the nose grew considerably. - **B:** Growth changes in a woman between age 34 (black) and 83 (red). Note that both jaws grew forward and somewhat downward, and that the nasal structure enlarged. *From Behrents RG: A treatise on the continuum of growth in the aging craniofacial skeleton. Ann Arbor, 1984. University* This is a cropped cephalometric tracing (labeled 'A') showing superimposed lateral outlines of a male craniofacial skeleton at two different ages. The black lines represent the profile at age 37, while the red lines represent the profile at age 77, illustrating forward growth of the maxilla and mandible and enlargement of the nose. A lateral cephalometric line tracing showing superimposed profiles of a woman at age 34 (black lines) and age 83 (red lines). The diagram illustrates developmental changes in the craniofacial skeleton, specifically highlighting how both the maxilla and mandible grew forward and somewhat downward, while the nasal structure enlarged over time.  Clinical photo showing two views of dentition: the top image displays a frontal view of upper and lower teeth, while the bottom image shows an occlusal view of the upper anterior teeth. • Infraocclusion→shorter incisally+long apically • Blue colouring of labial gingiva • Collapse of labial soft tissue coverage • Recession exposing abutment / implant • Lack of papilla especially D • Protrusion relative to natural teeth   - Infraocclusion → shorter incisally + long apically - Blue colouring of labial gingiva - Collapse of labial soft tissue coverage - Recession exposing abutment / implant - Lack of papilla especially D - Protrusion relative to natural teeth Clinical close-up photograph of the anterior maxillary dentition showing a prosthetic implant crown (center) that appears infraoccluded and protruded relative to adjacent natural teeth. The image illustrates soft tissue complications, specifically the collapse of labial soft tissue coverage and recession exposing the abutment area, along with a lack of interdental papilla. Clinical photo: A close-up intraoral view of the maxillary anterior teeth and gingiva. The image illustrates signs of implant failure or poor aesthetic integration, specifically showing a lateral incisor with infraocclusion (appearing shorter than adjacent teeth), blue-grey discolouration of the labial gingiva at the crown margin, recession exposing the abutment/implant collar, and a lack of interdental papilla. # Results In anterior maxilla of a young adult, risk unpredictable+unaesthetic side effects in LT due to ankylotic unit. Thilander Eur J Orthod 2001;23:715- Jemt CID+RR 2005;7:200- In the anterior maxilla of a young adult, risk of unpredictable + unaesthetic side effects in the long term due to the ankylotic unit. *Thilander, Eur J Orthod 2001;23:715-* *Jemt, CID+RR 2005;7:200-* **Koch etal 1996** **Consensus conference on oral implants in young patients** - Mandible 5-6yo - Maxilla - A fixed chronological age cannot be recommended - Use pros that won’t affect growth - When growth is complete - Can’t predict when, can tell when - Longitudinal body height measurement - Hand-wrist radiograph - Serial (12mo) cephs *Koch et al 1996 — Consensus conference on oral implants in young patients* - Mandible: 5–6 years old - Maxilla: - A fixed chronological age cannot be recommended - Use prostheses that won't affect growth - When growth is complete - Can't predict when, but can tell when: - Longitudinal body height measurement - Hand-wrist radiograph - Serial (12-month) cephalometric radiographs - **Tx of choice is the least invasive option that satisfies the aesthetic and functional objectives** - **Think lifelong** > Treatment of choice is the least invasive option that satisfies the aesthetic and functional objectives > Think lifelong  Clinical photo: A close-up view of the anterior dentition, showing the upper and lower teeth in a slightly open position. The image focuses on the central incisors and lateral incisors, revealing white enamel surfaces and healthy pink gingival tissue.  Clinical photo: A close-up view of a patient's smile, displaying the upper and lower anterior teeth and surrounding soft tissue. CT MAXILLA Se: 07/06/2023 8:35:16 AM Se: CT #602 Im: 1/3 A AH R W 3600 C 680 AH R W 3600 C 680 R Data acquired on 7/06/2023 8:31:55 AM at Envision Medical Imaging. Input Images: Number / Slice Thickness [mm] : 160 / 0.40 Reconstruction Increment [mm] / Kernel : n.a. / Ur69u Panorama: Distance / Slice Thickness [mm] : 2.0 / 3.00 Paraxial: Orientation / Length / Distance / Slice thickness [mm] : orthogonal / 30.0 / 2.0 / 1.00 *CT Maxilla — Series: 07/06/2023 8:35:16 AM; Series: CT #602; Image: 1/3. Panel A. R, W 3600, C 680.* *Data acquired on 7/06/2023 8:31:55 AM at Envision Medical Imaging.* - Input Images — Number / Slice Thickness [mm]: 160 / 0.40 - Reconstruction Increment [mm] / Kernel: n.a. / Ur69u - Panorama — Distance / Slice Thickness [mm]: 2.0 / 3.00 - Paraxial — Orientation / Length / Distance / Slice thickness [mm]: orthogonal / 30.0 / 2.0 / 1.00 | | RBB | IMPLANT | | :--- | :--- | :--- | | Prognosis | | | | Aesthetics | | | | Procedures | | | | Treatment time | | | | Cost | | | | Growth | | | | What next? | | |  | | RBB | IMPLANT | | :--- | :--- | :--- | | Prognosis | | | | Aesthetics | | | | Procedures | | | | Treatment time | | | | Cost | | | | Growth | | | | What next? | | | Table: A comparison matrix with column headers "RBB" and "IMPLANT". The rows list criteria for comparison, including Prognosis, Aesthetics, Procedures, Treatment time, Cost, Growth, and What next?, but the cells under the columns are currently empty. **The three levels of surgical wisdom** - Good surgeon - how to operate - Better surgeon – when to operate - Best surgeon – when not to operate The three levels of surgical wisdom: 1. Good surgeon — how to operate 2. Better surgeon — when to operate 3. Best surgeon — when not to operate # 3 Ways To Replace Teeth - (No treatment) - (Space Closure) - (Autotransplant) - Removable - Implant - Bridgework – Tooth supported (RBB) 3 ways to replace teeth: - No treatment - Space closure - Autotransplant - Removable - Implant - Bridgework — tooth supported (RBB) **RBB** * **Treatment of choice in some situations** * lower incisors * maxillary laterals * occasionally other teeth *with risk* * **Posterior RBBs** * low success * aesthetic problem in mandible #### RBB - **Treatment of choice in some situations** - lower incisors - maxillary laterals - occasionally other teeth *with risk* - **Posterior RBBs** - low success - aesthetic problem in mandible ### Assessment of tooth substrate – Need Enamel to bond and seal Need enamel to bond and seal. # **Alloy Choice=Non Precious** * **What does this mean** * Ni-Cr * CrCo * NP2 non Be * Rexillium=Be containing Ni-Cr * **Properties** * Rigid->RBB good * Less accurate to cast / polishing challenging * Grey oxide layer=bonding * Ni Sens possible #### Alloy Choice: Non-Precious **What this means** - Ni-Cr - CrCo - NP2 non-Be - Rexillium = Be-containing Ni-Cr **Properties** - Rigid → good for RBB - Less accurate to cast; polishing challenging - Grey oxide layer = bonding - Possible Ni sensitivity # **Surface Treatment** * **Root canals** * Air abrade (Sandblast) 50 um Al2O3 + ultrasonic * Roughens * Inc. SA * Cleans * Improves wetting * **Root filling** * Historically -> biomarra * Electrolytic etch -> micromechanical * Silanization/siloating via Silcoater or Rocatec -> chemical bond to alloy * 0.5 micron layer of SiOx-C (hybrid silica) added (this is already in porcelain) * Then silane coupling agent * Then unfilled resin #### Root Canals - Air abrade (sandblast) 50 µm Al2O3 + ultrasonic - Roughens - Increases surface area - Cleans - Improves wetting #### Root Filling - Historically → biomarra - Electrolytic etch → micromechanical - Silanization/siloating via Silcoater or Rocatec → chemical bond to alloy - 0.5 micron layer of SiOx-C (hybrid silica) added (this is already in porcelain) - Then silane coupling agent - Then unfilled resin **Resin Cement=Panavia** - Silanated quartz - Methacrylate resins (not BISGMA) - MDP - Phosphate ester / adhesive functional monomer - Chemical bond via metal oxide #### Resin Cement: Panavia - Silanated quartz - Methacrylate resins (not BISGMA) - MDP - Phosphate ester / adhesive functional monomer - Chemical bond via metal oxide  A clinical close-up photograph showing a tooth with a light-colored restoration or crown on the upper portion and dark, decayed tissue visible on the lower root section. The image highlights the contrast between the treated surface and the underlying pathological area. **Always Opaque Panavia** - Avoid grey show through - Can try in with opaque paste (no catalyst) #### Always Opaque Panavia - Avoid grey show-through - Can try in with opaque paste (no catalyst)  Clinical photograph showing a frontal view of the maxillary and mandibular anterior teeth in occlusion. The image displays the alignment, shape, and shade of the incisors and canines against the surrounding gingival tissue. The visible text on the slide is part of the medical text that is floating in the background behind the main image of the teeth. - **Crucial**: The main image of the lips and teeth is wrapped in a <img> tag because it matches the rule for images that are the sole focus. The text in the background is treated as part of a larger medical context, and therefore, no <div> wrapper/HTML.  Clinical photo showing a close-up of a patient's smile, featuring the upper and lower teeth and lips. The image highlights the alignment and condition of the anterior teeth, specifically focusing on the central incisors. **Resultant Metal-Resin-Enamel Complex** * Overall Strong bond=40MPa * **Components** * Tooth-tooth: Cohesive * Tooth-resin: Adhesive Weak * Resin-resin : Cohesive **Weakest**failure is cohesive * Resin-metal: Adhesive Stronger**high bond (2-3x tooth-resin) * Metal-metal: Cohesive * No need to improve on resin-metal interface * Need to improve TS of cement ***THIS IS THE REASON FOR TOOTH PREPARATION** WANT R+R TO DECREASE TENSILE F ON RESIN #### Resultant Metal-Resin-Enamel Complex - Overall strong bond = 40 MPa **Components** - Tooth–tooth: cohesive - Tooth–resin: adhesive, weak - Resin–resin: cohesive, **weakest** — failure is cohesive - Resin–metal: adhesive, stronger — high bond (2–3x tooth–resin) - Metal–metal: cohesive - No need to improve on resin–metal interface - Need to improve tensile strength of cement > **This is the reason for tooth preparation** — want R+R to decrease tensile forces on resin. **Preparation** * Precise mesial and distal grooves * Mechanical retention * Decrease tensile forces on resin cement * Retraction * Often electrosurge * 2 cords #### Preparation - Precise mesial and distal grooves - Mechanical retention - Decrease tensile forces on resin cement - Retraction - Often electrosurge - 2 cords # Resultant Metal-Resin-Enamel Complex * Overall Strong bond=40MPa ## Components * Tooth-tooth: Cohesive * Tooth-resin: Adhesive Weak * Resin-resin: Cohesive **Weakest** failure is cohesive * Resin-metal: Adhesive Stronger high bond (2-3x tooth-resin) * Metal-metal: Cohesive * No need to improve on resin-metal interface * Need to improve TS of cement ***THIS IS THE REASON FOR TOOTH PREPARATION** WANT R+R TO DECREASE TENSILE F ON RESIN #### Resultant Metal-Resin-Enamel Complex - Overall strong bond = 40 MPa **Components** - Tooth–tooth: cohesive - Tooth–resin: adhesive, weak - Resin–resin: cohesive, **weakest** — failure is cohesive - Resin–metal: adhesive, stronger — high bond (2–3x tooth–resin) - Metal–metal: cohesive - No need to improve on resin–metal interface - Need to improve tensile strength of cement > **This is the reason for tooth preparation** — want R+R to decrease tensile forces on resin. # Preparation * Precise mesial and distal grooves * Mechanical retention * Decrease tensile forces on resin cement * Retraction * Often electrosurge * 2 cords #### Preparation - Precise mesial and distal grooves - Mechanical retention - Decrease tensile forces on resin cement - Retraction - Often electrosurge - 2 cords # Margin configurations (a) (b) (c) (d) (e)      Margin configurations (a) (b) (c) (d) (e) A schematic line drawing showing two vertical lines, one straight and one curved, representing a margin configuration. A schematic line drawing illustrating a specific margin configuration, featuring a vertical stem that branches into a V-shape with two diverging arms. A schematic line drawing showing a vertical stem that bifurcates into two upward-curving branches, resembling a tuning fork or Y-shape. A simple line diagram illustrating a specific margin configuration, likely for a dental preparation. The drawing shows a vertical wall that curves outward to form a rounded shoulder or chamfer-like finish line. A schematic line drawing showing a vertical trunk that branches into two upward-curving lines, with a distinct step-like offset in the right branch. <img>Close-up intraoral images showing two adjacent maxillary posterior teeth with endodontically treated roots and bonded ceramic or composite restorations over the coronal aspects. The restorations cover the incisal edges and include visible composite buildups at the incisal edges, likely for structural reinforcement. The surrounding gingival tissue appears healthy. One image shows a front view of the teeth while the other shows a side or angled perspective. *Close-up intraoral images showing two adjacent maxillary posterior teeth with endodontically treated roots and bonded ceramic or composite restorations over the coronal aspects. The restorations cover the incisal edges and include visible composite buildups at the incisal edges, likely for structural reinforcement. The surrounding gingival tissue appears healthy. One image shows a front view of the teeth while the other shows a side or angled perspective.* <img>Dental crown fitting on molar and premolar teeth *Dental crown fitting on molar and premolar teeth*   Clinical photograph showing a close-up of the upper anterior teeth and gingiva. The image highlights a distinct, red, raised lesion located on the gum tissue between two central incisors. A close-up clinical photograph of teeth showing significant enamel defects and discoloration. The teeth exhibit brownish-yellow staining, pitting, and thinning or absence of the outer enamel layer, revealing the underlying structure. **Dental implant fixture:** Left micro-CT image showing internal threaded implants; Right clinical view of dental alveolus with bone defect location.  *Dental implant fixture:* Left micro-CT image showing internal threaded implants; Right clinical view of dental alveolus with bone defect location. Clinical intraoral photograph showing the posterior maxillary alveolar ridge with adjacent natural teeth. The image depicts the edentulous site and surrounding soft tissue where a dental implant fixture would be placed. # Bur * Thin tapered fissure TC * Sharp=NEW * (Halas p 82 Section 7 Fig. H23L) * TH 23L 314 010  #### Bur - Thin tapered fissure TC - Sharp = NEW (Halas p 82 Section 7 Fig. H23L) - TH 23L 314 010 A close-up clinical photograph shows a very thin, tapered dental instrument or bur positioned vertically next to a coin for scale. The image illustrates the fine size and sharp appearance of the tool relative to standard currency. **Provisional** * Provisional * Cavit grooves * RPD / Suspension bridge #### Provisional - Cavit grooves - RPD / Suspension bridge  A close-up clinical photograph of the maxillary posterior teeth showing a metallic dental restoration, likely an amalgam or metal crown, on a molar. The image captures the occlusal surfaces and surrounding gingival tissue in detail.    A clinical intraoral photograph showing the anterior teeth and gingiva. The image depicts a noticeable diastema (gap) between two upper central incisors, along with visible spacing between other teeth. Clinical photo: A close-up intraoral view showing teeth in the dental arch. There is a distinct, bulbous white mass or lesion attached to the side of one tooth, contrasting with the adjacent natural teeth and surrounding pink gingival tissue. Clinical photo: A close-up view of the anterior dentition, showing the upper and lower teeth in a partially open bite position. The image highlights the labial surfaces of the incisors and canines with visible gingival tissue. <details> <summary>Format Rules</summary> - Format tables in HTML (only tables, NOTHING ELSE). - Format flowcharts as tables as best as possible. - All other formatting must be in Markdown. FIGURE/IMAGE RULES (CRITICAL): - If a figure is an image with only labels or sparse text, output ONLY a brief 2-5 word description wrapped in [img][img] tags. Example: [img]Dental X-ray showing root canal[/img] - If the text on the page only makes sense in the context of a figure or image (labels, names with no context), treat the whole page as a figure: wrap a single brief description in [img][img] tags and output NOTHING ELSE. - NEVER output image descriptions as plain text outside of [img][img] tags. - NEVER output standard HTML image tags like [img src="..."]. - NEVER output [div][figure][section], or other HTML wrapper tags (except tables). - NEVER explain your reasoning, reference the instructions, or include meta commentary. Output ONLY the OCR text and/or [img][img] descriptions. DO NOT ADD ANYTHING TO THE TEXT ITSELF. YOU ARE ONLY TRANSCRIBING/FORMATTING. DO NOT SAY ANYTHING ELSE. </details> \nCases\n\n- Maxillary laterals\n - Mandibular incisors\n - Occasionally other teeth (with risk)\n- Diastemas?\n- Enamel\n- Occlusion on pontic to be avoided\n- Space for retainer\n- Cantilever\n - may reduce stress on cement\n - certainly avoids caries when one side debonds\n- Prepare tooth-low TS of cement\n- Sand-blasted non-precious alloy\n- Opaque Panavia Cases: - Maxillary laterals - Mandibular incisors - Occasionally other teeth (with risk) - Diastemas? - Enamel - Occlusion on pontic to be avoided - Space for retainer - Cantilever - may reduce stress on cement - certainly avoids caries when one side debonds - Prepare tooth – low TS of cement - Sand-blasted non-precious alloy - Opaque Panavia # Dental crown impression techniques * Metal-ceramic (PFM) * **Etchable ceramic** * Non-etchable ceramic - Metal-ceramic (PFM) - **Etchable ceramic** - Non-etchable ceramic # **Glass Ceramics** * Silica based * HF selectively dissolves glass * **Silane** * etc - Silica based - HF selectively dissolves glass - **Silane** - etc # Lithium disilicate ceramic ## Pre-etch   #### Pre-etch [img]Lithium disilicate ceramic surface before etching[/img] A scanning electron micrograph (SEM) showing the surface topography of lithium disilicate ceramic in its pre-etched state. The image reveals a dense network of interlocking, needle-like or rod-shaped crystalline structures with a scale bar indicating 10 micrometers. A scanning electron micrograph (SEM) showing the microstructure of lithium disilicate ceramic after hydrofluoric acid (HF) etching. The image reveals a roughened surface with exposed, randomly oriented rod-like or needle-shaped crystals, characteristic of the glass matrix being dissolved to create microporosity for bonding.  A close-up photograph shows a single tooth, likely a premolar or molar, with a large, opaque white restorative material placed in its central occlusal surface. The tooth is set against a dark background scattered with translucent, irregular fragments.  Clinical photo showing an intraoral view of the maxillary and mandibular teeth with a cheek retractor in place. A white plastic bite stick or articulating rod is held horizontally between the upper and lower anterior teeth to demonstrate vertical dimension or occlusal clearance.  Clinical photo showing a close-up view of the upper and lower anterior teeth with visible spacing (diastema) between the central incisors.  Clinical photo: A close-up view of a person's mouth showing the upper and lower teeth, lips, and surrounding skin. The image highlights the alignment and color of the teeth in a resting position.  The image displays two photographs of a dental prosthesis (specifically a cantilever fixed partial denture). The top photo shows the occlusal view of the restoration, featuring a pontic connected to a retainer. The bottom photo illustrates a clinical or laboratory procedure where dental floss is pulled through the interproximal contact area between the pontic and the abutment tooth. {\ "BOX_A": "",\ "BOX_B": ""\ }   A close-up clinical photograph of a human mouth showing the upper and lower teeth in occlusion. The image displays healthy pink gingival tissue and white teeth, with visible misalignment or crowding on the right side (viewer's right) where an upper tooth overlaps a lower one. Clinical intraoral photograph showing the anterior dentition with a noticeable gap (diastema) between the upper central incisors. ```html <h1>Li Disilicate Indications</h1> <ul> <li>Veneers (≥ 0.3 mm)</li> <li>Inlays and onlays</li> <li>Occlusal veneers, partial crowns</li> <li>Minimally invasive crowns (≥ 1 mm)</li> <li>Implant superstructures</li> <li>Hybrid abutment solutions</li> <li>Three-unit bridges up to the second premolar as the terminal abutment</li> </ul> <p><a href="https://www.ivoclar.com/en_us/products/metal-free-ceramics/ips-e.max-lithium-disilicate" style="color: blue; font-size: small;">https://www.ivoclar.com/en_us/products/metal-free-ceramics/ips-e.max-lithium-disilicate</a></p> ``` - Veneers (≥ 0.3 mm) - Inlays and onlays - Occlusal veneers, partial crowns - Minimally invasive crowns (≥ 1 mm) - Implant superstructures - Hybrid abutment solutions - Three-unit bridges up to the second premolar as the terminal abutment https://www.ivoclar.com/en_us/products/metal-free-ceramics/ips-e.max-lithium-disilicate   Clinical photograph: A close-up intraoral view of the anterior teeth in occlusion, showing the upper and lower incisors and canines along with the surrounding gingival tissue. Clinical photo: A close-up view of the anterior teeth in occlusion, showing a distinct gap (diastema) between the central incisors and misalignment of the lower incisors. **Li Disilicate Indications** - Veneers (≥ 0.3 mm) - Inlays and onlays - Occlusal veneers, partial crowns - Minimally invasive crowns (≥ 1 mm) - Implant superstructures - Hybrid abutment solutions - Three-unit bridges up to the second premolar as the terminal abutment https://www.ivoclar.com/en_us/products/metal-free-ceramics/ips-e.max-lithium-disilicate - Veneers (≥ 0.3 mm) - Inlays and onlays - Occlusal veneers, partial crowns - Minimally invasive crowns (≥ 1 mm) - Implant superstructures - Hybrid abutment solutions - Three-unit bridges up to the second premolar as the terminal abutment https://www.ivoclar.com/en_us/products/metal-free-ceramics/ips-e.max-lithium-disilicate *** **Li Disilicate Indications** * Not indicated for RBB due to connector fracture risk * But if connector size...bulky * 3mm vertical * 2mm horizontal - Not indicated for RBB due to connector fracture risk - But if connector size...bulky - 3 mm vertical - 2 mm horizontal   Clinical photo: Close-up intraoral view of teeth showing a dark metallic restoration (likely amalgam) on the proximal surface of a tooth, surrounded by natural enamel and gingival tissue. Clinical photograph showing a close-up view of dental restorations, specifically posterior teeth with what appear to be ceramic or composite crowns and inlays. The image illustrates the fit and occlusal morphology of indirect dental restorations against the natural tooth structure. - **Metal-ceramic (PFM)** - **Etchable ceramic** - **Non-etchable ceramic** - **Metal-ceramic (PFM)** - **Etchable ceramic** - **Non-etchable ceramic** **Zirconium oxide** * Can't etch non-silica based ceramic * No glass! (HF dissolves glass) * Try * Silica coat * "Hot bond" etchable glass * ACP **Zirconium oxide** - Can't etch non-silica based ceramic - No glass! (HF dissolves glass) - Try: - Silica coat - "Hot bond" etchable glass - APC # **Zirconium oxide (Y-TZP)** ## APC concept * Blatz etal Compendium 37(2016):9:611- * **A=Air-particle abrasion aluminum oxide (50um 1-2 bar)** * **P=Zirconia primer (MDP)** * **C=Composite resin** * **Adhesive phosphate monomer=MDP can be in the primer or adhesive** * **Eg. Panavia 21 (** **MDP** **)** **Zirconium oxide (Y-TZP)** #### APC Concept *Blatz et al., Compendium 37 (2016):9:611-* - **A** = Air-particle abrasion aluminum oxide (50 µm, 1–2 bar) - **P** = Zirconia primer (MDP) - **C** = Composite resin - Adhesive phosphate monomer = MDP can be in the primer or adhesive - Eg. Panavia 21 (**MDP**) * **Rocatec plus 50 micron particles (Silica coated alumina) under pressure of 2 bar** * Use of **phosphate** containing **primer**, ideally **Clearfil ceramic primer** (higher **MDP** content compared to rest of the product) if not Monobond plus * Panavia - Rocatec Plus 50 micron particles (silica-coated alumina) under pressure of 2 bar - Use of **phosphate**-containing **primer**, ideally **Clearfil Ceramic Primer** (higher **MDP** content compared to the rest of the products); if not, Monobond Plus - Panavia   Clinical photo: A close-up intraoral view showing the maxillary and mandibular anterior teeth in occlusion. The image displays the alignment of the incisors and canines along with the surrounding gingival tissue. Clinical photo: A close-up view of a human mouth showing the upper and lower teeth in a slightly open position, revealing natural variations in tooth color and alignment. # **Zirconium oxide (Y-TZP)** * Kern etal J of Dent 65(2017):51- * Ten-year outcome of zirconia ceramic cantilever RBB`s * 108 bridges in 87 pts * Mean observation 92mo=7.6 yrs * 8 bridges lost to follow up * 6 debonded (but were recemented) * no connector failures * Conclude "10 year survival rate of 98.2%" * Attn to: - 30mm2 SA, sound E - 0.7mm retainer (occ needs to allow) - 3mm high x 2mm wide min connector - air abraded with alumina--->cleaned alcohol - Panavia 21 etc **Zirconium oxide (Y-TZP)** *Kern et al., J of Dent 65 (2017):51-* - Ten-year outcome of zirconia ceramic cantilever RBBs - 108 bridges in 87 pts - Mean observation 92 mo = 7.6 yrs - 8 bridges lost to follow up - 6 debonded (but were recemented) - No connector failures - Conclude "10 year survival rate of 98.2%" #### Key Technical Points - Attention to: - 30 mm² SA, sound enamel - 0.7 mm retainer (occlusion needs to allow) - 3 mm high × 2 mm wide minimum connector - Air abraded with alumina → cleaned with alcohol - Panavia 21, etc. # Cantilevered ## Mesial cantilever →tip out of occlusion <img/></img>  #### Cantilevered Mesial cantilever → tip out of occlusion A schematic line drawing of a dental arch (specifically the left quadrant) viewed from an occlusal perspective, illustrating a cantilevered bridge design. The diagram shows two anterior teeth at the top (the free end or tip) unsupported by posterior abutments, with arrows pointing to each tooth position labeled with values in microns (μ), likely indicating deflection or movement. - Assessment of occlusion - contact in MIP but no excursive contacts - retainer space to be gained (cut teeth) or is available - Engineer to situation - **Bruxers** also need tooth replacements! - **Class II div II** also need tooth replacements! - Research often challenges dogma - Assessment of occlusion - Contact in MIP but no excursive contacts - Retainer space to be gained (cut teeth) or is available - Engineer to situation: - **Bruxers** also need tooth replacements! - **Class II div II** also need tooth replacements! - Research often challenges dogma - Berekally 1993 ADJ Adelaide, Australia - **2 abutments+/-prep** - Extremely high failure rates implies technique sensitive NOT that they do not work - Survival ~60% at 5 years, many debonded **VERY** early - *Berekally 1993, ADJ, Adelaide, Australia* - **2 abutments +/- prep** - Extremely high failure rates implies technique sensitive — NOT that they do not work - Survival ~60% at 5 years, many debonded **VERY** early 27 yo RBB placed at 29yo    27 yo, RBB placed at 29 yo Clinical photo showing a frontal view of the upper and lower teeth in a patient's mouth. Clinical intraoral photograph showing the anterior teeth in a frontal view, depicting the maxillary and mandibular incisors, canines, and surrounding gingival tissue. Clinical photo showing a close-up intraoral view of posterior teeth, specifically highlighting large metallic restorations (likely amalgam) on the proximal surfaces and occlusal areas. - **Probster 1997 IJP Mainz, Germany** - 2 abutments+/-prep - Survival 76% at 5 years 60% at 10 years - *Probster 1997, IJP, Mainz, Germany* - 2 abutments +/- prep - Survival: 76% at 5 years, 60% at 10 years - Gerry Barrack 1993 IJP NYU, USA - authors resin-bonded cast restorations from private practice - 11 year prospective - 127 restorations, 455 units(ranging 1-10 units) - Success=no debond - 92.9% over 11 years but 100% in latter 9 years(since 1983) - **No failures since 1983 when adopted**: - Grooves+rests+incorporating existing restorations - Panavia - Non-precious alloy sandblasted - Barrack, Bretz IJP 1993;6(5):428- - *Gerry Barrack 1993, IJP, NYU, USA* - Authors resin-bonded cast restorations from private practice - 11 year prospective - 127 restorations, 455 units (ranging 1–10 units) - Success = no debond - 92.9% over 11 years, but 100% in the latter 9 years (since 1983) **No failures since 1983 when adopted**: - Grooves + rests + incorporating existing restorations - Panavia - Non-precious alloy sandblasted *Barrack, Bretz, IJP 1993;6(5):428-* [^1]: Original PDF page 1: [[L8 Resin Bonded Bridges_slides.pdf#page=1|L8 Resin Bonded Bridges slides, p.1]] [^2]: Original PDF page 2: [[L8 Resin Bonded Bridges_slides.pdf#page=2|L8 Resin Bonded Bridges slides, p.2]] [^3]: Original PDF page 3: [[L8 Resin Bonded Bridges_slides.pdf#page=3|L8 Resin Bonded Bridges slides, p.3]] [^4]: Original PDF page 4: [[L8 Resin Bonded Bridges_slides.pdf#page=4|L8 Resin Bonded Bridges slides, p.4]] [^5]: Original PDF page 5: [[L8 Resin Bonded Bridges_slides.pdf#page=5|L8 Resin Bonded Bridges slides, p.5]] [^6]: Original PDF page 6: [[L8 Resin Bonded Bridges_slides.pdf#page=6|L8 Resin Bonded Bridges slides, p.6]] [^7]: Original PDF page 7: [[L8 Resin Bonded Bridges_slides.pdf#page=7|L8 Resin Bonded 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