Hal 26.

Elective soft tissue surgery may include alteration of muscle attachment, removal pf a wedge of
soft tissue distal to the molars, increase of the vestibular depth, or modification of edentulous
ridges to accommodate fixed or removable partial prostheses (Fig. 6-2).

HARD TISSUE PROCEDURES

Simple tooth removal is the most common surgical procedure involving hard tissue. It should be
performed as early during treatment as possible for maximum healing time and osseous
recontouring.

Tuberosity reduction (Fig. 6-3) is also common, especially when there is inadequate
space to accommodate is prosthesis. Although maxillaru or mandibular tori (Fig. 6-4) seldom
interfere with the fabrication of a fixed partial denture, their excision may make it easier to
design a removable partial denture and occasionally will improve access for oral hygiene
measures.

Impacted or unerupted supernumerary teeth should be removed if damage to adjacent

structures can be avoided.

ORTHOGNATHIC SURGERY

Candidates for orthognathic surgery require careful restorative evaluation and attention before
treatment. Otherwise, an expected improvement in the facial skeleton may be accompanied by
unexpected occlusal dysfunction. After surgery, the connection between plaque control, caries
prevention, and periodontal health should be stressed to the patient.

IMPLANT-SUPPORTED FIXED PROSTHESES.

Successful implant dentistry requires meticulous selection of the patient and skillful
execution of the chosen technique. A team approach to treatment is strongly recommended with
close cooperation between the specialties (see Chapter 13).

Fig. 6-2. A to D, Soft tissue surgery to correct an

unfavorable edentulous ridge before FPD fabrication.
 Fig. 6-3. Tuberosity reduction was indicated for this patienr to
accommodate a mandibular removable partial denture. A,
preoperative and, B, postoperative appearances (Courtesy Dr. J.
Bergamini)

Hal 27.
 Fig. 6-4. A, mandibulae torus requiring surgical reduction before
the fabrication of an RPD. B, Buccal torus that was interfering
with oral hygiene.

CARIES AND EXISTING RESTORATOINS

Crowns and fixed partial dentures are definitive restorations. They are time-consuming
and expensive treatment options and should not be recommended unless an extended lifetime of
the restorations is anticipated. Often, teeth requiring crowns are severely damaged or have large
existing restorations. Any restorations on such teeth must be carefully ecamined and a
determination made regarding its serviccability. If doubt exists, rhe restorations should be
replaced. Time spent replacing an existing restorations that in retrospect might have been
serviccable is a modest price to pay for the assurance that the foundation will be caries free and
well restored. Studies have shown that accurately detecting caries beneath a restoration without
its complete removal can be very difficult. Even on caries-free teeth, an existing, restoration may
not be a suitable foundation. Preparation design is different for a foundation than for a
conventional restoration, particularly regarding the placement of retention. Generally, when a
crown is needed, the dentist should plan to replace any existing restorations. Although most teeth
will require foundation restorations, small defects resulting from less extensive lesions can often
be incorporated in the design of a cast restoration or can be blocked out with cement (Fig. 6-5).
The latter is recommended on axial walls where an undercut would otherwise result. If a small
defect is present on the occlusal surface, however, it may be better to incorporated it into the
final restoration than to block it out. The difficulty, of course, is anticipating this during the
preparatory phase of treatment. Assessment is more difficult when an existing crown or FPD is
being replaced. Then the extent of damage can be seen only after the defective restoration has
been removed.

FONDATION RESTORATIONS

A foundation restoration, or core, is used to build a damaged tooth to ideal anatomic form
before it is prepared for a crown. With extensive treatment plas, the foundation may have to
serve for an extended time. It should provide the patient with adequate function and should be
contoured and finished to facilitate accurate occlusal and can be prepared essentially as if it were
intact. Guide grooves can be used to facilitate accurate occlusal and axial reduction ( see Chapter
8), and the preparation design will be consistent from tooth to tooth. The skills learned preparing
preclinical manikins with “ideal” teeth can be readily transferred to clinical practice.

Fig. 6-5. Small defects (arrows) that would create

undercuts are best blocked out intraorally with cement
or resin.

SELECTION CRITERIA

Selection of the foundation material depends on the extent of tooth destruction, the
overall treatment plan, and operator preference (Fig. 6-6). The effect of subsequent tooth
preparation for the cast restoration on the retention and resistance of the foundation should be
considered. Retention features such as grooves or pinholes should be placed sufficiently pulpal to
allow adequate room for thr definitive restoration. Adhesive retention may be helpful in
preventing loss of the foundation during tooth preparation.

Dental amalgam. Despite its limitations, amalgam is still the material of choice for most
foundation restorations on posterior teeth. It has good resistance to microleakage and is therefore
recommended when the crown preparation will not extend more than 1 m beyond the foundation-
tooth junction. It can be shaped to ideal restoration form and serves well as an interim. It has
better strength than the glass ionomers, and retention can be provided by undercuts, pins, or
slots. Adhesive bonding system such as those based on

Hal 28
 4-META are also available and may reduce leakage of the restoration. Additional
retention may be provided with the use of polymeric beads supplied with the amalgambond
system. Amalgam requires an absolutely rigid matrix for proper condensation. Otherwise the
foundation will break. Matrix placement can be demanding when restoring a tooth with little
remaining coronal tissue. This is discussed in the step-by-step procedure on p. 140. Amalgam has
a longer setting time than the other foundation materials. This normally delays crown preparation
to a subsequent patient visit. When this present a problem, a rapid-setting, high-copper, spherical
alloy should be chosen. These can be prepared for a crown about 30 minutes after placement.
Spherical amalgams are advantageous for foundation restoretions because they have greater early
strength than admixed materials, which makes fracture soon after placement less of a problem.

Fig. 6-6. The placement of a foundation restoration depends on the extent of damage to
the tooth and should always be designed with the definitive restoration in mind. A, Cement. This
is suitable when damage is minimal. B, amalgam. C, pin-retained amalgam. D, Cast gold. E,
Post-and-core. (see Chapter 12.)

Glass Ionomer Cement. This is a suitable choice for a small lesion. The material sets
rapidly, enabling crown preparation to be performed with limited delay. When placed correctly, it
exhibits adhesion to dentin, although conventional undercat retention is needed to supplement
this. Glass ionomer designed for use as a core or base are radiopaque; restoration formulations
are more radiolucent than dentin and should not be used as a core, because their radiographic
appearance may suggest recurrent caries. The presence of fluoride in glass ionomers may help
prevent recurrent caries. The chief disadvantage of glass ionomers is their coparatively low
strength, although newer formulation have improved properties. At this time, glass ionomers are
inferior to amalgam or composite resin for the restoration of extensive lesions.

Composite Resin. Composite resin exhibits many of the advantages of glass ionomers. It
does not require condensation and set rapidly. Formulations are available that release fluoride,
which may provide an anticariogenic benefit. Bonding is achieved with a dentinal bonding agent
or by etching a glass ionomer liner. Neither method develops the bond strength needed to
withstand high masticatory forces, and conventional undercut retention is also needed. There are
concerns about continued polymerization of the resin and its high thermal expansion coefficient,
which may lead to microleakage of the crown. Also of concern is the moisture sorption
properties of composite resin that causes delayed expansion and may lead to axial binding of
crowns made on composite resin cores. Delayed expansion is not a problem with the resin-
ionomer hybrids and the compomer materials. Conventional tooth-colored composite resin is not
recommended as a foundation material, because it is difficult to discern the composite-tooth
junction. Special colored materials should be used.

Pin-retained cast Metal Core. A cast metal core should be considered for an extensively
damaged tooth. The cemented foundation is retained by tapered pins. The preparation requires
careful location and placement of the pinholes but otherwise is straightforward. The foundation
is fabricated in the laboratory as an indirect procedure. This increase the complexity and expense
of treatment but facilities obtaining good preparation.

Hal 29.

Advantages and disadvantages of the available materials are summarized in Table 6-1.
Foundation Restoration Materials

Advantages Disadvantages Recommended Precautions

Use
Good Strength Preparation delay Most foundation Well-supported
Amalgam Intermediate Condensation matrix
restoration Corrosion
No bonding*
Rapid setting Low strength Smaller lesions Moisture control
Glass ionomer Adhesion Moisture
fluoride sensitive +

Rapid setting Thermal Smaller lesions Moisture control

Composite resin Ease of use expansion Anterior teeth
bonding Setting
contraction
Delayed
expansion
Highest strength Two-visit Extensive lesions Alignment of
Cast Gold Indirect procedure pinholes
procedures Provisional
needed

STEP-BY-STEP PROCEDURES.

Amalgam Core (Fig. 6-7).

1. Isolate the tooth. Rubber dam isolation is strongly recommended for moisture
control, infection control, and optimum visibility. Placement follows techniques
developed for conventional amalgam restorations, although with extensively
damaged teeth, placing the dam can be a problem. Spmetimes cotton roll isolation
must suffice.
2. Design the tooth preparationwith the intended cast restoration in mind. Be sure
that the cast restoration does not eliminate retention of the foundation. The
preparation will differ somewhat from a conventional amalgam restoration. The
ensuing discussion highlights these differences.
3. Limit the extent of the outline form. In contrast to conventional amalgam
preparations, which are extended to include unsupported enamel and the deep
occlusal fissures, a less extensive outline is recommended for foundation
restoration, because the fissures and contacts are removed during crown
preparation. Although minimizing foundation outline can help conserve
 supporting tooth structure, the foundation should be adequate for the detection of
any carious lesions (Fig 6-7, A).
4. Retain unsupported enamel if convenient. For a conventional amalgam
restorations, unsupported enamel must always be re moved; otherwise, the enamel
may fracture during function and leave a deficient margin. However, for a
foundation restoration, the unsupported enamel may be preserved most effectively
if it is substantial enough to withstand condensation forces and if it can be
determined whether the enamel-dentin junction is caries free. Preserving
unsupported enamel may facilitate matrix placement and improve amalgam
condensation (Fig. 6-7, B).
5. Finish the carvosurface margins. For conventional amalgam restoration,
carvosurface margins of 90 degrees are needed to minimize the potential for
fracturing the enamel and amalgam during function. However, for foundation
restoration, the amalgam-tooth interface will not be subjected to high stresses
(they are protected by the crown), and marginal fracture is not likely to be a
problem. Therefore, a 46- to 136-degree margin is acceptable. Furthermore, such
a margin will conserve useful tooth substance and improve condensation (Fig. 6-
7, C).
6. Remove any carious dentin carefully and thoroughly with a hand excavator or
large round bur in a low speed handpiece. Discolored but hard dentin can be left
on the pulpa wall, but caries-affected areas at the enamel-dentin junction should
be removed completely. If a pulp exposure occurs during the preparation, whether
carious or mechanical, endodontocs or tooth removal will be necessary. A direct
pulp cap is not a good choice for a tooth requiring an FPD; however, if
endodontics is elected and the pulp cannot be extirpated immediately, a suitable
sedative dressing should be placed.
7. Create optimum resistance form. Good resistance to masticatory forces is as
critical for a foundation as for a conventional restoration. Whenever possible, the
tooth preparation should be perpendicular to the occlusal forces. If a slopping
axial wall exist, it should be modified into a series of steps to enhance