2015 ‘Hands-on’ Tooth Preparation Course

Teachers / Demonstrators: Ahmed, Tracy & Peter March 2015

Tooth Preparation Course – Norfolk and Norwich

University Hospital - Dental Simulation Laboratory
 ‘Hands-On’ Didactic
Teaching
Hands-on Tooth Preparation
Course -

Clinical Simulation
Laboratory,
Norwich 2015
 Why are we all here?
• Confirm / Update our Knowledge
• Clinically Apply our Knowledge
• Accept Incompetency
• Work towards Proficiency
• Learn to be Competent
• Learn to be Proficient
• Exposure to new clinical skills
 ‘Phantom Head’ dentistry
• It has taught me what I am going to do before I do it
• It allows you to execute practical skills until you can
predictably achieve a satisfactory result
• It taught me the importance of reflective learning and to be
self-aware of my limitations – so I can improve them
• It also taught me to look at criticism positively – and realise
that a ‘nicey / nicey’ approach to teaching (and life) doesn’t
work in the long run
 Rules of the Day

• Get feedback from us and your colleagues

• Enjoy the day and have fun but and reflect on at you
have done
• Lets try and do step by step approach – keeping
together
• It’s not an exam – it’s a day to make mistakes
• We will take photos of the preps so we can discuss
them as a group
• We will come round & offer honest constructive
comments
• You will objectively score your preparations
 Practical Day
Objectivise where we all are with the skill of tooth preparation
Understand what is it that makes a good
or poor tooth preparation?

LEM DBC
 Simulation Environment
• In practice you will rarely be preparing virgin teeth
• The teeth will be heavily restored, broken down or worn
• You may be replacing failed ‘fixed’ restorations
• In practice you are dealing with the quirks of a patient
• You are also dealing with the strengths and weaknesses
of your trainer in your foundation year
Does anyone know what these three anterior tooth
preparations are for and why they are different?

DBC
LEM

WPFM
What do we want you all to do well today?
• Margins
• Taper
• Matching reduction to tooth
anatomy
• Matching reduction to
proposed material of
restoration
• Producing an overall circular
preparation shape
• Hold and control your hand-
piece properly
• Know the dimensions of your
burs – and why you are using
them
 Learning outcomes

• Produce taper appropriate to design and material of indirect

restoration
• Produce margins of appropriate depth, consistency and
height (relevant to gingival margin) for material choice
• 3D tooth reduction appropriate to material choice and
design of crown / indirect restoration
• Can prescribe to technician material choice and design and
work backwards from your choice of restoration to
preparation design
Tools for the day:

Silicone putty & sharp scalpel blade

Burs
Plastic Teeth
Sharp pencil
I look at a Putty Index like an implant stent
(you need help and guidance with precision)
 It will
demonstrate to
you the truth.
You are new to
this so I would
suggest that you
use a putty
index routinely
 Technical things that we can all
objectively check with the Putty Index

• Margin (dimension / height / consistency /

smoothness)
• Taper (appropriate for restoration DBC 15-
20 degrees)
• Adequacy of Reduction (compared to pre-
operative putty)
• Overall shape of preparation
• Appropriateness of preparation for the
material choice of the restoration
Putty Index – please use them for your patients
to improve your anatomical awareness
If you have time make two pre-preparation putty indices:

Cut one from buccal to palatal in middle of crown - to use

as a preparation guide

Cut the other across incisal edge

They will give you different information

 Tools for the day: Burs – you need to select the
right type and size of burs for the
job you need done
Silicone putty
Burs
Plastic Teeth
Sharp pencil
 Tools for the day:

1.3 mm
1.5mm
Tapered Broad Chamfer

&

Tapered Broad Shoulder

 Tools for the day:

Silicone putty
Burs
Plastic Teeth
Sharp pencil
Plastic Teeth – we have lots to practice on – this is a
good place to make mistakes

PB 2015
 Basic things
• Handpiece control – smooth cutting
• Holding the handpiece right – ‘parallelism’ control
• Using two hands for extra control when needed
• Bur selection
• Knowing bur size

PB 2015
We will not ask you to do
anything that we cannot

PB 2015
 Tools for the day:

Silicone putty
Burs
Plastic Teeth
Sharp Pencil
 Objectivise undercut assessment – should be able to
see the 4 points at each of the line angles with mirror
– this means no undercut(s) present

Use sharp pencil at each of the four

line angle to check for undercuts
If you can see all four then no
undercuts – if not you have an
undercut

Axial reduction and undercuts PB 2014

Draw on the labial aspect of your teeth prior to
preparation to:
• Identify the maximal labial contour
• Understand the directions of the two labial planes
• Identify mesial and distal marginal ridges
• Anatomy of different teeth is different
Multi-Plane Labial Reduction
 Two / three plane tooth reduction
which relates to crown anatomy. Worn teeth end up
thick at incisal tips

Incisal plane Cervical plane

Feedback
Assessment Forms
 1st Clinical Task

A ‘Winged’ VMK anterior tooth

preparation
Knowledge

Porcelain Fused to Metal Crowns

account for more than 85% of all
prescribed crowns in the UK
Knowledge

What is the preparation that we need to

execute ‘to allow’ or to facilitate’ a PFM?
• Full cast alloy metal core that provides
support for all the ceramic (the cut back)
• Metal ‘only’ coverage on palatal / lingual
aspect of tooth to involves ICP and initial
incisal guidance contacts
• Fully ‘supported’ labial, interdental and
incisal Ceramic
Knowledge

‘Good’ Ceramic support

‘Poor’ Ceramic support
Knowledge

WPFM Preparation

Preparation Specifications:

Incisal Reduction: 1.5 - 2.0mm

Labial Shoulder: 1.2 - 1.5mm
Palatal Chamfer: 0.5mm – for Metal only
Palatal Reduction: 0.7 - 1.0mm for Metal only (palato-occlusal
(gingival) 2/3s
1.2 -1.5mm for both Metal & Ceramic
(palato-incisal third)
Knowledge

The ‘Wings’
• If you need a 1.2 – 1.5mm shoulder labially (for metal
and ceramic)
• If you need a 0.5mm palatal chamfer (for metal only)
• Then you will end up with interdental ‘Wings’ where
the different dimensions of the margins meet
Knowledge

The wing is where the palatal metal preparation meets the

labial and interdental porcelain and metal preparation

PB 2015
Knowledge

We need to get the palatal chamfer

margin right and note how it slides round the outer
aspect of the ‘wing’!
Knowledge

Common errors with WPFM Tooth Preparation:

Single labial plane reduction – look carefully at the tooth before you
start to work out what you should aim for
Inappropriate change of Labial Plane
Uneven labial shoulder – want consistent depth
‘Universal’ preparation – no information on what surface should be covered by
porcelain and metal and which surfaces should be covered by metal alone – think
where you want metal only, where metal and ceramic and what this means to your
preparation
Gouging and lipping of labial shoulder – think about bur choice.
Start off by placing your margin supra-gingival and then refine near the very end
to avoid you placing your Margins too deep
Aim for labial margin, at or just below gingival level, and palatal margin supre-
gingival
Here are some other aspects that you need to consider:

Winged preparation – this provides the technician with information about

where you wish the ceramic/metal junction to be positioned.
Obvious demarcation interproximally and palatally where the preparation
changes from having sufficient space for metal and ceramic to having metal
alone.
Think very carefully how much and where you need to remove tooth tissue -
and why?
Measure the tips of your burs and understand how much tooth needs to be
removed.
Insight into performance

WPFM Objective Feedback Scoring

• Please fill in the quality

assessment sheet when you
have finished
• A total score of 20 is possible
• There is space for reflective
learning comments
• I want you all to discuss this
with your DF trainers / tutors
Go do it - a ‘Winged’ PFM preparation on one
of your maxillary central incisor (UL1)

PB 2015

DBCC WPFM
Common errors displayed with WPFM Today:

Over-preparation in some areas and under-preparation in

others
Over taper
Undercuts – check with sharp pencil and mirror at the line
angles
Too aggressive incisal length reduction – think how much you
need
Not enough interproximal space between preparation margins
and adjacent teeth – technician must be able to section the die –
so there must be enough space between the prepared tooth /
teeth
Try not to take too much off the very valuable parts of
the tooth – work on improving drill precision and
control – use your other hand to control and guide the
drill
Knowledge

Axial Height
Minimum 2mm Ferrule
Knowledge

Parallelism is essential for retention on short teeth

Knowledge

Remember
 Retention - the direction of the path of insertion
(occlusal direction)
 Resistance form any other lateral direction
 A function of:
 Taper
 Surface area/bulk of preparation
 Surface roughness Jorgensen 1955
Knowledge

‘Good, better, best. Never let it rest. Until

your good is better and your better is
best.’ Tim Duncan
2014 ‘Hands-on’ Tooth Preparation Course
Teachers / Demonstrators: Ahmed, Tracy & Peter March 2015

Tooth Preparation Course – Norfolk and Norwich

University Hospital - Dental Simulation Laboratory
Task 2 - DRBCC
Resin (Dentine) Bonded
Crown Preparation – can
easily convert a labial
ceramic veneer
preparation into a
DRBCC preparation
 Tooth Destruction

INDIRECT
DBC PJC
COMPOSITE
 Aesthetic restorations
looking good comes at a
biological price
DBC prep = 63% off tooth
PFM prep = 72% off tooth
PFM prep 20% > FGC prep
PFM prep x5 > Porcelain veneer
(feathered) x3 > Porcelain veneer
(butt joint)
Edelhoff & Sorensen (2002). Tooth structure removal associated with various preparation designs for anterior teeth. J Prosthet Dent; 87: 503-9

Edelhoff & Sorensen (2002). Tooth structure removal associated with various preparation designs for posterior teeth. Int J Periodontics Restorative Dent; 22:
241–249
 Dentine Resin-Bonded Ceramic Crown
Preparation
360o Heavy Veneer Preparation – but no undercuts can be allowed
 DRBCC Preparation

• Margin (supra-gingival): 0.5 - 0.7mm

consistent circumferential depth
• 3D tooth reduction of 0.5 - 0.7mm in all
dimensions
• 1mm inter-occlusal space palatal
clearance with rugby ball burs
• Taper of all walls: 8 - 10o
Rounded Contours

No
Undercuts
PB
 Convergence Taper
15 - 20o
Occlusal
Reduction
1.0 mm

Heavy
Axial Reduction Chamfer
0.5 - 0.7mm PB

Dentine Resin Bonded Ceramic Crown

 DRBCC Preparation
• ‘Ceramic-Veneer’ concept around the whole tooth
• Adhere hopefully to a good amount of enamel (as well as
dentine)
• Can use with one or two stage Dahl
• Need significant convergence taper as neo-parallel will
threaten # of crown on seating / cementing
• Most feel less tooth tissue removed – however you will be
surprised!
Note the difference - in my view it is much
more destructive palatally than a PFM
Can use RB Ceramic ‘Hats’ or Crowns – manage what is in front of you
 Common error in C&B preparation

Still need to use conventional sense –

e.g. good separation of ID margins but keep enamel peripherally if possible
 Indirect Palatal Veneers
• Can use DRBC Veneers – where aesthetics important
Now go and give it a go please
Knowledge

Task 3 - E-Max Anterior Crown

Knowledge

e.max core can be used in several ways

Knowledge

E-max

CAD CAM or Pressed:

• Layered
• Monolithic
• Hybrid (using the advantages of both layered
(labial) and the monolithic full-thickness core
(palatal))
Knowledge

Which is best and why?

Knowledge

Monolithic full contour e-max (400MPA) – v –

‘Layered’ e.max – (90 MPA)
Knowledge

Do not do this please:

If you must – then use monolithic

e.max as bridge framework:
Knowledge

‘Monolithic’ full contour e.max

(400MPA)
• 1.0 to 1.2 mm occlusal depth to
achieve appropriate occlusal
anatomy.
• 1.2 to 1.5 mm functional cusp tip
reduction.
• 0.7 mm gingival chamfer reduction
• 6-8 degree taper to the axial walls
Knowledge

3rd Task – a ‘Layered’ e.max anterior

all-ceramic crown
Knowledge

‘Layered’ e.max anterior crown

• Occlusal Reduction: 2.0mm
reduction
• Butt Margin: 1.0 - 1.2 mm
circumferential shoulder reduction
(with round internal line angle)
• Taper: 6-8 degree taper to axial walls
• Overall wall reduction: 1.5 mm in all
aspects
Knowledge

3rd Task - A Layered e.max anterior

all-ceramic crown

• 1.2mm butt joint margin at

gingival margin – all
rounded angles
• 1.5mm of facial, axial and
palatal reduction
• 2mm reduction of incisal tip
• 1.5-2.0mm of palatal
clearance in area of
occlusion
Knowledge
Feedback