Biologic consideration of

fixed restoration (1,2)

Prepared by:

Dr/ akram alhemeary

Biologic consideration of fixed restoration
(1,2)

Biologic considerations should be respected during :

1) Pre operative phase:
Proper diagnosis and treatment plan
Proper occlusal evaluation
Proper T.M.J evaluation
Proper motivation of the patient for good oral hygiene
2) Operative phase:

a) During teeth preparation

b) After teeth preparation

3) Post operative phase

● Proper care and maintenance
● Check up appointments

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►Biologic consideration during operative phase:
I) During tooth preparation:
Damage prone structure:
1)Tooth→ dentin/ pulp
2)Periodontium→gingiva
3)Soft tissues→ cheek/ lips/ tongue
4)TMJ
►HOW TO PREVENT DAMAGE?

A)Damage to adjacent tooth:

By placing matrix band (not preferred)
OR
Using thin tapered diamond (// to long axis) → leaving thin shell of
enamel of the prepared tooth which prevent injury to the adjacent (teeth
are 1.5-2 mm wider occlusally than cervically).

B) Damage to soft tissue:

e.g cheek/ tongue/ lips
By proper retraction using mouth mirrors/suction tips.
Sometimes double retraction is done….

C)Damage to the prepared teeth:

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The thickness of remaining dentin is inversely proportional to the pulpal
response, because any damage to odontoblasts may adversely affect the
odontoblastic nucleus…………
Cutting to within 50um of the pulp → produce damage as a bloodless
pulp exposure.
Conservation of tooth structure:
1-Use partial coverage rather than full coverage whenever possible.
2-Preparation with minimum taper.

3-Occlusal reduction following anatomical plane→O.W pulp exposure

(if high pulp horns).
4- proper axial reduction→ proper axial contour→ proper oral hygiene
measures.

5-Conservative margin design →compatible with restoration material.

6-Avoid apical extension of finish line without necessary.

D)Damage to the pulp:

Causes of pulp injury:
1)Thermal injury:
●Friction between rotary instrument & tooth surface → heat generation.
● Effect of dry cutting:
i) aspiration of odontoblast nucleus into the tubule
ii)↑ dehydration → flow of pulpal fluid into dentinal floor.
↓
Pain→ until nucleus return to its original position
within 2-3 days.
Therefore to ↓ ∆ generation → use sharp instrument.

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 → Air –water coolent.(air only cause dentin
dessication)
→ Intermitted cutting.

2)Chemical injuries:
•Cutting tooth structure→ results in production of tooth debris.
i) Enamel debris (15-20 um) → removed by flushing with warm
water + cotton pellet.
ii) Dentin debris (2-5 um) → removed by acid which ↑dentin
permeability therefore irritation.

Therefore use 3% peroxide is more safe because:

→ compatible with living tissue
→ Remove smallest particle due to its effervescent (bubbling) action.

3) Bacterial injuries:
Occue due to:
i)Remaining caries under restoration
ii)Microleakage at restoration margins
e.g composite→ due to polymerization shrinkage
inlay→due to wash of cement

►Dentainal pain versus pulpal pain:

•Clinician should distinguish between pulpal & dentinal pain why? → to
identify injury beyond repair required R.C.T OR possible recovery.

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 Dentinal pain Pulpal pain
Nature of pain Sharp lancinating Dull / throbbing
location Easily localized Diffuse.
stimulus •Cold •Heat /pressure
•touch •Pain ↑during sleep
•acid due to venous return
•dehydration •Cold relief pain.

II)Biological consideration related to periodontium:

Which depend on:

1.Margin placement and texture.

i)Subgingival finish line without tearing epithelium attachment
ii)Avoid rough finish line.

2.Tissue dilation :
Methods of tissue dilation:
A) Mechanical methods:
To attain the biological consideration:
i) Use blunt instruments
ii) Avoid excessive pressure
iii) Not last than 24 hours
Otherwise permanent gingival recession

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B)Mechano-chemical methods:
●This is done by using cord impregnated in :
1) Epinephrine 1/1000 contra-indicated in cardiac patient →
Otherwise epinephrine syndrome:
2) Epinephrine 8% i) Tachycardia
ii) ↑ blood pressure.
iii) Post operative depression.
iv)Nervosity.

3) Tannic acid (20-100%) → may cause teeth discoloration

4) Aluminum chloride (5-25%) Both may cause gingival

discoloration
5) Ferric sulphate (13.3%)

6) Alum solution → most safe (natural 100%)

Any of the above → cords → mechanical action.

→ chemicals → chemical action (astringent action)
With vasoconstriction of blood vessels.

Improper mechano-chemical methods lead to permanent gingival

recession ….HOW??
i)Excessive force during cord placement.
ii)Increase time of cord application
iii)The use of too thick cord

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N.B: Recently Gingitic /expasyl retraction gel.→ eliminate excessive
force during retraction

C)Surgical methods:
Indicated in case of gingival hyperplasia
i)Lancet
ii)Electrosurgery:
Contra-indicated → in patient with cardiac pace maker
→ thin attached gingival ( upper canine)

iii) Rotary curettage: (Gingettage) (Troughing)

• Removal of limited amount of inner epithelial tissue in the sulcus
while creating a chamfer F.L using → a Torpedo nosed diamond.
• Indications: → Sulcus depth < 3 mm.
→ Adequate keratinized gingival tissue.
→ No bleeding on probing.
iv)Laser :
•Advantages: Faster

More efficient.

Painless.

More sterile. Bloodless

3.Impression making……..how?
●avoid leaving any impression material residual within periodontium.

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●Polether impression material → may cause allergic reaction

4.Temporary crown material and texture…..

• Provisional overhangs→ mechanical irritation
→ plaque accumulation
↓
gingival inflammation
therefore proper finishing and polishing of provisional restoration
margin is manditary.

5.Cementation hazards→ avoid incomplete removal of excess cement.

6. Improper restoration margin

III)Effect of temporary Crown and Bridges:
•Freshly reduced abutment should be protected by temporary
restoration → to protect them against thermal / chemical / mechanical
irritation.

•Direct provisional (made of chemical resins) are more harmful than

indirect (laboratory processed resin) → bec of ↑ free monomer / ↑
polymerization shrinkage.

●New materials have been introduced for the custom made types as
the microfilled composite and urethane dimethacrylate which showed
better biocompatibility than polymethyl methacrylate

• Provisional margins→ ↓ adaptation →leakage

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 • Zno/E can't be used bec free E prevent polymerization + solve
acrylic resin .

• Leakage ↓ by → applying varnish or CaoH2

• Provisional overhangs→ mechanical irritation

→ plaque accumulation
↓
gingival inflammation

• Resin pontic→ plaque retention → inflammation of ridge mucosa.

Therefore acrylic provisional should be smoothened

IV) Effect of various restorations:

1)Amalgam:
• Disadvantages:
i) ↑Corrosion
ii) ↑Thermal conductivity
iii) ↑Galvanic action
iv) Marginal percolation due to difference in coefficient of
thermal expansion between it & tooth structure
v) Initially marginal leakage → which ↓ later by corrosion
product.
• Treatment: → The use of bases / varnish.
→ New alloys →↓ corrosion / ↑ marginal integrity.
2)Bases & liners:

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 • Insulate dentin & pulp under large metallic filling → therefore ↓
thermal & galvanic shockes.
• e.g modified Zno/E.
3)Fluorides:
• Provide anti –cariogenic effect→↓ caries.
• Added to glass ionomer & resin cements.

4)Composite:
Irritant bec of → residual monomer.
→ incorrect dentin conditioning

5)Castings:
a) Au alloy castings:
• Ionically neutral but→ cement may wash out → space →
↑bacteria & plaque.
•↑ polished Au → ↓plaque retention → ↓ gingival irritation
b)Ni –based casting: → cause allergy in 10-20 % of
patients.

6) Porcelain:
•Glazed porcelain →↓plaque retention
Unglazed porcelain → abrasion of opposing teeth.
• Jacket crown →↑marginal opening than Au metal →cement
dissolution → caries / plaque formation.

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 7) Gold foil:
• No corrosion
• Least micro –leakage.
But • Pulp reacts strongly to malleting force.

8)Titanium:
•Most biocompatible / corrosion resistant why?
Because of thin / tenacious / protective surface oxide layer.
•This layer may be affected by excessive use of topical fluoride &
polishing.

N.B minimal gap between restoration and tooth is 100um .

V)Effect of luting cement:

1)Zinc phosphate:
Irritant to the pulp why?
Because → acidic (ph 2-3) → which rise within 24 hrs
→ small molecules
To ↓ irritation → apply varnish
→ use frozen slab tech. →↑PH rise
2)Zno /E:
•Type I → unmodified for temporary cementation.
•Type II→ cement for final cementation
↓
EBA is added to liquid / alumina & polymer is added to the powder
to ↑ strength.

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 • Advantages: → Bio-compatible
→ Palliative to pulp
→ Sedative to pulp
→ bacteriostatic action
Take care;
•Non-eugenol formulas →was introduced as Eugenol inhibits
polymer (they contain aromatic oil / olive oil)

3)Zn polycarboxylate:
Excellent bio-compatibility… why?
i) Rapid rise in ph (PH 4.8)
ii) Large molecule of polyacrylic acid→ therefore prevent its
diffusion through D.T
4)Glass ionomer cement:

a) Conventional:
 post cementation sensitivity→bec of low PH during setting.
 Initial solubility. ( post cementation sensitivity)
 Clinical success depends on its early protection against
dehydration & desiccation.( cement at crown margin should
be protected by varnish)
 Release FL.
 Bacteriostatic.

b) Resin modified: (Hybrid Ionomer cement)

 Resin is added e.g HEMA or BIS-GMA.
 ↓Post cementation sensitivity.

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  ↑Resistance to initial solubility.

5)Resin luting cement:

a) Conventional composite resin:

Mechanical retention only
b) Adhesive composite resin:
•Chemical & micro-mech. Retention.
Both are irritant to the pulp which occurs from marginal leakage
due to polymer shrinkage.
However recent adhesive resin cement release fluoride
e.g Panavia F

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