TOOTH

PREPARATIONS
CLOVIS PAGANI

^ QUINTESSENCE PUBLISHING
tooth
preparations
 CLOVIS PAGANI

TOOTH
PREPARATIONS
S C I E C E & A R T

QUINTESSENCE PUBLISHING
Berlin, Barcelona, Chicago, Istanbul, London, Milan, Moscow, New Delhi,
Paris, Prague, Sao Paulo, Seoul, Singapore, Tokyo, Warsaw
 First published in Portuguese "Prepares Dentarios"
© Editora Napoleao Ltda., Brazil 2014
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Printed and bound in Germany

PREFACE
When I was invited to write the Preface for this book, I must confess that I did
not realize the commitment at the time. When the book arrived in my hands,
however, I began to gradually feel the responsibility that I was facing. Sud-
denly, that friend and colleague of 40 years turned into an earnest steward
demanding of me an accurate analysis of his work - a most powerful and com-
prehensive one, as he confidently said. I realized then that our friendship could
not interfere with that analytical process, since scientific purpose was the ab -
solute criterion of the action to be performed. I had no alternative but to start
reading. And then everything changed!
I found myself facing a work of undeniable value. From its prodigious and
exciting cover, I as the reader could already anticipate the wonder I would ex -
perience from then on. Care and good taste impressed me throughout my
reading; the book awakened in me the enthusiasm and desire to use it as
my sovereign guide in my clinical activity. This is said without exaggeration,
dear readers, for those who venerate books, as I do - I feel them, hold them,
squeeze them - this book is both a privilege and an ecstatic pleasure.
To those for whom it is intended, this book will be invaluable; an investment
comparable to that made by acquiring the venerable handbook Shillingburg in-
troduced to clinical and restorative dentistry at the time. I state without hesita -
tion that this book will enjoy the same success and have the same significance
for dental practitioners; furthermore, this work is up-to-date, has magnificent
3 D illustrations, and has a clear and objective meticulousness on the part of
the author and his collaborators.
The book is divided into eight carefully written chapters, providing the read-
er with essential theory, sound practice, and reliable guidance for further stud-
ies. Chapter 1 is an introduction to indirect restorations. It explains skillfully
and strongly the theory and practice of this important and ongoing stage of ev-
eryday practice. Chapter 2 deals with restorative planning, and it is marvelous!
The explanations lead not only to an understanding of the subject matter, but
to how to incorporate it into professional practice. In Chapter 3, the principles
and sequences of preparation are very clearly detailed, and are supported by
sophisticated illustrations, the quality of which is in keeping with the best and
most outstanding in dental books published to date. Chapters 4 and 5 focus
on intracoronal and extracoronal restorations, and the same textual and illus-
trative quality is maintained. Chapter 6 presents conservative preparations,
the focus being on preservation in operative procedure and the observation of
biology. The chapter also covers the appropriate tools for conservative dental
procedures. Chapter 7 discusses compromised teeth with the same attention
to detail and care. Chapter 8 is about adhesive milled restorations. The mater -
ial is well founded and presented in an innovative and clear manner, showing
that the issue should no longer be considered inaccessible, or a matter for the
privileged few, due to the technology available in dentistry today, which should
be used properly and with discretion.
I would like to honor and congratulate Professor Clovis Pagani and his col -
laborators for the esthetic consistency and relevance of this work. The editing
is true perfection. To future privileged readers of this book, it is my hope that
the knowledge you assimilate from it will make you more competent, more
skilled, and more professional. That is indeed what I wish for myself!

Happy reading!

Jose Roberto Rodrigues, Associate Professor

Former Director, School of Dentistry
Sao Jose dos Campos - UNESP
INTRODUCTION
More than merely specific expertise is expected from dental professionals to-
day; they are required to be skilled in human relationships, be able to com-
municate with their patients, take responsibility based on self-criticism, and,
above all, be accurate in their practice of dental operatory. In the past, the
pioneers of our profession claimed that the success of restorative practice
depended more than 60 percent on the technical refinement applied to cav-
ity preparations. This assumption still applies, and with more relevance than
ever before. The new materials require accurate measurements, dimensions,
and customization for dental procedures. Underlying this is the importance of
preserving dental tissue and function at all cost, as well as the sovereignty of
esthetics, the main measure of dental success for much of contemporary soci -
ety. While new technologies serve as auxiliary and complementary tools in the
routine of the modern dental practitioner, the suitability of clinical and restora -
tive choices also plays a major part in the success of clinical practice today.
Although traditional remnants of restorative practice still persist, cosmetic
dentistry is undeniably the main movement that is at the heart of, and is shap-
ing, the dentistry profession today. Patients are demanding that dental profes-
sionals adhere consistently to the rules of esthetics; philosophical principles
that derive from the fundamental works of Aristotle.
In the book that you hold in your hands, dear reader and colleague, we have
tried to approach - without semantic tricks and unnecessary erudition - the
significance of knowing the background and basic principles of current prac -
tices of cavity preparation; these being, in essence, utility and functionality.
Professionalism in dentistry is not about geographical location, the ergonomic
arrangement of pieces of work equipment, or dazzling waiting rooms. Rather,
it is mainly about skills and the refinement of operative details - in short, the
essential, non-negotiable principles of precision, care, and a sound biological
and scientific knowledge base.
You will find in this work a step-by-step approach to the current require-
ments demanded by cavity preparation in every indication that may arise, to
enable you to accomplish successful clinical and restorative treatments. You
will see, for example, that a detailed and comprehensive planning phase is
mandatory in order to carry out cavity preparation efficiently and effective-
ly. You will understand that the sequence of cavity preparation respects peri-
odontal health, the protection of the pulp- dentin complex, the tooth remnant,
occlusion, and the mechanical function of the elements to be restored. The
first and only purpose of this book is to provide colleagues who care about
the quality of their clinical activities the close attention to detail and the cavity
preparation steps that have never gone out of fashion. Indeed, how could a
philosophy of practice that carries with it the essential factors for success ever
go out of style?
We hope, dear colleagues, that this book gives you the opportunity to prac -
tice a dentistry that has as its foundation the principles of quality, honesty, and
the true fire that earns our profession its place amongst the elite professions
in the world today.
Thank you for your attention, we wish you all success.

Clovis Pagani
DEDICATION
I dedicate this work to the countless individuals and professors who participat-
ed in my academic and professional training, whom I shall never forget. I want
to thank and honor:

Prof. Dr. Armando Curti Junior

Prof. Dr . Cervantes Jardim
Prof. Tit. Dan Mihail Fichman
Prof. Dr . Delcio Pasin
Prof. Dr . Henrique Cerveira Neto
Prof. Dr. Joao Candido Carvalho
Prof. Dr. Joao Vieira de Morais
Prof. Adj. Jose Roberto Rodrigues
Prof. Tit. Julio Jorge D'Albuquerque Lossio
.
Prof. Dr Marcelo Augusto Galante
Prof. Dr. Marco Antonio Bottino
Prof. Tit. Maria Amelia Maximo de Araujo
Prof. Dr. Newton Jose Giachetti
Prof. Dr. Pedro Americo Machado Bastos
Prof. Dr. Ruy Fonseca Brunetti

To the School of Dentistry of Saojose dos Campos - ICT - Sao Paulo State Uni -
versity - UNESP.

To the professors of the Department of Restorative Dentistry, School of Den-

tistry - ICT - Universidade Estadual Paulista - UNESP.

To the Napoleao Publishing Elouse - Leonardo, Guilherme and all employees

for the friendship, caring, dedication, and promptness in the preparation of
this work.

To the students Beatriz, Isabella and Geraldo, and all undergraduate and grad-
uate students, you are surely the main reason for this work.

I have been a teacher for 40 years and have taught many people during that
time, but most importantly I am a learner.

I GIVE INFINITE THANKS TO GOD, WHO ALWAYS SUPPORTS ME .

»
AUTHOR
CLOVIS PAGANI
Master in Clinical Dentistry, Faculty of Dentistry, Uni-
versity of Sao Paulo - USP
Doctor in Clinical Dentistry, Faculty of Dentistry, Uni-
versity of Sao Paulo - USP
Head of the Department of Restorative Dentistry, Fac-
ulty of Dentistry of Sao Jose dos Campos, Sao Paulo
State University - ICT - UNESP

Professor of the Post-Graduate Program of Restorative

Dentistry (Master and Doctorate) of the Faculty of Den-
tistry of Sao Jose dos Campos, Sao Paulo State Univer -
sity - ICT - UNESP

Specialist in Aesthetic and Prosthetic Dentistry

SPECIAL THANKS
To my parents Francesco (in memoriam) and Malvira
.
(in memoriam), thank you for my existence I am grate-
ful for the love and care you gave me during my whole
life. YOU were my first teachers.
To my brother Giacomo, you were a guide, friend,
and always a reference.
To my dear and beloved wife Marcia. Thank you for
believing I could do anything, for not letting me falter
and especially for being a partner and the mother of
.
our three wonderful children The pain decreases over
time, but the missing...
To my dear children Rodrigo, Vinicius, and Lucas, I
cherish the understanding and inspiration, you are the
main stimulus in everything I do. You always have been
and will be the main reason for my battle in this life.
To dear Ana Lucia Sampaio Galante, for your sup-
port and encouragement. Thank you also for being at
my side in times of sorrow and joy.

If this step is an achievement, it is not only mine, IT'S OURS.

I love you all.
f
CO- AUTHOR
EDUARDO GALERA DA SILVA
Master in Partial Fixed Prosthesis - ICT FOSJC - UNESP
Doctor in Partial Fixed Prosthesis - FOUSP

Specialist in Prosthetic Dentistry - CRO SP

Professor responsible for the Nocturnal Integrated
Clinic - ICT FOSJC - UNESP

SPECIAL THANKS

To my parents, Joao and Alice, who by being an ex-

ample of character have guided my familial and pro-
fessional life.
To my wife Ana Paula, for the encouragement and
motivation in all the moments of our lives.
To our daughters, Julia and Luisa, for the joy you
bring to us.
To my friend Professor Clovis Pagani, mentor of
this work, for your idealism and objectivity.
9
CO - AUTHOR

DANIEL MARANHA DA ROCHA

Adjunct Professor of the Department of Odontology
of Lagarto from the Federal University of Sergipe
Master in Restorative Dentistry - Aesthetic Dentistry -
Institute of Science and Technology of Sao Jose dos
Campos - UNESP
Doctor in Restorative Dentistry - Aesthetic Dentistry -
Institute of Science and Technology of Sao Jose dos
Campos - UNESP

SPECIAL THANKS
To my godfather Francisco Saliby (in memoriam),
great encourager and professional and personal ex-
ample, I owe to him my being the professional that I
have become.
To my wife Milena, for the unconditional support
and love, thank you for always being present, sharing
joy and giving strength to overcome the obstacles on
the pathway.
My parents Cesar and Beatriz, for the example in
life and for the dedication of every day that made it
possible for me to get where I am today.
To my sister Rita, for all the times we've spent to-
gether and the great gift you gave us.
To my friend Clovis Pagani, for the opportunity to
participate in this magnificent project.
#
CONTRIBUTORS

RODRIGO FURTADO DE CARVALHO

Specialist in Prosthodontics, Bauru School of Dentistry, University of Sao Paulo
( USP)

Master in Dental Clinic, Emphasis in Prosthodontics, School of Dentistry,

Federal University ofjuiz de Fora (UFJF)
PhD, Restorative Dentistry, Emphasis in Prosthodontics, School of Dentistry of
Sao Jose dos Campos, Paulista State University (ICT - UNESP)

DENNISJ. FASBINDER, DDS, ABGD

Head of the Department of Cariology, Restorative Sciences and Endodontics,
Faculty of Dentistry, University of Michigan
Director of the Computerized Dentistry Postgraduate Program and Computer-
ized Dentistry Center of the School of Michigan

GISELE NEIVA, DDS, MS

Clinical Associate Professor and Director of Restorative Dentistry Graduate
Clinic of the Department of Cariology, Restorative Sciences and Endodontics at
the University School of Dentistry Michigan
Master in Restorative Dentistry and in Clinical Research and Biostatistics from
the University of Michigan
 LUN I bN b
INTRODUCTION TO INDIRECT RESTORATIONS

RESTORATION PLANNING

PRINCIPLES OF CAVITY PREPARATION

INTRACORONAL RESTORATIONS

EXTRACORONAL RESTORATIONS

CONSERVATIVE PREPARATIONS: MINIMALLY INVASIVE DENTISTRY

PREPARATION OF ENDODONTICALLY COMPROMISED TEETH

MILLED ADHESIVE RESTORATIONS

INTRODUCTION TO INDIRECT
INTRODUCTION
The replacement of missing natural teeth by artificial ones has long been a
concern of humans. One of the difficulties encountered in making these re-
placements is realizing a treatment that restores function and esthetics in a
satisfactory manner and ensures clinical longevity without overloading the
.
abutment teeth 3 6 "

The preparation of a tooth to receive an indirect restoration can be con -

ceptualized as a selective grinding process of enamel and/or dentin in various
.
quantities, areas, extensions, and predetermined forms This grinding process
is accomplished within a pre-established operative sequence of steps, employ-
ing instruments with specific forms and dimensions to create space for a single
.--
restoration or a fixed or removable prosthesis 2 3 7
Indirect restorations are among the main restorative options indicated for
teeth with extensive coronal destruction. This type of restoration is manufac -
tured on a gypsum model in the laboratory and then luted to the tooth that
was previously prepared and impressioned. Indirect restorations may be indi-
cated for the reconstruction of one or more elements of an arch.
The main indications for indirect restorations are depicted in Figures 1-1
-
to 1-7.1 7

Fig 1-1 Teeth with extensive coronal de- Fig 1- 2 Teeth with fractured cusps,
struction.

I
i .
Fig 1-3 Replacement of direct restorations
Fig 1- 4 Correction of the position
of extruded, non-occluding or
malpositioned teeth.

Fig 1- 5 Teeth with malformation,

such as hypoplasia and amelogen-
esis imperfecta.

Fig 1- 6 Closure of small diaste-

mas.

Fig 1-7 Teeth with short clinical

crowns.

I n t r o d u c t i o n t
wm
'

INTRACORONAL RESTORATIONS
Intracoronal restorations are those that fit within the anatomic contour of the
tooth's clinical crown; those that do not cover any cusp are classified as inlays
( Fig 1 -8).
In the absence of one or more dental elements, a fixed partial prosthesis is
indicated, in which the replaced missing tooth, called a pontic, is connected to
the remaining neighboring teeth, called abutment teeth, which have intra - or
extracoronal preparations (Fig 1 - 9).

Fig 1- 8 Intracoronal restoration. Occlusal ( A). Mesio-occlusal (B).

Fig 1- 9 Fixed partial prosthesis.

EXTRACORONAL RESTORATIONS
Extracoronal restorations are those that cover the external surface of the
tooth's clinical crown. Full - contour extracoronal restorations cover the entire
outer surface of the tooth; partial- contour extracoronal restorations cover one
or more parts of the surface of the tooth (Fig 1 -10).

Chapter
01

Fig 1-10 Extracoronal full-contour restoration ( A). Extracoronal partial-contour restoration (B ).

I n t r o d u c t i o n t o indirect restorations
 n
Crowns are extracoronal res-
torations in which the external
surface of the clinical crown
of a single tooth is covered
by a single piece. The main
functions of crowns are to re -

L1+ A
establish the morphology and
function of the lost coronary
portions of the tooth and to
protect the remaining denti-
tion. When some surfaces of
the clinical crown are covered,
the indirect restoration is
called a partial- contour extra -
coronal restoration, and can
be classified as either an onlay
or an overlay.
Onlays are those restor -
ations that cover one or more
cusps of a tooth. When the
coverage extends partially to
the buccal and lingual surfac-
es, they are called overlay res-
torations (Fig 1-11A and B).
Ceramic veneers are par -
tial-contour restorations. In-
terest in these restorations
has grown in recent years,
mainly due to the increasing
search for improved esthetics,
in conjunction with the devel-
opment of ceramic materials
and adhesive dentistry. For
ceramic veneers, a thin layer
of ceramic material is applied
that is cemented to the tooth
using resin cement (Fig 1-11 C).

Fiy 1-11 Onlay ( A). Overlay (B). Anterior veneer (C) ,

REFERENCES
1. Concei ao EN . Dentistica - Saude e Estetica, ed 2 , Porto 5. Shillingburg PIT, Hobo S, Whitsett LD. Fundamentos de
^
Alegre: Artmed, 2007. protese fixa, ed 4. Sao Paulo : Quintessence, 2007.
2. Martignoni M, Schonenberger A. Precisao em protese 6. Touati B, Miara P, Nathanson D , Inlays e Onlays cerami -

fixa . Sao Paulo: Santos, 1998. cas. In: Odontologia estetica e restauragoes ceramicas.
3. Mezzomo E, Suzuki RM . Reabilitagao Oral Contem - Sao Paulo: Santos, 2000:259-291.
poranea . Sao Paulo: Santos, 2006. 7. Vieira FLT, Silva CHV, Menezes Filho PF, Vieira CE . Estetica
4. Saito T. Preparos denials funcionais em protese fixa, ed odontologica: solugoes clinicas. Nova Odessa. Sao Paulo:
2. Sao Paulo : Santos, 1999. Napoleao, 2012.
 CHAPTER 02

RESTORATION
INTRODUCTION
,
There are a wide variety of alternative treatments for restoring decayed bro
-
the
ken, and missing teeth. The greater the availabilit y of alternativ es, the greater
and lim-
need to know the particular properties of materials and the advantages
comes
itations of treatment techniques. Every patient seeking dental treatment
to the dental office with specific needs , motivation s, and expectatio ns. Restora -
tive planning involves the application of scientific concepts that guide a rehabili-
tation, based on the observation of the patient's needs and expectations. Much
sensitivity is required to understand that people are unique in their reactions.
Knowing howto reverse pessimistic or misguided beliefs and expectations is one
of the challenges for the clinician.
The first contact with a patient is not only the chance to diagnose the dental
problem, but also an opportunity to build trust between the patient and the
dental team. Fradeani ( 2006) stated that the first step toward success is to
establish a relationship of trust with patients.5 This relationship is fundamen-
tal to creating a relaxed and friendly atmosphere, where patients feel free to
express themselves with confidence.6 This initial conversation, which should
take place before the intraoral examination, should ideally reduce the tension
usually present during the first consultation. It is predominantly psychological,
and serves as the opportunity for the clinician to get to know the patient's
personality, way of being/thinking, and emotional needs. The patient also has
the chance to evaluate his or her confidence in the team and the treatment
setting.1
According to Telles, Hollweg, and Castellucci, the teeth symbolize strength
26 ,
.
aggression, and an active attitude Losing them can lead to insecurity and anxi-
. .
ety Therefore, teeth help to improve people's self-image Usually, patients
only
seek treatment when they experience problems related to esthetics, despite their
awareness of the complexity of their dental problems. To achieve treatment suc-
cess, the clinician should suggest a treatment plan that meets the patient's needs
.
and expectations This approach can be summed up in four stages: recognizing
and understanding the problem; exploring and identifying the problem; inter-
preting and explaining the problem; and offering solutions to the problem based
on a unique biopsychosocial model.26

DIAGNOSTICS
The diagnostic process is extremely important to achieve a successful reha -
.
bilitation Through this process, the patient’s treatment needs and wishes are
identified. Data collection occurs in several interrelated steps that guide the
development of the treatment plan.
ANAMNESIS

A questionnaire (Fig 2- 1 ) about the patient's medical and dental history is an

.
essential tool to obtain information during the diagnostic process Various
types of information can be collected in this way.

Medical history
Takingthe medical history provides information relating to pre-existing systemic
.
diseases Based on this information, certain adjustments of conduct may be re-
quired in the course of treatment to ensure its success. Systemic diseases such
as diabetes and hypertension, for example, require caution when surgical pro-
cedures are required.
As important as knowing about the patient's chronic or acute systemic dis-
eases is knowing the medications indicated for their treatment. In some cases,
the side effects of these medications can influence future oral problems A .
number of pre- existing conditions may induce immunosuppression and hy-
posalivation (decreased salivary flow), thus increasing the risk of developing
major oral pathologies (caries and periodontal disease). Evaluation of the fam-
ily history can reveal a genetic predisposition to the development of diseases,
as well as cultural factors and insights into a patient's lifestyle.

Survey of eating habits and the presence of parafunction

Certain habits, such as smoking or chewing hard objects, may be deleterious
to the patient and negatively influence the treatment outcome. Some occu-
pations are hazardous; for example, wine tasters are more likely to develop
non-carious lesions.
The presence of wear facets on anterior and posterior teeth, and the exces-
sive wear of the tooth structure, may indicate the presence of parafunctions
such as bruxism, which could limit certain types of treatment.
A cariogenic diet associated with poor chemo-mechanical control of dental
biofilm limits the implementation of prosthetic restorative treatment because
the risk of caries and the development of periodontal disease can decrease the
longevity of treatment.
Dental history
It is important to know the frequency of visits to the dentist, dental treatment
history, oral hygiene habits, and treatment expectations .

R e s t o r a t i o n p l a n n i n g
 PHOTO

DATE / /
CLINICAL RECORD No . /

PATIENT IDENTIFICATION
Name:
SSN : TIN:
Date of birth: Age: Place of birth:
Nationality: . Gender: Marital status:
Skin color: Education level:
Home address: No.:
ZIP: City: State:
Phone number( s) for contact: ( )

Descendancy:
Father 's name:
Mother 's name:
Legal guardian / responsible party:
Referred by:

Work information:
Profession: ...Working hours:
Function: .Company name:
Work address: No .: .
ZIP: City:
Phone number ( s ) for contact : ( )
Address for correspondence:

Partner 's name:

Socioeconomical aspect:
How many people are living at the residency?
How many dependants?

Patient's signature

Fig 2-1 Example questionnaire to be employed.

This record is strictly confidential , Answer It truthfully so that your treatment can be properly
planned and executed.
1 - What is the reason for your visit?
2 - Which treatment would you like to have done?
3 - How frequently do you visit the dentist?
4 - How many times per day do you brush your teeth?
5 - Did you receive brushing instructions from a professional? ( ) Yes ( ) No ( ) Don't know
6 - Do you use dental floss? ( ) Yes ( ) No ( ) Don't know
7 - Do your gums often bleed? ( ) Yes ( ) No ( ) Don't know
8 - Are your teeth sensitive to temperature changes? ( ) Yes ( ) No ( ) Don't know
9 - Are your teeth sensitive to sweet foods? ( ) Yes ( ) No ( ) Don't know
10 - Do you have the habit of sucking on your fingers? ( ) Yes ( ) No ( ) Don't know
11 - Do you have the habit of biting on objects? ( ) Yes ( ) No ( ) Don’t know
12 - Do you frequently bite your tongue, lips, cheeks? ( ) Yes ( ) No ( ) Don’t know
13 - Do you usually breathe through your mouth? ( ) Yes ( ) No ( ) Don't know
14 - Do you frequently drink coffee / soft drinks? ( ) Yes ( ) No ( ) Don't know
15 - Do you frequently have aphthous ulcers? ( ) Yes ( ) No ( ) Don’t know
16 - Do you have herpes labialis? ( ) Yes ( ) No ( ) Don't know
17 - Do you ever notice that your teeth have some mobility? ( ) Yes ( ) No ( ) Don't know
18 - Have you ever undergone chemotherapy or radiotherapy? ( ) Yes ( ) No ( ) Don't know
Why?
19 - Have you ever lived in a rural area? ( ) Yes ( ) No ( ) Don’t know
Chapter
20 - Have you ever had other professions? ( ) Yes ( ) No ( ) Don't know
Which? 02
21 - Are you currently undergoing medical treatment? |( ) Yes ( ) No |( ) Don't know
Which?
22 - Are you currently taking any medication? |( |
) Yes ( ) No ( ) Don't know
Which?
23 - Have you ever undergone any surgery? |( ) Yes |( ) No |( ) Don’t know
Which?
24 - Have you ever been hospitalized? |( ) Yes |( ) No ( ) Don't know
Why?
25 - Have you recently lost or gained weight quickly? |( | |
) Yes ( ) No ( ) Don't know
Why?
26 - Do you practice sports or physical exercise? |( |
) Yes ( ) No |( ) Don't know
Which?
How frequently?
Since when?
27 - Are you pregnant? |( | |
) Yes ( ) No ( ) Don't know
How many months?
28 - Do you consume alcoholic drinks? |( ) Yes |( ) No ( ) Don't know
Which?
How frequently?
29 - Do you smoke? |( ) Yes | ( ) No ( ) Don’t know

R e s t o r a t i o n p l a n n i n g
ALLERGIES
30 - Do you/ did you ever take:
Anticoagulants? ( ) Yes ( ) No ( ) Don't know
Anticonvulsants? ( ) Yes ( ) No ( ) Don't know
Tranquilizers? ( ) Yes ( ) No ( ) Don't know
Antihistamines? ( ) Yes ( ) No ( ) Don't know
Analgesia? ( ) Yes ( ) No ( ) Don't know
Aspirin? ( ) Yes ( ) No ( ) Don't know

Dipyrone? ( ) Yes ( ) No ( ) Don't know

Antibiotics? ( ) Yes ( ) No ( ) Don't know
Penicillin? ( ( Yes ( ( No ( ) Don't know
Benzylpenicillin ( penicillin G)? ( ( Yes ( ( No ( ) Don't know
Corticosteroids? ( ( Yes ( ) No ( ) Don't know
Sulfonamide? ( ( Yes ( ( No ( ) Don't know
31 - Have you ever had a reaction to a medicine? ( ( Yes ( ( No ( ) Don't know
Which?
32 - Have you ever undergone dental anesthesia? ( ( Yes ( ( No ( ) Don't know
Did you have a reaction? ( ( Yes ( ( No ( ) Don't know
33 - Have you ever had an allergic reaction to food? ( ( Yes ( ( No ( ) Don't know
34 - Have you ever had an allergic reaction to cosmetics? ( ( Yes ( ( No ( ) Don't know
35 - Do you have any other allergies? ( ( Yes ( ( No ( ) Don't know
Which?

RESPIRATORY DISORDERS
36 - Have you ever had pneumonia? ( ( Yes ( ( No ( ) Don't know

37 - Sinusitis? ( ( Yes ( ( No ( ) Don't know

38 - Rhinitis? ( ( Yes ( ( No ( ) Don't know
39 - Bronchitis? ( ( Yes ( ( No ( ) Don't know
40 - Asthma? ( ( Yes ( ( No ( ) Don't know
41 - Hemoptysis? ( coughing up blood ) ( ( Yes ( ( No ( ) Don't know
42 - Pneumoconiosis? ( ( Yes ( ( No ( ) Don't know
43 Pulmonary emphysema ?
- ( ( Yes ( ( No ( ) Don't know

44 - Other respiratory problems? ( ( Yes ( ( No ( ) Don't know

Which?

CARDIOVASCULAR DISORDERS
45 - Do you have a cardiac prosthetic device? ( ( Yes ( ( N o ( ) Don't know
46 - Do you have a pacemaker ? ( ( Yes ( ( No ( ) Don't know
47 - Do you ever feel palpitations? ( ( Yes ( ( No ( ) Don't know
48 - Do you ever have chest pain? ( ( Yes ( ( No ( ) Don't know
49 - Do you ever feel shortness of breath or fatigue when ( ( Yes ( ( No ( ) Don’t know
doing light tasks?
50 - How many pillows do you use when you sleep?
51 - Do you have hypotension ( low blood pressure )? ( ) Yes ( ) N o ( ) Don’t know
52 - Do you hypertension ( high blood pressure )? ( ) Yes ( ) No ( ) Don't know
CARDIOVASCULAR DISORDERS
53 - Do you bleed a lot when you cut yourself or when your teeth ( ) Yes ( ) No ( ) Don't know
are extracted?
54 - Do you have varices? ( ) Yes ( ) No ( ) Don't know
55 - Have you ever had a heart attack? ( ) Yes ( ) No ( ) Don't know
56 - Have you ever had a stroke (CVA)? ( ) Yes ( ) No ( ) Don't know
57 - Do you ever have swollen feet or legs? ( ) Yes ( ) No ( ) Don't know
58 - Do you/did you ever have any cardiac problem? ( ) Yes ( ) No ( ) Don't know
Which?

ENDOCRINE DISORDERS
59 - Do you have polyphagia (eating too much)? ( ) Yes ( ) No ( ) Don't know
60 - Polydipsia ( excessive thirst)? ( ) Yes ( ) No ( ) Don't know
61 - Diabetes? ( ) Yes ( ) No ( ) Don't know
62 - Is your menstruation regular ? ( ) Yes ( ) No ( ) Don't know
63 - Do you have hypothyroidism? ( ) Yes ( ) No ( ) Don't know
64 - Hyperthyroidism ? ( ) Yes ( ) No ( ) Don't know
65 - Hypoparathyroidism ? ( ) Yes ( ) No ( ) Don't know
66 - Are you breastfeeding? ( ) Yes ( ) No ( ) Don't know
67 - Do you/ did you ever have any other endocrine problem? ( ) Yes ( ) No ( ) Don't know
Which?
Chapter
02
GASTROINTESTINAL DISORDERS
68 - Do you have gastritis? ( ) Yes ( ) No ( ) Don't know
69 - Do you have ulcers? ( ) Yes ( ) No ( ) Don't know
70 - Have you ever vomited blood? ( ) Yes ( ) No ( ) Don't know
71 - Do you / did you ever have any other gastrointestinal ( ) Yes ( ) No ( ) Don't know
problem?
Which?

NEUROLOGICAL DISORDERS
72 - Do you often faint? ( ) Yes ( ) No ( ) Don't know
73 - Do you have frequent cephalgias ( headaches)? ( ) Yes ( ) No ( ) Don't know
74 - Do you ever have neuralgia in the face? ( ) Yes ( ) No ( ) Don't know
75 - Do you ever have convulsions? ( ) Yes ( ) No ( ) Don't know
76 - Do you have epilepsy? ( ) Yes ( ) No ( ) Don't know
77 - Have you ever been treated by a psychiatrist? ( ) Yes ( ) No ( ) Don't know
How long ago?
Why?
78 - Do you feel stressed? ( ) Yes ( ) No ( ) Don't know
79 - Do you/did you ever have any other neurological problem? ( ) Yes ( ) No ( ) Don't know
Which?

R e s t o r a t i o n p l a n n i n g
RENAL DISORDERS
80 - Have you ever had nephritis? ( ) Yes ( ) No < ) Don't know
81 - Do you need hemodialysis? ( ) Yes ( ) No ( ) Don't know
82 - Do you have polyuria ( urinate excessive volumes)? ( ) Yes ( ) No ( ) Don't know
83 - Do you have frequent urination? ( ) Yes ( ) No ( ) Don't know
84 - Do you have dysuria (painful urination)? ( ) Yes ( ) No ( ) Don't know

85 - Do you have cystitis (bladder infection)? ( ) Yes ( ) No ( ) Don't know

86 - Do you/ did you ever have any other renal problems? ( ) Yes ( ) No ( ) Don't know
Which?

BLOOD DISORDERS
87 - Do you have anemia? ( ) Yes ( ) No ( ) Don't know
88 - Leukemia? ( ) Yes ( ) No ( ) Don't know
89 - Hemophilia? ( ) Ves ( ) No ( ) Don't know
90 Have you ever received blood transfusions?
- ( ) Yes ( ) No ( ) Don't know
Why?
91 - Have you ever hemorrhaged? In which region? |( ) Yes |( ) No |( ) Don't know
Why?
92 - Do you have other blood- related problems? |( ) Yes |( ) No |( ) Don't know
Which?

ARTICULARY/BONE DISORDERS
93 - Have you ever broken a bone? |( ) Yes |( ) No |( ) Don't know
In which region?
94 - Have you ever suffered polytrauma of the face? ( ) Yes ( ) No ( ) Don't know
95 - Do you have arthritis? ( ) Yes ( ) No ( ) Don't know
96 - Do you have arthrosis? ( ) Yes ( ) No ( ) Don't know

97 - Do you have rheumatism? ( ) Yes ( ) No ( ) Don't know

98 - Do you have rheumatic fever? ( ) Yes ( ) No ( ) Don't know
99 - Do you have osteoporosis? ( ) Yes ( ) No ( ) Don't know
100 - Have you ever had a problem with bone calcification? ( ) Yes ( ) No ( ) Don't know
101 - Do you/ did you ever have any other problems of the ( ) Yes ( ) No ( ) Don't know
joints or bones?
Which?

TRANSMITTABLE DISEASES
102 - Do you/ did you ever have gonorrhea? ( ) Yes ( ) No ( ) Don't know
103 - Do you/ did you ever have syphilis? ( ) Yes ( ) No ( ) Don't know
104 - Do you have AIDS? ( ) Yes ( ) No ( ) Don't know
105 - Do you/ did you ever have hepatitis? ( ) Yes ( ) No ( ) Don't know
106 - Do you/ did you ever have tuberculosis? ( ) Yes ( ) No ( ) Don't know

107 - Do you/ did you ever have any childhood disease? ( ) Yes ( ) No ( ) Don't know
Which?
OPHTALMIC DISORDERS
108 - Do you have glaucoma? ( ) Yes |( ) No [( ) Don' t know

HEPATIC DISORDERS
109 - Do you have cirrhosis? ( ) Yes ( ) No |( ( Don't know
110 - Other liver problems? ( ) Yes ( ) No ( ) Don't know
Which?

SALIVARY DISORDERS
111 - Do you have excessive salivation? ( ) Yes ( ) No ( ) Don't know
112 - Do you have xerostomia ( dry mouth)? ( ) Yes ( ) No ( ) Don't know
113 - Do you have salivary stones? ( ) Yes ( ) No ( ) Don't know

DISORDERS OF THE TEMPOROMANDIBULAR JOINT

114 - Do you grind your teeth at night ? ( ) Yes ( ) No ( ) Don't know
115 - Do you chew only on one side of your mouth? ( ) Yes ( ) No ( ) Don't know
Why?
116 - Do you feel pain in the region close to your ears? ( ) Yes ( ) No ( ) Don't know
117 - Do you hear a click when you open or close your ( ) Yes ( ) No ( ) Don't know
mouth?
118 - Do you feel pain in your ears, head, nape, neck, face? ( ) Yes ( ) No ( ) Don't know
119 - Do you have difficulties opening your mouth? ( ) Yes ( ) No ( ) Don' t know Chapter
120 - When you wake up, do the muscles of your face hurt? ( ) Yes ( ) No ( ) Don' t know
And your teeth? ( ) Yes ( ) No ( ) Don't know

FAMILY ANTECEDENTS
121 - Do you have any diseases that run in the family? |( ) Yes |( ) No |( ) Don't know
Which?
122 - Do / did any of your relatives have:
Cancer ? ( ) Yes ( ) No ( ) Don't know
Diabetes? ( ) Yes ( ) No ( ) Don't know
Heart attack? ( ) Yes ( ) No ( ) Don' t know
Hypertension? ( ) Yes ( ) No ( ) Don't know
Renal problems? ( ) Yes ( ) No ( ) Don't know
123 - Have you ever had any other health-related problem ( ) Yes ( ) No ( ) Don't know
not mentioned in this questionnaire?
Which?

I declare that all the information in this questionnaire, including in the registration, is truthful as far
as I am aware. I undertake to report to the dental practice any change/s that may occur regarding
my current health situation .
Signed on this day of. 20.

Signature of patient / responsible party

R e s t o r a t i o n p l a n n i n g
CLINICAL EXAMINATION

GENERAL ASPECT (Extraoral)

Eruptions Asymmetry of face and neck

Nodules Exophthalmia

Musculature Salivary glands

Blemish Scars

Cervical and perioral ganglia Others

-
BUCCODENTAL INSPECTION (Jntrcoral)
Attrition/abrasion/ erosion

Cheeks Enamel hypoplasia

Retromolar space Staining

Tongue Plaque coating

Tongue base Calculus /tartar

Mouth floor Gingival retraction

Palate Gingiva

Tonsils Tooth mobility

Oropharyngeal isthmus Occlusion

Absent teeth Speech abnormalities

Supernumerary teeth Oral hygiene

Diastema Salivary flow

Frenulum /frenula Others

VITAL SIGNS
Pulse ( normal 60-90 bpm)

Arterial pressure (normal 90/130 < mmHg)

Respiratory rate (normal 15-20 breaths /min)

Temperature (normal 36.8 + 0.2°C)

OBSERVATIONS
 CLINICAL RECORD

n i i
< '

X *i

LEGAL IDENTIFICATION SECTION

Conditions found: surfaces of the teeth, present work, and material used (circle where applicable)
18 - 38 -
17 - 37 -
16 - 36 -
1 5 /55 - 35/75 -
14/ 54 - 34/74
13 / 53 - 33 / 77 - Chapter
12 /52 - 32 /72 -
11 /51 - 31 /71 -
21 / 61 - 41/81 -
22 /62 - 42/82 -
23 / 63 - 43 / 83 -
24/ 64 - 44/84 -
25/65 - 45/85 -
26 - 46 -

27 - 47 -
28 - 48 -
OBSERVATIONS

ABBREVIATIONS
Fixed prosthesis + no. of elements = FPP + no. Caries - Ca
Restoration = R + material Removable partial denture = RPD
Material: Composite = Com; Amalgam = Am Mesial surface = M; Distal surface = D
Metal cast crown = RMF + metal Vestibular surface = V; Lingual surface = L
Metal: Nickel Chrome = NiCr Absent tooth - AT
Metal: Copper Alumina = CuAI Residual root = Root
Metal: Silver = Ag; Gold = Au alloy Any kind of lesion = Les

R e s t o r a t i o n p l a n n i n g
 TREATMENT PLANNING

CLINICAL RECORD

1st OPTION 2nd OPTION

3rd OPTION 4th OPTION

Treatment authorization

I hereby declare that, after having been duly informed about the purposes,
risks, costs, and alternatives of the treatment presented above, I accept and
authorize the execution of the treatment.

I undertake to comply with the guidelines given by the professional assistant

and to bear the costs stipulated in the presented budget.

I UNDERTAKE FULL RESPONSIBILITY FORTHE INFORMATION PROVIDED HEREIN.

Signed on this day of. 20.

Signature of patient / responsible party

 CLINICAL RECORD

ACCOMPLISHED TREATMENT
Date Tooth region Work Signature of
responsible
professional

R e s t o r a t i o n p I a n n n g
During the clinical examination, it is first of all necessary to recognize the pa-
tient
's main complaint, so that the planning can be focused on resolving that
problem. Thereafter, the stages of clinical data collection should be followed,
which serve as the basis on which the optimal treatment plan is developed for
each case.

EXTRAORAL EXAMINATION
The clinical examination begins with the extraoral examination, in which the
following are analyzed: facial symmetry, facial contours, labial fissures and sul-
ci, skeletal profile, muscles, spams, lymph nodes, speech, lips, and smile.
The analysis of the facial structure is fundamental for the success of an es-
thetic rehabilitation. This examination evaluates the facial harmony by deter -
mining symmetry and proportion (Fig 2-2) .
References such as the interpupillary line
and midline are fundamental to iden-
tifying alterations in harmony. These
are aided by horizontal lines that
subdivide the face into thirds, and
vertical lines such as the tangent
of the nasal sidewall that guide
i the positioning of the maxillary
.
canines These references help
[ to identify the patient's facial
type (square, triangular, round,
* oval), which has an influence on
| determining the characteristics
of the tooth shape (Fig 2-3) .
Recognizing asymmetries is
critical, as it is often possible to
soften these by adopting small
compensations in the restorative
treatment, such as in the case of a
midline shift 15.

Fig 2- 2 Vertical and horizontal lines

that help identify facial asymmetry.
 Chapter
02

Fig 2- 3 Facial types . Square (A) , Triangular ( B). Round (C) Oval ( D )

R e s t o r a t i o n p l a n n i n g
There are three classical profile variations, depending on the position of the
subnasale with respect to the nasal perpendicular: normal profile (subnasale
coincides with the nasal perpendicular), convex profile (subnasale lies in front
of the nasal perpendicular), concave profile (subnasale lies behind the nasal
perpendicular)26 (Fig 2-4).
 Facial spasms can be gen-
erated by involuntary or
voluntary muscle contrac-
tions, leading to changes in
the patient's expression in
the affected area (Fig 2-5) .
Spasms may be exacerbat-
ed or triggered by voluntary
contractions of the face, as
well as by stress, fatigue,
.
and anxiety 10 It is the re-
sponsibility of the clinician
to detect these changes
and to refer the patient to
a specialist.24

Fig 2- 5 Facial musculature.

Lymph nodes of the head and neck are of great clinical importa
nce because
the lymphatic vessels are major pathways through which infectio proce
us sses
and malignant tumors are spread. There is also the possibility of
them convert-
ing into infectious or neoplastic foci (Fig 2 6).
-
Knowledge of the regional nodes is important so as to recognize
nodes that
are possibly compromised once the site of infection or tumor is known. It also
is
important in the diagnosis of a probable unknown location of a pathological
process if an individual lymph node or lymph node group is found to be affect-
ed. This is verified through palpation and visualization of volumetric changes.20
The clinician, who plays an important role in the prevention and early diag-
nosis of oral cancer, must have knowledge of the lymphatic drainage of the oral
cavity and the surrounding regions, enabling the clinical interpretation of cases
of acute or chronic lymphadenopathy and their possible origin. Even though the
oral cavity is easy to inspect, oral cancer is one of the most common malignan-
cies in the dental environment. Most people seeking
treatment in specialized centers are already
in the advanced stages of the disease,
when the chances of cure are greatly
reduced.

Fig 2-6
of the face.
The lips can be defined as the thick skin and muscle layer juxtaposed with the
thin and delicate red zone consisting of transition epithelium between skin
and mucosa. The hypodermis of the lateral labial region affects the adhesion
of the skin and mucosa to the muscles. The lack of additional support at that
level, and excess muscle movement, can lead to the appearance of wrinkles.
The skin of the chin region is thin and the depressor anguli oris muscle and the
platysma are located in the projection of the labiomarginal groove.22
When analyzing the margins of the lips, the upper margin corresponds to
the nasal base, the lateral margin to the nasolabial fold, and the lower margin
to the mentolabial groove. The lips extend further than the red area of the
mouth and also include the adjacent skin. The perfect lip structure includes
a visible white or transition line between the mucosa and the skin, a median
tubercle, a V-shaped Cupid's bow, the red of the lip, and the line ascending
from the oral commissure. The ratio between upper / lower lips is 1:1.618. The
philtrum, which is the cutaneous central point of the upper lip accentuated by
two vertical ridges, is an important landmark. The Cupid's bow is the concavity
at the base of the philtrum. Profound labiomental and nasolabial lines result
in an aged appearance.22 The upper limit of the chin region is the labiomental
groove, the lower is the base of the mandible, and the lateral is the labiomar -
ginal groove ( Fig 2-7).

Fig 2-7 Labiomental fissures and lines.

The lips have a great influence on the har -
mony of the smile and can be classified
according to their thickness (fine, regular
or thick) (Fig 2- 8). Changes are often ob -
served,7 which can be related to the pa -
tient's age. Elderly patients tend to have
thinner lips as a result of loss of muscle
tone .
The length and curvature of the lips
significantly influence the exposure of the
teeth during speech and when smiling.2
The lower lip is critical in determining the
smile curve, following the curvature of the
maxillary teeth. However, the upper lip
functions as a reference for determining
the position of the gingival plane of the
maxillary incisors (Fig 2-9).
Speech is another factor that should be
analyzed carefully. The teeth and restora-
tive treatments can have a direct influence
on the patient's pronunciation and pho - Chapter
netics. The presence of a prosthesis can af-
fect the patient's pronunciation of sibilants
("s" sounds).

Fig 2-8 Types of lips. Fine (A). Regular (B). Thick (C).
INTRAORAL EXAMINATION

During the intraoral examination, it is important that the entire oral cavity is
thoroughly inspected in the search for any type of change: lips, mouth floor,
ventral and dorsal tongue, buccal mucosa, hard and soft palate, retromolar
.
region, gingiva, and the tonsillar pillars It is important to examine carefully
the periodontal, endodontic, and restorative condition, as well as analyze the
occlusion and the temporomandibular joint.
In addition to the many esthetic references mentioned above, there are
numerous exclusively dental elements that must be taken into consideration:
dental axis, shape, height and width, proportion, form of the incisal edge,
interincisal angle, arrangement, interproximal contacts, texture, and color
.
(Fig 2-10) It is important that all of these references are sought in conjunction
with functional principles: occlusion, incisal guidance, canine guidance, over-
bite, and overjet.15

Fig 2-10 Dental references.

ADDITIONAL EXAMINATIONS

The principal additional tests applied as an aid in the diagnosis process are:
• Mounting of the models in the articulator with a record of the jaw relation;
• Diagnostic wax -up;
Radiographs;
Photographic documentation;
• Computed tomography;
• Magnetic resonance imaging (suspected temporomandibular disorder);
• Color analysis (visual or digital);
• Microbiological tests to disclose periodontal disease;
• Pulp vitality tests;
• Biopsy of suspicious lesions.

TREATMENT PLAN
Once all the relevant data are collected, an individualized treatment plan can
be formulated in line with the patient's needs and wishes. It should be clear
to the patient that complex treatments often require a multidisciplinary ap-
proach, which can increase the treatment duration. The patient should un-
derstand the importance of each procedure that comprises the sequence of Chapter
-- - -
treatments preceding the prosthetic restorative treatment.2 4 5 8 11 12 14,17-19,23
''
The treatments should be ordered in such a way that the infection sources in
02
.
the oral cavity are eliminated first
A number of factors need to be taken into consideration when the restora-
.
tive treatment is planned Factors such as the choice of the restorative ma-
terial should be analyzed carefully because they can directly influence the
wear and longevity of the treatment. Metal restorations undergo less wear,
which is often critical to maintaining the vitality of the tooth when the available
space is limited. Metal-free and metal- ceramic restorations are at higher risk
of cracking and fracturing when the antagonist is also a ceramic restoration.
They therefore require a more refined occlusal adjustment and protective
measures, such as occlusal splints, especially in patients with parafunctional
habits. The wrong indication leads to failure and contributes to the creation of
distorted opinions about the technique.

R e s t o r a t i o n p l a n n i n g
 Other helpful knowledge in restorative treatment planning is related to the
fragility of the teeth. When devitalized teeth support a fixed partial denture,
they are four times more prone to fracture than vital teeth.9 Moreover, teeth
weakened by the loss of mineralized structure or through endodontic treat-
jnent'a/ e.also more likely to fracture than sound teeth, especially when they
are used as an abutment in a fixed partial prosthesis. The position and type of
tooth involved are also factors that need to be considered.25
Pulp involvement should be avoided when vital teeth need to be prepared.
Pulp involvement occurs due to improper preparation technique, lack of re-
frigeration, temporary protection, or inadequate luting. Planning is critical in
situations involving the correction of inclinations and malpositions, where it is
necessary to foresee the possibility of compromising the vitality.
One of the factors associated with the success of a treatment plan is the
follow- up after treatment. Systematic follow-up by the dentist can increase the
longevity of the treatment. The patient should be made aware that treatment
success is intrinsically related both to follow-up and self-care, including the
maintenance of oral hygiene.
For the implementation of restorative planning, specific instruments are
necessary to provide adequate access to the site of interest and to allow differ -
ent approaches, depending on the procedure to be carried out.13

INSTRUMENTS FOR PREPARATION

There is a range of instruments that, when used successfully, can create a
wide variety of intra- and extracoronal dental preparations. For cavity prep -
aration, it is necessary that the instruments provide adequate access to allow
for the different approaches required for the procedure that needs to be
executed.
Two groups of instruments for preparation can be considered as the main
tools used by clinicians: manual instruments and rotatory cutting instruments.
More recently, new techniques and technologies have been developed for the
same purpose, such as the ultrasonic-tip system, but these are still not used in
everyday clinical practice.
 Manual cutting instruments
Manual (hand) instruments are suitable to BLADE
cut and shape the outline of the tooth struc -
ture. They complement the action of rota -
tory instruments, which can be classified as
single - ended or double- ended. Single -end-
ed instruments have one active blade, and SHANK
double - ended instruments have two, one at
each end.
In cavities that are finished with manual
cutting instruments, there is a significant
reduction in marginal infiltration compared
to those finished with rotary cutting instru-
ments. This is due to the removal of the
resulting unsupported enamel prisms that
remain after the preparation with rotatory
instruments.13
Manual cutting instruments are com-
posed of three main parts: the shaft, the
shank, and the blade (Fig 2-11 ).
Chapter
02

Fig 2-11 Manual cutting tools. Single-ended (A).

Double-ended (B).
A formula is used to identify and classify the instruments, which consists of
either three numbers (when the active end of the instrument has a straight
angle) or four numbers (when the active end of the instrument is angulated
relative to the longitudinal axis of the instrument). For all instruments, the first
number always indicates the width of the blade. For instruments with three
numbers, the second number indicates the length in millimeters, and the third
number indicates the angle between the blade and the longitudinal axis of the
.
instrument in centesimal degrees (Fig 2-12) For instruments with four num-
bers, the fourth number appears in the second place and indicates the angle
generated by the inclination of the blade (Fig 2-13). Figure 2-14 shows the grip
of manual cutting instruments for restorative and prosthetic dentistry.

14
Fig 2-12 Instruments with three numbers.
25
 Chapter
02

Fig 2-13 Instruments with four numbers.

R e s t o r a t i o n p l a n n i n g
Themain types of manual cutting instruments are:
Chisels: used to shape the outline and for planing the enamel. They
can be divided into straight, mono-angle, binangle, Wedelstaedt, and
cl isels'to cut and smooth the gingival wall (Fig 2-15).
-^

Fig 2-15 Chisels. Straight (A). Binangle (B). Wedelstaedt (C,D). Chisel cutting and
smoothing the gingival wall (E).
Hoes: used to smoother) the walls of the cavity preparation and to
plane enamel walls. They are distinguished from the chisels by the in -
creased angulation of the active point to > 12.5, close to 25 centesimal
degrees ( Fig 2-16).

Fig 2-16 Hoes. Mono - angle- - ( A ). Binangle ( B ) . Triple angle (C) . Smoothening the
gingival wall (D).

R e s t o r a t i o n p l a n n i n g
Enamel hatchets: used to cleave and smooth the enamel; also to plane
the buccal and lingual walls of proximal boxes (Fig 2-17).

Fig 2-17 Enamel hatchets. Binangle ( A, B). Triple angle (C). Cleaving and smoothen-
ing (D) .
Dentin hatchets: used to shape retentive areas in the incisal portion of
the preparation ( Fig 2-18).

Fig 2-18 Dentin hatchets. Binangle (A,B). Triple angle (C). Cutting and smoothening
the wall and angle (D) .
Gingival margin trimmers: used to plane the gingival cavosurface an-
gle of intracoronal preparations, round the axiopulpal line angle, and
shape theretentive areas of the gingival walls (Fig 2-19).

Fig 2 -19 .
Gingival margin trimmers (A, B ) , Cutting the gingival margin (C)
Angle formers: used to accentuate and dihedral and trihedral angles, determin-
ing the shape retention (Fig 2-20).

Chapter
02

Fig 2- 20 Angle formers (A,B),

R e s t o r a t i o n p I a n n i. n g
Fig 2- 22 Burs . Plain round bur (A). Plain cylinder bur ( B). Plain inverted cone bur (C). Plain
tapered bur ( D). Cross cut round bur ( E). Cross-cut cylinder bur ( F). Cross-cut inverted cone
-

bur ( G). Cross-cut tapered bur ( H)

1
R e s t o r a t i o n p l a n n i n g
' 'J'
v
47
 .
Fig Z - Z 3 Shapes of diamond abrasives Round (A). Inverted cone (B). Flat-end taper
(C). Pointed taper (D). Cylinder (E). Beveled cylinder (F). Round-end taper (G). Wheel (H).
Fig 2-24 Multilaminated burs are used to
prepare dentin.
Chapter
02
The use of burs and diamond abrasives is
only possible together with a high- or low-
.
speed turbine Low-speed motors work in
the range of 500 to 20,000 rotations per
minute (rpm) and promote greater con-
trol of wear. Intraoral preparations are
usually done with 1:1 contra-angles. Their
biggest disadvantage is the greater vibra-
tion and the need for greater pressure to
achieve the wear of the dental tissues.
These motors are used for finishing cavi-
ty walls, removing dentinal caries, and for
conservative preparations (Fig 2-26) .
High- speed turbines work in the range
of 380,000 rpm, providing greater ease of
wear and causing less vibration and less
need for pressure to carry out the prep -
.
arations 30 These turbines are used for
rapid reduction of dental structures and
.
to shape the contour However, if the
burs and diamond abrasives are not ade-
quately cooled, there is a risk of irrevers
ible damage to the pulp and adjacent
periodontal tissues due to overheat-
ing 3,27,28,30,31

-
Pig 2 2 (5 Low-speed turbine (A)
.
Contra-angle (B)
 Preparation at high speed is less
harmful to the pulp than preparation
at low speed because the vibration is
reduced. However, even when cool-
ing air/ water spray is used, some de-
gree of pulpal irritation will occur21
(Fig 2-27).
A great alternative to dental prep-
aration is the use of multiplier con-
tra-angles (1:4.2 or 1:5) that work in
the midrange between the low-speed
and high-speed motors, at around
170,000 to 200,000 rpm. These con-
tra -angles can be used with either
a pneumatic or an electric motor
(Fig 2-28) .

-
Fig 2 27 High-speed turbine.

i1

^ 'J
ALTERNATIVE SYSTEMS FOR
DENTAL PREPARATIONS
The ultrasonic preparation is based on
the use of diamond burs developed
for use in an ultrasound apparatus
(Fig 2-29).
Chemical vapor deposition (CVD) is an
innovative way of producing the diamond
abrasive, with a single diamond stone
that covers the active part of the tip The .
integrity of the diamond and its high ad-
herence to the metal rod improve the
.
durability of the tip Tips developed with
CVD technology are available in different
formats and sizes, with a roughened and
smoothly distributed diamond-impreg-
nated surface. The main advantage of
CVD -produced tips in sonic and ultrason-
ic systems is that they do not cut adja-
cent soft tissues during preparation.31
They are also quieter than high-speed i
turbines, and generate less sensitivity.

Fig 2- 29 Ultrasonic apparatus (A). Preparation tips (B). Finishing tips (C).
REFERENCES

1. Ahmad I. Protocolos para restaurar;oes esteticas pre- 17. Pagani C, Rocha DM, Saavedra GSFA, Carvalho RF. Pre-
visfveis. Porto Alegre : Artmed, 2008. visibilidade e Estetica: A utilizagao do ensaio restaurador
2. Chiche GJ, Pinault A. Estetica em protese fi xa anterior , ( Mock-up) na constru ao da beleza do sorriso. In: Calle-
Sao Paulo: Artmed, 2002. ^
gari A, Dias RB ( eds) . Espedalidade em foco: beleza do
3. Derbabian K, Marzola R, Arcidiacono A . The science of sorriso. Nova Odessa: Napoleao, 2013:114-145.
communicating the art of dentistry. J Calif Dent Assoc 18. Ricketts RM. Planning treatment on the basis of the fa -
1998;26:101-106. cial pattern and an estimate of its growth. Angle Orthod
4. Drago CJ. Clinical and laboratory parameters in fixed 1957;27:14-37.
prosthodontic treatment. J Prosthet Dent 1996;76: 19 . Rieder CE. The role of operatory and laboratory person-
233-238 . nel in patient esthetic consultations. Dent Clin North Am
5. Fradeani M. Reabilita $ao estetica em protese fixa. Analise 1989;33 : 275-284.
estetica: uma abordagem sistematica para o tratamento 20. Shannon JL, Rogers WA. Communicating patients' es-
protetico. Sao Paulo : Quintessence, 2006. thetic needs to the dental laboratory. J Prosthet Dent
6. Garber DA, Salama MA. The aesthetic smile: diagnosis 1991;65:526-528.
and treatment. Periodontal 2000 1996;11:18-28. 21. Shavell HM. Dentist-laboratory relationships in fixed pros-
7. Giirel G. The Science and Art of Porcelain faminate thodontics. In: Preston JD (ed). Perspectives in dental
Veneers. London : Quintessence, 2003 . ceramics: Proceedings of the Fourth International Sympo-
sium on Ceramics. Chicago: Quintessence, 1988:429-437.
8. Hirata R. Tips - Dicas em odontologia estetica. Sao Paulo :
Artes Medicas, 2010 , 22. Sobotta J, Becher H. Atlas de Anatomia Humana, ed 17.
Rio dejaneiro: Guanabara Koogan, 1977.
9. Holm C, Tidehag P, Tillberg A, Molin M , Longevity and
quality of FPDs: a retrospective study of restorations 23. Stanley HR. Dental iatrogenesis, Part 2. Dent Today
30, 20, and 10 year after insertion, Int J Prosthodont 1995;14:76-81.
2003;16:283-289. .
24 Tamura BM. Facial anatomy and the application of fill- Chapter
10 . Marsden CD. Peripheral movement disorders, In: Mars- ers and botulinum toxin - Part I. Surg Cosmet Dermatol
den CD, Fahn S ( eds) . Movement Disorders 3. Oxford: 2010;2:195-204. 02
Butterworth-Heinemann, 1994:406- 417. 25 . Tanaka A. Successful technologist-dentist teamwork ,
11. Martin D. The dental technologist's role in the clin- In: Preston JD ( ed) , Perspectives in dental ceramics:
ical team. In: Preston JD ( ed). Perspectives in denial Proceedings of the Fourth International Symposium on
ceramics: Proceedings of the Fourth International Sym- Ceramics. Chicago : Quintessence, 1988:439-444,
posium on Ceramics. Chicago : Quintessence, 1988: .
26 Telles D, Hollweg H, Castellucci L. Protese total convencio -
421-428. nal e sobre implantes. Sao Paulo: Santos, 2003.
12. Materdomini D , Communicate visually with your labora - 27. Vieira FLT, Silva CHV, Menezes Filho PF, Vieira CE. Estetica
tory. J Am Acad Cosmet Dent 1994;1:32-34. odontologica: soluqoes clfnicas. Nova Odessa: Napoleao,
.
13 Micheli PR, Prates RA, Magalhaes MT, Zezell DM, 2012.
Micheli G , Analise de temperatura intrapulpar no darea - 28. Walton TR. An up to 15-year longitudinal study of 515
mento dental com laser de diodo in vitro. Rev Assoc Paul metal-ceramic FPDs : Part 2. Modes of failures and influ-
Cir Dent 2005;59:117 121.
- ence of various clinical characteristics. Int J Prosthodont
14. Mondelli J , Fundamentos de dentfstica operatoria, ed 2. 2003;16:177-182.
Sao Paulo: Santos, 2006, 29 . Worms FW, Spiedel TM, Bevis RR, Waite DE. Posttreat-
15 . Netter FH. Atlas de Anatomia Humana, ed 5. Rio de Janei- ment stability and esthetics of orthognathic surgery. An-
ro: Elsevier, 2011, gle Orthod 1980;50;251-273.
16. Nevins M. The periodontist, prosthodontist and labora -
30. Zach L, Cohen G. Pulp response to externally applied
tory technician: a clinical team . In: Preston JD ( ed) . Per- heat. Oral Surg Oral Med Oral Pathol 19651, 9:515-530.
spectives in dental ceramics: Proceedings of the Fourth 31. Zollner A, Gaengler P. Pulp reactions to different prepar-
International Symposium on Ceramics. Chicago: Quintes- ation techniques on teeth exhibiting periodontal disease.
sence,!988:407-419. J Oral Rehabil 2000;27:93-102.

R e s t o r a t i o n p l a n n i n g
 LESOF CAVITY
PR1NCIP

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INTRODUCTION
Dental preparation can be defined as the biomechanical treatment of lesions
that compromise the dental hard tissue so that the remaining structures can
receive a restoration to protect them, to make them resistant, and to prevent
caries recurrence.37 Dental preparation may also be indicated to reestablish
the function and esthetics of compromised dental structures .
Greene Vardiman Black was the pioneer who formulated, in 1908, a logical
sequence of procedures for cavity preparation. Although many of his concepts
are still relevant today, cavity preparation has undergone significant chang-
es due to the emergence of new materials and restorative techniques. It is
important to note that the design of the cavity preparation and details of its
shape depend on the restorative material to be used.11
The prosthetic preparation can be defined as a selective grinding process of
a predetermined quantity of enamel and/or dentin in specific areas. It follows
pre-established operative steps, with the use of selected and specific instru-
ments. Its purpose is to create space for an individual restoration or a fixed or
removable prosthesis.35
The phase in which the tooth is prepared to later receive an indirect res-
toration must be carefully planned and executed to ensure the longevity of
.
the treatment The restoration should restore the function, phonetics, and es-
thetics, which are the basic requirements for patient satisfaction of the final
results.48 Apart from following common principles, each preparation has its
own specific requirements. Customization should always be pursued in each
clinical situation. During the planning, the interaction between mechanical,
biological, and esthetic principles should be considered.

MECHANICAL PRINCIPLES
RETENTION AND STABILITY
It should be noted that even though retention and stability are defined sepa -
rately, they depend on each other and are always intertwined. The difference
between these properties is the direction of the forces exerted on the prepar -
ation.
Retention is the ability of a restoration to resist a displacement in the oppo -
site direction to its insertion axis when subjected to tensile forces. This basically
depends on the existing contact between the internal surfaces of the restoration
and the external surface of the prepared tooth, which is called frictional resis-
tance46 (Fig 3-1 ). Thus, retention is closely related to the parallelism obtained by
the walls and the prepared area. The more parallel the axial walls and the great-
er the surface contact, the greater the resultant retention (Fig 3-2).
 .
Fig 3-1 The retention is dependent on the parallelism of the opposed walls in different restorations
Extracoronal restoration (A). Intracoronal restoration (B).

-
Fig 3 2 Illustration of the relation between retention and the angulation of the preparation
retentiveness of preparations of the same size decreases when the preparation angle increases;^ ^ '

P r i n c i p l e s o f .
c a v l t y p r e p a r a t i o n
As such, it seems reasonable to make the preparation as parallel as possible to
enable better frictional retention. However, a more parallel preparation com-
plicates the cementation procedure because the flow of the cement is hin-
dered. This causes a misfit of the restoration and increased thickness of the ce-
ment film, especially on the occlusal and cervical portions of the preparation.
Another factor of secondary importance that improves the retention is the
.
action of the cement Zinc phosphate-based cement aids the mechanical inter-
locking as it takes advantage of the micro roughness of the preparation and
restoration. Glass ionomer and resin cements act through micromechanical
union, in addition to the adhesive properties. The type of cement used has a
direct effect on the cementation of the restorations. It has been found that the
bond strength of adhesively cemented preparations is superior to that of prep-
arations with zinc phosphate and glass ionomer cements.5 A good preparation
should have a wall inclination with adequate frictional retention, complete
seating with the lowest possible cement thickness, and resistance to displace-
ment from different masticatory forces (Fig 3-3).
The degree of convergence will be determined by the individual character-
istics of each preparation. Teeth with short clinical crowns require less conver-
gence to provide greater retention, and teeth with long clinical crowns require
greater convergence (Fig 3 -4).
As the frictional retention depends on the contact between the surfaces of
the preparation and the restoration, the greater the clinical crown of a pre-
pared tooth, the larger the contact surface, and consequently the greater the
final retention. Thus, when the teeth are long, the inclination of the walls can
be increased to achieve greater occlusal convergence, sufficient to maintain
adequate retention. On the other hand, the walls of shorter teeth should be
prepared close to parallel to maintain an effective retention. It has been pro-
posed that the anterior teeth and premolars should have a minimum occluso-
cervical dimension of 3 mm, and the molars a minimum dimension of 4 mm .
Teeth that do not have these minimum dimensions should be modified to in-
crease their retention through additional retention.23 Goodacre et al (2001)22
found that a minimum preparation height of 3 mm was necessary to provide
sufficient resistance to lateral displacement of the restoration when the occlu-
sal convergence angle does not exceed 10 degrees.
In preparations with a height of 5 mm, changing the convergence angle
from 2 to 10 degrees decreases the surface area by 13.9%. An increase of just
1 mm in preparation height results in a considerable gain in surface area. Since
the surface area increases, increasing the height of the preparation and redu-
cing the angulation may result in improvement in the function of the luting
agent, the resistance to lateral displacement, and the retention of the fixed
.
prosthesis9 (Fig 3- 5)
Fig 3-3 The action of the ce-
ment is secondary to the re-
tention. However, adequate
cementation is important for
the longevity of the restora-
tive treatment (A,B).

Fig 3- 4 Existing relationship

between the height and an-
gulation of the preparation.
Shorter teeth should have a
smaller 0 (A). Longer teeth
should have a larger 0 (B).
Chapter
03

Fig 3-5 Existing relationship

between surface area and
retention of the prepar-
ation. In the same tooth, a
partial preparation has less
retentiveness than a total
preparation. Preparation for
partial crown (A). Preparation
for crown (B). With teeth of
the same height, the same
preparation in a premolar
will be less retentive than in
a molar. Preparation for a
full crown on a premolar (C).
Preparation for a crown on a
molar (D).

P r i n c i p l e s
The angulation or occlusal convergence of the preparation was one of the first
aspects of crown preparation to receive specific attention. The convergence
angles between the opposed surfaces of a full-crown preparation influence
their retention and resistance to rotation, with the angle being theoretically
optimal between 2 and 4 degrees. Due to the difficulty in fitting and preparing
a crown with these angles, angles between 2 and 22 degrees are considered
. ^
acceptable 22 ,54,65 when different inclinations of occlusal convergence (12 or
20 degrees) and different preparation heights (4 and 6 mm) of crowns made by
a computer-aided design/computer-aided manufacturing (CAD/CAM) system
were compared, it was shown that preparations with a 12-degree convergence
angle show better internal adaptation compared to those with a 20-degree
convergence angle.38
The pursuit of a well-executed preparation requires the clinician's dexterity
and concentration. Studies reporta significant variation in convergence values
( between 14 and 20 degrees) in preparations made by different profession-
als 3^,56
Stability is the property of a preparation to withstand the displacement of a
.
restoration due to oblique forces These can lead to rotation of the restoration,
such as during mastication or in the presence of parafunctional habits. Prepar -
ations with a high degree of convergence or short preparations can be subject-
.
ed to dislodging forces in various directions The shorter the preparation, the
more important the occlusal convergence angle. All measures taken to limit
the freedom of movement of restorations subjected to torsional and rotational
forces in a horizontal plane will increase their stability. To obtain stability in
a preparation, two alternatives can be employed: decreased convergence of
surfaces, and adding grooves to occlusal surfaces (Fig 3-6).
Shillingburg et al (2007)54 suggest that the length of the tooth should al-
.
ways be greater than its base to ensure stability Based on the principles of the
height/width ratio of the preparation, Pegoraro et al (2004)46 suggested that if
the width is greater than the height, the radius of rotation increases, impairing
adequate stability. For the same height, crowns with larger diameters have
comparatively less stability (Fig 3-7).
Some theories consider the relationship between angle, diameter, and
preparation time as regards a restoration's retention and stability. According
to Lewis and Owen,29 when you draw a line from the center of rotation perpen-
dicular to the line that forms the axial wall of the preparation at the opposite
end of the preparation, you will find intersection point "B". All points located
.
above "B" are stabilizers Another equally applicable theory was proposed by
Zukerman,69 who said that if you draw a circle with the floor of the preparation
as the diameter, all points above the "B" intersection, located between the cir-
.
cumference and the axial wall of preparation, are stabilizers (Fig 3-8)
Fig 3-6 To avoid displacement of a crown, it is necessary for the tangent point to be
located on the lower half of the crown. High angulation of the preparation will result in
a crown with low resistance to displacemenLThis can be verified by the position of the
.
tangent point located above the half of the crown (A) An alternative for correcting the
angle is by reducing the diameter of the base, making the surfaces more parallel and
improving stability (B) . Another alternative for improving stability is the realization of ad-
ditional grooves, creating smaller displacement arcs (C).

Chapter
03

Fig 3-7 Existing relationship between the height and diameter of the preparation.Tooth
with smaller diameter (A). Tooth with larger diameter (B).

ZUCKERMAN

A o E

Fig 3-8 Illustration of the theories of Lewis and Owen29 and Zukerman.69

P r i n c i p l e s o f c a v i t y p r e p a r a t i o n
Whenever possible, the teeth should be prepared in such a way that they have
circumferential irregularity. When teeth are anatomically reduced, they have
characteristic geometric shapes. For example, when maxillary molars are pre -
pared, they have a rhomboid shape when viewed from the occlusal side; man-
dibular molars have a rectangular shape, and most of the anterior teeth and
.
premolars have an oval shape These forms provide circumferential irregular -
.
ity 23 The value of these irregularities was assessed by comparing the areas
.
of conical and pyramidal preparations The pyramidal preparations showed
increased resistance.24 Therefore, it is important to preserve the "edges" of a
preparation. When a prepared tooth does not have "edges" because of its mor -
phology or an existing condition, it must be modified by additional retentions
to ensure resistance to displacement. All means to increase the contact surfac-
es result in the increase of retention and are called auxiliary retentive features.
They are categorized as grooves, boxes, and pinholes10 (Figs 3-9 and 3-10).

Fig 3 - 9 Preparation ot additional grooves.

Fig 3-10 The grooves must have slightly round-
ed margins (A). Occlusal view of the same tooth
prepared with and without circumferential irreg-
ularity; an example of the application of addition-
al grooves (B). The difference in wear between a
partial and full crown causes a difference in sta -
bility of the restoration; the additional grooves
are an alternative to increase the stability (C,D).

P r i n c i p l e s o f c a v
An interesting aspect of the groove is that the rotation direction forms an arc
away from one of the walls of the groove, and the arc from the other wall caus-
es stabilization, providing resistance in both directions of movement (Fig 3-11).
The structure of the tooth in which the groove is placed must be able to with-
stand the forces to prevent rotation of the crown, so they should be placed in
.
structurally sound regions 45 Another alternative is to reconstruct the lost walls
through core buildup with composite or glass ionomer (Fig 3-12) .
Grooves and boxes are also of great importance in helping to ascertain a
.
single insertion axis for the restoration Restorations with more than one in-
.
sertion axis have a poorer prognosis A single-path insertion means that the
restoration has only one way to be seated or removed from the preparation
(Fig 3-13). These alternatives are important as we are often faced with limited
preparation options.

Fig 3-11 Mechanical principle of

the action of the grooves.

*
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Chapter
Fig 3-12 Coronal reconstruction, allowing the creation of additional grooves (A,B).
03

np n (1)

• •
1 w i
ft 0
Fig 3-13 Different insertion situations. Crown with adequate angulation and a single insertion
axis (A). Crown with increased angulation and multiple insertion axis (B). Crown with increased
angulation, additional grooves, and a single insertion axis (C).

P r i n c i p l e s o f c a v i t y p r e p a r a t i o n
RESISTANCE
Considering that diverse forces of
varying magnitude and direction
are present in the oral cavity, it is
necessary for the restoration to be
resistant enough to withstand these
forces so that there are no fractures,
deformations or displacement. The
tooth should be prepared in a man-
ner that allows for a restoration of
sufficient thickness that is able to
withstand masticatory forces The .
tooth reduction required for good
structural stability will depend on the
restorative material of choice.
The structural stability is regarded
as the minimum material thickness
of the restoration to resist the action
of mastication loads without deform-
ing.35 For metal restorations, a reduc-
tion permitting an occlusal thickness
of 1.0 mm ought to be sufficient to re -
ceive and transmit the occlusal loads
.
to other dental structures When the
metal is combined with porcelain in a
metal- ceramic crown, this reduction
should be 1.3 to 2.0 mm to achieve
adequate strength for porcelain. For
all- ceramic restorations, there must
be enough room for 1.5 to 2.0 mm of
material. An inadequate thickness or
an excessive occlusal load may cause
deformation or at least tensions,
which may result in dislodgement
( Fig 3 -14).

Fig 3-14 Adequate amount of reduction in

accordance with the material. Metal crown
( A), Metal-ceramic crown (B). All ceramic
-

crown (C).
 The teeth should be uniformly reduced to
ensure a restoration with suitable shape
and esthetics. The uniform reduction eas -
es the job of the laboratory technician to
create esthetic restorations with a color
and translucency that resemble the nat-
ural tooth. Uniform reduction also pro -
motes the production of a restoration with
normal contours.23 However, lack of prop -
er tissue reduction can lead to disfigure-
ment or weakness of the restoration due
to lack of material. The attempt to correct
inadequate reduction leads to an over -
contoured restoration, causing biological
damage ( Fig 3 -15).

Fifj o - IS Inadequate reduc-

'

tion causing marginal over-

contouring.

,
P r i n c i p l e s o f c a v i t y p r e p a r a t i o n
' v69yj’
 The occlusal thickness must be care-
fully checked in the centric conten-
tion areas of the cusps ( lower ves-
tibular and upper palatal) and in the
fossae, where the incidence of forces
is higher. It is important to note that
the occlusal reduction should fol-
low the existing anatomy, including
pits and fissures, and reproduce the
main ridges, allowing an appropriate
occlusal morphology of the restor -
ation (Fig 3 -16). The axial walls of a
restoration must restore the ana -
tomical contours of the tooth, and
the preparation should facilitate this
process. These walls also play an im -
portant role in transmitting the mas-
ticatory forces to the cervical regions
of the preparations.
The angles of the preparations
should be rounded to increase the
strength of the ceramic restorations
and to facilitate laboratory manu-
Fig 3-16 Inadequate reduction, without con-
sidering the anatomy (A). Adequate reduc -
facturing steps and the adjustment
tion, taking the anatomy into account ( B). of the metal restorations (Fig 3 -17).
Acute angles on the prepared sur -
faces act as stress concentration
regions.41 Rounding these angles
increases the strength of all- ceram-
ic crowns. Full-metal and metal- ce -
ramic crowns do not show increased
resistance, but models and wax pat -
u terns without entrapped bubbles can
m be made with greater ease. The pres -
ence of bubbles in the infrastructure
mm may hamper complete seating of
the restoration if not detected and
removed. Moreover, if present, they
are easier to detect and remove
when the angles of the preparations
are rounded.23
Fig 3-17 Preparation with rounded angles.
 BIOLOGICAL PRINCIPLES
PRESERVATION OF THE PULPAL TISSUE
The objectives of rehabilitation are to avoid major damage, to minimize post-
operative sensitivity, and to preserve pulp vitality before restoring the shape
-
and function of the tooth.13 51
The dental pulp is a unique tissue. Its importance in the longevity and long-
term prognosis of the tooth is often ignored. It is the only tissue that is located
in a chamber that provides mechanical and biological protection. If this struc-
ture loses its integrity, the threat to pulpal tissue increases due to the pres-
ence of caries, cracks, fractures, and marginal maladjustment, which serve as a
pathway for the penetration of microorganisms and their toxins.66
The reaction of the pulp tissue to the tooth preparation for direct and in-
direct restorations is the subject of constant concern during the restorative
treatment.68 The thickness of the dentin remaining after tooth preparation has
been shown to be a critical factor in protecting the pulp from the aggression
caused by the preparation.39 Studies consider a range of 1 to 2 mm of remain-
--
ing dentin to be sufficient to prevent damage to the pulp44 57 58 (Fig 3-18).

Chapter
03

DENTIN
PULP

GINGIVA

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The dental structure remain-
ing after the preparation of the tooth
is very important with regard to pulpal
.
$ protection

1
mms,:
During the preparation of a tooth for subsequent placement of a full crown,
about 30,000 to 40,000 tubules per mm2 of dentin are exposed, which renders
a total of about 1 to 2 million exposed dentinal tubules20 (Table 3-1) (Figs 3 -19
and 3-20).
Table 3- 1 Relationship between distance from the pulp and the number and diameter of
dentin tubules
DISTANCE FROM AVERAGE NUMBER OF AVERAGE DIAMETER
THE PULP ( mm) TUBULES ( X 10,000 / mm2) OF TUBULES (pm)
0 45 2.5
0.1 -0.5 43 1.9
0.6-1.0 38 1.6
1.1 -1.5 35 1.2
1.6-2.0 30 1.1
2.1 -2.5 23 0.9
2.6-3 0 20 0, 8
3.1-3.5 19 0.8
Adapted from Garberoglio & Branstrom, 197619

Fig 3-20 SEM photomicrograph of

deep dentin (1 OOOx).

P r i n c i p l e s o f c a v i t y p r e p a r a t i o n
The main factors that can compromise the pulp vitality are:
• Inappropriate cavity preparation;
Evolution of the carious process;
• Trauma;
• Restorative materials .
Paradoxically, the proper treatment to repair the tooth can cause damage to
.
the dental pulp Cavity preparation is a common cause of pulp inflammation
because it promotes heat and dehydration, particularly when approximating
the pulp. Preparation at high speed is less harmful to the pulp than prepar -
ation at low speed due to the decrease of vibration and heat generation, but
even when air/water spray is used to cool the area, some degree of pulp irri-
tation will occur.58
During preparation, worn diamond burs require more pressure from the
.
clinician This excessive pressure generates more heat on the tooth surface
and may cause pulp damage (Fig 3-21). The pulp tissue should not undergo
temperature increases of greater than 5°C, since this could lead to inflamma -
.
tory reactions and even irreversible damage to the pulp 67 A temperature in-
crease of 5.6°C in the dental pulp can result in a 15% incidence of necrosis, es-
pecially in less voluminous dental elements where pulp necrosis occurs more
frequently.16

Fig 3- 21 Photomicrograph of diamond burs for preparation. New bur, appropriate

for use (A,B). Used bur, inappropriate for use (C,D).
PRESERVATION OF THE
PERIODONTIUM
The dental-periodontal relationship is an on-
going subject of research, in particular the
junction between the teeth and the gingiva12
(Fig 3 -22), where the interrelationship between
periodontics and prosthodontics is more pro-
nounced because it is an area that is relevant
to the work of both periodontist and prostho-
dontist, The preparation procedure occurs in
this area, as does the gingival retraction and
impression. Moreover, it is the preferred loca-
tion of most of the preparation finish line, and
therefore the region of restoration adaptation.
The periodontium forms the basis for es-
thetics, function, and comfort of the dentition.
A healthy periodontium is a prerequisite for all
.
prosthetic rehabilitations The interaction be-
tween periodontics and restorative dentistry
occurs on several fronts: location of the res- fhantpr

toration margins, contours of the prosthetic

crowns, and response of the gingival tissues to
the preparation procedure 42 .
To control biofilm, the restoration margins
of the preparations must have regular ends
and be positioned in areas with better access .
This leads to a better periodontal outcome.36
A deeper location of the restoration margins
into the gingival sulcus results in more intense
.
inflammatory responses 26'40 Some authors
have reported the presence of restorations
with subgingival margins as one of the main
.
risk factors for periodontitis50'55 (Fig 3-23) The
positioning of the gingival level of the cervical
finish line of the preparation has been thor-
oughly discussed. Various authors have sug-
gestions regarding the positioning at three
different levels - supragingival, gingival, and
subgingival - depending on the clinical situ-
ation. The finish line should end in enamel The dentogingival junction comprises
wherever possible. the space between the cementoenamel junction
and the border of the marginal gingiva. When
handled improperly, it can lead to inflammation
(A,B).

7s \j
P r i n c i p l e s o f c a v i t y p r e p a r a t i o n
(
^' '
Even experienced dentists can miss
defects up to 120 pm in terms of sub -
gingival location.14 In many situations,
the intrasulcular location of the restor -
ation margin is inevitable, either for es-
thetic reasons in the anterior area, or
to achieve a better outline or retention
shape.7'21 Nevertheless, care should be
taken not to invade the biological width.
If the restoration margin is located in this
region, it will cause gingival inflamma-
tion, resorption of crestal alveolar bone,
and periodontal pocket formation.25 -
To avoid this harmful process, a peri-
odontal surgical procedure should be
carried out to increase the clinical crown,
to move the alveolar crest apically, and
to correct the position of the restoration
margin. If the margin is located in the
interproximal region, and the need for
bone removal could compromise the
adjacent tooth, extraction of the affect-
ed tooth should be considered rather
than compromising the healthy adjacent
tooth.42

Fig 3- 23 Although the restoration margin

should preferably be placed supraglngivally (A),
for esthetic reasons it is sometimes placed gingi-
vally (B) or subgingivally (C).
 It has been proven that the supragingival margin is
the ideal, not only through-
out the prosthetic treatment, but also for the
maintenance and longevity of
the margins. The position of 2 mm below the free gingival level allows for the
performance of all stages of preparation and restorative procedures without
causing trauma to the gingival tissues. This, in turn, allows for more efficient
hygiene.
Whenever possible, the cervical boundary should be scribed at first, follow
ing the anatomical contour of the region. This is a safe way to establish the
-
width of the cervical reduction and guide the axial preparation. Gingival re-
traction is another alternative that can be employed to minimize the risk of
damaging the epithelium during preparation (Fig 3-24) .

Chapter
03

Fig 3- 24 Alternatives that help to preserve the periodontium duringtooth preparation. Gingival
groove (A). Gingival retraction cord (B).

P r i n c i p l e s o f c a v i t y p r e p a r a t i o n
 An adequate reduction of the tooth
should always be pursued during prep-
aration to create enough space for the
placement of the future restoration. If
insufficient tissue has been removed,
the future restoration will be overcon-
toured. Overcontouring of indirect res-
torations is considered to be a factor
contributing to the development of
gingival inflammation and possible peri -
odontal attachment loss, due to the in-
creased likelihood of biofilm retention.
Q In addition to increased accumulation
of biofilm due to poor contour restor-
ations, there is the increased presence
of periodontal pathogens.42 Undercon-
touring can lead to increased food im -
paction and cause damage to the peri-
odontal tissues, leading to the formation
of periodontal pockets (Fig 3 -25).

ESTHETIC PRINCIPLES
When rehabilitation is required in the
esthetic zone, many resources and ex -
tensive knowledge are required by the
o clinician to deal with the complexity of
the procedures involved in the restitu-
tion of function and a natural- looking
esthetic appearance.32

Fig 3- 25 The emergence profile of the restor-

ation exerts a considerable influence on the peri
-

G odontal health. Adequate contour (A). Overcon-

tour ( B). Undercontour (C).
When planning the esthetic rehabilitation of a smile, references should be
sought that aid in directing the case. The composition of a smile that is consid-
ered beautiful, healthy, and attractive involves a balance between the shape
and symmetry of the teeth, lips, and gums, including the way in which these
elements relate to and harmonize with the patient's face.63 Thus, for the cor -
rect planning and execution of esthetic rehabilitations, clear principles should
be applied to obtain a detailed and accurate analysis of all these elements. Im-
portantly, all these references should be sought in conjunction with functional
principles of occlusion, incisal guidance, canine guidance, overbite, and over -
jet.43 The dental preparation has a fundamental importance in the planning,
acquisition, and application of these principles.

CERVICAL FINISH LINES OF THE PREPARATION

Classically, it would be preferable to position the restoration margins in the re-
gion of the gingival sulcus, with the aim of improving the retention and esthet-
ics and promoting preventive extension, so that the marginal gingiva protects
- -
the dental tissue not covered by the restoration.27 36'45 62
The location of the preparation finish line is directly related to the know -
ledge of anatomical and histological characteristics of the marginal peri-
odontal structures, which contributes to proper planning and the imple- Chapter
.
mentation of the restorative procedure 8 The outline of the coronal portion
03
of a tooth is essential for the preservation and maintenance of periodontal
condition. This contour is the combination of curves found in the anatomic
crown, where the crown is more prominent than the root. The difficulty lies
in knowing the size of this prominence, which is based on criteria of propor -
tion, skill, inclinations of the coronal planes, and the long axis of the tooth
relative to its inclination in the arch. These criteria are well established for
the partial reconstruction of an anatomical crown (inlay or onlay), where
the remaining tooth structure serves as a guide to direct an appropriate
contour.
When preparing a crown, mechanical, biological, and esthetic principles
must be respected. These principles act in a concomitant way in the search for
and implementation of the preparation finish line. This finish line is primarily
responsible for the marginal integrity of the restoration, being closely related
to its cervical adaptation. A qualitative adaptation of these restorations reduc-
es the biofilm accumulation and the chance of periodontal tissue damage, thus
extending the longevity of the prosthetic treatment. The preservation of the
marginal integrity is directly related to the most critical stage of the prepar -
ation, which is the preparation of the cervical finish. This may have different
configurations, depending on the properties of the materials to be used in the
manufacturing of the indirect restoration.

P r i n c i p l e s o f c a v i t y p r e p a r a t i o n
 Maintaining marginal integrity is directly
related to the level of marginal adaptation
defined by the space between the inner
surface of the prepared tooth and the res-
.
toration (Fig 3-26) The success of a total
restoration depends on several factors,
one of the most important being the mar-
ginal adaptation,4'15'19'31 which can be in-
fluenced by the finish line design, the rep-
positioning of the etition of ceramic firings,6'34 and the luting
.restoration margin favors maintaining
marginal integrity.
.
agent 29
There is no consensus among dentist-
ry professionals regarding an acceptable marginal discrepancy. A marginal
gap ranging from 10 to 500 pm with average values between 50 and 100 pm
has been defined as acceptable.15 Marginal openings from 50 to 120 pm are
-
considered clinically acceptable in terms of longevity.30 59'60 For CAD/CAM res-
torations, the generally acceptable marginal discrepancies range from 50 to
--
100 pm.1 4 28'64
The cervical finish line is usually the last step of a crown preparation To .
obtain greater smoothness and uniformity in reduction, the use of a rotating
device with minimum pressure, maximum cooling, and new diamond burs is
recommended. The correct indication and execution of the finish line contrib-
utes significantly to the preservation of health and periodontal integrity Se- .
lecting the type of finish line depends on local (eg, the length of the clinical
crown) and esthetic factors, as well as on the chosen restorative material. In
teeth with a short clinical crown, the preparation must provide retention and
stability, and the type of finish is of great importance to preserve these char -
acteristics. In long teeth, anatomical peculiarities contraindicate certain types
of cervical finish lines.
The cervical finish line can be prepared in various ways and can be classified
into:
• Shoulder or 90-degree butt joint margin;
• Shoulder or 90-degree butt joint margin with a 45-degree bevel;
Rounded shoulder or 90-degree butt joint;
Rounded shoulder or 90-degree butt joint with 45-degree bevel;
• Shallow chamfer or concave;
Wide chamfer or concave;
• Chamfer or concave with 45-degree bevel;
• Mini-chamfer;
• 135-degree margin or bevel;
• Knife-edge or zero margin.
SHOULDER OR 90-DEGREE BUTT JOINT MARGIN
This type of termination was used in the past for hollow crowns made of por -
celain, and metal- ceramic crowns with the porcelain ending in a shoulder.2 It
was chosen specifically because these materials required greater thickness
for better resistance, reducing the risk of fracture. This type of termination is
critical in terms of the accuracy of the adaptation and the flow of the cement-
ing agent. Today, concepts have changed with the advent of adhesive cemen -
tation techniques, and this type of finish line has fallen into disuse (Fig 3-27).

Fig 3-27 Prepar

m ation of a shoul-
> >. t - der or 90-degree
butt joint margin

P r i n c i p l e o f c a v i t y p r e p a r a t i o n
 SHOULDER OR 90- DEGREE BUTT JOINT MARGIN WITH
45- DEGREE BEVEL
This finish line preparation is indicated for metal-ceramic, anterior or posterior
crowns. The bevel on the finish line improves the insertion and marginal fit of
the crown. However, this type of termination requires an excessive removal
.
of tooth structure without offering any advantage over chamfers Some au-
thors consider the appearance of the metal ring to be a disadvantage, causing
a compromise in esthetics. Other authors attribute to this ring greater resis-
tance to functional loads.
Saito (1999)53 offers some cautionary remarks regarding the use of a bev-
eled shoulder with a metal ring. The long bevel, with an inclination of 70 de-
grees, has the disadvantage of making it difficult to finish and polish the metal
infrastructure. The beveled 45 degrees may distort during heat treatment of
the ceramic if the metal band has a width of less than 0.5 mm. If the metal
band is wider than 1.0 mm, it will resist any distortion; however, the esthetics
will be compromised, since the bevel cannot be covered by ceramic (Fig 3-28).

Fig 3- 28 Preparation ot ”a shoul

a
or 90-degree butt joint margin with a
45- degree bevel.
ROUNDED SHOULDER OR 90- DEGREE BUTT JOINT

In this type of preparation finish line, the gingival wall forms an angle of 90
degrees relative to the axial reduction, with a rounded axiocervical angle.
This finish is suitable for all-ceramic crowns, which need greater reduction in
the cervical region of the prepared tooth, providing increased strength and a
well-defined preparation line.13 However, this finish behaves inferiorly to the
broad chamfer when certain types of ceramic are used, and poses a higher
risk of adverse reaction with pulp involvement.48 Furthermore, it is difficult to
obtain a clear margin with this finish. In cases where the tooth has abfractions
and restorations, it is more difficult to achieve a uniform reduction. In poster -
ior teeth, uniform wear is impeded by the limited access to the distal surface
of the molars. This type of termination reduces the stress concentration and
-
facilitates the flow of the luting agent33 61 (Fig 3-29).

-
 ROUNDED SHOULDER OR 90- DEGREE BUTT JOINT WITH
45- DEGREE BEVEL
In this type of preparation finish line, the gingival wall forms an angle of 90
degrees relative to the axial reduction, with a rounded axiocervical angle, but
with the addition of a bevel. This finish line has been indicated for anterior or
posterior metal- ceramic crowns; the bevel improves the insertion and margin-
al fit of the crown54 (Fig 3-30).

M^§x:v
Fig 3-30 Preparation of a rounded shoulder '
or 90-degree butt joint with 45-degree bevel;
SHALLOW CHAMFER

.
The shallow chamfer is widely used as a finish line It is suitable for full-metal
.
crowns and lingual preparations of posterior teeth and veneers With this ter-
mination it is possible to obtain a thin restoration margin. Wear is minimized
and there is sufficient space to assure the material's resistance. The rounded
.
concavity results in lower stress concentrations ( Fig 3-31) The development of
modern adhesive technology and ceramic materials with high resistance and
increased fracture toughness enable preparation with a minimally invasive ap-
proach, which minimizes weakening of the tooth and pulpal irritation.49 As a
result of this process, thickness of the infrastructure of the restorations can be
decreased, and less invasive finish lines can be prepared, such as the shallow
.
chamfer 17

Chapter
03

Vs
6? 1 '
. -
I

s i
/.
V
Fig 3-31 Preparation
Mm:
.
shallow chamfer
 WIDE CHAMFER
The gingival wall of this type of finish forms a circular segment from the axial
wall to the finish line itself. This type of termination is designed for all-ceramic
restorations, to enable a lower marginal discrepancy and a better flow of luting
agents.230,47 This termination promotes better stress distribution and a sharp
finislrline, and allows the clinician to obtain an appropriate contour in the cer-
vical, vestibular, and proximal regions (Fig 3-32).

t .
« '

*5
V
Fig 3-32 Preparation of a
wide chamfer. re
CHAMFER WITH 45- DEGREE BEVEL

The beveled chamfer is carried out when there is the need for a chamfer.
However, this chamfer is very wide, resembling the termination in a shoulder,
hence the necessity of a bevel to improve adaptation. The beveled chamfer is
well suited for metal-ceramic crowns. There is some controversy among au-
thors regarding the need for a metal band on the border of the crown, unless
the metal is made thicker for cases such as this (Fig 3 -33).

Chapter
03

Fig 3-33 Preparation ot a

chamfer with 45-degree
bevel.

P r i n c i p 1 e
MINI- CHAMFER

When there is a need to extend a preparation in the apical direction, the reten-
tion, resistance, and esthetic appearance of the restoration will improve. The
subgingival preparation of the margins is also indicated when caries or anoth-
er type of loss of dental structure has occurred prior to preparation (abrasions,
.
abfractions, erosions, and fractures) The denomination "chisel edge" refers to
the more apical location (involving cementum) of termination of preparation,
and resembles a shallow chamfer (Fig 3-34).

m\
Fig 3-34 Preparation of rs
a mini-chamfer.
135-DEGREE MARGIN OR BEVEL

A bevel finish line forms an obtuse angle of 135 degrees with the axial wall
of the preparation. The finish can be extended to the intrasulcular region,
reaching to the root portion, especially in teeth with periodontal involvement
and gingival recession. A full metal- ceramic crown that respects the anatom-
ical contours without exposing a metal collar can be made, as it does not re-
quire a depth of high tissue reduction and enables a satisfactory esthetic result
(Fig 3-35).

I Chapter
03
r

W
1 \
^* \
HSS
- i
\
V
Fig 3-35 Preparation of
a 135-degree margin or
.
bevel

P r i n c i p l e s o f c a v i t y p r e p a r a t i o n
0;
 KNIFE- EDGE OR ZERO MARGIN

When it comes to reduction, a metal can be

~~T V
'

vX;. 5fe£>.\
& '«
^
Fig 3-36 Preparation of a knife-edge or zero margin
 18 . Di Febo G, Carnevale G, Sterrantino SF. Treatment of a
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1. Akbar JH, P etrie CS, Walker MP, Williams K, EickJD. Mar- odontics Restorative Dent 1985;5:52-62.
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3 . Annerstedt A, Engstrom U, Hansson A, et al , Axial wall

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21 Goodacre CJ, Campagni WV, Aquilino SA. Tooth prepar -
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5. Ayad MF, Maghrabi AA, Rosenstiel SF. Assessment of
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Omegan 1977;70: 62 65.
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25 . Jameson LM, Malone WF. Crown contours and gingival

6. Balkaya MC, Cinar A, Pamuk S. Influence of firing cycles response. ) Prosthet Dent 1982;47:620-624.
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Dent Mater J 2007;26 : 659 664.
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cal height interactions in molar full crown preparations. 28. Kumbuloglu O, Lassila LV, User A, Vallillu PK. A study of the
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grooves and boxes in mandibular molar crown prepar- 29. Lewis RM, Owen MM. A mathematical solution of a
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12 , Carranza Junior FA Glickman periodontia clfnica, ed 7. crowns. J Prosthodont 2009;18:162-166.
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31 Magne P, Magne M. Using additional wax-up and
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14 Christensen GJ . Marginal fit of gold inlay castings. J Pros- 32. Martignoni M, Schonenberger A , Precisao em protese
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37. Mou SH, Cliai T, WangJS, Shiau YY. Influence of different .
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41. Padbury AJr , Eber R, Wang HL. Interactions between the 58. Stanley HR. Dental iatrogenesis, Part 2. Dent Today
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.
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61. Touati B, Miara P, Nathanson D . Inlays e Onlays cerami-
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1993;2:61-66. 62. Tylman SD, Malone WFP. Tylman'sTheory and Practice of 03

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63. Vieira GF Atlas de anatomia de denies permanentes:
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1994;72:585-590. um-oxide-based ceramic four-unit fixed partial dentures,

.
47 Pigozzo MN, Lagana DC, Mori M, Gil C, Mantelli AG. generated with three different CAD/CAM systems, before
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.
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-
65 . Wilson AH Jr, Chan DC, The relationship between prepar-
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—

for all- ceramic fixed partial dentures : a review of the lit- .

67 Zach L, Cohen G , Pulp response to externally applied
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-

50. Reeves WG. Restorative margin placement and peri- 68, Zollner A, Gaengler P. Pulp reactions to different prepar-
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 CHAPTER 04

INTRACORONAL
TYPES OF PREPARATIONS
Major structural losses with consequent destruction of the cusps or coronal
portions of teeth due to caries, fracture or other causes occur relatively often in
.
everyday practice Treatment planning is dependent on a careful examination
of the clinical situation, including an analysis of the amount of lost hard tissue,
possible pulp involvement, relation of tooth to the other teeth, condition of
the periodontium, masticatory forces to which the tooth will be submitted, etc.
Cavity preparation does not only comprise the reduction or cutting of hard
tooth structures. When there is a need to proceed to a therapeutic or prosthet-
ic reduction to ensure a satisfactory outcome, a number of operative maneu-
vers are required that are dependent on the characteristics of each situation
or case.MO
Shillinburg et al12 cited some basic principles related to the tooth structure:
preservation of tooth structure, form of retention and form of resistance, du-
rability of the restoration structure, marginal integrity, and preservation of the
periodontium. Although these principles should be clinically integrated, com-
promising one or more of them to favor others is sometimes necessary .
Thus, the classical principles of cavity preparation advocated by Black, or
the suitability of the cavity for an adhesive restoration, are not valid here. It is
necessary to make some changes in the preparation of the remaining struc -
ture using retentive features that compensate for the absence of the original
tissue.1 A 5,10-12,14
Some of the main types of intracoronary restorations are:
• Inlays - strictly intracoronal preparations;
• Onlays - preparations involving some cusps;
• Overlays - preparations involving all cusps up to the middle third of the crown.

The burs and abrasives used for the preparation discussed in this chapter are
shown on pages 98 and 99.
I n t r a c o r o n a l r e s t o/ a t o n s
rA

T TYPES OF BURS AND ABRASIVES

O
w
jEr '
^
ROUND CARBIDE

ROUND
SMALL 0

ROUND LARGE 0
PEAR,
MEDIUM GRIT

PEAR,
EXTRA-FINE GRIT
FLAME,
MEDIUM GRIT
,
rr

FLAME,
EXTRA -FINE GRIT
POINTED TAPER ,
MEDIUM GRIT
i [#T* J

POINTED TAPER,
ROUNDED TAPER, EXTRA-FINE GRIT
MEDIUM 0,
MEDIUM GRIT

T /

ROUNDED TAPER,
WHEEL, MEDIUM 0,
MEDIUM GRIT MEDIUM GRIT
 ROUNDED TAPER,
LARGE 0,
MEDIUM GRIT

FLAT- END CYLINDER,

MEDIUM GRIT

BEVELED CYLINDER,
MEDIUM GRIT

ROUNDED SHORT
TAPER,
MEDIUM GRIT

MULTILAMINATED
PEAR
(8 TO 36 BLADES)

MULTI LAMINATED
ROUNDED TAPER
( 8 TO 36 BLADES),
LARGE 0

I n t r a c o r o n a l
METAL RESTORATIONS
INDICATIONS
Metal restorations are considered less esthetic. Due to advances in recent
years they have been replaced by other dental materials, yet they still have
great applicability and are indicated in everyday practice. Knowledge of the
principles of metal restorations is necessary for the understanding and appli-
.
cation of basic concepts 8'9'12
One of the great advantages of metal restorations is their biocompatibili-
.
ty They are indicated for: large cavities or extensive reconstructions, preven-
tion of periodontal problems through the reconstruction of contact points,
protection of endodontically treated teeth, areas of large masticatory forces,
resistance to the application of masticatory forces protecting the remaining
structures, retainers for fixed prostheses, splinting, replacement of deficient
restorations, teeth that need to be restored in the case where the antagonist is
also a metal restoration, support for removable partial dentures, and occlusal
reestablishment.8'9

MAIN TYPES OF INTRACORONAL RESTORATIONS

The main intracoronal metal cast restorations are mesio-ocdusal (MO), me-
sio-occluso-distal (MOD), and disto-occlusal (DO). These may be present as a
single box, or they may be more complex with the coverage of one or more
cusps.

Inlay
In the preparation of an inlay, variations exist that may or may not involve the
proximal walls, ie, turning it into an MO or DO preparation. Attention should be
paid to preserving the marginal ridges in case there is no need to involve them
(Figs 4-1 to 4-4). Preparation of the occlusal box should involve the central third
of the main fossa, reducing the coronal height by 1/3, with a 3- to 5-degree
taper of the walls. For the preparation of the proximal box, the adjacent tooth
should be protected with a metal strip, removing the contact point. The re-
duction is deepened by 2/ 3 of the coronal height in the gingival direction. The
cavosurface angle of the occlusal and proximal boxes should be beveled once,
.
so as not to create a discontinuity between the boxes 2'9
 Chapter
04

Fig 4-1 Intact tooth (A) , Slicing of the proximal surface, removing the interproximal contact (B),
Occlusal and proximal boxes with sharp angles prepared with a flat-end cylindrical diamond bur
(C) . Preparation of the proximal box with straight walls, sharp angles, and walls diverging in the
occlusal direction (D), Final aspect of the preparation (E,F).

I n t r a c o r o n a l r e s t o r a t i o n s
Fig 4- 2 Intact tooth ( A). Slicing of
the proximal surface (B). Occlusal
and proximal boxes with sharp an-
gles prepared with a flat -end cylin-
.
drical diamond bur (C) Final aspect
.
of the preparation (D E).
 Chapter
04

Fig 4-3 Intact tooth (A) . Slicing of the proximal surface with a tapered diamond bur (B). Ves-
tibular box (C) . Divergence of the vestibular box provided by the diamond bur (D). Final aspect
of the preparation (E-G).
 Chapter
04

.
Fig 4- 4 Intact tooth (A) Slicing of the proximal surfaces ( B). Proximal box (C). Occlusal box (D).
Bevel of the cavosurface angle (E). Final aspect of the preparation (F,G).

I n t r a c o r o n a l r e s t o r a t i o n s
Maxillary onlay
The preparation is started following the same principles as for inlay. A prep-
aration for a maxillary onlay involves the functional maxillary palatal cusps
.
(Fig 4-5) For the occlusal reduction, orientation grooves should be made, fol-
lowing the dental anatomy. Balancing cusps (buccal) should be reduced by
.
1.0 mm, and functional ( palatal) cusps by 1.5 mm It is necessary to verify the
occlusal reduction to determine if there is enough space for the restorative ma-
.
terial This step is created to increase the strength of the metal structure and
to reinforce it, preventing deflection and displacement of the restoration 8'12 .

A proximal box is prepared to in-

crease the resistance of the restor -
ation by increasing its volume. The
creation of a beveled finish line im-
proves the marginal adaptation of the
.
restoration (see Fig 4-6)

-
Fill 4 5 intact tooth (A), occlusal reduction
(B). Reduction of the vestibular surface, form
-
.
ing an occlusal step (C) Occlusal box with a
flat-end cylindrical diamond bur (D), Proximal
-
box with a flat end cylindrical diamond bur
Chapter
04
Mandibular onlay
A preparation for a mandibular onlay involves the functional mandibular buccal
cusps (Fig 4-7). For the occlusal reduction, orientation grooves should be made,
following the dental anatomy. Balancing cusps (lingual) should be reduced by
1.0 mm, and functional (buccal) cusps by 1.5 mm. It is necessary to verify the oc-
.^
clusal wear to determine if there is enough space for the restorative material 8

Fig 4-7 Intact tooth (A). Occlusal box re-

duction (B) . Proximal box reduction ( C).
Functional cusp reduction (D). Beveling
of the cavosurface angle alongjts entire
length (E,F) . Final aspect of the prepar -
ation (G).
Overlay
The preparation is started following the same principles as
for the onlay. The difference is in the greater occlusal reduc-
tion, which is applied to both the cusps. It is necessary to
verify the occlusal reduction to determine if there is enough
.-
space for the restorative material 8 12 Figures 4-8 and 4-9
show the preparation steps for maxillary and mandibular
overlays, respectively.
 I

L
i
A

[© i

V*

I
\
^
Chapter -
. 04

.
Fig 4-8 Intact tooth (A) Preparation of buccal and lingual surfaces with a flatrend cylindrical
.
diamond bur for the cusp coverage (B) Occlusal box with flat-end cylindrical diamond bur (C),C
^
Smoothing of the pulpal wall of the preparation with a flat-end cylindrical diamond bur,( D ') / ^

. ^
Proximal box with a flat-end cylindrical diamond bur (E), Beyelirigcrf the bucfcal alingMlTimv;
ish line of the preparation (F).' Slicing of the proximal wall, removi.ng the,iot§rprox1rnatcpntact
point (G). Final aspect of the preparation (H)

I
t
 i

/
II
• '1
I1

' A
.
3a

,
Fig 4-9 Intact tooth (A). Occlusal reduction (B). Occlusal and proximal boxes with a flat;dnd
.
tapered diamond bur (C). Reduction for coverage of the supporting and balanGing'cusp'(R).'
'
Beveling with a flame-shaped diamond bur (E). Slicing of the proximal surfaces (E)jfFjnal
|ispeG
of the preparation (G-l).
£

I n t r a c o r o n a l r e s t o, r a t i o n s.. ; ;
METAL- FREE RESTORATIONS
INDICATIONS
The concept of metal-free restorations in ceramics dates back to the end of
the last century, when the first metal-free restorations were made. With the
advent of adhesive techniques, cavity preparation for indirect restorations has
been simplified, requiring increasingly fewer geometric artifices to achieve re-
. ^.
tention and stability while preserving dental structure 1 13,14
One of the great advantages of metal-free restorations is their esthetics,
which mimic the peculiarities of natural teeth. They are indicated for: teeth
presenting caries or traumatic injuries, teeth with restorative needs where the
antagonist is also a ceramic restoration, teeth where it is difficult to develop
shape retention, esthetic requirements, replacement of deficient restorations,
extruded or infraoccluded teeth, teeth that have structural defects or deforma-
tions, prevention of periodontal problems through the reconstruction of con-
tact points, protection of endodontically treated teeth, retainers, fixed pros-
theses, diastema closure in anterior teeth, vital teeth with extensive coronal
destruction, and teeth with short clinical crowns.

MAIN TYPES OF INTRACORONAL RESTORATIONS

The main intracoronal metal-free restorations are mesio -occlusal (MO), me-
.
sio -occluso-distal (MOD), and disto-occlusal (DO) These may be present in a
single box or they may be more complex, with the coverage of one or more
cusps.
Inlay
Figures 4-10 and 4-11 show the preparation steps for maxillary and mandib -
ular inlays, respectively. In the preparation of a ceramic inlay, variations exist
that may or may not involve the proximal walls, turning it into an MO or DO
preparation. Attention should be paid to preserving the marginal ridges in case
there is no need to involve them. Preparation of the occlusal box should in-
volve the central third of the main fossa, reducing the coronal height by 1/3,
.
with a 7- to 12-degree taper of the walls For the preparation of the proximal
box, the adjacent tooth should be protected with a metal strip, removing the
contact point. The reduction is deepened by 2/3 of the coronal height in the
gingival direction, ensuring that the isthmus has a minimal width of 2 mm to
---
provide adequate resistance to the restoration.3 6 7 14
Fig 4-10 Intact tooth (A). Occlusal box with a round- end tapered diamond bur ( B). Proximal
box with a round end tapered diamond bur (C). Final aspect of the preparation (D-F).
-
Fid 4 - 11 Intact tooth (A). Occlusal box with a
round-end tapered diamond bur (B), Proximal box
with a round-end tapered diamond bur (C). Final
aspect of the preparation (occlusal view) (D).
n
n t r a c o r o n a r e s t o r a t i o n s
Maxillary onlay
The preparation is started following the same principles as for the inlay. The
preparation steps for a maxillary premolar are shown in Figure 4-12, and for
a maxillary molar in Figures 4-13 and 4-14. A preparation for a maxillary on-
lay involves the functional maxillary palatal cusps. For the occlusal reduction,
.
orientation grooves should be made, following the dental anatomy Balancing
cusps ( vestibular ) should be reduced by 2.0 mm, and functional (palatal) cusps
by 2.5 mm. It is necessary to verify the occlusal reduction to determine if there
is enough space for the restorative material. This step is created to strengthen
and reinforce the ceramic structure, minimizing cracks and fracture of the res -
toration. Special attention should be paid to the internal angles of the prepar -
ation, which should be rounded.3^

.
Fig 4-12 Intact tooth (A) Occlusal reduction (B). Wear of the vestibular surface forming the
occlusal step (C). Reduction of the occlusal box and the buccal cusps with a round-end cylin-
drical diamond bur (D). Occlusal box with a flat end cylindrical diamond bur (E). Final aspect of
-

the preparation (F-H).

I n t r a c o r
 Chapter
04

- .
Fig 4 13 Intact tooth (A). Occlusal reduction (B) Occlusal step of the functional cusp with a
.
round-end tapered diamond bur (G) Occlusal box with a round-end tapered diamond bur (D).
Proximal box with a round-end tapered diamond bur (E). Wear of the functional. cusps and
, .
working cusps (F) Reduction of the functional cusps (0), Final aspect of the preparation (H,I)

I n t r a c o r o n a l r e s t o r a t i o n s 11251
'
Mandibular onlay
A preparation for a mandibular onlay (Figs 4-15 and 4-16) involves the func -
tional mandibular buccal cusps. For the occlusal reduction, orientation grooves
should be made, following the dental anatomy. Balancing cusps (lingual)
should be worn by 2.0 mm, and functional (buccal) cusps by 2.5 mm. It is nec-
essary to verify the occlusal wear to determine if there is enough space for the
restorative material.3,14
Fig 4 -15 Intact tooth ( A). Reduction of the proximal box ( B).
Reduction of the occlusal box (C). Reduction of the balancing
cusp (D). Final aspect of the preparation (E,F).
 Chapter
04

zm
///

// /

VA
//>
'
Fig4-16 Occlusal step of the functional cusp with a round end tapered diamond bur (A) . Oc
- -
>
clusal box with a round- end tapered diamond bur (B) Proximal box with a round end tapered
, -

diamond bur (C). Wear of the functional and working cusps (D). Final aspect of the preparation
( E, F).

I n t r a c o r o n a l r e s t o r a t i o
Overlay
The overlay preparation is begun following the same the principles as for the
onlay. The difference is in the greater occlusal reduction, which is applied to
.
both the cusps (buccal and lingual) (Figs 4-17 to 4-22) It is necessary to verify
the occlusal wear to determine if there is enough space for the restorative
material.3.14
 >v

r s

f y

Fig 4-17 Intact tooth ( A). Vestibular reduction with round-end tapered diamond bur (B), Pal -
.
atal reduction with round end tapered diamond bur (C). Reduction of the free surfaces with
-
/s
%
round end tapered diamond burs (D) . Wear and reduction of the functional cusp (E). Wean of ..
- '

the proximal box with a round-end tapered diamond bur (F). Wear of the proximal box with a yv '/
round end tapered diamond bur ( G). Final aspect of the preparation (H-J ).
-
v

I n t r a c o r o n a l .
r e s t o r a t i o n s v.
>
 - Intact tooth (A). Wear of the ves
Fig 4 1l.i -

tibular surface with a round-end tapered di

amond bur ( B). Wear of the palatal surface
with round-end tapered diamond bur (C) ,
Occlusal box with a round end tapered di-
-

amond bur (D). Occlusal box with a round-

end tapered diamond bur ( E). Proximal box
with a round-end tapered diamond bur (F).
Proximal box with a round- end tapered Chapter
diamond bur (G). Occlusal box with a with
a round-end tapered diamond bur ( FI ).
Reduction of the functional and balancing
04
cusps (I), Final aspect of the preparation
 Chapter
04

Fig 4-19 Intact tooth ( A) . Reduction of the occlusal box with a round-end tapered diamond
bur (B) . Proximal reduction with a round end tapered diamond bur (C). Vestibular occlusal step
-

with a round-end tapered diamond bur (D) . Reduction of the working and balancing cusps (E).
Wear of the lingual surface and formation of the cervical finish line and functional cusp reduc-
tion (F) . Final aspect of the preparation (G,H)
.

I n t r a c o r o n a l r e s t o r a t i o n s
Fig 4- 20 Final aspect of the preparation (A, B).
 Chapter
04

Fig 4- 21 Intact tooth ( A) , Reduction of the proximal box with round-end tapered diamond
bur ( B).

I n t r a c o r o n a l r e s t o r a t i o n s
Fig 4- 21 Reduction of the occlusal box with a round-end tapered diamond bur (C). Reduc-
tion of the vestibular and lingual portion with a round-end tapered diamond bur (D) .
 Chapter
04

Fig 4- 21 Reduction of the balancing cusps with a round-end tapered diamond bur (E). Final
aspect of the preparation (F).

I n t r a c o r o n a l r e s t o r a t i o n s
 Chapter
04

Fig 4- 22 Intact tooth (A). Occlusal reduction (B). Occlusal reduction (C) . Occlusal box with a
round-end tapered diamond bur (D) . Proximal box with a round-end tapered diamond bur (E).
Reduction of the buccal and lingual surfaces of the cusps with a round-end tapered diamond
bur (F) .

I n t r a c o r o n a l r e s t o r a t i o n s
Fig 4- 22 Final aspect of the preparation (G,H) ,
PECULIARITIES OF PREPARATIONS FOR METAL- FREE
RESTORATIONS

The tooth preparation for esthetic indirect posterior restorations is different

from the classical preparations made for cast metal restorations. These mod-
ifications mainly relate to the fragility of these esthetic restorative materials
before final cementation. They aim to provide proper resistance for the try- in,
adjustment, and cementation of the workpiece. In the adhesive restorations
there is no concern regarding the retentive shape, since the preparation must
be divergent. Some factors must be observed during cavity preparation: pas -
sive seating of the workpiece, reduction of points of stress concentration by
smoothing the angles, and resistance form of the material.
Some characteristics of the preparation can be highlighted: reduction of the
occlusal box of 1.5 to 2.0 mm, cusp reduction of 2.0 to 2.5 mm, 1.5 to 3.0- mm
width of the occlusal isthmus, 1.0 to 1.5-mm width of the gingival wall, 7- to
12-degree taper, edge of the cavity and cervical finish, beveled or concave butt
angle margins, rounded internal angles, and sharp edges in enamel that do not
coincide with the occlusal contacts.3 14 -
REFERENCES Chapter
1. Baratieri LN, MonteirojuniorS, Andrada MAC, Vieira LCC, 8. Martignoni M, Schonenberg A. Precisao em protese fixa . 04
Ritter AV, Cardoso AC. Odontologia Restauradora: funda - Tokyo : Quintessence, 1998.
mentos e possibilidades , Sao Paulo: Santos, 2001. 9 . Mezzomo E, Suzuki RM. Reabilitag3o oral contem-
2. Blaser PK, Lund MR, Cochran MA, Potter RH. Effect of poranea. Sao Paulo: Santos, 2006.
designs of Class 2 preparations on resistance of teeth to 10. MondelliJ, Sene F, Ramos RP, Benetti AR. Tooth struc-
fracture . Oper Dent 1983;8: 6-10. ture and fracture strength of cavities. Braz Dent J
3. Bremer BD, Geurlsen W. Molar fracture resistance after 2007;18:134-138.
adhesive restoration with ceramic inlays or resin-based 11. Robbins JW, Fasbinder DJ, Burgess JO. Posterior inlays
composites. Am J Dent 2001;14:216-220. and onlays. In: Schwartz RS, Summit JB, Robbins JW
4. Garber DA, Goldstein RE , Porcelain and composite in- ( eds). Fundamentals of operative dentistry: a contempo-
lays and onlays : esthetic posterior restorations , Chicago : rary approach. Chicago: Quintessence, 1996:229-250.
Quintessence, 1994. 12. Shillingburg HT, Hobo S, Whitsetl 10, Jacobi R, Brackett
5 . Garone W. Restauragoes ceramicas em dentes posteri- SE. Fundamentos de protese fixa, ed 4, Sao Paulo: Quin-
ores. Estetica do sorriso : arte e ciencia. Sao Paulo: San- tessence, 2007.
tos, 2003 . 13. Soares CJ, Martins LR, Fonseca RB, Correr-Sobrinho L,
6 . Khera SC, Goel VK, Chen RC, Gurusami SA . Parameters of Fernandes Neto AJ . Influence of cavity preparation design
MOD cavity preparations: a 3-D FEM study, Part II. Oper on fracture resistance of posterior Leucite -reinforced
Dent 1991;16 :42-54. ceramic restorations. J Prosthet Dent 2006;95:421 429.
-

7. Lin CL, Chang CH, Ko CC. Multifactorial analysis of an 14. Touati B, Miara P, Nathanson D . Inlays e Onlays cerami-
MOD restored human premolar using auto-mesh finite cas. In: Odontologia estetica e restauragoes ceramicas.
element approach. J Oral Rehabil 2001;28:576-585. Sao Paulo: Santos, 2000:259 -291.

I n t r a c o r o n a l r e s t o r a t i o n s
PREPARATIONS FOR PARTIAL CROWNS
Coronal preparations are made to promote maximum retention and resis-
tance; to preserve the structure of the tooth; and to favor the periodontal
.
health, durability, and marginal integrity of the restoration The classic prepar-
ations of the abutment teeth are made without modifications for fixed partial
.
dentures. The teeth may either be intact or damaged The tooth is prepared
after a previous restoration of a portion of the crown or a post 7.
Partial preparation is one of the most conservative options among the
crown preparations and requires little reduction of the dental structure. The
indication is based on the concept that the tooth should not be unnecessarily
prepared. This preparation has the advantage of a facilitated evaluation of the
adaptation of exposed margins. Another advantage is related to the cementa-
tion procedure because the cement can flow more easily, thus allowing a more
precise seating. In this preparation, the external surface of the tooth remnant
serves as a reference to create the most appropriate outline for the restor-
ation.6

3/4 PARTIAL CROWNS

Preparation for a 3 / 4 partial crown prevents the appearance of metal on the
buccal surface, which allows for better esthetics. However, this preparation re-
quires more time and skill on the part of the clinician due to its features regard-
ing reduction and parallelism. The success of a 3/4 preparation in the anterior
region depends on careful planning of the case before the start of treatment.
This type of preparation should be used for abutments for a fixed partial res-
toration when there is reduced space, in teeth with small restorations. The an-
atomical shape of the tooth should be considered in the planning, taking into
.
account the biomechanical principles of the preparations This preparation is
best suited for longer teeth, while preparation of shorter teeth is difficult,7
Teeth that need to be prepared must have a good alignment in the dental
arch and cannot present an accentuated constriction in the cervical region. The
presence of a deep overbite requires more reduction. The preparation is con-
servative, but the tooth should have sufficient buccolingual thickness to allow
for the reduction with the preparation.6 7-
Anterior teeth
In the preparation for a 3/4 crown, special attention should be given to the
.
reduction of the tooth structure For lingual reduction, approximately 0.7 mm
of structure should be removed to create a surface with double concave incli-
nation in the maxillary canines and a smooth, continuous surface in the man-
.
dibular canines and incisors (Figs 5-1 and 5-2) The incisal reduction should
be approximately 0.7 mm, following the natural mesial and distal inclinations
of the incisal borders of the canines, and a straight line on incisors. Special
attention should be given to the proximal axial reduction, since insufficient
preparation in this area causes a reduction of the retentiveness of the restor -
ation . Proximal grooves must have approximately 1.0 mm of depth and must
be parallel to the middle of the incisal third of the buccal surface . Occasionally,
the grooves may be replaced by boxes in the case of existing caries or prep -
arations. The incisal channel follows the incisal anatomy, which is different in
canines (inverted V-shape) and incisors ( straight line).6

Fig 5-1 Intact tooth ( A) . Intact tooth (B). Reduction of the cervical portion of the lingual (palatal)
surface with a tapered diamond bur (C) . Reduction of the palatal surface with a pear shaped -

diamond bur ( D )
Fig 5-1 Reduction with a tapered diamond bur on the proximal surfaces, preserving the buccal
.
surface (E ). Proximal groove (F) Bevel at the cervical finish line (G). Retention groove (H).
 Chapter
05

Fig 5 -1 Final view of the prep

aration , Proximal view (I). 4/5 prep-
aration of inferior tooth 43 (]).
Fly 5 - 2 Intact tooth (A). Occlusal re-
duction with a round-end tapered bur
(B) , Cusp reduction (C). Reduction of
the buccal surface (D), Preparation of
the proximal grooves with a round-
.
end tapered bur (E) Preparation of
the occlusal groove with a flat-end
tapered bur (F).
4/5 PARTIAL CROWNS

The preparation for 4/ 5 partial crowns is one of the most conservative coronal
'preparations, requiring a small reduction of the tooth structure. This prepar -
ation enahles tbe. precise evaluation of supragingival margins, and facilitates
^ .
the flow of the cement, allowingfor better seating This preparation is not indi-
cated in teeth with extensive destruction or when there is need for maximum
retention or esthetics.7
The posterior partial crowns differ from the anterior ones due to the inser -
tion plane that is usually parallel to the long axis of the tooth. The preparations
in the maxillary and mandibular teeth differ significantly as regards the work-
ing>ajsps. In the maxillary teeth, the preparation does not involve the buccal
surface, whereas cuspal coverage is necessary in the buccal cusps of the man -
'
dibular teeth, since these are the functional cusps.6

Maxillary teeth
When preparing 4/ 5 partial crowns for maxillary teeth, attention should be
paid to achieving proper occlusal reduction (Figs 5-3 to 5 -6). The reduction of
the functional (palatinal) cusp should be approximately 1.5 mm ( Figs 5 - 3 A to
.
D, and 5 - 4B) To minimize the appearance of metal, the angle of the vestibu-
lo -occlusal line should be reduced by 0.5 mm, and the working cusp ( buccal) by
1.0 mm. The axial walls must be reduced by approximately 0.5 mm, Proximal
grooves must be approximately 1.0 mm deep, and parallel to the middle of the
incisal third of the buccal surface (Figs 5-3E to G, and 5-4C and D ). Occasionally,
the grooves may be replaced by boxes due to the existence of preparations
.
or carious lesions (Figs 5- 7 to 5-9) The occlusal groove follows the anatomy
( inverted V-shape) and is 1.0- mm wide (Figs 5 - 3 H and 5-5A) A 7
All line angles of the preparation are smoothed, the margins are beveled,
and the proximal boxes are checked for convergence toward the occlusal as -
pect of the tooth (Figs 5-3 I to M, 5-5B, and 5-6).
 Chapter

Fig 5-3 Intact tooth (A). Occlusal reduction

with a tapered diamond bur (B).

f 157
^ Sj '
 Chapter
05

Fig 5 - 3 Occlusal reduction (C). Reduc-

tion (bevel) of the supporting cusps (D).
Reduction of the lingual (palatal) surface,
extending until the removal of the inter -
proximal contact between the mesial
and distal surfaces (E) Proximal groove
( F), Proximal groove (G). Groove on the
working cusp, flat -end tapered diamond
bur (H) .
Fig 5-3 Proximal grooves (I). Bevel of the cervical finish line ())• Beveling the working cusp
with a flame - shaped diamond bur (K). Final view of the preparation (L,M).
Fig 5 - 4 Intact tooth (A).
Occlusal reduction with a
round-end conical bur (B).
Mesial and distal (M and
D) proximal reduction with
a pointed tapered bur (Q.
L
M and D proximal finishing
with a round-end conical
bur (D),
 .V
r‘.K >*
. J ^ '7'- x ,
'. ’ Aifr -U
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I 'IzGtfixl i
•i.•i/. ,v>V/'t 1
f
-

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/

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-;
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» J.V
1 • *

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*

, .*
i
r »t
A
mSBR
* r
*
4 i

L sHB
^ / r\
'«
v

I
/ »7/. Hii
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- * t

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i

r \finRxS
••
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i <
f
I *
A
i
•

* tP
'
4 «
<
!

- I \

3.'feSwI
1
'
>r ->v5gw0'i yfrj’ I
•s
ir yffi mil
. # Av M>;x,5 . ..*
-
’
r# i . > ^Tv <frkV
<
. .

/, . « »H.
* -
A
'
 -
Fig 5 6 Final view of the preparation
 Chapter
05

Fig 5- 8 After caries removal ( A) . Insertion of the filling material (B-E).

Preparation of the palatal surface with a rounded tapered bur (F).

E x t r a c o r o n a l r e s t o r a t i o n s
Fig 5 - 9 Preparation of the
occlusal surface, wheel (A).
Bevel preparation, flame-
shaped bur (B). Final view of
the preparation (C,D).
Mandibular teeth
When preparing 4/ 5 partial crowns for
mandibular teeth, care should be taken
to achieve proper occlusal reduction.
The reduction should be approximately
1.5 mm of the functional cusp ( buccal),
and 1.0 mm of the working cusp (lin-
gual). A reduction of 1.5 mm at the angle
of the labial- occlusal line, followed by a
1.0 mm-wide step is carried out to pro -
vide greater resistance to the restoration
( Figs 5 -10 to 5 -12). The axial walls should
be reduced by approximately 0.5 mm,

Fig 5- 10 Intact tooth (A). Final view of the preparation (B,C).

 .
Fig 5 - 12 Final view of the preparation. Occlusal view (A). Buccal view (B)

E x t r a c o r o n a l r e s t o, r a t i o n s 1173
V '
7/8 PARTIAL
CROWNS
7/ 8 partial crowns can be
indicated for both maxil-
lary and mandibular pre-
molars and molars. It is
a variation on the prep-
aration for a 4/ 5 partial
crown, and is indicated
when the mesial as-
pect of the mesiobuc -
cal cusp is intact, but
also for restored, frac-
tured or decalcified
.
teeth It is a conserva -
tive preparation, hav-
ing its initial indication
for the first molar, avoid-
ing a full-crown prepar-
ation. A 7/8 partial crown that
encompasses the buccal surface
of the preparation presents a greater re-
tention and stability than a 4/ 5 preparation,
hence it can be indicated for short crowns.7

Posterior
When preparing 7/8 partial crowns, attention should be paid to the achieve-
ment of occlusal reduction. This should provide a reduction of approximately
.
1.5 mm in the functional cusp To minimize the metal appearance, the angle
of the labial - occlusal line must be reduced by 0.5 mm, and the working cusp
.
by 1.0 mm The axial walls must be reduced by approximately 0.5 mm. The
grooves must be roughly 1.0 mm deep and have to be parallel to the middle of
.
the incisal third of the labial surface (Fig 5-13 B to D) Occasionally, the grooves
may be replaced by boxes, in the case of existing preparations or caries. The
occlusal groove follows the anatomy (inverted V-shape) and is 1.0-mm wide
(Fig 5 -13F and G).6
 -
Fig 5 13 Intact tooth (A). Pal-
atal reduction. Preparation of
the proximal groove, rounded
tapered bur (B,C).
 1 Chapter
05

Fig 5-13 Preparation of

the occlusal surface, flat
tapered bur (D). Bevel -
ing, flame- shaped dia-
mond bur (E). Final view
of the preparation (F,G).
FULL-CROWN PREPARATION
The full-crown preparation covers all aspects of the coronal portion of the
tooth and is used in many clinical situations. One of its main features relates to
its high retentive potential. Therefore, this preparation is largely indicated for
the rehabilitation of compromised teeth, abutments for fixed partial dentures
.
(FPDs), and teeth with short clinical crowns Malpositioned, rotated, extrud-
ed, and intruded teeth may also be corrected with a full-crown preparation
(Figs 5-14 to 5-17). This preparation is also indicated for esthetic reasons, when
a correction with less invasive preparations would not suffice.8 The greatest
limitation of the preparations for a full crown is the aggressive reduction of the
tooth structure.4

FULL-CONTOUR METAL CROWNS

Among all full-crown preparations, those for metal crowns are regarded as the
least aggressive. This is because the thickness of material required for a suit-
able mechanical behavior necessitates less volume reduction (Figs 5-18 and
.
5 -19) However, these restorations are considered to be less esthetic and are
used more often in posterior teeth. Since they require less reduction, they are
.
indicated for cases with reduced occlusal space They can be prepared with a
thickness of as little as 0.8 mm. They also comprise the preparation of grooves
.
as an alternative to aid in the insertion and retention of the restoration 7

Posterior teeth
The ideal occlusal reduction for a metal crown preparation varies from 1.0 to
1.5 mm. The functional cusps should be reduced by approximately 1.5 mm,
and make an angle of 45 degrees with the axial wall. The preparation should
end in a short chamfer, facilitating the seating and cementation of the crown.
The inclination of the axial walls should range between 6 and 12 degrees .
Grooves that aid retention can be prepared in cases where the crown has a
-
reduced occlusal height.6 7
 Chapter
05

Fig 5-14 Intact tooth (A). Occlu-

sal reduction, rounded tapered
bur (B),

V^
(
179
V
Fig 5-15 Cusp reduction (A). Buccal re-
duction, rounded tapered bur (B).
 Chapter
Fig 5-16 Palatal reduction.
Rounded tapered bur (A) . Fi
-
05
nal view of the preparation,
occlusal view (B).
 Chapter

05

L 1
Fl{| 5- 18 Prepara -
tion for a full metal
crown of a maxillary
molar ( tooth 17). Fi-
nal view of the prep-
aration (A,B).

( 183 V
 Chapter
05

Fig 5-19 Intact tooth ( A). Occlusal reduction (B) , Occlusal reduction (C). Beveling
.
of the supporting cusp ( D) Reduction of the buccal surface, tapered diamond bur
.
( E). Creation of the finish line, tapered diamond bur (F)

E x t r a c o r o n a l r e s t o r a t i o n s
Fig 5 -19 Orientation groove
the buccal surface (G). Finishing of
the termination line with a flame-
shaped diamond bur (H). Rnal view
of the preparation (IJ),
PORCELAIN FUSED TO
METAL CROWNS

These restorations are composed of

a metal infrastructure covered by
.
a ceramic superstructure For the
manufacturing of the metal infra-
structure, noble alloys such as high
gold alloys are the most appropriate,
to obtain optimal adaptation and
less oxidation. These restorations
possess the advantage of strength
and precise adaptation of the metal
infrastructure, combined with the es-
thetics provided by the ceramic. Their
limitation is that they need more re-
duction (1.2 to 2.0 mm) to bear the met-
al (0.3 to 1.0 mm) and the ceramic (0.8
.
to 1.5 mm) The presence of the metallic
collar generates a gray halo at the gingival
margin, which is a limitation of the tech-
-
nique.4'5 7

Anterior
When preparing for porcelain fused to metal
(PFM) crowns, attention should be paid to the
double inclination of the buccal wall, allowing
adequate space for the metal and ceramic lay-
.
er of the restoration (Fig 5-20B, C, and E) The
reduction in a single plane for parallel to the in-
sertion axis can result in insufficient space for
porcelain in the incisal third. The reduction in a
single plane for creating space for the ceramic
results in a very tapered preparation, and is very
close to the pulp in the incisal region. The reduction
should be approximately 1.2 mm on the buccal surface and 2.0 mm on the
incisal border for restorations with non-precious metal alloys (Figs 5 - 20D and
5 -21 F). Precious alloys require a slightly aggressive reduction. The incisal re-
.
duction should follow the 45-degree inclination (Fig 5-20D) A reduction of
0.7 mm in the lingual region is sufficient when the metal is not covered with
ceramic ( Figs 5 -20I to K, and 5-21 D). If the clinician chooses to cover the metal,
a reduction of approximately 1.4 mm is required. The preparation end should
.-- -
be a short chamfer, facilitating seating and cementation of the crown 1 2 4 7
Fig 5- 20 Intact tooth (A). Orientation groove for the reduc -
tion, following the inclination of the cervical, middle, and incisal
third of the buccal surface (B).

E x t r a c o r o n a l r e s t o, r a t i o n s
Fig 5- 20 Orientation groove for the reduction of the incisal border (C). Incisal reduction
(D). Union of the orientation line with a round-end diamond tapered bur ( E). Reduction of
the buccal surface with a round-end tapered diamond bur (F). Reduction of the proximal
surfaces with pointed tapered burs (G,H).

j
 li c
Fig 5-20 Cervical reduction of the palatal surface (I). Reduction of the proximal surface 0 ) .
Lingual reduction, using a pear-shaped diamond bur (K). Final view of the preparation (L).
 hg 5 - 21 Intact tooth ( A,B). Reduction of the buccal and pal
atal surface with a round-end tapered diamond bur with the
delimitation of the cervical finish line (C).

-
E x t r a c o r o n a l r e s t or a t i o n s
Fig 5- 21 Reduction of the palatal
surface with a pear - shaped diamond
bur (D). Beveling of the cen/ical finish
line with flame-shaped diamond bur
( E ). Incisal reduction ( F) . Final view of
the preparation (G - l).

( 197 )
V Ji'
Fig 5- 22 Intact tooth (A), ©sclusal
-eduction, rounded tapered bur ( B).
Reduction of the M and D proxiiml sur -
faces, rounded tapered bur (C).
 Chapter
05

Fig 5- 22 Cusp reduction (D). Reduction of the cusp and palatal side, rounded tapered bur.(E).'
Creating the bevel, flame-shaped diamond bur (F). Final view of the preparation (G-l). . i
E x t r a c o r o n a l r e s t o r a t i o n s
 Chapter
05

Fig 5- 23 Intact tooth (A ). Occlusal reduction ( B).

Reduction (bevel) of the functional cusp, tapered
diamond bur; slicing of the proximal surface with
a pointed tapered diamond bur (C). Greater reduc -
tion of the buccal surface with a tapered diamond
bur. Lingual reduction (D). Note the greater reduc-
tion on the buccal aspect to create space for the re-
storative material (E). Final view of the preparation

( 201 >
v yj
 T METAL-FREE FULL
O CROWNS
O Metal-free crowns have some
T specific characteristics. They
H provide the best esthetic results
when compared to other types
P of crowns.10 However, they re-
quire more reduction (2.0 to
R
2.5 mm) and rounding off of
E the preparation angles to avoid
P areas of stress concentration
A and consequent fracture of the
R ceramic.9 Each ceramic class
of the several ceramic mater-
A ials used in dentistry possesses
T specific mechanical and static
characteristics that guide the indi-
O cation.1'3
N
Anterior teeth
s When preparing for metal-free crowns
(Figs 5 -24 to 5 -26), attention should
be paid to the double inclination of the
buccal wall (Fig 5-24A), allowing adequate
space for the ceramic so as to enable ad-
equate strength. The reduction should be
r A approximately 2.0 mm on the buccal sur -
face (Fig 5 -24D) and 2.5 mm on the incisal
202
) border (Fig 5 -24C). Unlike other restorations,
the lingual and proximal surfaces take part
in the buccal reduction of 2.0 mm (Fig 5-24E
and F). The preparation end must be a deep
chamfer, providing strength and facilitating
the seating and cementation of the crown.2' 3
 Chapter

Fi[| 5-24 Intact tooth (A). Orientation grooves following

the three curvatures of the buccal surface, using a round-
ed tapered diamond bur (B),

Extracoronal r e s t o r a t i o n s
Fig 5- Z 4 Incisal reduction, union
of the orientation grooves, tapered
diamond bur (Q. Buccal incisal .ire-
.
duction (D) Union of the orientation
grooves, tapered diamond bur ® .
Reduction of the buccal surface,
Invading the proximal surfacesito-
ward the lingual (palatal) surface,
rounded tapered diamond bur (F).
Fig 5 - 24 Reduction of the
buccal surface, removing the
interproximal contact point
(G) . Complete reduction of the
proximal and lingual surfaces
(H). Reduction of the cervical
part of the lingual surface,
tapered diamond bur (I). Re
duction of the lingual surface,
pear -shaped diamond bur (J,K) ,
Final view of the preparation
( L,M). Final view of the prep -
aration with simulation of the
ceramic crown that will be de-
livered (N).
Fig 5- 25 Intact tooth (A, B). Reduction with a round-end tapered bur, formation of the ter -
mination line on the palatal surface, and a modified round-end tapered diamond bur for the
buccal surface (C). Reduction of the palatal surface with a pear-shaped diamond bur (D). Incisal
reduction of the buccal surface with a round-end tapered diamond bur (E). Incisal reduction (F).
Final view of the preparation (G-l).
 -
Fig 5 26 Intact tooth ( A). Reduc-
tion of the occlusal plane and the
functional cusp with a rounded ta -
pered bur (B). Axial reduction with a
rounded tapered bur (C).
550
T Posterior teeth
o With regard tometal-
ceramic crowns, when pre-
o paring metal- free crowns
T attention should be paid to
H the double inclination of the
buccal wall, allowing ade -
P quate space for the ceramic
so as to enable adequate
R strength ( Fig 5-27). The re-
E duction should be approxi-
P mately 2.0 mm on the buc-
A cal surface and 2.5 mm on
R the occlusal surface. Unlike
other restorations, the lin-
A gual and proximal surfac -
T es are involved in the 2.0-
mm buccal reduction. The
O preparation end must be a
N chamfer, providing strength
and facilitating seating
S and cementation of the
crown.3'9

Fig 5- 27 Intact tooth (A). Occlusal

reduction, using a rounded tapered
bur ( B,Q. Reduction of the interprox -
imal region, removing the contact
point, pointed tapered bur (D) ,
 1 ) 5 - 27 Reduction of the function-

al cusp ( E ) . Reduction of the buccal

surface with extension to the prox-
imal surfaces, tapered diamond
bur (F). Axial reduction (G). After
finishing the axial reduction (H).
REFERENCES
1. Chiche GJ, Pinaut A. Esthetics of Anterior Fixed Prostho- .
7 . Oliveira AA Understanding, Planning, Implementing: The
dontics. Tokyo: Quintessence, 1994. Universe of the Ceramic Restoration [in Portuguese],
2. Conceipo EN. Operative Dentistry: Health and Aesthetics, Nova Odessa: Napoleao, 2012.
ed 2 [in Portuguese] Porto Alegre : Artmed, 2007. 8. Shillingburg HT, Hobo S, Whitsett LD . fundamentals of
3. Douglas RD, Przybylska M . Predicting porcelain thick- Fixed Prosthodontics, ed 4 [ in Portuguese ] , Sao Paulo :
ness required for dental shade matches , J Prosthet Dent Quintessence, 2007.
1999:82:143-149. 9. Soares CJ, Martins LR, Fonseca RB, Correr -Sobrinho L,
4. Irfan A. Protocols for predictable aesthetic denial restor- Fernandes Neto AJ. Influence of cavity preparation design
ations. Oxford: 8lackwell Munksgaard, 2006. on fracture resistance of posterior leucite-reinforced ce-
5. Martignoni M, Schonenberg A. Precision in Fixed Pros- ramic restorations. J Prosthet Dent 2006:95:421 429.
-

thodontics. Tokyo: Quintessence, 1998. 10 . Vieira FLT, Silva CHV, Menezes Filho PF, Vieira CE . Dental
6. Mezzomo E, Suzuki RM . Contemporary Oral Rehabilita -
Aesthetics : Clinical Solutions [in Portuguese], Nova Odes-
tion [in Portuguese ], Sao Paulo : Santos, 2006 . sa : Napoleao, 2012 ,

Chapter
05
 CHAPTER G6

CONSERVATIVE
\ RA
MINIMALLY INVASIVE DENTISTRY
 *
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W NSEfTOlS

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W/y

INTRODUCTION
The search for excellence in the reestablishment of esthetics and function in
cases of rehabilitation led to the improvement and development of techniques
.
in the dental industry This ultimately fulfilled patients' needs for functional,
long-lasting restorations, and a beautiful and harmonious smile.1 11 -
Demand for lifelike, unnoticeable esthetic restorations requires painstaking
resources and knowledge from dental professionals in order to deal with the
complexity of the procedures involved in the reestablishment of function and
esthetics.2 With the growing trend toward ceramic-based, indirect restorative
materials, as well as the progress made in adhesive systems and the evolu-
tion of restorative materials, minimally invasive preparations have become a
reality.3
The underlying premise of minimally invasive preparations is maximal pres-
ervation of healthy tooth structure. Thus, the preparation will not follow geo-
metrical patterns, nor should it have boxes or retention grooves. Rather, it is
based on the minimum reduction required to provide sufficient thickness to
the restorative material to obtain the desired esthetics and function. An im-
portant feature of the preparation is to provide a form which facilitates the
proper insertion of the restoration.14'15 Minimally invasive preparations can be
distinguished from traditional preparations, especially with regard to retention
and form of resistance.36
A minimal amount of geometrical preparation is required to facilitate the in-
sertion and positioning of the restoration during the final cementation proced-
ure. Of secondary importance are the geometric and mechanical parameters
.
of a preparation This allows for the maximum preservation of the remaining
tissues and therefore a conservative approach (about a quarter of the amount
. -
of tooth reduction compared to a full-crown preparation) 13'37-40 43
A key objective in minimally invasive dentistry is to provide sufficient reduc-
tion of the tooth, since a restoration requires adequate thickness to provide me-
-
chanical strength to the material.41 42'44 Recommended thicknesses are about
0.3 to 0.5 mm for the cervical area, 0.7 mm in the middle and incisal thirds, and
.
a minimum of 1.5 mm for the incisal coverage 16 21 These values correspond to
the mean thickness of enamel.22 Accuracy in obtaining these dimensions is the
most difficult aspect of tissue reduction because these final thicknesses are
closely related to the final volume and shape of the restoration.16
Tooth reduction is guided by the shape, thickness,and position of the future
restoration. Therefore, it is of fundamental importance that the shape of the
future restoration is known prior to the completion of the preparation (Fig 6-1) .
Several techniques can be used to obtain the goal of tooth reduction,23 27 such
’

as a diagnostic wax -up followed by a restorative trial (mock-up) that indicates

.
the position of the future restoration 14 28-
Upon approval of the mock -up, the next step is the completion of the prepar -
ation. The amount of structure that needs to be reduced will be determined
by the selected restorative material and the relation between the shade of the
substrate and that of the final restoration. Darker substrates require greater
reduction to achieve the desired final result with lighter colors, always within
the limitations of each case.

Chapter
06

Fig 6-1 Simulation of an initial clinical situation (A). After the diagnostic wax -up on the model
( B). Ideal recontouring of the anatomy (C) .

C o n s e r v a t i v e p r e p a r a t i o n s
The diagnostic wax-up that represents the original tooth volume should be
used as a reference for the tooth preparation. This basic principle saves a sig-
nificant amount of healthy tissue; not only is the enamel preserved, but also
the dentinoenamel junction. The simplest and most important tool for enamel
reduction in this technique is a silicone guide made from the wax -up, which is
.
vertically or horizontally sectioned (Fig 6-2) 29 30 -

.
Tig ii - f Buccal reduction With -
out the aid of a mock-up (A). With
.
the aid of a silicone guide (B)
PREPARATION FOR VENEERS
Veneers are partial extracoronal restorations usually indicated for anterior es-
thetic rehabilitations. The main purpose of a veneer is to cover the labial-prox -
imal surfaces and potentially the incisal border of the anterior teeth in an at-
tempt to correct color discrepancies, shape, texture, function, and position of
the elements in the dental arch.4
Veneers in anterior teeth have existed in dentistry since the 1930s. This
technique was described by Pincus,5 who made temporary veneers for Holly-
wood actors and actresses to modify their smiles for filming and photo shoots.
However, they only began to be used in dentistry in the early 1980s, when in
-
1983 Simonsen and Calamia,41 and Calamia 6 7 described the porcelain etching
process, which solved the problem of the longevity of these restorations by
improving their adhesion to dental tissue.
The characteristic of minimal invasiveness in preparations for dental ve-
neers has become increasingly important due to the current focus in dentistry
on conservative procedures.
Veneers are indicated when a conservative solution is sought to resolve
.
esthetic problems 10 The main indications for veneers / laminates are:810
teeth with discoloration that are resistant to whitening procedures, unsatis-
factory shape or contours ( size or volume) requiring morphological changes, Chapter
closing diastemas, minor alignment corrections, restoration of defects in the
enamel, teeth with fluorosis, and teeth with small fractures and tooth defor -
06
mities.
The severity and extent of any of these factors require further evaluation,
which is instrumental in achieving the goals of treatment and recovering func-
tion and esthetics.
-
However, there are situations in which the use of veneers is less suitable:10 12
cases with reduced interocclusal space, presence of deep bite with slight over -
jet, bruxism, parafunctional habits, severe dental crowding, periodontal dis-

l
ease, and teeth with extensive restorations that are indicated for a total crown.
There are several preparation designs for ceramic veneers,31 which vary ac-
cording to the extent of the preparation (Table 6-1) .
The use of different preparation techniques is dependent on several fac -
tors: amount of remaining tooth structure, presence of previous restorations,
length of the clinical crown, and presence of endodontic treatment.
Different clinical studies have evaluated the long-term behavior of teeth
.
restored with ceramic veneers, using several preparation designs 32-35 These
studies have concluded that ceramic veneers are a good restorative option.
Survival and success rates of over 80% for these restorations have been re -
ported.5

C o n s e r v a t i v e p r e p a r a t i o n s
Table 6-1 Types of conservative preparations, extension, and labial and proximal views
 CONVENTIONAL CONVENTIONAL EXTENDED PREPARATION
PREPARATION WITH PREPARATION WITH
INCISAL COVERAGE PALATAL/LINGUAL
CHAMFER

mu
Preservation of the preservation of the proximal Removal of the proximal
proximal contacts with contacts with coverage of contacts with coverage of
coverage of the incisal the incisal border, creating a the incisal border until the
border palatal/lingual chamfer middle third

Chapter
06
PREPARATION FOR
VENEERS
The continuing evolution of bonding pro-
cesses to dental structures makes possible
the implementation of more conservative
restorative techniques and enables the use
of minimally invasive preparations (Figs 6-3
to 6- 8). In teeth with slight or no discolor -
ation, for example, ceramic veneers with
thicknesses ranging from 0.3 to 0.7 mm may
be used 33.
Based on this philosophy, extremely thin
ceramic veneers (0.1 to 0.7 mm) emerged,
requiring minimal tooth reduction that is
limited to merely smoothing sharp angles
and eliminating undercuts. Teeth indicated
to receive this type of restoration usual-
ly have favorable characteristics such as a
good insertion axis and adequate space for
.
the restoration These preparations have
very specific indications, where reshaping or
correction of tooth volume is necessary by
adding material .
It should be noted that ceramic veneers
are of limited use in situations requiring ma-
jor correction.

Fig 6-3 Preparation of the central incisor without

involvement of the incisal edge. Intact tooth (A).
Orientation grooves on the labial surface, with a ta-
pered diamond bur following the inclination of the
incisal, middle, and cervical thirds (B). Labial reduc -
tion (C).
 Chapter
06

Fig 6- 3 Labial axial reductions (D). Proximal axial reductions (E). Final preparation from the
labial aspect (F). Final preparation from the proximal aspect (G).

C o n s e r v a t i v e p r e p a r a t i o n s
Fig 6- 4 Preparation of the central incisor with in-
volvement of the Incisal edge. Intact tooth (A). Orien-
tation grooves on the labial surface, with a tapered
diamond bur following the inclination of the Incisal,
middle, and cervical thirds (B). Incisal reduction (C ).
Fig 6- 4 Reduction of the labial surface, using a tapered diamond bur (D,E ). Axial and proximal
reduction of the labial surface (F,G).
f

Fig 6- 4 M and D proximal

incisal reduction (H). Palatal
incisal reduction In the shape
of a concave chamfer (I ).
Chapter
06
Fit) 6-6 Preparation of the canine
without involving the incisal edge In-
tact tooth (A,B). Axial, Incisal, and prox-
imal aspects of the preparation of the
labial surface with a rounded tapered
diamond bur (C,D). Final aspect of the
preparation, from the frontal, prox -
imal, and incisal views (E-G).

C o n s e r v a t i v e
L

*
p r e p a r a t i o n s
J

1241
^ 'J '*
Fig 6-7 Preparation of the canine with involvement of the incisal edge. Intact tooth (A, B). Labial
reduction with a rounded tapered diamond bur (C,D).
 Chapter
06

Fig 6-7 Incisal reduction (E-H),

/
 -
Fig 6 8 Intact tooth (A) . Labial orientation grooves, using a rounded bur (B). Labial reduction
in several planes, using a rounded diamond bur (C F).-
 Fig 6- 8 Oblique ( 6) and buccal ( H) views of the finished prepar -
ation.

C o n s e r v a t i v e p r e p a r a t i o n s
REFERENCES

1 . Andrade OS, Lobo M . Ultra - thin and conventional ce- 14. Ferrari M, Patroni S, Bailed P. Measurement of enamel
ramic laminates: ultraconservative approach for ceramic thickness in relation to reduction for etched laminate
restorations [ in Portuguese ] In : Callegari A, Chediek W veneers. Int J Periodontics Restorative Dent 1992;12:
( eds). Focus on Specialty : Beauty of the Smile , Nova 407- 413.
Odessa: Napoleao, 2014: 58-91. 15. Garber DA, Goldstein RE, Feinman RA, Porcelain laminate
Belser UC, Magne P, Magne M. Ceramic laminate ve- veneers. Chicago: Quintessence, 1988.
neers : continuous evolution of Indications . ) Esthet Dent 16. Gresnigt M, Ozcan M . Esthetic rehabilitation of anterior
1997;9:197-207 . teeth with porcelain laminates and sectional veneers,
.
3. Bispo LB . Aesthetic veneers : state of the art Revista J Can Dent Assoc 2011;77:b143.
.
Dentistica 2009;8:11-14. http://coral.ufsm br /dentisti- 17. Gresnigt MM, Kalk W, Ozcan M. Randomized clinical trial
caonline /0810.pdf . Accessed 1 January 2015. of indirect resin composite and ceramic veneers: up to
4. Bottino MA, Valandro LF, Faria R. Perceplion. Sao Paulo: 3-year follow-up. JAdhes Dent 2013;15:181-190 .
Artes Medicas, 2009 . 18 . Guess PC, Stappert CF. Midterm results of a 5-year
y Burke FJ, Lucarotti PS. Ten-year outcome of porcelain prospective clinical investigation of extended ceramic
laminate veneers placed within the general denial ser- veneers. Dent Mater 2008;24: 804-813.
vices in England and Wales. J Dent 2009;37 : 31-38.* 19 . Gurel G. The Science and Art of Porcelain Laminate
6. Calamia JR . Etched porcelain facial veneers: a new treat- Veneers . Chicago : Quintessence, 2003 .
ment modality based on scientific and clinical evidence. 20. High ton R, Caputo AA, MatyasJ. A photoelastic study of
NYJ Dent 1983;53: 255-259. stresses on porcelain laminate preparations . J Prosthet
7. Calamia JR . Etched porcelain veneers: the current state of Dent 1987;58:157 161.
-

the art. Quintessence Int 1985;16 : 5-12. 21. Kina S, Bruguera A . Invisible: ceramic restorations ed 2.
,

8. Calamita MA, Coachman NS, Sesma N. Tooth prepar- Maringa : Dental Press, 2008.
ations and impressions in today's restorative practice. 22. Kina 5, Ferreira AG. Ceramic laminates [ in Portuguese ] ,
What do we need to know? [in Portuguese] In : Calle- In: Fonseca AS (ed). Cosmetic dentistry: the art of perfec-
gari A, Chediek W ( eds ) . Focus on Specially: Beauty of tion. Sao Paulo : Artes Medicas, 2008:159 198 .
-

the Smile. Nova Odessa : Napoleao, 2014:244 287.

-
23 . Layton D, Walton T. An up to 16 year prospective study
-

9. Cherukara GP, Seymour KG, Samarawickrama DY, Zoti L. of 304 porcelain veneers. Int J Prosthodont 2007;20:
A study into the variations in the labial reduction of teeth 389 396 .
-

prepared to receive porcelain veneers - a comparison 24. Lehner CR, Margolin MD, Scharer P. Crown and laminate
of three clinical techniques. Br Dentf 2002;192:401 -404; preparations . Standard preparations for esthetic ceram -

discussion 392. ic crowns and ceramic veneers [in French, German].

10. Cherukara GP, Seymour KG, Zou L, Samarawickrama DY. Schweiz Monatsschr Zahnmed 1995;105 :1560 1575.-

Geographic distribution of porcelain veneer preparation 25 . Magne P, Belser U . Bonded Porcelain Restorations in
depth with various clinical techniques. J Prosthet Dent the Anlerior Dentition: A Biomimetic Approach. Chicago:
2003;89:544-550. Quintessence, 2002.
11. Christensen GJ, Christensen RP. Clinical observations 26 . Magne P, Belser UC . Novel porcelain laminate prepar-
of porcelain veneers : a three-year report. J Esthet Dent ation approach driven by a diagnostic mock -up , J Esthet
1991;3:174-179. Restor Dent 2004;16 : 7 16; discussion 17 18.
- -

12. Clavijo V, Bocabella L, Kabbach W , Ceramic restorations 27. Magne P, Kwon KR, Belser UC, Hodges JS, Douglas WH.
with minimal tooth preparation: Ullra - thin veneers [ in Crack propensity of porcelain laminate veneers : A sim -

Portuguese], In: Callegari A, Dias RB ( eds). Focus on .

ulated operatory evaluation J Prosthet Dent 1999;81:
Specialty: Beauty of the Smile, Nova Odessa: Napoleao, 327-334.
2013 : 22-65 .
28. Magne P, Magne M. Use of additive waxup and direct in-
13. Edelhoff D, Sorensen JA . Tooth structure removal associ- traoral mock up for enamel preservation with porcelain
-

ated with various preparation designs for anterior teeth. laminate veneers. EurJ Esthet Dent 2006;1:10-19.
J Prosthet Dent 2002;87: 503-509 .
29 . Magne P, Versluis A, Douglas WH. Effect of luting com- 36. Pires LCM. Ultra -thin veneers: laminates and ceramic
posite shrinkage and thermal loads on the stress distri- fragments [in Portuguese], ed 2. Nossa Odessa: Na-
bution in porcelain laminate veneers. J Prosthet Dent poleao, 2015.
1999;81:335-344. 37. Radz GM. Minimum thickness anterior porcelain restor-
30. Marson FC, Kina 5. Aesthetic restoration with ceram -
ations. Dent Clin North Am 2011;55:353-370.
ic laminates [in Portuguese] , Rev Dental Press Estet 38. Scopin de Andrade 0, Borges G, Stefani A, Fujiy F, Ba-
2010;7:76-86. tistella P. A step-by- step ultraconservative esthetic reha-
31. Napoleao A, Rodrigues T. Clinical cases: restaura oes bilitation using lithium disilicate ceramic. Quintessence
^
adesivas ceramicas: uma visao clinica: lentes de contato, Dent Technol 2010;33:114-131.
fragmentos, facetas e coroas, Nova Odessa: Napoleao, 39. Scopin de Andrade 0, Kina S, Hirata R- Concepts for an
2014. ultraconservative approach to indirect anlerior restor-
.
32 Nocchi E, Silva FB, Pereira junior JCD. Laminados e ations. Quintessence Dent Technol 2011:34:103-119,
"lentes de contato" de porcelana: o elo entre biologia e .
40 Scopin de Andrade O, Romanini JC, Hirata R. Ultimate
estetica. In: Miyasliila E, Oliveira GG ( eds) . Odonlologia Ceramic Veneers: a Laboratoiy Guided Ultraconservative
Estetica: os desafi os da clinica diaria. Nova Odessa: Na - Preparation Concept for Maximum Enamel Preservation.
poleao, 2014:268-293. Quintessence Dent Technol 2012;34:29-43.
33 . Pagani C, Rocha DM, Saavedra GSFA, Carvalho RF. Pre - 41. Simonsen RJ, CalamiaJR.Tensile bond strengths of etched
visibilidade e estetica : a utiliza ao do ensaio restaurador porcelain [abstract 1099]. J Dent Res 1983;62:297.
^
( Mock-up ) na construct) da beleza do sorriso , In: Calle - 42. Smales R], Etemadi S. Survival ol ceramic onlays placed
gari A, Dias RB ( eds ). Especialidade em foco: beleza do with and without metal reinforcement. J Prosthet Dent
sorriso. Nova Odessa : Napoleao, 2013 : 114-145 , 2004;91:548-553.
34. Pincus CL. Building mouth personality. California: Califor - 43. Strassler HE. Minimally invasive porcelain veneers: indica-
nia Slate Dental Association, 1937. tions for a conservative esthetic dentistry treatment modal-
35. Pini NP, Aguiar FH, Lima DA, Lovadino JR, Terada RS, ity. Gen Dent 2007;55:686 694; quiz 695-696, 712.
-

Pascotto RC. Advances in dental veneers: materials, 44. Weinberg LA. Tooth preparation for porcelain laminates ,
applications, and techniques . Clin Cosmet Investig Dent NY Slate Dent ] 1989;55:25-28.
2012;4:9-16.
OF EN DODONTICALLY
COMPROMISED TEETH

1 1
ENDODONTICALLY
COMPROMISED TEETH
The Indication of post -and- core res -
torations is mainly associated with
the form of retention and resistance
requirements of the abutment / pros-
thetic preparation.21'22 One of the
criteria for the indication of restor -
ations is the level of coronal destruc -
tion when maneuvers are necessary
to reinforce and protect the tooth
remnant structure.23 The extensive
coronal destruction and the amount
of remaining tooth tissue are limiting
factors for the proper accomplish-
ment of intracoronal or extracoronal
preparations (Fig 7-1 ).
In such cases, it becomes neces -
sary to use a post to recover the ana -
tomical characteristics in order to fa -
vor the retention of the restoration
biomechanically.24 The approach is
determined by the presence or ab -
sence of pulp vitality and the degree
of coronal destruction.17
However, placing an intraradicu-
lar post does not increase the frac -
ture resistance.6 A number of re -
searchers have shown that posts do
not reinforce the tooth structure, but
in fact weaken it.13'19 Ideally, a post
should minimize the tooth stresses
by distributing occlusal loads evenly,
and should be easy to remove if root
canal retreatment is needed. More -
over, its modulus of elasticity must
be similar to that of dentin to avoid
root fracture.1 The more tooth struc -
ture that is preserved, the higher the
fracture toughness will be, regard-
less of the post system used.18
 -
Fig 7 1 Dental elements with extensive coronal destruction lack sufficient remaining tooth structure for
.
the retention of the restoration Molar (A). Central incisor (B).

P r e p a r a t i o n o f e n d o d o, n t i c a l l y c o m p r o m i s e d t e e t h
MANAGEMENT OF VITAL TEETH

A frequent doubt that arises when planning a restorative prosthetic treatment

is the management of teeth with pulp vitality. There are situations where it is
indispensable to carry out an endodontic treatment to create the best condi-
tions for prosthetic rehabilitation. However, in cases where the coronal tooth
structure is favorable, more conservative procedures are preferred over end-
odontic treatment.
For the complete evaluation and planning of indirect restorations in de-
cayed teeth, some modifications may be necessary; therefore, it is essential
to initially evaluate the pulp vitality and periodontal conditions. If there is any
doubt regarding the pulp condition, endodontic treatment should be indicated
prior to the rehabilitation process.4 The periodontal tissues should be evalu-
ated for the presence of fractures with subgingival extension or previous res-
torations that invade the biological width, which may require surgery prior to
restorative procedures.9' 15
Defective restorations should be removed, since there might be carious le-
sions or even small pulpal exposures. Undermined surfaces and unsupported
enamel regions should be avoided, which may all be removed and/or blocked
out to promote an adequate form of retention and contour, and ultimately
greater resistance of the remaining walls.
A basic rule for decision-making is the analysis of the remaining amount of
tissue. If this is approximately half the height of the coronal tooth structure, a
core buildup material or additional means of retention is necessary, such as
parapulpar pins. In situations where the remaining tooth is found to be insuf-
ficient to retain the restoration, the tooth should be treated endodontically,
followed by the placement of an intraradicular post.17

MANAGEMENT OF DEVITALIZED TEETH

If the coronary destruction impairs a core buildup, intraradicular posts are indi-
cated. In endodontically treated teeth, various types of intraradicular posts may
be indicated: prefabricated (metal and esthetic) posts or cast metal posts (Fig 7-2).
Cast metal posts were considered the best type of intraradicular posts for
a long time, especially with regard to their adaptation to the root canal, since
they were customized for each tooth. The search for prefabricated posts in-
tensified with the development of new materials. This was combined with the
evolution of adhesive systems.
The advantages of metal-free prefabricated posts, of which there are sever -
al types, are less tooth structure wear and better adhesion to dentin through
the use of adhesive resin cements. Among the prefabricated posts, fiber-re -
inforced (carbon and glass) posts have gained popularity because they have
properties similar to the dentin struc -
ture, especially the modulus of elastici -
ty, which allows for a better distribution
of occlusal forces to the tooth remnant .
Prospective clinical and in vitro stud -

ies have emphasized their advantages

compared to cast metal posts and pre -
fabricated metal posts.7'11'12'25 When es-
thetics is paramount, prefabricated pins,
particularly glass fiber ones, have great-
er applicability than metal posts.17
Although cast metal cores were once
one of the main alternatives for the res-
toration of endodontically treated teeth,
they have several limitations: chairside
time, cost, and loss of weakened tooth
structure. Furthermore, due to their high
modulus compared to dentin, the major
part of the received stresses is trans -
ferred to the root.17
One of the techniques suitable for fill- Chapter
ing flared canals is the individualization
of the post. The root canal is molded
07
using composite resin associated with a
prefabricated fiber post. This technique
extends the indication of prefabricated
IS
im
posts, reducing the amount of cement Its
reti
that would be needed to fill the space be- rt j)
‘
tween the post and the dental structure. M
The individualization of the post allows
I) <»
for a good adaptation to the root canal,
forming a thin uniform layer of resin ce-
ment, creating favorable conditions for
the retention of the post.

Fig 7- 2 Cast dowel ( A). Prefabricated threaded

metal post (B). Ceramic dowel ( C). Prefabricated
carbon fiber post (D). Prefabricated glass fiber
post (E )

Preparation of endodontically compromised teeth < 2S5 ) I

V
PREPARATION OF THE CROWN REMNANT

The preparation of the coronal structure must precede the intraradicular prep-
aration. At this stage, any pre-existing restorations, carious lesions, and un-
dermined hard tissues are removed, thus maximally preserving the remaining
tooth structure (Fig 7 - 3).

1
 w
Fig 7-3 Preparation sequence of a root remnant (A -J).

^toJ
i
7 »
i
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i
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Chapter
i
i A
07
1
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i
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® T

Preparation of endodontically compromised tee

T INTRARADICULAR PREPARATION
0
Four factors need to be analyzed in order to provide adequate retention for
0 the post to be fabricated: root canal length, inclination of the walls, diameter,
T .
and surface characteristics 17
H .
The ideal length of a post is extensively discussed in the literature 17'23 As
a general rule, the post should present two thirds of the total length of the
P remaining structure. However, for teeth that exhibit bone resorption, the post
length must be at least half of the supporting bone (Fig 7-4). I
R
E
P
A
R I
A ''

* t
T t
o
N
if ^ i
s

m i

iU
A
Li
!
M
%

7
' IM i
£

k
wm
mtm fm
m
 Fig 7 - 4Ideal dimensions of an In- 1
traradicular post: two thirds of the
remaining root ( A). Post space prep -
aration with half of the height of the
.
osseous insertion (B) Post space
preparation with the same length
as the prosthetic crown (C ).

umi
Fig 7-5 Preparation of the root canal in
length. Short (A). Ideal (B). Long (C).

In general, the post should take advantage of the maximum length available
without invading the apical sealing of 4.0 mm of gutta-percha, so as not to in-
.
terfere with the apical sealing of the root canal The retention and stress distri-
.
bution are directly proportional to the length of the post 5 However, the shape
of the roots and the root canal system are important factors to be considered,
as shortened or curved roots often do not allow for adequate post length, re-
sulting in a less predictable outcome.10
The length of the pin inside the root canal is ex-
tremely important to ensure longevity of the treat-
ment, since stresses distributed evenly through-
out the root surface reduce the risk of fracture
(Fig 7 -5).17 It has been established that the greater
the length of the post, the greater the retention
will be. However, when adhesive techniques are
used, any further preparation of the tooth struc -
ture should be avoided, thus minimizing the inter-

-
vention and preserving healthy structures.3 20 21
'
Fig 7-6 Preparation and flaring of the root
canal (A,B). Walls with excessive conver -
gence induce a wedge effect (C).
•A ~ s
'
^

Chapter
07

During flaring of the preparation, the clinician

should pay attention to the correct inclination
of the root canal walls. The increased inclination
of the walls may lead to decreased retention
and a less favorable distribution of tension, re-
sulting in a wedge effect (Fig 7-6).17'23
Special attention should be paid to the conformity of the preparation. The
preparation for cast metal posts should follow the root anatomy, with care be-
ing taken to create an oval rather than a circular shape. This prevents rotation
of the dowel, which reduces the chance of fracture (Figs 7-7 and 7-8).

Fig 7-7 Preparation of the canal must fol-

low the root anatomy. Inadequate prepar-
ation (A) . Adequate preparation (B).
 Chapter
07

1
Fig 7-8 Occlusal view of the canal preparation. Inadequate preparation (circular) (A). Adequate
preparation (oval) (B).

P r e p a r a t i o n o f e n d o d o, n t i c a l l y c o m p r o m i s e d t e e t h
Prefabricated posts can have different designs with respect to the inclination
of the canal walls (Fig 7 - 9). According to the literature, double- tapered posts
exhibit better stress distribution and therefore better mechanical behavior.14

/
f
/
/
/
/
/

Fig 7- 9 Root canals pre -

pared for different types of
prefabricated posts. Cylin-
drical (A). Double-tapered
(B). Tapered (C).
In addition to the inclination of the walls,
another aspect to be analyzed during
preparation is the diameter of the root
canal after preparation, which should
match the root post. This should have
a diameter that provides sufficient me -
chanical resistance in order to withstand
the masticatory loads transmitted to the
restoration without weakening the re-
maining root. The ideal diameter of the
post should not exceed one third of the
root diameter (Fig 7-10).17'23

Fig 7-10 Ideal preparation for a root post ( A).

Post with insufficient diameter increases the
risk of post fracture (B). Post with excessive
diameter leads to weakening of the remaining
tooth, increasing the risk of root fracture (C).
SEQUENCE FOR POST
SPACE PREPARATION
Heated endodontic pluggers may be used
to start root canal preparation in order to
remove the filling material (gutta-percha ),
which should ideally be removed entirely
with heated instruments, although this is
not always possible due to technical dif-
.
ficulties Peeso reamers, Largo or Gates
Glidden burs can be used to aid this re -
moval. To select which burs to use, their
diameter and length should be compared
with the periapical radiograph (Fig 7-11 ).17

Fig 7-11 Instruments used for the re -

moval of gutta -percha from the root
canal and for post space preparation,.
Contra -angle ( A ) , Low - speed micromo -
. .
tor ( B) Carbide bur #170 (C) Endodon-
tic pluggers ( D F).
-
 —
rr
v
-\

Chapter
07
 f I
A A

§|
A A

I
 Fig 7-11 Set of Peeso reamers, and
Largo or Gates Glidden burs (G -l). II
Endodontic pluggers and operatory
.
sequence (J -M)
Chapter
07

Preparation of endodontically co
Fig 7-12 Prefabricated glass fiber ' <
h
post system and the respective ''
;
burs for post space preparation
(A,B) Prefabricated threaded met -
al post system and its respective
Proper selection of the bur diameter to be used for post space preparation is
.
crucial to ensure the most conservative treatment This step applies to both
.
cast metal posts and prefabricated posts A radiograph is used to guide the
selection of the most suitable drill, with a diameter compatible to the tooth
.
being prepared ( Fig 7-13) 17.23

rhanter

-
Fig 7 13 Representative diagram ot a radiograph showing the selection of the most appro
priate bur diameter for cast metal posts and prefabricated posts
 i
;

Fig 7-14 Silicone stop adapted to the neck of

a Largo bur, serving as a depth guide for the
post space preparation (A,B).

To avoid excessive removal of the filling material, a reference point must be set
to indicate the measurement of the length that will be used for the post / dowel
space preparation. In order to mark the length determined by the initial mea-
surement, a silicone stop can be placed on the neck of the bur, which functions
as a depth guide (Fig 7-14).
 1 fgm iarJ *

jt
-
The orifice of the canal is then wid-
ened using burs in increasing diam-
eters . There is an alternative meth-
od described in the literature for the
preparation of the remaining root to
receive a metal cast post, which in- Chapter
volves the use of a #170 L bur for the
preparation of a groove at the en -
07
trance of the root canal. This groove,
 T
O
O
T
H
Fig 7 - 16 Prepared tooth. Esthetic
post ( A) Metal post ( B).
P
R
E
P
A
R
A
T
I
O
N
S

r A
276
)
After post space preparation,
the treatment should continue
according to the type of post se -
lected (Fig 7-16).
Split or segmented post and
cores are an alternative for cast
metal root posts in multirooted
teeth. They are more frequent-
ly used in teeth with divergent
roots, and the procedure may
be carried out in different ways
(Fig 7-17) 23
 B

Chapter
07

w, p 1

L
\

[Fig 7-17 Post space preparation in

multirooted tooth. Dovetail (A). In-
.
clined plane (B). Bolt (C)

P r e p a r a t i o n of e n d o d o n t i c a l l y c o m p r o m i s e d t e e t h I
\J
f 277
^
'
 PREPARATION OF TEETH WITH REDUCED
PERIODONTAL INSERTION
The presence of a biofilm is a fundamental factor for the development of major
diseases affecting the oral cavity, ie, dental caries and periodontal disease .
In periodontally compromised teeth, some adjustments must be performed
during the planning stage to improve the final biomechanics of the restorative
treatment. Typically, the preparation design, in particular the cervical finish line
of the preparations, requires modifications in cases of compromised root due
to loss of bone support or changes of the bone and/or gingival architecture .
The design and positioning of the finish line strongly influence the ultimate
success of the restoration.2
The extension of carious lesions and the amount of remaining tooth struc -
ture in relation to the periodontal ligament determine the placement of the
.
restoration margins Ideally, the finish line should be located in enamel, prefer-
ably away from the gingival sulcus. However, in situations where there is a loss
of bone support, migration of the gingival tissue toward the apical direction
.
takes place This is also known as gingival recession, and leads to suboptimal
positioning of the finish line (Fig 7-18).

f
' • :

r v ' •-• T
*
*
4
•f
TF9&M ^
-
Fig 7 18 Gingival recession: I
loss of bone support leading
to the apical migration of the
*
gingival tissue (A-D).
Gingival recession is defined by the American Academy of Periodontology (MP)
as an apical displacement of the marginal gingiva toward the cementoenamel
junction, causing various problems that compromise the patient's health and
esthetics.
The main factors that can lead to the development of gingival recession,
whether localized or generalized, are:
• Abrasion due to traumatic toothbrushing;8.26
• Frena and muscle insertions located near the gingival margin;16
• Malpositioning of the teeth (proclination causing bone dehiscence);27
• Decreased thickness of the keratinized mucosa;16
• Iatrogenic factors related to restorative treatment/rehabilitation;27
• Mechanical injuries (nail biting, removable partial denture (RPD) clasps, tooth-
picks);16.27
• Presence of biofilm.27

The areas of root exposure from periodontal disease are characterized by the
presence of surfaces with depressions, undercut areas, and areas with furca-
.
tion exposure that contribute to biofilm retention In such cases, the prepar-
ation of a full crown can protect the exposed root region, which is more sensi-
.
tive to pain and caries development 28
Chapter
07

.i
%
ft
o; I
v‘ a

Preparation of endodontically compromised teeth

 T CHANGES IN PLANNING FOR THE. PREPARATION OF
0 TEETH WITH REDUCED PERIODONTAL ATTACHMENT
o Teeth with a loss of periodontal attachment have long clinical crowns and con
T -
.
sequent exposure of the root portion It is known that the root portions of
the
H teeth are gradually tapered toward the apical aspect. Thus, the more apical the
location of the finish line of the preparation becomes, the narrower the thick
-
P .
ness of the dental tissue to be prepared (Fig 7-19) Therefore, the restoration
type to be indicated and, consequently, the design of the termination line are
R
E
very important .
Preparations which require greater reduction, such as those for porcelain
P fused to metal and metal-free restorations, require approximately 2 mm
of
A thickness near the termination lines for the material. This is less suitable for
R periodontally compromised teeth. Preparations that remove a greater amount
of tooth structure have a greater risk of pulp injury and may even lead to
A pulp
exposure and the need for endodontic treatment.23
T
r
O
N
S i

(g)
k

r "N
280
)

©
Fig 7- 19 The root anatomy is
increasingly tapered toward the
apical aspect.
REFERENCES
1. Akkayan B. An in vitro study evaluating the effect of 14. Morgano 5M. Restoration of pulpless teeth: application
ferrule length on fracture resistance of endodontically of traditional principles in present and future contexts.
treated teeth restored with fiber-reinforced and zirco- J Prosthet Dent 1996;75:375-380.
.
nia dowel systems J Prosthet Dent 2004;92:155-162. 15. Muniz L, Mathias P, Teixeira ML, et al. Aesthetic rehabili-
2. Carranza FA, Newman MG, Takei HH, Klokkevold PR, Car- tation in endodontically treated teeth. Sao Paulo: Santos,
ranza FA. Clinical Periodontology, ed 10 [in Portuguese], 2010.
Rio de Janeiro: Elsevier, 2007. 16 . Murrin JR, Barkmeier WW. Restoration of mutilated pos-
3. Chuang 5F, Yaman P, Herrero A, Dennison JB, Chang CH. terior teeth: periodontal, restorative, and endodontic
Influence of post material and length on endodontical- considerations. Oper Dent 1981;6:90-94.
ly treated incisors: an in vitro and finite element study. 17. Nevins M, Mellonig JT. Periodontal Therapy: Clinical
J Prosthet Dent 2010;104:379-388. Approaches and Evidence of Success. Chicago: Quintes-
4. Dilts WE. Pulpal considerations with fixed prosthodon- sence, 1998.
tic procedures. Quintessence Int Dent Dig 1982;13: 18. Pegoraro LF, Valle AL, Araujo CRP, Bonfante G, Conti PCR,
1287 1294.
-
Bonachela V. Fixed Prosthodontics [in Portuguese], Sao
5. Fernandes AS, Dessai GS. Factors affecting the fracture Paulo: Artes Medicas, 2004.
resistance of post-core reconstructed teeth: a review. 19. Pontius O, Nathanson D, Giordano R, Schilder H,
IntJ Prosthodont 2001;14:355-363. HutterJW. Survival rate and fracture strength of inci-
6 . Goodacre CJ, Spolnik KJ. The prosthodontic management sors restored with different post and core systems and
of endodontically treated teeth: a literature review. Part I. endodontically treated incisors without coronoradicular
Success and failure data, treatment concepts. J Prostho- reinforcement. J Endod 2002;28:710-715.
dont 1994;3:243-250. 20. Robbins JW, Earnest LA, Schumann SD. Fracture resistance of
7. Ho YC, Lai YL, Chou IC, Yang SF, Lee SY. Effects of light endodontically- treated cuspids. Am J Dent 1993;6:159-161.
attenuation by fibre posts on polymerization of a dual 21. Santos-Filho PC, Castro CG, Silva GR, Campos RE, Soares Chapter
cured resin cement and microleakage of post-restored CJ. Effects of post system and length on the strain and
teeth. J Dent 2011:39 : 309-315 , .
fracture resistance of root filled bovine teeth Int Endod J 07
8. Ingber JS, Rose LF, Coslet JG. The "biologic width" - a 2008;41:493-501 ,
concept in periodontics and restorative dentistry. Alpha 22. Scotti R, Ferrari M , Fiber posts: theoretical considerations
Omegan 1977;70:62-65. and clinical applications [original in Italian, Portuguese
9. Jung SH, Min KS, Chang HS, Park SD, Kwon SN, BaeJM. version], Sao Paulo: Artes Medicas, 2003 ,
Microleakage and fracture patterns of teeth restored with 23. Scotti R, Valandro LF, Galhano GA, Baldissara P,
different posts under dynamic loading. J Prosthet Dent Bottino MA. Effect of post length on the fatigue resistance
2007;98:270-276 , of bovine teeth restored with bonded fiber posts: a pilot
10. Khocht A, Simon G, Person P, Denepitiya JL. Gingival study. IntJ Prosthodont 2006;19:504-506.
recession in relation to history of hard toothbrush use . 24. Shillingburg Jr HT, Hobo S, Whitsett LD, Jacobi R,
J Periodontol 1993;64:900-905. Brackett SE , Fundamentals of Fixed Prosthodontics [in
11. Lertchirakarn V, Palamara JE, Messer HH. Finite element Portuguese ]. Sao Paulo: Quintessence, 2007.
analysis and strain-gauge studies of vertical root fracture. 25. Sorensen JA, Engelman MJ . Ferrule design and fracture
J Endod 2003;29:529-534. resistance of endodontically treated teeth.J Prosthet Dent
12. Makade CS, Meshram GK, Warhadpande M, Patil PG , 1990;63:529-536.
A comparative evaluation of fracture resistance of end- 26 . Vehkalahti M. Occurrence of gingival recession in adults.
odontically treated teeth restored with different post J Periodontol 1989;60:599-603.
core systems - an in-vitro study. J Adv Prosthodont 27. Vieira FLT, Silva CHV, Menezes Filho PF, Vieira CE. Dental Aes-
2011;3:90-95 . thetics: Clinical Solutions. Nova Odessa: Napoleao, 2012.
13 . Massa F, Dias C, Bios CE. Resistance to fracture of man- 28. WennstromJL. Lack of association between width of attached
dibular premolars restored using post-and- core systems. gingiva and development of soft tissue recession. A 5-year
Quintessence Int 2010;41:49—57. longitudinal study] Clin Periodontol 1987;14:181-184.

Preparation of endodontically compromised teeth

Dental preparations for indirect restorations are not only dependent on the
material selected for the restoration, but also on the manufacturing method.
Several current ceramic restorations are fabricated using computer-aided
.
design / computer - aided manufacturing (CAD/CAM) CAM steps involve using
prefabricated ceramic blocks, from which the final restoration is milled us-
.
ing a subtractive method The milling machine has one or more automated
diamond burs that remove excess ceramic material from the block, resulting
in a final monolithic restoration.
Diamond burs are available in various shapes and sizes, hence they have a
direct influence on the geometry of the inner surface to be milled. If the prep -
aration presents sharp and narrow areas, these areas may not be properly
milled, since the diameter of the diamond bur may be greater than the more
critical areas of the preparation, resulting in thin lateral walls or the perfor-
ation of the restoration during the machining process. Especially acute areas
of the cavosurface margin are milled poorly, which can result in a larger space
between the restoration and the preparation (marginal gap).10 These diamond
burs are not designed to mill 90- degree angles, so all interior angles of the
.
preparations should be smooth (Figs 8-1 and 8-2) Otherwise, these areas will
probably impede the complete seating of the final restoration 1 .
The selection of restorative ceramic to be used will also directly influence the
geometry of the preparation, particularly with respect to the reduction need-
ed to ensure the restoration's ultimate strength. Glass-ceramics are brittle in
nature and are prone to fracture if their thickness is insufficient. Polycrystal-
line ceramics tend to be more resistant in reduced thicknesses compared to
.
glass-ceramics, and therefore do not require extensive tooth reduction Ceram-
ic restorations must be seated passively to avoid the concentration of stress
points on the inner surface of the restoration, which would result in fracture of
.
the restoration Therefore, all internal angles must be continuous and smooth.9
Most ceramic CAD/CAM restorations are cemented with an adhesive tech-
.
nique Adhesive retention by means of resin cement requires specific charac -
teristics of the preparation compared to preparations for metal restorations,
which in turn possess retentive characteristics due to their mechanical nature.
The availability of a larger surface area, especially in enamel, is essential for
bonding ceramic restorations. Therefore, preference is given to maintaining
the cavosurface margin completely in enamel in order to maximize adhesive
.
retention 4 The use of purely mechanical retention preparation methods, such
as sharp line angles and highly defined preparations, would result in compen -
satory internal rounding during the machining process, resulting in a greater
thickness of cement instead of improvement in the final retention of the res-
toration .
Fig 8-1 Milling of a ceramic block (A,B).

Fig 8-2 Rounded characteristics of the preparation for a ceramic restoration.

BASIC PRINCIPLES FOR THE PREPARATION OF MILLED
ADHESIVE INLAY AND ONLAY RESTORATIONS
Inlays and onlays usually have an occlu-
sal isthmus. The width of the isthmus is
usually determined by the extent of the
carious lesion or the size of the defective
restoration to be replaced. The occlusal
isthmus should be at least 2.0 mm in
both the buccolingual and mesiodistal
directions in order to provide resistance
to the ceramic restoration .
The contour of the occlusal portion
Fig 8-3 Mesial view of an inlay in place. of inlay or onlay restorations must have
Note the slight divergence of the prox- soft curves and rounded transitions ex-
.
imal boxes to the occlusal aspect
tending laterally, starting from the cen-
tral portion of the preparation. 1 Angulated preparations with sharp lines are
not milled appropriately and, therefore, will eventually result in incomplete
adaptation of the restoration, and cracks in the occlusal cavosurface margin .
The cavity walls of the occlusal isthmus, as well as the proximal boxes of
metal restorations, should diverge by at least 6 to 8 degrees in the occlusal
direction ( Fig 8 -3) to ensure adequate mechanical retention.8 In contrast, the
preparations for milled adhesive restorations must have a more pronounced
degree of divergence, from 12 to 15 degrees, so that they can be properly
.
milled, and also to ensure the passive fit of the restoration 6 The walls must
be smooth and without irregularities to ensure the perfect adaptation of the
ceramic restoration to the tooth.9
.
The cavosurface margins must be clear and well defined (Fig 8-4) Well-de-
fined margins are necessary for the proper identification of the cavosurface
finish line during the design of the restoration in the CAD software. The margin
should not have bevels or rounded edges, as these characteristics make it dif-
ficult to precisely mill the margin .
Proximal boxes are often used in larger inlay and onlay restorations, when
there is decay in the interproximal area, or when the existing faulty restor -
ation extends to these areas. Similarly, the vertical walls of the proximal boxes
should diverge from 12 to 15 degrees in the occlusal direction and should not
have retentive areas. The cavosurface angle of the occlusal box floor should
be smooth and well defined. The angle between the floor and the walls of the
proximal boxes should be smooth and rounded to enable adequate milling of
the ceramic box.1
m
nn
K§
Chapter

08

nn
Fig 8- 4 Characteristics of an inlay and onlay preparation (A-H).

M i l l e d a d h e s i v e r e s t o r a t i o n s
m
Fig 8-5 External angles of proximal boxes (A,B).

The external angles of the walls of the proximal boxes should be about 90 de-
grees to ensure sufficient thickness of the ceramic at the proximal margin (Fig
.
8-5) There is a risk that more acute external angles may lead to a thin, sharp
edge in ceramic, which is more prone to fracture during the try-in or cemen-
.
tation of the restoration Bevels should be avoided at the cavosurface margin
of proximal boxes because they result in fine ceramic areas that are prone to
fracture .
The prerequisites for the occlusal reduction for an onlay adhesive resto-
ration of machined ceramics are based on the type of ceramic that is selected
for the preparation of the restoration. In general, most restorative ceramics
require 1.5 mm of reduction in the occlusal central fossa, and 2.0 mm over the
.
cusps (Fig 8-6) 6 It is not necessary to extend the preparation in the cervical di-
rection beyond the dimensions of the defect that needs to be restored in order
to maximize the surface area available for adhesive bonding.12
Fig 8- 6 Minimal occlusal reduction and width of the proximal boxes.

<2 mm

> 1.5 mm

> 2 mm
Placement of the buccal margin in the middle third of the tooth can result in a
visible enamel - ceramic junction. Margins of 90 degrees are not preferred for
optimal esthetic results. To improve the esthetic transition from the margin,
a 45-degree rounding should be made directly on the cavosurface margin us-
ing a pear -shaped diamond bur (Fig 8 - 7).5 This type of margin finish line also
provides a superior overall adaptation of the restoration when compared to
margins that end in a 90- degree angle.
Mechanical retention should be avoided in adhesive milled restorations.12
The retention must be obtained from the adhesive cementation to the tooth,
and should not be related to the height of the walls or divergence angle of the
preparation. Preparations for restorations with a more intricate internal geom-
etry result in a more complex milling path and increase the risk of poor internal
adaptation of the ceramic restoration (Fig 8-8).

Chapter

08

Fig 8- 7 45 - degree finish of the cavosurface margin (A,B).

Fig 8- 8 Internal geometry of an onlay preparation (A,B) ,

CROWN PREPARATIONS
Occlusal and axial reductions for adhe-
sive ceramic milled restorations depend
directly on the ceramic material to be
used, regardless of the machining pro-
cess. Polycrystalline ceramic crowns
(zirconia) require less occlusal and axial
reduction compared to glass-ceramic
crowns. The minimum occlusal reduc-
tion recommended for glass-ceramics is
1.5 mm in the central fossa, and about
Fig 8- 9 Minimum recommended occlu- 2.0 mm at the cusps. The axial reduction
' sal. reduction. should be at least 1.2 mm, and the cervi-
cal-incisal divergence angle should not exceed 12 to 15 degrees (Fig 8-9).
The occlusal reduction of a full-crown preparation should also have round-
ed contours to avoid angulated areas over the cusps. Rounded occlusal surfac-
es lead to better adaptation of the restoration because the internal geometry
of the crown is reproduced with greater precision during milling 3 .
Ideally designed margins should provide sufficient thickness of the ceram-
ic at the restoration margin, have adequate axial reduction, and have round-
ed internal line and point angles to ensure sufficient resistance to the ceramic
.
and marginal fit Therefore, preparations that end in a shoulder or chamfer with

90-degree Deep chamfer

shoulder

I Bl Bl
Knife-edge Beveled chamfer Straight chamfer

G 1s I
Fig 8-10 Types of finish lines ( A- F) .
s I
rounded internal angles provide
good results (Fig 8-10).8
Marginal finish lines that do
not provide sufficient ceramic
thickness of the preparation in
the margin area should be avoid-
ed because they increase the
risk of fractures at the margin.7
However, it is important to note
that chamfer margins can create
the risk of a "gutter -like" margin
(Fig 8-11 A). This may occur be-
cause rounded, tapered diamond
burs are preferentially used for
this type of preparation. Only half
of the diameter of this diamond
bur is used to create a cham-
fer -shaped geometry. When a cy-
lindrical, small-diameter diamond
bur is used, more than half of the
diameter of the bur is needed to Chapter
create an axial reduction of at
least 1.2 mm. As a result, a "ditch"
08
will be created in the cervical mar-
gin, and this must be removed to
ensure the integrity and precision
of the crown margin.10
The ideal location for the gin-
gival margin is atthe equigingival
or supragingival level in order to
make the adhesive cementation
more predictable. Subgingival
margins can also be used;11 how-
ever, the degree of subgingival
extension is directly related to
the possibility of adequate iso -
lation of the margin for adhesive
cementation, and not necessarily
to the milling of the crown.2

Fig 8-11 Groove created at the cervi-

cal margin (A). Juxtagingival preparation
(B). Supragingival preparation (C).
PREPARATIONS FOR ENDODONTICALLY
TREATED TEETH
Posterior teeth require full coverage of the
jHF cusps after an endodontic procedure due
to their increased risk of cusp fracture.
B / \ Conventional treatments require the cre -
jt I / II ation of a core buildup or cast metal core
11,1/ I m to replace part of the root filling material.
B/ \B The core should then be prepared to re -
B ceive a full crown. A feasible alternative to
the conventional core-and- crown system
may be a combination of CAD/ CAM restor -
B
^
flB A
'
A
§0
ation and adhesive retention. These prep -
arations are known as endocrowns or en-
do -onlays (Fig 8-12).
The retentive adhesion is created by
resinous cement between the ceramic res-
toration and the inner walls of the pulp
chamber . Extending the preparation of
the cervical margin in order to match or
exceed the height of the pulp chamber
does not offer any retentive advantage
(Fig 8 -13). The complexity of this geometry
hampers the precise milling of the restor -
ation, resulting in poor internal adaptation

n
and a wider cement line under the crown.5

A R Fig 8-12 Intraradicular crown (A). Conventional

B crown over core buildup (B). Intraradicular onlay (C).
* W
,
Ihanter

Fig 8-13 Geometry ot an intraradicular preoaratio

REFERENCES
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-

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12. Yatani H, Watanabe EK, Kaneshima T, Yamashita A,
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Tooth Preparations: Science & Art by Prof. Clovis Pagani and co-authors
is a fully illustrated guide on tooth preparations, a fundamental part of
daily dental practice. It contains essential theory and sound practice, in-
cluding more than 700 high-quality 3D images. The most current con-
cepts on tooth preparations for indirect restorations are covered, with
a focus on biological care, preservation in operative procedure, and pre-
cision. The book is divided into eight chapters, covering topics such as
restorative planning; state-of-the-art principles, sequences, and tools for
preparations; intra - and extracoronal restorations; compromised teeth;
adhesive milled restorations; minimally invasive preparations; and prep -
arations for CAD/CAM restorations. This book provides a clear and objec-
tive outline of different conservative preparation designs indicated for a
variety of clinical situations and is an indispensable addition to the collec -
tion of all restorative dentists.

ISBN 978-1-78698-001-4

9781786980014
.
www quintpub.co.uk