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J Am Dent Assoc, Vol 131, No 12, 1742-1749.
© 2000 American Dental Association
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SPECIALTIES

PROSTHODONTICS: ACHIEVING QUALITY ESTHETIC DENTISTRY AND INTEGRATED COMPREHENSIVE CARE



KENNETH A. MALAMENT, D.D.S., M.SC.D.


   ABSTRACT
TOP
 ABSTRACT
ADVANCES IN PROSTHODONTICS
 CONCEPTS USED IN BUILDING...
 CONCLUSION
 REFERENCES
 
Background. Prosthodontics is the dental specialty responsible for diagnosis, rehabilitation and maintenance of patients with complex clinical conditions involving missing or deficient teeth and/or craniofacial tissues. The essence of the specialty is expert treatment planning.

Overview/Literature Reviewed. In recent years, new approaches and technology have been introduced as a result of research performed in universities and by industry. The field of prosthodontics continues to evolve owing to a better understanding of the biology of the oral cavity and the introduction of new techniques and improved biomaterials. Improvements in periodontal and oral surgical techniques, implant procedures and materials, esthetic restorative materials, and jaw tracking recorders and articulators have led to enhanced functional and esthetic oral and maxillofacial prostheses.

Conclusions and Clinical Implications. The complexities of today’s technical and clinical procedures and the higher expectations for more esthetically pleasing dentistry by the general patient population have placed a premium on teamwork involving general dentists, specialists and dental technicians.

Prosthodontics is one of the oldest of the nine specialties recognized by the American Dental Association; the American Board of Prosthodontics was established in 1947. It is the dental specialty responsible for diagnosis, rehabilitation and maintenance of patients with complex clinical conditions involving missing or deficient teeth, craniofacial tissues or both, and for providing treatment via the use of biocompatible substitutes such as implants. The essence of the specialty, however, is expert treatment planning.

Prosthodontists have developed and popularized most restorative techniques, including esthetic dentistry, implant dentistry, materials science and occlusal management and have served in the academic, research, military and hospital communities.1–42 It is interesting to note that within the last decade, the majority of prosthodontists have chosen full- or part-time private practice.43 The specialty follows standards regulated by the ADA emphasizing comprehensive care in areas of fixed, removable and maxillofacial prosthodontics. In addition, the American College of Prosthodontists, or ACP, has developed the Classification System for Complete Edentulism44,45 to guide practitioners and students in assessing objective diagnostic criteria that will assist in treatment recommendations and referrals. This diagnostic system enables the dentist to evaluate the severity of edentulism using a scale that ranges from 1 (least difficult) to 4 (most difficult). It allows dentists to recommend treatment scenarios appropriate for an individual patient’s diagnostic level. The ACP is developing other areas in prosthodontic classification as well.


   ADVANCES IN PROSTHODONTICS
TOP
 ABSTRACT
 ADVANCES IN PROSTHODONTICS
CONCEPTS USED IN BUILDING...
 CONCLUSION
 REFERENCES
 
A team approach. The practice of prosthodontics has evolved from a somewhat formulaic procedural beginning to a biologically based standard of treatment that recognizes the importance of a multidisciplinary approach to patient care. The generation of a successful resolution for a patient’s problems depends on a prosthesis that restores esthetics, form and function. This results from the integration of the skill and knowledge of general dentists, prosthodontists, other dental and medical specialists, oral biologists, material scientists and industry. The practice of dentistry as a whole and of prosthodontics in particular has changed dramatically in the last two decades. The most significant changes in the practice and teachings of prosthodontics46 result from the continued advances made in implant therapies, esthetic and adhesive dentistry, and material science and dental technology, as well as in periodontics and maxillofacial surgery. All of these improvements have made dentistry significantly more complex. In the hands of practitioners with advanced training who can render expert decisions, this complexity translates into more treatment options that lead to better function and esthetics.

Periodontics. Classic periodontal treatment47–49 in conjunction with prosthodontic treatment (Figure 1Go) has improved during the past 20 years, allowing the retention of teeth (as abutments) that in the past would have been sacrificed. In addition, periodontics has developed better methods to control periodontal infection.50,51



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  		Figure 1. A. A patient in need of a complete reconstruction because of worn restorations, periodontal disease and caries. B. Supportive therapy as completed by a periodontist, an oral surgeon, an endodontist and a dental technician, using metal-ceramic and all-ceramic restorations.

 
Maxillofacial surgery. Maxillofacial surgery has improved grafting procedures for bone and soft tissue in all areas of the mouth. Surgical grafting and alveolar distraction osteogenesis52,53—a process that splits bone and uses forces to slowly separate it, resulting in the growth of new bone—have facilitated better and more esthetic implant placement as well as improved soft-tissue defects. As a result, yesterday’s long-span fixed bridge often is today’s combination of single restorations and implant prostheses.

Implant dentistry. Implant dentistry has improved the quality of life for countless patients54,55 (Figures 2Go and 3Go). Prosthodontists have been influential leaders in implant research and design, and their work has led to restoration treatment (whether involving a single tooth or a complete dentition) that is wholly different from that of the past. Important research continues in the field of tissue engineering that may lead to the replacement of missing oral and facial structures, which permits implant and prosthesis placement in previously deficient sites.56,57 Technology for computer-assisted design/computer-assisted manufacturing is being explored as an aid in the development of hard and soft tissue that might contain implants to retain extraoral and intraoral prostheses.58 Dental implants have been especially important for patients needing maxillofacial treatment.2 Implants today can securely retain extraoral prostheses for orbital, auricular and nasal areas of the face, as well as larger areas of the face. They can retain prostheses to repair defects caused by clefts, facial deformities, tumors and trauma. Implant therapy has advanced to allow immediate loading with a provisional prosthesis in certain conditions.59,60



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  		Figure 2. A patient with a severely resorbed edentulous mandibular ridge that provided limited support for a complete denture. An oral surgeon placed bone grafts and then osseointegrated implants at the site.

 


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  		Figure 3. A metal-ceramic implant prosthesis that includes gingival ceramics.

 
In complex treatment and in higher-risk surgical placement, screw-retained and retrievable implant prosthetic designs are advantageous. Prosthodontists have developed different fixed-implant abutments, such as those fabricated of high-strength ceramics,61 to realize more esthetic anterior and single-tooth therapeutic results. Thus, prosthodontics has become more complicated, and the specialty has responded by working more efficiently through teamwork 3 with other dental specialists, including dental technicians, for treatment planning and therapy. Dentists not trained extensively in comprehensive care and the complexities of implant and advanced treatment can make errors that can be costly. Prosthodontists are trained to resolve these difficult problems, and so general dentists and other specialists may want to consult them about potential referral.46

Ceramic materials. Fixed prosthodontic restorations predominate in the practice of dentistry today.62–64 Dental materials for fixed prosthodontics continue to improve in strength, marginal accuracy and color. Ceramics are long-lasting, esthetically pleasing materials widely available in improved all-ceramic and metal-ceramic systems. The interest in all-ceramic materials grew out of the desire to eliminate the metal substructure and the need for greater translucency to correct potential negative color properties of metal-ceramic restorations. While esthetically pleasing, all-ceramic materials are useful primarily as individual restorations,4–27 some may have potential for use in small-span cantilever or three-unit anterior fixed bridges. Generally, they are not as strong as metal-ceramic materials. Nevertheless, the fracture rate of all-ceramic materials28–36 should decrease owing to recognition of the influence of tooth position and the core material (dentin or core substitute) to which the restoration is luted as determinants of survival. In addition, the continuing development of improved dentin bonding and luting agents65–80 should help to minimize fractures.

Research and development in all-ceramic materials will continue because of their esthetic excellence and utility in simple restorations such as veneers, inlays, dowel cores and crowns. Advances are being made in the development of "metal-free dentistry," but as of today, such materials are not without problems. Compared with more traditional materials, heat-processed and layered resin-based composite restorations have poorer margins81,82 and higher wear rates,83,84 exhibit microleakage37 and are chemically degradable.37 Few clinical survival studies have been conducted to warrant the use of these new-generation esthetic materials in large or complex single-tooth restorations.

Metal-ceramic materials38 continue to be dentistry’s state of the art. They can be used in any situation, in a single-unit restoration or in the most complex complete fixed or implant prosthesis, provided that there is enough space to ensure that the prosthesis will have the strength necessary to withstand dental forces. Metal-ceramic technique is continuing to advance with the incorporation of different lower-fusing feldspathic and glass-ceramic materials85 (Figure 4Go). A problem in the traditional metal-ceramic design was the poor esthetic effects of metal visibly underlying ceramics at the margin. Practitioners continued to use this technique because of the belief that metal provided the best marginal seal.86 However, prosthodontists developed a technique that provided better esthetic results without compromising marginal accuracy.87–93 This was done by cutting back the metal from the margin area and up the axial wall to permit an increased zone of a 360-degree buccal ceramic shoulder. This technique has proved beneficial in areas in which esthetics are a major concern, but using it requires increased skill on the part of the dental technician. A crucial treatment goal is to create a prosthesis that, after removal of pathology, will restore form and function and protect the tooth against breakage. Ceramics meet these stand ards in most conditions, yet one must bear in mind (if for nothing more than a standard of reference) that the most time-tested and successful dental material and the continued standard of care for the posterior restoration is gold.



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  		Figure 4. A. A patient with a skeletal abnormality, anterior open bite, worn and unesthetic fixed bridge. She experienced pain, in part because she had full molar disclusion. B. The patient after treatment by an orthodontist and oral surgeon who completed orthognathic surgery to restore normal arch integrity and occlusion. Her maxillary anterior teeth were rehabilitated with a metal-glass ceramic bridge to restore her occlusion and esthetic profile.

 

   CONCEPTS USED IN BUILDING A SUCCESSFUL PROSTHESIS
TOP
 ABSTRACT
 ADVANCES IN PROSTHODONTICS
 CONCEPTS USED IN BUILDING...
CONCLUSION
 REFERENCES
 
The use of quality materials alone does not guarantee a superior dental prosthesis that will be long-lasting. The solutions to esthetic and functional problems depend in large part on the education and talent of the prosthodontist/dental technician team. There are many steps in building a successful prosthesis, and the temptation to combine or omit any of them should be resisted.

Practitioners must realize that the esthetic resolution in fixed prosthodontics is determined not only by color, but also by anatomy. Teeth have both three-dimensional (form) and two-dimensional (silhouette) properties.39,94 The nature of the gingival framing or dark spaces around teeth affects their symmetry. In addition, the esthetic appearance of teeth is controlled more by form, surface texture and the emergence profile than by color. This underscores the importance of the following steps in preparing prostheses.

Use of diagnostic predictors. An accurately mounted diagnostic cast can be prepared and a diagnostic wax-up made to reestablish proper arch form, occlusal plane and functional form, tooth contours and esthetics. Preparing a diagnostic cast is an essential step, because the cast can be used as a blueprint both for the provisional, surgical stage of treatment and for the final restoration.

Prosthodontists helped to develop and encourage the use of dental photography, computer imaging, computerized tomographic scanning, digital radiography and computer design as well as volumetric bone-imaging techniques. These diagnostic procedures are helpful in developing treatment plans that recognize the patient’s esthetic needs, even when the problems are simple. Treatment waxing—placing tooth-colored wax95 in the mouth to aid in modeling the projected prosthesis—can demonstrate three-dimensional problems that both the prosthodontist and the technician will face and need to resolve. Furthermore, the diagnostic wax-up can be helpful as a teaching model. The patient can better understand potential problems by seeing them and discussing them with the practitioner. The information can be shared with the technician, and any necessary alterations can easily be made.

Tooth preparation. A strong, well-fitting and esthetically pleasing dental restoration absolutely requires proper tooth preparation. Preparation length, width, tapering, resistance form and marginal design are physical factors important to a long-lasting prosthesis. The development of the adhesive technique and improvements in materials science have led us to reexamine preparation design for different conditions.96,97 Shoulder or chamfer preparations are advocated for use with ceramic materials.98 A minimal reduction of 1.4 millimeters commonly is recommended for any type of dental ceramic except in veneer procedures. If the practitioner lutes all-ceramic restorations principally to enamel, he or she can reduce veneer, partial-coverage and full-coverage restorations by 0.3 mm to 0.5 mm. Ceramic restorations should be physically strong, and their color should be developed by layering or stratification methods. The development and use of electrically driven high-speed or air-driven, slower-speed, high-torque handpieces and microscopes allow the prosthodontist to develop better preparation anatomy with more ease.

Creation of master dies. The new generations of polyvinyl siloxane and poly-ether impression materials produce accurate, stable dental impressions, which can be poured many times to produce accurate stone casts.99 Because they are more stable than earlier-generation materials, they do not have to be poured immediately. Previous die systems used plaster bases, which—because setting plaster has unpredictable expansion properties—could experience dimensional distortion. Newer master die systems use indexed plastic resin bases100 that have better die positional accuracy and stability. Therefore, when a die is sectioned off a master cast, its relation to the original cast is less likely to be compromised. Unfortunately, many variables, including the expansion properties of impression materials or setting stone, still have the potential to distort the positional accuracy of a sectioned master cast. Try-in procedures for fixed-bridge procedures should not be omitted until further improvements are made in pin and individual die stability.

Making intraoral records. These records, made by the dentist, consist of centric-relation, facebow (arbitrary or kinematic) and pantographic tracings. A pantographic record can be used to record excursive mandibular movements.41,101 Research has brought to dentistry electronic computerized pantographs102 that are efficient and easy to use. A prosthodontist now can record and study mandibular motion quickly. The electronic information recorded is analyzed by a computer to provide information and settings for any of several chosen adjustable articulator systems. Casts then can be mounted on the articulator with the facebow and centric relation records.

Treatment waxing. First developed for patients with complete dentures, esthetic try-in procedures are a cornerstone of prosthodontic treatment.42 Tooth-colored try-in wax materials have been popularized by prosthodontists for fixed and implant dentistry95 and can considerably improve understanding, communication and collaboration among the practitioner, the dental technician and the patient. The procedure allows all parties to preview the esthetic result and to test the contour and shape of the simplest anterior restoration or the most complicated complete rehabilitation anticipated for the final prosthesis. The treatment wax is easily altered. A full-contour wax-up can be used as an index103; it is an accurate tooth contour guide that allows the technician to build prosthetic copings or frames that provide optimal strength, occlusion and ceramic color properties.

Selection of color. Research continues to develop methods to record the complexities of tooth color with computers that analyze such data.104 The environment and a dentist’s color perception influence shade decision,39 owing to variations in daylight and artificial light. Tooth color has been described as a function of hue, chrome and value.39,104 Different areas of a tooth have different color properties and factors that influence the absorption and reflection of light, such as opacity, translucency, opalescence, iridescence and fluorescence. Opaque and translucent areas in teeth—and even the size, shape and color of the gingival frame—are other factors that need to be determined before an individual tooth color can be developed.105

Work continues on the improvement of commercial dental shade guides, because quality control problems exist that produce inconsistent and often inaccurate color information.106 They are manufactured of either acrylic resin or layered high-firing feldspathic porcelain and are not regular dental ceramics. Prosthodontists have developed techniques to create custom-made shade tabs107 that can aid in producing more accurate color because they consist of metal-ceramic or all-ceramic cores with matching dental ceramic to represent the desired prosthesis color. Treatment wax-up can be of further help, because it tests the final prosthetic design. Dentists and technicians may overlook this step and make bisque ceramic teeth first—but if major alterations are needed, the metal frame may no longer properly support the ceramic. Even if the dentist grinds away contour in the bisque ceramic phase, important color effects previously achieved can be lost permanently. Layering and stratifying different opaque and translucent porcelains produce the best ceramic color,108 and technicians spend a lot of time developing these subtle but essential effects.

Tooth shade selections are difficult. In the end, the communication between the practitioner and the technician still is based on informed guesswork, modified by countless factors such as training, experience, environment and acuity of perception. Given the limitations on the prosthodontist’s ability to determine the proper color of teeth, it is helpful to involve the patient directly in decisions about color so as to ensure his or her satisfaction. It also is essential to involve the technician, who ultimately must make the ceramic article. Dental ceramics then can be built up easily to develop the correct tooth color.

Use of ceramic oral mucosa. Gingiva-colored ceramics have been developed sufficiently so that they now are suitable for use in tooth- or implant-supported fixed prosthodontics.102,109 They are used to re-create normal mucosal contour and are particularly effective in flat edentulous areas or in areas with residual ridge defects. They also can improve dental-gingival symmetry or correct gingival defects that cannot be repaired surgically (Figure 5Go). Finally, they can provide lip support for patients with implants, and they offer the advantage of being easy to clean. Developments and improvements in different gingiva-colored porcelains are continuing.



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  		Figure 5. A. The replacement of an aged fixed bridge. The patient had extensive alveolar ridge resorption and was not a candidate for implants. B. A metal-ceramic fixed bridge completed with gingiva-colored feldspathic porcelain was used to represent the resorbed alveolar ridge and lost gingival anatomy. Marginal buccal butt gingival ceramics provided the appearance of shorter canine lengths. A periodontist provided gingival and connective-tissue grafting to build and fortify the remaining anterior edentulous ridge.

 

   CONCLUSION
TOP
 ABSTRACT
 ADVANCES IN PROSTHODONTICS
 CONCEPTS USED IN BUILDING...
 CONCLUSION
REFERENCES
 
During the last decade, dental technology, science and practice have advanced dramatically, greatly expanding and improving the choices of materials and techniques. The most important issue in dentistry today is not the debate about which material, color or technique is best; rather, it is the establishment of good communication among general practitioners, prosthodontists, other dental specialists and dental technicians and patients. Emphasis needs to be placed on engaging the patient and members of the multidisciplinary team more directly and earlier in the process of restorative treatment so that cooperative goals can be established and better ways found to share knowledge. Teamwork and referral of complex treatment can be beneficial for the general dentist and overall patient care. Practitioners and technicians have much to share with each other in identifying potential difficulties posed by a patient’s condition, specific dental materials and techniques, or stages of work in progress.


   FOOTNOTES
 

Dr. Malament is a clinical professor, Postgraduate Prosthodontics, Tufts University School of Dental Medicine, Boston. He also maintains a private practice in prosthodontics. Address reprint requests to Dr. Malament at 50 Staniford St., Boston, Mass. 02114, e-mail "kamalam{at}ibm.net".


   REFERENCES
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 ABSTRACT
 ADVANCES IN PROSTHODONTICS
 CONCEPTS USED IN BUILDING...
 CONCLUSION
 REFERENCES
 

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