Protocol
Fixed prosthetics is one of the most demanding disciplines in dental medicine. Such therapies are generally quite complex because they continue after other possibilities within the profession have been exhausted, after the durability of the teeth has decreased, when one or more teeth are missing and if there are genetically predisposed conditions that cannot be treated conservatively. The therapist must also know other branches of dental medicine in order to get the best possible preparation for making prosthetic work. All of this is extremely important because, it should be emphasized, there is no completely safe solution in prosthetics. That is why the risk should be reduced as much as possible, because the difference between a good and a bad clinician is only in the number and percentage of failures. Failure is unfortunately present, ultimately due to a biological factor, and it also depends individually on various factors such as hygiene, chewing forces, reduced tooth elasticity after endodontic treatment, anchoring of the abutment in the tooth due to greater loss of the clinical crown of the tooth, and the like.
All of the above is a reason to understand and arrange fixed prosthetics according to the correct protocol, because implementing only the work phases and not understanding the entire therapy creates errors. There are too many different situations in clinical practice to predict and learn from them all. Lifelong education implies knowledge of the profession and protocols and does not work on their understanding, on the contrary, today it is very narrow and sometimes tied to lecturers who work only on the basis of their own experiences, with too little basic scientific and professional knowledge, which sometimes confuses even the clinician. In addition, there are a large number of different approaches and schools, which is especially visible in implant prosthetics. The protocol that will be described can be applied to implant prosthetics, but the focus of this book is on fixed prosthetic therapy supported by teeth. The profession is currently at a turning point where it will be realized over time that it is simpler to maintain gingival health on a reduced periodontium than on an implant, and that the success of an implant is not only its survival but also the absence of inflammation. This is why fundamental knowledge of fixed prosthetic therapy on teeth is important as the basis of the profession.
01 / Planning
The first stage is planning. For many years, planning was the shortest phase. Namely, it was often planned according to the experience of the clinician, who would conclude the planning phase at the first visit based on the situation in the mouth and possibly X-rays. Depending on his experience and skills, such therapy had varying degrees of success. In addition, it also depended on the experience of the technician who had to create finished works without a plan. This was often the cause of failures that may not have been immediately apparent. The question is whether the therapy is successful if after ten years the same work cannot be repeated and if the new therapy should include other teeth or use implants and mobile prosthetic therapy.
The precision of the work in the mouth and the laboratory production of restorations, as well as the knowledge of dental materials, certainly play a role here. If a therapy plan is drawn up, it will be possible to test the work in the mouth before starting the therapy, which is very useful because then the therapy can be changed or even, without consequences, stopped. It is the first phase of testing in which the patient also participates and where his wishes and views are defined. In this protocol, the planning phase is the most important phase and includes all preparatory work as well as complete diagnostics. Only after detailed planning can the second phase begin.
02 / Execution
The second phase is the implementation of the plan. As mentioned, this stage moved too quickly and sometimes started at the patient’s first visit. This can only be justified in the case of extremely simple prosthetic, indirect restorations or for financial reasons, which should by no means be a priority for doctors. In such therapies, the teeth were ground by heart and according to the clinician’s assessment, which is not justified because the grinding is irreversible. If he starts from a good plan, he will also receive guidelines for grinding, which is necessary if minimally invasive procedures are performed.
Such guidelines can be used for all types of prosthetic work. In that phase, we transfer the information from the mouth to the one who is doing the final work and a simple temporary work is made according to the therapy plan, and not according to the initial state, as was traditionally done. This is the second time the therapy plan has been tested. This phase should no longer be so demanding if proper planning has been carried out because, regardless of experience, the therapist has guidelines for the work and in fact the work is determined by the plan and the selection of materials.
03 / Manufacturing
The third stage is manufacturing. After the clinical part, therapy is carried out, i.e. prosthetic work is made by the dental technician. This implies making a replica of the final work in polymer material so that everything can be tried before the final production of the prosthetic restoration. The basis of this phase is function, and then aesthetics.
In the part of aesthetics, we are talking about the shape and slope, and not the color of the restoration, which is still not realistically visible because the same materials as for the final work are not used. If necessary, the patient can test this temporary restoration for a longer period of time and even hone the details of the occlusion. After that, the situation and information about possible changes are transferred to whoever finishes the work.
04 / Finalization
The fourth phase of the work is the final phase. At this stage, the testing that started in the planning phase also ends. Final restoration, function and aesthetics are reviewed. If everything matches the plan and wishes of the patient, the work is fixed in the mouth using one of the cementation techniques. In recent times, attempts have been made to perform adhesive cementation in order to obtain the best possible bond between the teeth, cement and prosthetic restoration. It should be said here that even in the execution phase, depending on the material of choice and the cement, the tooth preparation is adapted to retention or adhesion, and the principles of such preparation are not the same. The final stage is followed by instructions on hygiene and work maintenance.
01 / Planning
The first stage is planning. For many years, planning was the shortest phase. Namely, it was often planned according to the experience of the clinician, who would conclude the planning phase at the first visit based on the situation in the mouth and possibly X-rays. Depending on his experience and skills, such therapy had varying degrees of success. In addition, it also depended on the experience of the technician who had to create finished works without a plan. This was often the cause of failures that may not have been immediately apparent. The question is whether the therapy is successful if after ten years the same work cannot be repeated and if the new therapy should include other teeth or use implants and mobile prosthetic therapy.
The precision of the work in the mouth and the laboratory production of restorations, as well as the knowledge of dental materials, certainly play a role here. If a therapy plan is drawn up, it will be possible to test the work in the mouth before starting the therapy, which is very useful because then the therapy can be changed or even, without consequences, stopped. It is the first phase of testing in which the patient also participates and where his wishes and views are defined. In this protocol, the planning phase is the most important phase and includes all preparatory work as well as complete diagnostics. Only after detailed planning can the second phase begin.
02 / Execution
The second phase is the implementation of the plan. As mentioned, this stage moved too quickly and sometimes started at the patient’s first visit. This can only be justified in the case of extremely simple prosthetic, indirect restorations or for financial reasons, which should by no means be a priority for doctors. In such therapies, the teeth were ground by heart and according to the clinician’s assessment, which is not justified because the grinding is irreversible. If he starts from a good plan, he will also receive guidelines for grinding, which is necessary if minimally invasive procedures are performed.
Such guidelines can be used for all types of prosthetic work. In that phase, we transfer the information from the mouth to the one who is doing the final work and a simple temporary work is made according to the therapy plan, and not according to the initial state, as was traditionally done. This is the second time the therapy plan has been tested. This phase should no longer be so demanding if proper planning has been carried out because, regardless of experience, the therapist has guidelines for the work and in fact the work is determined by the plan and the selection of materials.
03 / Manufacturing
The third stage is manufacturing. After the clinical part, therapy is carried out, i.e. prosthetic work is made by the dental technician. This implies making a replica of the final work in polymer material so that everything can be tried before the final production of the prosthetic restoration. The basis of this phase is function, and then aesthetics.
In the part of aesthetics, we are talking about the shape and slope, and not the color of the restoration, which is still not realistically visible because the same materials as for the final work are not used. If necessary, the patient can test this temporary restoration for a longer period of time and even hone the details of the occlusion. After that, the situation and information about possible changes are transferred to whoever finishes the work.
04 / Finalization
The fourth phase of the work is the final phase. At this stage, the testing that started in the planning phase also ends. Final restoration, function and aesthetics are reviewed. If everything matches the plan and wishes of the patient, the work is fixed in the mouth using one of the cementation techniques. In recent times, attempts have been made to perform adhesive cementation in order to obtain the best possible bond between the teeth, cement and prosthetic restoration. It should be said here that even in the execution phase, depending on the material of choice and the cement, the tooth preparation is adapted to retention or adhesion, and the principles of such preparation are not the same. The final stage is followed by instructions on hygiene and work maintenance.