BSRDGuidelines

THE BRITISH SOCIETY

FOR RESTORATIVE DENTISTRY

Note from Editorial Director

Dental Update has been offered the opportunity to publish these authoritative guidelines,
Richard Ibbetson
which I feel will be of value to readers who carry out crown, bridge and implant treatments.
Ken Hemmings and Ian Harris The co-operation of the BSRD in facilitating this publication is much appreciated.

Guidelines for Crowns, Fixed

Bridges and Implants
Dent Update 2017; 44: 374–386

Why is it that teeth decay? You

don’t always have to go to the
doctor’s to have holes in your arm
stopped up do you? It’s a flaw in
the design.
Alan Bennett

Standards in healthcare are of fundamental

importance. Evidence-based dentistry, audit
and peer review are essential components
of effective clinical practice. To assist
with these processes, the BSRD perceives
a need for guidelines on acceptable
levels of care in restorative dentistry.
Some guidance is already available
from our sister organizations, the British
Endodontic Society, the British Society of
Periodontology and The British Society
of Prosthodontics, within their spheres of
interest. This document is intended to act as
a stimulus to members of the Society and to
the profession to seek attainable targets for quality in fixed prosthodontics. It is hoped Indications
that this document from the Society will
The decision to provide a crown
assist in the pursuit and maintenance of
Richard Ibbetson, BDS, LDS RCS(Eng), or fixed bridge, whether tooth- or implant-
high standards of clinical practice.
MSc, FDS RCS(Eng), FDS RCS(Ed), These guidelines should not supported, depends on many factors,
Director of Dentistry, The University of be considered prescriptive or didactic. including:
Aberdeen Dental School, Westburn Drive, Obviously, there will be circumstances,  The motivation and aspirations of the
Aberdeen AB25 3BZ, Ken Hemmings, encountered during patient management, patient;
BDS, MSc, DRD RCS, MRD RCS, FDS RCS, when the ‘ideal’ treatment may not be  The oral and general health of the
ILTM, FHEA, Consultant, Department of possible nor the outcome optimal. In patient;
Prosthodontics, Eastman Dental Hospital, addition, new techniques and materials will  The condition of the remaining teeth and
London WC1X 8LD and Ian Harris, BDS, become available which will bring about tooth tissues, the periodontal condition and
MSc, FDS RCS(Eng), FDS(Rest Dent) change. However, it is the Society’s belief oral hygiene maintenance;
RCS(Eng), Consultant in Restorative that these standards can and should be the  Analysis of the benefits, disadvantages
Dentistry, Department of Prosthodontics, goal during management of the majority of and long-term consequences of providing a
Charles Clifford Dental Hospital, Sheffield. clinical cases. crown or fixed prosthesis;
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 BSRDGuidelines

 Complications which limit the likelihood

of clinical success;
 The skill and experience of the clinician.
In all situations, the clinical
advantages and long-term benefits of
crowns and fixed bridges should justify
such treatment and outweigh their
disadvantages. They should only be
undertaken in those situations in which
such advanced restorative care will clearly
contribute to the oral health and welfare of
the patient.
The replacement of failed
crowns and bridges and the teeth or
implants which support them should
be conditional on an understanding of Definition of a fixed bridge adjacent suitable teeth or when they would
the aetiology and successful preventive not benefit from restoration, implant-
Any dental prosthesis that is
management of the cause(s) of failure. supported prostheses should be considered.
luted, screwed or mechanically attached
or otherwise securely retained to natural Dental implants offer the benefit of being
able to facilitate tooth replacement without
Alternatives to crowns and teeth, tooth roots, and/or dental implant
the need to involve teeth adjacent to the
fixed prostheses abutments that furnish the primary support
for the dental prosthesis. edentulous area. Where implant placement
Modern dentistry offers many and restoration are complicated and the
The Glossary of Prosthodontic
opportunities to provide direct and use of tooth-supported fixed bridgework
Terms. J Prosthet Dent 2005; 94: 10−92.
indirect restorations which satisfy aesthetic is contra-indicated the use of removable
and functional requirements of patients partial prostheses will require evaluation by
without the need for significant, if any, The rationale for the use of both the dentist and the patient.
tooth preparation. crowns
Vital bleaching, composite
 To restore the form, function and
resins, ceramic inlays and onlays and
appearance of teeth which are badly broken
Assessment
resin-retained bridges frequently have
major roles in any treatment plan. Where down, worn or fractured to the extent that Aims
teeth are minimally or moderately simpler forms of restorations are contra-  To determine the patient’s requirements
restored at the time of presentation, indicated or have been found to fail in and expectations and to gain an informed
adhesive restorations are generally clinical service. opinion of the patient’s suitability for
most appropriate. For example, in the  To improve the form and appearance of treatment involving the use of crowns or
management of the worn dentition, unsightly teeth which cannot be managed fixed prostheses.
particularly that damaged by erosive by more conservative cosmetic procedures.  To obtain a history, which includes details
substances, the use of full coverage crowns  To reduce the risk of fractures occurring of all previous conditions and experiences
has little to commend it as the first option in extensively restored teeth including of relevance including information
for treatment. endodontically treated posterior teeth. pertaining to any adverse reactions to
Dental implants may frequently  More rarely, to alter significantly the treatment, the administration of drugs and
be the treatment of choice when missing shape, size and inclination of teeth for the use of materials.
teeth are to be replaced. The biological cosmetic and functional purposes.  A medical history is mandatory for all
cost to the patient is low when sufficient  To restore a dental implant. patients. Treatment involving the provision
bone is available to house them. Aspects of dental implants should additionally
of the provision of implant-based include questioning regarding the following
restorative dentistry are similar to those The rationale for the use of recognized risk factors:
for teeth, whilst others require different fixed bridges – Osteoporosis;
considerations and skills. These guidelines  To replace one or more teeth of – Bisphosphonate therapy;
will refer to implant-supported crowns and functional or cosmetic importance to the – Uncontrolled diabetes;
fixed prostheses as necessary. patient. – Smoking;
The development of adhesive  More rarely, to prevent tooth movement – Radiotherapy.
techniques and the predictability of dental and improve occlusal stability. Tooth- Patients with medical conditions may still
implants reduce the need for the removal supported bridges require the availability of be treated with implants following advice
of sound tissue as part of restorative sufficient abutments of appropriate quality from their physician.
treatment. and prognosis. Either in the absence of  To complete a comprehensive clinical
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 BSRDGuidelines

examination which will include a review Treatment planning sound tooth tissue;
of the clinical performance and mode of  Facilitate optimal tissue response;
Aims
failure of any existing restorations. This will  Take account of:
 To establish the diagnoses, related
require a diagnosis of existing disease and – The materials and tissues
clinical findings and treatment alternatives,
an assessment of the processes that have forming opposing and
together with the patient, and to determine
resulted in the need to provide restorations adjacent contacts;
the nature and most appropriate sequence
and prostheses. – Technical considerations.
of events, which should result in the
 To analyse the effectiveness of the  Be limited to those which satisfy the
successful achievement of agreed treatment
patient’s control of their own dental relevant standards.
objectives.
disease. Implant-supported crowns and
 To devise a realistic management strategy
The clinical examination may fixed bridges should use an implant system
which should:
be supported by special tests, which may which:
– Control and prevent further
include:  Is supported by a good evidence base;
active disease;
 Sensibility testing of teeth;  Has good company support for training,
– Be efficient and effective
 Radiographic examinations; product availability and a guarantee of
yet involving only minimal
 Analyses of study casts mounted long-term supply;
operative intervention;
in a semi-adjustable articulator in an  Fulfils national and international
– Satisfy the patient’s
appropriate jaw relationship; standards;
expectations and
 Assessments of the patient’s response  Is made of appropriate material and has
requirements;
to initial instruction in oral hygiene suitable shape and surface configuration;
– Result in optimal outcomes
procedures.  Provides a variety of implant lengths and
and long-term benefits;
Other forms of special test may diameters;
– Involve minimum
include:  Provides a variety of abutments;
psychological trauma;
 Dietary analyses;  Has an internal connection for
– Facilitate any further
 The use of diagnostic and provisional abutments;
treatment, which may be
appliances;  Has protocols to allow single stage
required;
 Direct observations of occlusal and surgery, two stage surgery, immediate
– Take account of long-term
masticatory function; placement, immediate loading, cemented
maintenance.
 Long-term monitoring against base-line or screw-retained restorations;
 To decide on the design and material(s)
study casts.  Has a universal implant for all bone types;
to be used in the construction of the crown
Diagnoses may take time to  Allows ease of use with rationalized
or fixed bridge.
establish and require the use of additional components;
special tests including dental investigations  Has low start-up costs;
to stabilize or determine a prognosis for Design  Is affordable for the patient.
one or more teeth. Any case considered The design for tooth-supported Treatment planning is facilitated
to be beyond a clinician’s capabilities and fixed bridges should: by:
experience should be referred for further  Be as simple and conservative as possible,  Having demonstration models and
assessment, advice and possibly treatment. yet sufficient to satisfy physical and illustrated case histories to discuss with
Many clinical situations benefit mechanical requirements; patients;
from the involvement of additional dental  Avoid where possible using multiple,  The use of study casts to rehearse
specialists or those with particular skills. linked abutments; preparations, and for the purposes of
Such involvement should take place prior  Consider the use of dental implants as diagnostic wax-ups. The use of diagnostic
to the establishment of a treatment plan an alternative to tooth-supported fixed wax-ups or ‘try-ins’ for both tooth- and
and may increase the options available prostheses; implant-supported prostheses is highly
to the patient. Implant-based treatment  Enhance occlusal relationships and beneficial in all cases and is nearly always
may be provided either by a single function, yet minimize adverse loading; essential for optimal treatment;
competent operator or by a team led by a  Encourage optimal tissue response  Liaison with the technician who will
prosthodontist and including a surgeon. and facilitate effective oral hygiene construct the crown or prosthesis;
The need for inter-disciplinary provision maintenance. Particular attention needs to  Effective audit and peer review processes.
and restoration of implants is based on be paid to the maintenance of embrasure Before finally agreeing to a
the complexity of the case and the skill spaces to facilitate oral hygiene; particular treatment strategy, patients
and wishes of the dentist providing the  Be realistic in terms of being attainable should be made aware of the implications,
restorative care. It is important that the clinically with an acceptable prognosis. possible sequelae and anticipated life-
whole dental team is knowledgeable The choice of material(s) should: expectancy of the work and other options
about dental implants. Training of dental  Allow the realization of patients’ for their continuing care. In addition,
nurses, technicians and reception staff is cosmetic expectations, but not necessitate patients must understand and accept
mandatory. preparations involving excessive removal of that the success of the treatment will be
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 BSRDGuidelines

restoration.
 There should be sufficient space for the
implant to be placed in the bone without
compromising adjacent structures.
 Where implants are placed between teeth
or adjacent to each other there should be
sufficient space to allow normal soft tissue
contours around them. Implants should be
fully covered by the bone. Where there is
insufficient bone augmentation procedures
should be considered.
 Anatomical structures may prevent the
simple placement of dental implants in the
posterior maxilla and posterior mandible.
 Bone concavities or thin ridges may
compromise implant placement.
 The effects of gross resorption following
tooth extraction and the presence of flabby
ridges make implant placement more
difficult.
 Care must also be taken with implant
placement if there is a large incisive canal or
submandibular fossa.
highly dependent on their subsequent unambiguous and prepared in a legible
commitment to oral healthcare form.
maintenance. This constitutes an essential The number and position of implants
part of the process of obtaining informed The number and position
consent from the patient prior to Preparatory management of implants is influenced by the type of
treatment. Preparatory management prosthesis provided, the quantity and
All treatment plans should be should, where indicated, include quality of bone and the occlusal loads
kept under continual review throughout demonstrable completion of: expected. For edentulous patients the
all stages of patient management.  Relief of pain, extraction of hopeless following may be a guide:
Contingency treatment options should teeth, control of carious lesions and any  Fixed bridge: – Maxilla – 6 implants
form part of the overall strategy for patient necessary preliminary occlusal adjustment. – Mandible – 4 implants
care.  Non-surgical periodontal therapy.  Overdenture: – Maxilla – 4 implants
While not always essential, pre-  Assessment of the patient’s response to – Mandible – 2 implants
operative photographic records may assist initial treatment.  The implants should be placed at regular
in the provision of treatment and form part  Investigation of individual teeth and the intervals and correspond to the correct
of a baseline record. placement of cores. tooth positions.
 Definitive endodontic treatment.  It is not necessary to use an implant
 Assessment for dental implants if part for every missing tooth if long and stable
Consent of the treatment strategy. These require implants can be placed.
It is important to obtain particular consideration to optimize the
written informed consent for all forms final prosthetic result. Surgical protocols for implant placement
of fixed prosthodontic treatment: this  Any necessary orthodontic treatment.  The placement of dental implants is
should include a clear understanding of  Any necessary surgical periodontal under constant development. The main
the financial cost of treatment. Consent treatment. aim of these developments is to reduce
may only be obtained following a full  Definitive occlusal adjustment or treatment times and improve patient
discussion of the proposed treatment with equilibration if required. care. It is important for the clinician to
the patient.  Placement of dental implants if part of follow protocols produced by companies,
the treatment plan. or experienced teachers in the field of
implantology.
Clinical records  Drilling procedures should follow
In common with all other
Dental implants standard protocols. Initial stability is
documentation related to the patient, Space requirements for dental implants important for osseointegration to occur.
clinical records detailing the provision of  There should be adequate inter-dental  A surgical guide (template or stent) is
crowns and bridges should be complete, and inter-occlusal space for an implant necessary for planning, surgical placement
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 BSRDGuidelines

pathology;
 It is helpful if there is at least 5 mm of
apical bone to the tooth socket to allow
for good (primary) implant stability on
placement;
 This technique is more difficult for
multi-rooted teeth.

Immediate loading
 The temporary crown or prosthesis
is attached to the implant immediately
after surgical placement of the implant;
 It can be employed for a single tooth,
multiple tooth spans or a full arch;
 It is important that good primary
stability of the dental implant stability is
achieved;
 Occlusal loading must be controlled;
 This treatment can be successful in the
anterior mandible;
 Longer spans or full arch restorations
require multiple stable implants.

Healing times
Healing times refer to
the time that the implant needs to
osseointegrate in the jawbone.
 With developments in implant design
and surface configuration these are
under constant review;
and the prosthodontic stages to help with Single versus two-stage surgery
 A safe healing time in the mandible
design of the superstructure. The guide There is no evidence of
would be two to three months and three
helps with the positioning, spacing and improved outcomes between single and
to four months in the maxilla;
angulation of single or multiple implants in two stage surgical treatments. Single
 If there are complications with
the surgical field. stage surgery is convenient for patients
implant treatment it is recommended
 The surgical flap will be influenced by the and reduces treatment times. A two-
that the healing times should be
extent of surgery, the anatomical structures stage procedure, whereby the implant
lengthened to allow a better chance of
and the experience of the operator. Larger is buried and subsequently uncovered osseointegration.
flaps will be needed to identify the mental after an appropriate healing time, should
or inferior dental nerve and during sinus lift be considered under the following
procedures. circumstances: Cemented or screw-retained restorations
 ‘Flapless’ surgery involves perforation  Where the temporary prosthesis is a The decision on whether to
of the mucosa at the implant site only, denture; provide a restoration that is cemented
followed by the bone osteotomy and  Where bone augmentation has been or screw-retained depends on the
subsequent implant placement. The carried out; following factors:
morbidity is low and surgical time reduced.  Where there is poor initial stability of the  Appearance;
For this technique to be successful, good dental implant.  Security of fixation;
bone volume needs to be present or careful  Serviceability or future maintenance;
placement carried out with a CAD-CAM  Space.
produced surgical drilling guide based on a Immediate placement A screw-retained prosthesis
CT scan. In this type of treatment the may have a visible screw access hole but
 Preservation of the gingivae or attached dental implant is placed immediately it provides the most secure retention
mucosa is important for the final functional into the tooth socket following dental and simplifies any future maintenance.
and aesthetic result. Soft tissue surgery, extraction. The angulation of the implant may
possibly involving free or pedicle grafts,  The bone should be healthy with no prevent the use of screw-retention of the
may facilitate the prosthodontic stages. evidence of peri-radicular infection or restoration.
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 BSRDGuidelines

Determination of colour and of the provisional restoration may be used  Considerations of long-term sequelae;
form of restorations to develop soft tissue form adjacent to the  Aesthetic requirements.
Shade determination should crown or fixed prosthesis. If pulp vitality/integrity of the
involve consideration of the hue, chroma tooth is likely to be put in jeopardy by the
and value for the body, cervical and extent of the preparation required, then
incisal portions of the proposed crown
Tooth preparations additional preparatory treatment involving
and bridge. This should involve:  Principal considerations: orthodontic realignment or elective root
 Use of a neutral colour environment;  Conservation of tooth tissue; canal therapy may be indicated. Specific
 A shade guide familiar to the technician  Control of the path of insertion; consent must be sought prior to elective
and appropriate for the tooth-coloured  Optimal retention and resistance form; root canal therapy.
materials to be used;  Appropriate clearance in occlusion and When it is intended to remove a
 Assessments under different lighting articulation; finite amount of tooth tissue a guide or pre-
conditions;  The removal of adequate tooth tissue to operative index is a valuable aid to avoid
 An initial rapid scan of the guide allow the manufacture of restorations with excessive preparation.
against the teeth to be restored, followed appropriate contours and aesthetics;
by short duration (<5 s) assessments of  The retention of basic occlusal and axio-
occlusal form;
Impressions
the suitability of possible shades;
 Time (15−30 s) spent between  The need for well-defined margins of Master impressions
assessments looking at a blue appropriate design, wherever possible, on Purpose
background colour to minimize the supragingival, sound tooth tissue; To obtain an accurate,
influence of negative after-images.  Damage limitation through the use of dimensionally-stable, fully-supported
Shade determination is best atraumatic techniques. impression of the prepared teeth, any
completed pre-operatively to minimize All preparations should be dental implants and associated soft tissues.
errors related to eye fatigue, dehydration planned taking account of access and with
of teeth and apparent shifts in shade reference to radiographs and study casts.
The equipment for tooth Materials
following the removal of tooth tissues.
preparation should be well maintained  Impression materials should be selected
Details of features, such
and include an appropriate range of to meet the specific requirements of
as areas of opacity and translucency,
instrumentation. individual situations on the basis of
cracks and any special staining effects
Decisions regarding the form their physical properties and handling
required should be recorded as part of
and dimension of preparations should take characteristics;
the shade determination. A written and
account of:  The impression material(s) used should
diagrammatic prescription will facilitate
conform to relevant standards;
the transfer of information between the  Tooth morphology and anatomy;
 In the set state, all impression materials
dentist and the technician.  The quantity and location of remaining
must be able to withstand effective
Where appropriate, the patient tooth tissue responsible for the retention of
decontamination procedures.
and, whenever possible, the technician existing restorations including cores;
who will construct the restorations,  Occlusal relationships and function;
should participate in the completion  The need for realignment; Impression trays
of the prescription of colour and form.  Relationships with adjacent teeth and Whether custom-made or of the
Clinical photographs may be of value soft tissues; stock variety, impression trays should:
in assisting a technician who is unable  The material(s) to be used;  Have sufficient extension to support an
to examine the patient in person.
Electronic colour determination using
scanning devices may be helpful but
an appreciation of their limitations is
required.
Where teeth are to be
replaced, the use of a diagnostic wax-up
is beneficial and may be used to construct
a provisional prosthesis to facilitate
patient and dentist understanding of
the final form of the restoration prior
to beginning definitive prosthodontic
treatment. In the case of implant-
supported restorations and some tooth
supported fixed prostheses, the contours
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 BSRDGuidelines

impression of all structures to be recorded;

 Be sufficiently rigid in use;
 Incorporate occlusal stops and, where
indicated, features appropriate to aid the
retention of impressions;
 Have appropriate features to allow the
use of any necessary impression copings for
dental implants;
 Have a robust handle, preferably integral;
 Be capable of withstanding autoclave
sterilization if designed for re-use.

Technique
 The impression must allow accurate
relations to be established between casts
within the dental laboratory and provide
sufficient information in respect of occlusal
form, function and relationships;
 Soft tissue management and moisture
control must be effective but atraumatic;
 Impression materials must be used in
strict accordance with manufacturer’s of teeth is being restored and there are mandible;
instructions. sufficient remaining contacts between the  The registration material or device should
Completed impressions should unprepared teeth to allow the technician be positioned or applied as appropriate;
be: to establish adequately the intercuspal  The registration material should not
 Washed thoroughly; position (ICP) or centric occlusion (CO). impede or prevent complete mandibular
 Inspected carefully; Sufficient information informing the closure;
 Subjected to an effective technician which teeth make contact in the  Positioning of the mandible should be
decontamination procedure; patient’s mouth on mandibular closure will completed within the working time of the
 Identified; facilitate this. registration material;
 Protected and stored in an appropriate  Only reproducible and definable
manner ready for transit to the dental positions of the mandible should be
laboratory in a way which will preclude Materials recorded;
damage, distortion or contamination. The material selected to record  Following the set of the registration
occlusal registrations should: material, the positioning of the mandible
 Readily and accurately record detail should be verified and, if required, the
Opposing arch impressions of the occlusal and axio-occlusal tooth registration refined;
Impressions of the opposing surfaces;  The technique adopted for the
arch are critical to the success of crown and  Exhibit limited flow following application; removal, cleaning and decontamination,
bridgework. While such impressions may  Have a working time sufficient to allow identification and storage of registrations
generally be successfully completed using correct positioning of the mandible, yet should not result in the introduction of any
alginate, great care is required to avoid the exhibit an abrupt transition to the solid significant errors;
introduction of significant errors in their state;  The accuracy of the inter-occlusal record
use.  Be dimensionally stable and capable of should be verified by both the dentist and
Impressions of the opposing being adjusted without distortion when set technician.
arch should be handled, decontaminated, or in the solid state.
protected and stored with the same care In situations where patients have
adopted for master impressions. lost posterior occlusal support, it may only Principal mandibular positions
be possible to make an occlusal registration When adopting a conformative
approach (ie the crown or bridge is to be in
Occlusal registration for by using wax occlusion rims. However, the
harmony with existing jaw relationships),
working casts limitations of these for fixed prosthodontic
the intercuspal position (ICP)/centric
work should be recognized.
The purpose of occlusal occlusion (CO) should be recorded. When
registration is to allow opposing casts to a reorganized approach has been planned,
be related accurately either in a cast relator Technique it is advantageous if the change in the jaw
or an articulator. A formal registration  The patient should be instructed and relationship has been made prior to making
may not be required if a small number rehearsed in the desired position of the the tooth preparations such that ICP/CO
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 BSRDGuidelines

and the Retruded Axis Position (RAP)/ restorations should be cemented to the
Centric Relation (CR) coincide. This makes Qualities teeth with a material that provides an
the recording of jaw relationships easier. Provisional restorations adequate marginal seal but has physical
Temporary restorations may properties that allow removal of the
also be used to test form and function and provisional restoration without damage to
Functional relationships
develop soft tissue contours adjacent to the underlying preparation.
Correct functional
relationships are of considerable restoration: these are more appropriately
termed ‘provisional restorations’. Provisional
importance to the clinical success of
crowns and bridges should incorporate
Laboratory prescriptions
crown and bridgework. To facilitate
correct functional relationships, most of the qualities of the final restorations Purpose
registration procedures should include a which will replace them. These should To record and communicate
include: precise details of all aspects of the crown
facebow transfer. Lateral and protrusive
 Restoration or, where indicated, and bridgework required.
registrations are often recommended,
improvements in tooth form and function; Laboratory prescriptions are best
but in the dentate patient confer little
 Marginal adaptation and seal; completed together with the technician.
benefit where there is reasonable
 Minimal tissue response and favourable In situations in which this is impractical,
anterior guidance. Appropriate records
hygiene features. Care needs to be taken misunderstandings and omissions in
to allow the duplication of the anterior
to ensure a good quality of marginal prescriptions may be minimized by effective
guidance may be helpful for the
fit without ledges and an adequate clinician/technician liaison, including the
restoration of anterior teeth: this is
reproduction of embrasure space to clinician inspecting various stages of the
particularly the case where multiple
facilitate oral hygiene; laboratory work, notably working casts and
restorations are planned.
 Fracture and wear resistance sufficient for wax-ups.
The use a functionally-
anticipated time in clinical service;
generated path (FGP) technique can
 Properties which serve to protect the
create an inter-occlusal record of Requirements
health of the underlying dental tissues;
assistance in providing information Laboratory prescriptions should
 Functional comfort and control of
about the relationship of antagonist include:
sensitivity;
teeth to posterior preparations on  The clinician’s name, practice address and
 Acceptable appearance.
mandibular closure and mandibular contact telephone/fax number(s) or email
excursions. address;
The accuracy of inter-occlusal Technique  Details of the patient;
records should be confirmed by the There is much to commend  Name, initials or reference number;
dentist and technician. The use of a replica technique for the fabrication  Age;
shimstock foil, a split-cast technique or of provisional crown and bridgework in  Sex;
copings are all techniques which may situations in which tooth form and function  Any relevant photographic records
assist in achieving accuracy in relating should remain unchanged. However, there available;
working casts. However, the quality are a number of methods which may  Pertinent aspects of the social history.
of the inter-occlusal record remains all give acceptable results. Practitioners  Summary of the treatment being
paramount. nonetheless need to be aware of the undertaken:
advantages and limitations of the method – Overall plan;
selected. – Stage of treatment;
Temporary, provisional and When planning a significant – Present work;
interim restorations in fixed change in form or function the diagnostic – Subsequent care.
prosthodontics wax-up can be used to produce an index for  Details of the teeth and/or implants
the production of provisional restorations. involved (number/notation), the type of
Purpose
This approach allows the clinician to assess crown or prosthesis to be constructed, the
Temporary restorations the patient’s response to the proposed design for any dentures to be subsequently
To restore, protect and changes prior to the construction of the provided/replaced and, where appropriate,
maintain the position of prepared teeth definitive restorations. information regarding contingency and
between appointments and until the During the fabrication and long-term planning should be given;
placement of the final restoration. placement of provisional crown and  Date and time of recording impressions;
bridgework, care is required to ensure:  Date and time for latest return of
 Occlusal accuracy; completed laboratory work;
Interim prostheses
 Maintenance of pulpal and periodontal  Unambiguous statement of type of
Interim prostheses may be
health; alloy(s) and other material(s) to be used;
required to maintain form and function
 Good marginal adaptation.  A detailed description of the design
during treatment involving the use
Temporary and provisional features for the crown or bridge, including
of dental implants. Tooth-supported
prostheses
May 2017 are preferable in this respect. DentalUpdate 383
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 BSRDGuidelines

directions regarding:
– Form and function, not
forgetting pontics;
– Materials to form margins and
occlusal contacts;
– Shades and characterization;
– Surface features and finish.
 A description of the occlusal
registration(s) provided;
 Miscellaneous clinical observations and
specific patient requests.
The use of labelled diagrams
together with study casts, diagnostic
wax-ups and impressions of temporary or
provisional restorations greatly facilitates
communication. Clinical photographs
may assist the technician in the design of
crowns particularly with aspects of form
and surface texture but should not be relied
upon to communicate colour accurately.

Try-in
Purpose
To confirm the clinical
which, for example, alter vertical face height cleaned, isolated and, where indicated,
acceptability of completed or partially
or change aesthetics or occlusal functional primed and conditioned as required for the
completed crowns or fixed bridges in terms
relationships, despite satisfying immediate cement selected. The luting system should
of:
criteria for clinical acceptability; be dispensed, mixed and applied in strict
 Seating and marginal adaptation;
 Having patients confirm the comfort accordance with manufacturer’s instructions
 Contacts and relationships with adjacent
and their acceptance of the appearance of whilst the operating field should be
and opposing teeth;
crowns and bridges should be considered a controlled.
 Form;
routine element of try-in procedures. The final restorations must be
 Aesthetic qualities;
fully seated within the available working
 Patient acceptance.
time using appropriate techniques to
Final placement of restorations overcome the effects of hydraulic forces.
Principles The final placement of tooth- While it is highly desirable to have some
 Prior to an appointment for try-in supported and implant-supported excess luting material present along the
the restorations should be carefully restorations has a number of common entire margin of the restoration, completely
inspected, together with the master casts elements but also significant differences. filling the restoration with cement will
and, when available, the impression of impede the seating of crowns and fixed
the preparations, to confirm satisfactory Tooth-supported restorations bridges. The restorations must not be
completion of the laboratory work; allowed to move relative to the underlying
Aim
 Assessment of the acceptability of preparation(s) during the critical initial set
restorations, at the time of try-in, may be To cement/bond crowns and
or polymerization of the lute. At this time
facilitated by the use of magnification bridges considered to be satisfactory by
special precautions may be required to
or radiographs for implant-supported both the operator and the patient at the
isolate and protect the luting material used.
restorations; time of try-in or following a period of
When set, the excess luting
 Any minor adjustments or further temporary cementation.
material should be removed using
laboratory instructions are generally best instruments and techniques least liable to
completed while the patient is still present; Technique cause damage. It is of particular importance
 If a crown or bridge is considered to The luting system should be to ensure that no excess cement is left in
be unsatisfactory at try-in, the cause of chosen with the following in mind: interproximal or subgingival sites.
the problem should be identified before  The nature and condition of the prepared Newly cemented/bonded
modifying or remaking the item; tooth; crowns and bridges must be examined with
 Consideration should be given to  The fit-surface finish of the restorations. particular regard to:
temporarily cementing crowns and bridges The preparations should be  Degree of seating;
384 DentalUpdate May 2017
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 BSRDGuidelines

 Proximal contacts and relationships To assess the patient’s have received tooth-supported crown and
with adjacent and opposing teeth; response to the restorations and to deal bridgework: radiographs are advisable one
 Occlusal function. with any post-operative difficulties, year following treatment to check that
Where indicated, suitable concerns, pain or discomfort which arise coronal bone levels have been maintained.
adjustments should be completed, after placement. All patients should be reviewed at least
including refinishing of roughened areas. annually. They should be encouraged
to return to the provider of the implant
Procedure
treatment if they feel that there has been
Implant-supported crowns and fixed  During the initial review, attention
any deterioration.
prostheses should be paid to patient satisfaction and
To monitor clinical performance
Aim comfort; and any deterioration in acceptability,
To attach securely crowns and  Proximal contacts and relationships detailed records should be kept of clinical
bridges considered to be satisfactory by with adjacent and opposing teeth should observations made during reviews of crown
both the operator and the patient at the be checked; and bridgework.
time of try-in or following a period of  Special note should be made of When a dental hygienist or other
temporary use. the initial tissue-response and the dental care professional is part of the dental
The final restoration may effectiveness of the patient’s oral hygiene team undertaking long-term care of crowns
be screw-retained or cemented to an maintenance in relationship to the and bridges he/she must be aware of the
abutment attached to the implant. restorations; specific maintenance issues and potential
Screw-retained crowns and  Where indicated, suitable adjustments modes of failure.
prostheses: should be completed with all altered
 The final restoration is seated and surfaces being refinished;
retained by a screw, tightened to the  Where indicated, further instructions Concluding remarks
manufacturer’s recommended torque. and advice should be given regarding oral The provision of crowns and
 The screw hole is restored with a direct hygiene maintenance. fixed bridges to a high standard is an
restorative material. exacting task for the whole dental team,
 Beneath the direct restoration but clinician, technician, nurse and other
separating it from the head of the Long-term review support staff, as well as for the patient.
retaining screw is a plug of intermediary Long-term reviews of crowns Provision of high-quality crown and
material usually either PTFE tape or light- and fixed prostheses should form part bridgework accompanied by excellent
bodied impression material. of routine recall examinations. These maintenance can produce long-term
Cement-retained crowns and examinations should, from time to time, success which is rewarding for both the
prostheses: include radiographic examinations using patient and the dental team.
 Small volumes of cement should be intra-oral films. The Society hopes that these
used to minimize extrusion of excess Care needs to be taken during guidelines are helpful and act as a practical
cement into the surrounding tissues; long-term review to ensure that the reminder of the standards that we try
 The area overlying the abutment- cement lute remains intact for all tooth- to achieve. Guidance notes are never
retaining screw should be protected supported indirect restorations. This is of complete, and these are no exception. The
by PTFE tape or a plug of impression particular importance for fixed bridges or Society will be reviewing this document
material; linked crowns where failure of the cement at regular intervals for accuracy and
 It is of particular importance to lute may lead to rapid and extensive in the light of contemporary thinking.
ensure that no excess cement is left in dental caries. Any comments you may have would be
interproximal or subgingival sites. Follow-up of implant patients gratefully received and should be addressed
is just as important as for those who to the Honorary Secretary of the Society.
For all restorations
Before discharging a patient,
following the placement of crowns and
bridgework, suitable instructions should
be given regarding immediate care, action
to be taken in the event of post-operative
pain or discomfort, and appropriate oral
hygiene measures.

Initial review
Purpose

386 DentalUpdate May 2017

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