PONTIC DESIGN &

ADVANCEMENTS

Done by:
Amira Mokhtar
Alzahraa Adel
Mohamed Swelim
Alaa Alsayed
Amr Islam

Under supervision of: Dr Eman Ezzat

Dr Gomaa Soliman
Definition:

Pontics are the artificial teeth of a fixed partial denture (FPD) that replace missing natural teeth, restoring function and appearance.

In the anterior region, where esthetic appearance is a concern, the pontic should be well adapted to the tissue to make it appear as if it
emerges from the gingiva.

In the posterior regions (mandibular premolar and molar areas), contours can be modified in the interest of designs that are less esthetic
but with interest of oral hygiene.

PONTIC CLASSIFICATION

Pontic designs are classified into two general groups:

According to Rosensteil:

Mucosal & No mucosal contact.

Several sub-classifications exist within these groups that are based on the shape of the gingival side of the pontic.

Mucosal Contact No mucosal contact

Ridge-lap sanitary

Modified ridge-lap modified sanitary

Stein pontic

Ovate

Modified ovate

Conical

Split

• Recent types of mucosal contact

E-pontic
F-pontic
S-pontic

Mucosal contact

Saddle and Ridge-Lap Pontic

The saddle pontic has a concave fitting surface that overlaps the residual ridge bucco-lingually, simulating the
contours and emergence profile of the missing tooth on both sides of the residual ridge.

This pontic design sits over the alveolar ridge in intimate contact with the mucosa.

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Used in:

posterior and anterior teeth.

Not recommended because, the concave gingival surface of the pontic is not accessible to cleaning with dental
floss, which leads to plaque accumulation and tissue inflammation.

So, should not be used as a definitive restoration.

Modified Ridge-Lap Pontic

the modified ridge-lap pontic overlaps the residual ridge on the facial side (to achieve the appearance of a tooth emerging from the
gingiva), but convex at the ridge on the lingual side to enable optimal plaque control.

Tissue contact should resemble a letter T.

whose vertical arm ends at the crest of the ridge.

Facial ridge adaptation is essential for a natural appearance.

It has a minimal point contact with the labial/buccal mucosa and exert no pressure
on the mucosa. (passive contact)

Recommended location

➢ The modified ridge-lap design is the most common pontic form used in areas of the mouth
that are visible during function (maxillary and mandibular anterior teeth, maxillary
premolars, and first molars).
If the edentulous ridge is not severely resorbed, acceptable esthetics can usually be expected.

➢ Ridge lap pontic designs can be used in provisional restorations of patients with a high smile before modifying their shape,
adding poly methyl methacrylate (PMMA) or composite to simulate missing soft tissues.
They are also helpful in evaluating the area to reconstruct with soft tissue augmentation procedures as they help visualize the expected
result to be achieved after surgery.

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Advantage

Good esthetics

They are easier to clean than conventional ridge lap.

Disadvantage

Its drawback is the un-esthetic result in situations

where vertical resorption has occurred. This situation increases teeth length, compensating for vertical bone remodeling. In addition,
papilla volume is reduced, leading to open gingival embrasures that cause saliva, air exchange, and food impaction. Even though the
concave surface is reduced, it remains challenging to clean with dental floss.

stein pontic

It is a variation of the modified ridge lap pontic.

It is designed for sharp edentulous ridges, exhibits minimal tissue contact, and offers acceptable esthetics

It is contraindicated in edentulous ridges with broad buccolingual dimensions.

Conical pontic

Called egg-shaped, bullet-shaped, or heart-shaped.

It should be made as convex as possible and should have only one point of contact:
at the center of the residual ridge.

The facial and lingual contours are dependent on the width of the residual ridge; a
knife-edged residual ridge necessitates minimum contours with a point tissue contact area.

SO, this type of design may be unsuitable for broad residual ridges because the emergence profile associated with the small tissue
contact point may create areas of food entrapment.

The sanitary or hygienic pontic is the design of choice in these clinical situations.

Recommended location

This design is recommended for the replacement of mandibular posterior teeth, for which esthetic appearance is a lesser concern.

Advantage

Good access to oral hygiene.

Disadvantage

Poor esthetics

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Ovate pontic

The ovate pontic is the pontic design that is most aesthetically appearance.

Its convex tissue surface resides in a soft tissue depression making it appear that a tooth is emerging
from the gingiva.

*Apply light pressure on the gingiva.

The convex surface extends into the mucosa by 1–2mm.

Socket-preservation techniques should be performed at the time of extraction.

For a pre-existing residual ridge, surgical augmentation of the soft tissue is required.

When an adequate volume of ridge tissue is present, a socket depression is sculpted into the
ridge with surgical diamonds, electro-surgery, or a dental laser.

Indicated in

Very high esthetic requirement Maxillary incisors, canines, and premolars.

High smile line.

A thin knife-edge ridge is a contraindication for an ovate type of pontic.

Advantages

• Superior esthetics and strength.

(The broad convex geometry is stronger than that of the modified ridge-lap pontic because the
porcelain at the gingiva-facial extent of a pontic is supported).

• Papillae supported and reduce the presence of a black triangle.

• No food entrapment.
• Ease of cleaning.
(Because the tissue surface of the pontic is convex in all dimensions, it is accessible to dental floss).

Disadvantages

• Need for surgical preparation.

• The patient may complain due to the large contact area, which could cause inflammation if it is not well maintained.
Modified Ovate Pontic

The apex positioned more facially on the residual ridge, rather than at the crest of the ridge.

Less convex than ovate.

Indicated in

This alteration allows the use of the pontic In clinical scenarios in which horizontal ridge width is not sufficient for
a conventional ovate pontic.

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Advantages

Cleansing of this pontic is also purported to be easiest of all pontic types.

Split pontic

Indicated in

• Tilted abutment cases

• Pier abutment cases
Split pontic is known as NRC placed entirely in the pontic

one half of the pontic ( the bottom half) is attached to a retainer, while the other half of the
pontic (the top half) is attached to another retainer.

The two pieces of pontic are not cemented together for relieving stress.

The split pontic stress-releasing effect acts as “safety valves” against the connectors leverage forces as they give a chance for rotation
and resiliency between the prosthetic restoration and abutment teeth.

Split pontics are expected to provide promising designs for prosthesis stability and retention with accepted esthetics.

Designs for split pontic in case of tilted molar :

a) Key-hole split pontic design, b) Bone split pontic design c) Relief cut split pontic design

In long-span fixed partial denture restoration, especially when pier abutment is present, a non-rigid

connector as a stress breaker is indicated.

The Non-rigid connector is classified into a dovetail, loop connector, split

pontic, cross-pin, and wing. Split pontic is an attachment placed entirely inside the pontic

Split pontic also transfers the shear stress to the alveolar bone, minimalizes the

mesiodistal torquing of the abutment teeth, and enables individual tooth movement.

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• case of pier abutment

• after tooth preparation

• Designing the bridge component with

CAD/CAM

• Metal Framework.

• Metal try-in

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 • Cementation of fixed movable bridge

In this case, we use a modified split pontic with attachment placed entirely inside the pontic.

The dovetail-shaped male component is placed at the distal part of the pier abutment and the female component covers the entire male
component assembling the pontic. This design has several advantages such as conventional tooth preparation with minimal tooth
reduction for the tilted tooth and better esthetic as the porcelain build-up can be done, so there is no metal exposure of the non-rigid
connector. The disadvantages are technique sensitive and consuming more time and cost.

E-pontic

The E-pontic design consists of a flat design with sharp borders (90-degree angles) that promotes the gingival facial tissue to migrate
over the pontic, creating a gingival sulcus.

at least 2mm of soft tissue should be present over the bone crest migrate over the pontic, creating a
gingival sulcus.

3-5mm of soft tissue coverage is ideal.

The E-pontic is subgingival on the facial and interproximal aspects gradually sloping to the lingual
where it is positioned on top of the tissue.

• The main advantage of the E-pontic is the esthetic result that can be achieved by using it without
previous tissue preparation during the interim restoration phase.
• Food accumulation does not occur because of its unique adaptive design to the pontic site.
• esthetics

Limitation of E-pontic

alveolar ridge defect with apico-coronal loss of tissue and/or a combination of buccolingual and apico-
coronal loss of tissue, resulting in a significant loss of normal height and width.

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F-pontic

The flat pontic is a modification of the ovate pontic.

The round angles in the facial and lingual pontic-tissue contact areas facilitate hygiene and the
prosthesis seating.

The central portion of the pontic has a semi-flat design, preventing excessive pressure on the crest.

This pontic design has high esthetic results, good sealing, hygiene, and efficient provisional
seating.

but it requires a previous surgical procedure to be used, which is the main disadvantage.

The flat pontic is indicated in sites with adequate tissue obtained through a previous preservation or reconstructive procedure.

Step-pontic

The step pontic is a modification of the flat pontic.

In the S pontic design there is a concavity in the facial aspect of the pontic which allows
the gingiva to migrate coronally, resulting in a shorter clinical crown with better stability of
the gingival margin and a more natural emergence profile.

The step pontic is indicated in situations where previous preservation or reconstruction of

the ridge has been done but a shallow soft tissue defect is still present due to tissue
shrinkage.

In this situation the use of the flat pontic would lead to a longer crown than desired.

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Non mucosal contact

Sanitary or Hygienic Pontic

the primary design feature of the sanitary pontic allows easy cleaning because its tissue surface
remains clear of the residual ridge.

Indicated in

the mandibular molars

Disadvantage

• Entrapment of food particles, which may lead to tongue habits that annoy the
patient.
• Placement of pontic close to the ridge can cause tissue proliferation.
• Poor esthetics.

**Nowadays, it is used in the mandible when a patient is given a full-arch

implant-supported prosthesis to help with hygiene in cases when the vestibule is
shallow and the vertical bone deficiency is moderate to severe.

This design is contraindicated in full-arch implant-supported prostheses of the

maxilla, as it may lead to phonetic problems due to the lack of seal.

Modified sanitary

Its gingival portion is shaped like an archway between the retainers.

It is also less susceptible to tissue proliferation that can occur when a pontic is
too close to the residual ridge.

Indicated in

1. Extreme resorption of the alveolar ridge

2. Shallow vestibule

3. Insufficient or lack of attached gingiva

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 ❖ Different pontic designs

Pontic Appea Adv Dis Indi Contra Tissue

design rance antages advantages cations indication contact

Ridge-lap -Acceptable -Difficult for -Not -Not -Intimate

esthetics oral hygiene recommended recommended contact
with the
ridge
Modified -Acceptable -Moderately -Area with -Where -Tissue
ridge-lap esthetics easy to clean esthetic minimal contact
concern esthetic resembles
- favorable concern exists letter T
option for - unesthetic (passive
cases with results in contact)
Mild crest situations
defects. Where vertical
- used in resorption has
provisional occurred
restorations of
patients with a
high smile
before
modifying
their shape
Stein -Acceptable -Moderately -Sharp -broad -Minimal
esthetics easy to clean edentulous buccolingual tissue
ridge ridge contact

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Conical -Good for -Poor -Posterior teeth -Poor oral -One point
oral esthetics hygiene of the
hygiene contact
with
center of
the ridge
Ovate -Highly -Necessitates -Need high - Patient’s -Apply
esthetics surgical esthetics unwillingness light
-papilla Preparation -high smile to undergo pressure
support line surgery with a
-reduce -vertical mild -Residual ridge ridge
black ridge defect defects
triangular <2mm
Modified- -Highly -Necessitates -Horizontal -Patient’s -Apply
ovate esthetics surgical ridge width is unwillingness light
-Easiest preparation not sufficient to undergo pressure
type for for a surgery with a
cleaning conventional ridge
ovate pontic
Split Stress -Failures may -Tilted teeth -Cases that the
pontic breaking in occur at - pier abutment design needs a
special pontic as it rigid connector
cases as technique
tilted molar sensitive
and pier -consuming
abutment more time and
cost
E-pontic -High -Necessitates -need high -significant -Adapted
esthetics surgical esthetics loss of normal with the
-easy for preparation -high smile height and ridge with
cleaning line width of ridge light
pressure

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S-pontic -High -Necessitates -need high -Patient’s -Adapted
esthetic surgical esthetics unwillingness with ridge
-easy for preparation -shallow to undergo with light
cleaning vertical ridge surgery pressure
defect <1mm
F-pontic -High -Necessitates -need high -Patient’s -Adapted
esthetic surgical esthetics unwillingness with ridge
-Easy of preparation -ideal vertical to undergo with light
cleaning soft tissue surgery pressure
volume
Sanitary -good -Poor - Non-esthetic -Where -No tissue
access for esthetics zones Impaired esthetics is contact
oral -tissue oral hygiene important Away
hygiene proliferation - minimal from ridge
may occur vertical 2mm
dimension
Modified- -good -Poor - Non-esthetic -Where -No tissue
zones
sanitary access for esthetics esthetics is contact
Impaired oral
oral hygiene important away from
hygiene -minimal ridge 2mm
- Extreme
resorption of vertical
the alveolar
dimension
ridge

-Shallow
vestibule

-Insufficient or
lack of
attached
gingiva

Classification of pontic according to material

Metal pontic

Metal-ceramic pontic

Ceramic pontic

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Metal pontic

Metal is placed in tissue contact, and should be highly polished

Well-polished gold is smoother, less prone to corrosion, and less retentive of plaque than unpolished or porous casting.

However, even highly polished surfaces accumulate plaque if oral hygiene measures are ignored.

Metal ceramic pontic

Highly glazed porcelain is easier to clean than are other materials.

The framework must provide a uniform veneer of porcelain.

The excessive thickness of porcelain lead to inadequate support and predisposes to fracture.

For ensuring uniform thickness of porcelain is to wax the fixed prosthesis to complete anatomic contour and then accurately cut back the
wax to a predetermined depth.

The metal surfaces to be veneered must be smooth and free of pits.

Sharp angles on the veneering area should be rounded.

The metal-ceramic junction should not be in contact with the residual ridge on the gingival surface of the pontic.

For easier plaque removal and biocompatibility, the tissue surface of the pontic should be made in glazed porcelain.

Occlusal contacts should not fall on the junction between metal and porcelain during centric or eccentric tooth contacts.

For this reason, occlusal centric contacts must be placed at least 1.5mm away
from the junction

**ceramic tissue contact may be contraindicated in edentulous areas where

there is minimal distance between the residual ridge and the occlusal surface.

**When vertical space is minimal, the fourth design (porcelain tissue and occlusal coverage) may be contraindicated..

Ceramic pontic
Zirconia has been shown to be a biocompatible material. The soft tissue response to this material is superior to other porous materials
because of its low bacterial colonization potential.
A thin layer of porcelain can be added to improve esthetics (porcelain fused to zirconia).

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References
1- Contemporary fixed prosthodontics, sixth edition
2- Gahan, Matthew J., et al. "The ovate pontic for fixed bridgework." Dental Update 39.6 (2012): 407-415.
3- Gomez‐Meda, Ramon, and Jonathan Esquivel. "Perio‐prosthodontic pontic site management, part I: Pontic
designs and their current applications." Journal of Esthetic and Restorative Dentistry (2023).
4- LIU, CHIUN‐LIN STEVEN. "Use of a modified ovate pontic in areas of ridge defects: a report of two
cases." Journal of Esthetic and Restorative Dentistry 16.5 (2004): 273-281.
5- Oswal, Mansi Manish, and Manish Sohan Oswal. "Unconventional pontics in fixed partial dentures." Journal
of Dental and Allied Sciences 5.2 (2016): 84.
6- Mukhopadhyay, Pronoy, et al. "Managing Tilted Molar Abutment Using a Digitally Fabricated Split-Pontic
Fixed Dental Prosthesis—A Case Report." Open Journal of Stomatology 11.8 (2021): 311-316.
7- Beleidy, Marwa, and Ahmed Ziada. "The influence of split pontic designs on the fracture resistance of
CAD/CAM fabricated monolithic zirconia FDPs under simulating aging conditions." Egyptian Dental
Journal 66.2-April (Fixed Prosthodontics, Dental Materials, Conservative Dentistry & Endodontics) (2020):
1351-1361.
8- Korman RP. Enhancing esthetics with a fixed prosthesis utilizing an innovative pontic design and periodontal
plastic surgery. J Esthet Restor Dent. 2015 Jan-Feb;27(1):13-28. doi: 10.1111/jerd.12110. Epub 2014 Jul 1.
PMID: 24986098
9- Gomez‐Meda, Ramon, and Jonathan Esquivel. "The flat and step (F and S) pontics. Novel pontic designs for
periodontally reconstructed sites." Journal of Esthetic and Restorative Dentistry 34.7 (2022): 999-1004.
10- IVANA, SYAFRINANI, and Ricca CHAIRUNNISA. "The modification of split pontic as non-rigid connector in
the management of pier abutment." (2020)

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 Treatment plan
• Several parameters should be analyzed before deciding on the pontic design to be used:
1. Gingival considerations.
• Assess the outline, quantity and color of the soft tissues to achieve a natural emergence of the restoration ( esthetic
transition between the tissues and restorations.
2. Lip line considerations
• If the contact area with the alveolar ridge is visible when the patient speaks or smiles.
additional techniques to reconstruct the pontic site before the prosthodontic approach.
3. Patient related factors
• Evaluate the patients’ expectations as some will have high esthetic expectations.
• More complex cases will require surgical treatment to generate ideal emergence profiles. So, is the patient willing for this long
process ?

Ovate, modified ovate, E-pontic, Flat, and Step pontic designs are indicated in patients with high expectations and gummy smiles
whenever the soft tissue volume is adequate or has been augmented.

The techique depends on the ridge defect's severity.

➢ Mild and moderate defects can be regenerated by mucogingival techniques.
➢ More severe defects may require bone regeneration procedures as well.

Seibert’s classification of residual ridge deformities after EXTRACTION: (figure 3)

• Class I: buccolingual loss of the ridge contour.(width)
• Class II: apicocoronal loss of the ridge contour.(height)
• Class III: combined loss of the ridge contour.(width + height)

In 1997, Studer et al. described a new semiquantitative classification according to the degree of severity in vertical and
horizontal dimensions in relation to adjacent papilla tips is as follows:
• Mild vertical/horizontal defect: < 3 mm.
• Moderate vertical/horizontal defect: 2–6 mm.
• Severe vertical/horizontal defect: > 6 mm.

Prosthetic soft tissue conditioning and communication with the dental laboratory:
This conditioning may be required in post-extraction sockets or in healed ridges,
1. Post-extraction sockets:
• After extraction , immediate pontic conditioning may be done. A highly polished interim restoration with an ovate pontic design done.
• It introduced 2.5 mm into the socket (if pontic is deeper than 2.5 mm: reduce the tissue surface of interim pontic till optimum length or
shallower than 2.5 intrasulcular: reline the tissue surface with composite and polish it)
• and left for 4–6 weeks while the site heals and there is tissue stability.

The pontic site volume should be equal to that of the extracted tooth. To:
1. help support the gingival margin outline
2. reduce the chances of ‘black triangles’ and developing a natural emergence profile.

• After 4–6 weeks, the interim restoration is removed and modified, leaving a 1 mm depression in the gingiva. This area should be
adequately cleaned using super floss to avoid inflammation.
• A long-term interim restoration should be kept in place for 6–12 months before fabricating the final prosthesis with a pontic design set
about 0.5 mm into the gingiva.
Clinical steps :
First visit
• Primary impression of the arches
• Tooth Preparation was done for the abutments
• Impression after preparation.
• The tooth to be extracted was cut from the cast making 3 mm depression simulating the post-extraction socket.
• Provisional bridge was fabricated using tooth coloured polymethymethacrylate resin (PMMA) figure (5a)

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 Second visit
• The tooth was extracted atraumatically taking great care not to damage both buccal and lingual plates.
• This step is very critical for bone conservation as well as to preserve the interdental papillae. (Figure 5b)

Figure 5a. Figure 5b

1) Placing Provisional bridge in situ with tissue surface of the pontic 2–3 mm inside the socket.

2) Recall the patient after 3 months of healing period to inspect intra oral view of the extraction socket

3) Replace the provisinal restoration with the final bridge

In modified ovate pontic : samliar to the previous clinical step for ovate pontics expcept it is placed more labially placed on
ridge than ovate pontic.

Remaing root to Immediate placement of

provisional restoration. with modified ovate
be extracted

Advantage of Ridge and socket preservation is a more conservative approach in limiting both horizontal and vertical bone loss in
post-extraction sites, thereby minimize the need for soft or hard htissue augmentation.

The Normal (Flat) ridge :

• For this type of ridge, it is first necessary to determine the anatomical characteristics of the site.
• When the tooth was removed, osseous fill of the healing socket but marking its level with tips of the two interdental
osseous crests.
• This situation is NOT ideal because;
The bone in the center of the pontic site is now at a level more coronal to that point at which the maximal
curvature of the CEMENTO-ENAMEL junction (CEJ) normally would have been, Thus inadequate space for a pontic with
dimensions to be placed.

How to manage??
the anatomical topography of the site must be determined by needle probing under local anesthesia
• If there is a thickness of 3 or 4 mm of soft tissue above center of the alveolar ridge, Soft tissue gingivoplasty is developed.
• If Soft tissue thickness: 2 mm (osteoplasty) would be done

Surgical Preparation of the Pontic Recipient Site

2. Healed ridges (3-4 mm soft tissue thickness above alveolar bone)

• become more labor-intensive, when delayed pontic conditioning is required.
• Presence of an excessive soft tissue, interfere with the interim restoration sitting due to the resistance from the
healed gingival tissues.
• If this happens, gingivoplasty or prosthodontic site-conditioning must be done to adapt the pontic to the
gingiva.

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• First, The interim restoration is prepared in the laboratory on a working cast imitating the emergence profile of
the adjacent teeth by sculpting the plaster 2 mm where the ovate pontic design is needed

• The clinician's challenge is to design the proper pontic space intraorally in the soft tissues to serve as a recipient
site for the interim restoration designed.

• The patient bites down on a cotton roll so that the interim restoration should push the soft tissues buccally.

• The interim restorations should apply light pressure on the gingiva.

It is important to note that:
• The pressure creates ischemia so the amount of pressure exerted must allow the soft tissues to recover the blood supply within 5 min.
• This procedure can be repeated every 2 weeks until the proper soft tissue contours are created.

Gingivoplasty or tissue sculpting is a minimally invasive procedure for tissue conditioning.

Methods for gingivoplasty: Laser, bur abrasion, and electrosurgery can be used for conditioning of the pontic site by
removing the epithelium 1 mm and applying pressure to the soft tissues immediately with the interim restoration.
• The interim restorations can be readjusted and polished after 2 weeks if necessary.
• After gingivoplasty, the mucosa heals by second intention over weeks.
• Interim restorations should be kept for 3 months, but there is little evidence for this.

Instead of gingivoplasty or tissue sculpting, a central incision with a scalpel is enough for
shallow pontic defects.
• This incision can also be made vertically, with lateral gingival displacement at pontic site.
• H or T-shape incision helps seat the interim restoration at the same time as small amount of soft tissue are displaced and adapted to the
provisional, enhancing the emergence profile's appearance

If the needle probing reveals a soft tissue depth of only 2 mm,

surgical procedure with osteoplasty of the ridge is necessary.
rarely, this excessive bone is due to tooth extrusion, and an osteotomy done to properly seat the interim
restoration,

Clinical steps:

• Mucoperiosteal "trapdoor" flap is raised from the palatal aspect ( to avoid labial scarring) ,providing access to the
underlying flat osseous ridge.
• Osteoplasty of the ridge to develop rise and fall similar to that of the adjacent teeth.

• leaving a minimum of 2 mm of space between the pontic design outline to the bone crest for biological width.

• Osseous topography following the osteoplasty procedure in the radiographic figure.

Depending on the type of pontic to be used, the flat osseous ridge is reshaped in one of two ways

Ovate Pontic--The flat ridge is reshaped so that when viewed from the direct buccal aspect, it is in harmony with the
scalloped osseous form of the adjacent teeth.
• Next, a depression 1 mm deep and 5 mm in diameter is created midway between the two abutments in line
with the central fossa

Modified Ridge Lap Pontic--The flat ridge is decreased in width from the lingual aspect only, allowing the
pontic to make contact predominantly on the buccal aspect, since this pontic touch the gingive in T-zone.
• For esthetic reasons, an indentation is then created on the buccal aspect which permits the placement of a
pontic which blends in with the adjacent teeth
• The flap is sutured in position over the reshaped alveolar ridge (the pontic recipient site) and held by
the pontic until healing occurs

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 Laser has been used for creating a gingival profile of an ovate pontic
• The diode laser-introduced in the late1990s-
• has been effective for oral surgery, endodontic treatment and soft tissue procedures.
• This laser also helps treat oral cavity disease and corrects aesthetic flaws.
• Used at wavelength of 808 to 980 nm.
• Laser’s Advantages over conventional procedure:
1. minimally invasive.
2. good healing tendency.
3. minimal postoperative bleeding of the site.

Electrosurgery electric current is precisely applied to the soft tissues by electrodes to obtain cutting of tissues.
Advantages
• Tissue separation is clean with little or no bleeding.
• The technique is pressureless and precise.
• Planing of soft tissue is possible.
• Healing discomfort and scar formation are minimal.
• Chair time and operator fatigue are reduced. (Fast technique)
Disadvantages
• Can not be used on patients with pacemakers or near flammable gas.
• The odor of burning tissue is present but can be overcome by using high-volume suction.
• The initial cost of the ES equipment is far greater than the cost of a scalpel.

CLINICAL TECHNIQUE of ( Flat Pontic)

1) Fabricate an interim poly-methyl-methacrylate (PMMA)restoration with a pontic to replace the missing tooth structures.

2) a microsurgical soft tissue preservation is done when the tooth is extracted. Or An augmentation
technique is necessary in a healed ridge when a hard tissue, soft tissue defect, or a combination of both is
present.
The interim restoration isDesigned with a flat surface and an acute angle between the palatal and
facial surface which allows enough space for the soft tissue overcorrection
▪ Placed after the extraction and soft tissue preservation procedure.
3) Recall the patient after 2-month of interim insertion.
as after 2 months of healing period,
a shrinkage of 25–45% of the soft tissues is present
So, Relining of the basal area of the pontic is necessary, as it is important to keep a flat surface.
4) The angle between the facial and basal surface has to be changed making it perpendicular or even obtuse to the underlying tissues.
• The provisional restoration should be introduced at least 0.5–1 mm into the overcorrected gingiva, causing the soft tissues to blanch.
• The blanching of the gingiva should disappear within 5 min.
• If ischemia last > 5 min and a thick phenotype is present, a gingivoplasty with ( electrosurgery , laser , or a round bur ) can be performed
to seat the interim restoration with the desired shape.

The flatter and wider the basal surface of the pontic design is,
1. the more the soft tissues are pushed facially and proximally,
2. The more supporting the papillae
3. and the more shaping the crown's buccal sulcus imitating a natural tooth.

The F-pontic design should be:

• equi-gingival on the facial
• subgingival in the interproximal areas.
• gradually sloping lingually where it is positioned supragingival .
After 3 months of stabilization:
the final impression and final restoration can be made.
• The larger the site reconstruction procedure, the longer the clinician should wait for the maturation of the tissues before delivering the
final prosthesis.
• In the esthetic sector, a 6-month waiting period is recommended before the final impression to ensure long-term stability of the
reconstructed tissues.

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 If any shrinkage and loss of ridge volume occurs during the interim stage ??
the F-pontic can be easily modified into a step pontic or an ovate pontic by adding composite to the basal area of interim restoration.
• The final restoration will be copy-milled from the interim restoration:
to maintain the adequate contours which ensure esthetic and biologic stability of the prosthesis upon delivery.

Step pontic ( similar to flat pontic but Designed by creating a 1–1.5 mm concavity in the subgingival facial
aspect of the restoration with a flat or ovate design.
• This concavity will:
1. alleviate the pressure on the mucosa allowing the coronal migration of the gingiva.
2. Provide a more natural emergence profile.
3. better stability of the marginal tissue.

Clinical technique

• Fabricate an interim poly-methyl-methacrylate (PMMA)restoration with a pontic to replace the missing tooth structures.
• 2 weeks after delivery of the interim restoration, re-assess if any coronal migration of the soft tissues has occurred.
• at least 3 months waiting with interim restoration: in cases where a healed ridge was present and a tissue
reconstruction procedure was done.
• A 6-month period is recommended: in cases where a tooth was immediately extracted.
The waiting period is important:
to ensure tissue stability before the final impression is made.

Impression technique for these pontics:

• A pick-up impression or a digital intraoral scan (will be discussed

later) can be made to precisely communicate the final design to the
laboratory technician.
1. Create a provisional restoration that simulates the design of the definitive
restoration. Figure 1
2. After tissue sculpting, make a complete arch impression by using a custom tray.
3. Cast the impression with stone to produce a definitive cast that will allow the lab technician to fabricate the FPD framework
4. Evaluate the framework intraorally. (There may be a gap between the FDP and gingiva)
5. So place the provisional FPD in position (wimout provisional cement), make a transfer impression of the
FPD, using a heavy-body vinyl poly-siloxane material
6. Remove the impression from the mouth, ensuring that the provisional restoration remains in the impression
(figure 1)
7. Isolate the impression and the provisional restoration with separating media. Inject a medium- vinyl
polysiloxane impression material into the impression to obtain a silicone cast. Figure 2
8. remove the silicone cast from the impression. (Figure 2)
9. Adapt the FPD framework on the silicone cast and reline it with a self-curing or light-cured acrylic resin according
to silicon cast.(figure 2)
10. Place the customized FPD framework intraorally over the abutment teeth, pick-up impression of the structure made
by a medium-viscosity polyether or vinyl polysiloxane (VPS) to transfer the pontic design to the working cast where
you have recorded the accurate dimension of the pontic and gingiva.
✓ Pick-up impressions of the interim restoration or the bisque try-in are essential to:
1. properly communicate the amount of ceramic necessary to shape the prosthesis's emergence profile with the
dental laboratory.
2. communicate the precise soft tissue impactation that consists on adding composite resin to the framework or
bisque try-in to the lab

19
 Technique and Procedure in the Fabrication of the E-Pontic
1. Determine the amount of tissue thickness over the edentulous ridge by:
osseous sounding the alveolar crest with a periodontal probe or endodontic file.
• At least 2 mm of soft tissue over the alveolar bone is necessary to create the site
• Ideally: 3–5 mm of soft tissue coverage.

2. At the tooth preparation and impression appointment,

the pontic site does not have to be anatomically developed by the provisional at this stage;
because the site will begin anatomical development at the delivery appointment.
However, it is important to have the appropriate amount of mature tissue on the facial aspect of the ridge to embed the
pontic.

3. The master models are fabricated and mounted on a semi-adjustable articulator with a facebow
and an appropriate centric relation or maximum intercuspation position registration.
• The ceramist completes the sculpting of the pontic site based on the final contours and outline form
of the pontic on the solid and sectioned master models.
• It is important to instruct the ceramist to create 90-degree line angles facially and interproximally when sculpting the model at a
predetermined depth.
• The E-pontic is then adapted to the sculpted pontic site on the model.
• The sharp line angles that are formed between the tissue side and the 90-degree walls of the pontic
are critically important components of the E-pontic design for developing and stabilizing the gingival
tissue.
• This pontic design has a flat surface on the tissue side of the pontic enables the dental floss easily make
contact with all its surfaces.

At the delivery appointment (gingivoplasty)

a color transfer applicator is applied to the tissue surface of the pontic and then imprinted onto the pontic
tissue site while seating the FPD.
The tissue imprint :
1. represents the gingival outline of the pontic.
2. acts as a guide for electrosurgical or laser surgical contouring of the tissue.
The pontic site is surgically sculpted layer by layer until the prosthesis is almost fully seated.
The sculpting depth is:
➢ primarily at the facial and interproximal line angles
➢ minimal sculpting as you move lingually along the pontic tissue site.
• The patient is then instructed to close down on a cotton roll for approximately 10 minutes with the prosthesis in
place until blanching abates.
• The goal is to visually identify blanching of the tissue around the pontic site; to ensure that tissue compression
is taking place facially and laterally.
• Thus, this process squeezes the tissue:
1. to fill interproximal space, achieving the desired tissue volume and papilla height due to The flat pontic design
with its sharp 90-degree line angles
2. promoting coronal migration of the facial gingival tissue over the pontic

20
 A 2-month and 17-month postoperative view of a posterior FPD

The pontic is:

➢ subgingival on the facial and interproximal aspects.
➢ gradually sloping up to the lingual, where it is positioned on top of the tissue.

References:
• Garber DA, Rosenberg ES. The edentulous ridge in fixed prosthodontics. Compend Contin Educ Dent
(Lawrenceville). 1981 Jul-Aug;2(4):212-23. PMID: 6950860.
• Korman, R.P. (2015), Innovative Pontic Design and Periodontal Plastic Surgery. J Esthet Restor Dent, 27:
13-28.
• Gomez-Meda, R, Esquivel, J. Perio-prosthodontic pontic site management, part I: Pontic designs and
their current applications. J Esthet Restor Dent. 2023; 1- 12.
• Gomez-Meda, R, Esquivel, J. The flat and step (F and S) pontics. Novel pontic designs for periodontally
reconstructed sites. J Esthet Restor Dent. 2022; 34( 7): 999- 1004.
• Walid, A. (2020) Application of Laser Technology in Fixed Prosthodontics
—A Review of the Literature. Open Journal of Stomatology, 10, 271-280.
• Guruprasada. Creating natural gingival profiles of missing anterior teeth using ovate pontic. Med J Armed
Forces India. 2015 Jul;71(Suppl 1):S124-6. doi: 10.1016/j.mjafi.2012.01.001. Epub 2012 Nov 3. PMID:
26265806; PMCID: PMC4529523.
• Marzadori, M., Stefanini, M., Mazzotti, C., Ganz, S., Sharma, P. and Zucchelli, G. (2018), Soft-tissue
augmentation procedures in edentulous esthetic areas. Periodontol 2000, 77: 111-122.

21
 PRETREATMENT ASSESSMENT
Pontic space
Residual ridge
ridge contour
Certain procedures enhance the success of an FDP. In the treatment-planning phase, diagnostic casts and waxing procedures may prove especially valuable
for determining optimal pontic design

Pontic Space
One function of an FDP is to prevent tilting or drifting of the adjacent teeth into the edentulous space. If such movement has already occurred, the space
available for the pontic may be reduced and its fabrication complicated. At this point

• Drifting / tilting and opposing over erupted

• Reduced pontic space
• difficult in fabricating pontic

tilting and opposing tooth over erupted Reduced pontic space /After missing teeth adjacent teeth Drifting

1-Treatment modalities for a decreased pontic space mesio distally

If tilting with in 25 degree acceptable conventional fixed partial denture
If tilting more than 25 degree alternative treatment will be considered
A. ortho dontic reposition
B. Modification of abutments with complete coverage retainers, where the space discrepancy is distributed over the retainers and the pontic
Use small pontics in non ethatic zone

A. Anterior tilting
Problem of anterior tilting
The primary concern of the tilted anterior abutment is to achieve a common path of insertion as well as manage the space problem with a pontic dimension of accepted
esthetic
Treatment options
1. Orthodontic treatment

2. implant

3. Fixed bridge
22
1. Orthodontic Space Closure of a Missing Maxillary Lateral Incisor Followed by Canine Lateralization

2. Fixed bridge
On the primary cast primary reduction is done to assess the amount of reduction that will be needed and the finish line design then diagnostic wax up will be done to assess
the final shape of the teeth
In case of tilting causing space problem if
Minor 1 mm to 1.5 mm ..> solved by optic illusion (color and staining, principle of lines, arrangement of teeth)
Moderate 2mm ..>space redistribution on the whole abutments in the design
Severe…> Reshaping with slight contoured crowns

Minor space problem could be managed by the following:

law of the face:
Shadows created as light strikes the facial surface of the tooth begin at the transitional line angle.
These shadows delineate the boundaries of the face.
Changing the position of line angle ...> changes the amount of light reflected from the surface
Placing line angles close to each other …> longer crown
Placing line angles far distally...> wider crown

principle of line.
the use of horizontal and vertical lines. (by staining and texturing)
A horizontal line causes an object to appear wider and shorter
vertical line causes an object to appear longer and narrower

Using color modifiers

Moderate space problem could be managed by:

A diagnostic waxing up is done with a mock up for the patient following the RED ratio to assess the amount of distribution of the space to the abutments assessment of

the final look

Severe space problem could be managed by:

Reshaping with slight contoured crowns
Over contouring the tooth mesio-distally ….> appears narrower
Under contouring mesio-distally..> appears wider
Over contouring inciso-cervically..>> appears shorter
Under contouring inciso-cervically..> appears longer

\Orthodontic treatment or Fixed restoration

23
A retrospective study was done on orthodontic space closure versus restorative treatment in anterior area
Conclusion The acceptance of the morphology change and colour in the maxillary anterior area was greatly influenced by the patient aesthetic perception, thus affecting
the result toward more favoring the results after orthodontic treatment

B. Posterior tilting
Problem of tilted molars
1. Tilting in one of the abutments results in discrepancy in the long axis of the abutment result in impairing the seating the fixed partial denture because the
tooth distal to the FPD intrudes on the path of insertion

2. space reduction
3. Supra-version of the antagonist
4. Can cause food impaction
5. dental caries and periodontal problem

treatment options
tilting is slight less than 25
recontouringthe mesial surface of the second molar
May cause over tapering of second molar and decrease in retention
solution
1. Addition of facial and lingual grooves on the preparation

2. Using split pontic Cross Pin and Wing and kye kye hole

3. using a proximal half crown

4. using a telescope crown

5. use of non-rigid connector

1. Addition of facial and lingual grooves on the preparation

the problem can be solved by restoring or recontouring the mesial surface of the tilted molar by selective grinding technique: which is done on the diagnostic cast

a feather edge finish line design is preferred in the tilted surface to be more conservative
the over tapered second molar preparation must have its retention regained by the addition of facial and lingual groove

use of a split-pontic design

A segmented fixed dental prosthesis provides a very conservative solution for mis-aligned abutments.
The incorporation of a non-rigid connector in the form of a split-pontic design provides for a periodontal favorable prosthetic strategy.

Cross Pin and Wing

Mesial retainer with mesial part of the pontic with hole
Distal retainer with distal part of the pontic with hole

24
Dove tail (key-key lock) or (tenon- mortise)
Precision Attachment Is Included In The Retainer

Accurate alignment of the dovetail or cylindrically shaped mortise is crucial; it must parallel the path of placement of the distal retainer. Paralleling is normally accomplished
with a dental surveyor.
When the cast is aligned, the path of placement of the retainer that will be contiguous with the tenon is identified.
The mortise in the other retainer is then shaped so that its path of placement allows concurrent seating of the tenon and its corresponding retainer.
The mortise can be prepared freehand in the wax pattern or with a precision milling machine. Another approach is to use prefabricated plastic components for the mortise
and tenon of a nonrigid connector
In general, the use of attachments, whether extracoronal or intracoronal, should be limited. Attachments add to the complexity and cost of the restorative service and
often necessitate remaking the fixed retainers when the attachments wear out.

Orthodontic treatment
✓ A helical up righting spring is inserted in to a tube on the banded molar and activated by hooking it

helps in distribution of forces under occlusal loading

helps to eliminate bony defects along the mesial surface of the root

GINGIVALLY PONTIC DECREASED SPACE INCISO-

Due to over eruption opposing tooth to edentulous space. If a tooth supra-erupts, it can eventually grow out of the socket ! It can
also cause you to bite your cheek It can be difficult to keep clean ,

• Treatment modalities
• ) Enameloplasty to remove 1-2mm of the enamel to improve the occlusion

• . 2) RCT if reduction of enamel so drastic the pulp will definitely be affected more than 2 mm .

• 3 (Extraction of the tooth if the root is involved and the tooth is too far outward .

• 4) Orthodontic intrusion.

• 5) Surgical reconstruction of the edentulous space.

INCISO-GINGIVALLY 4 -INCREASED PONTIC SPACE

• Due to bone resorption in pontic site

non surgical modalities

• In mild bone resorption
• Recontouring of the cervical half of the labial surface of pontic . overcome the shadow under the pontic

25
 In moderate bone resorption
• Simulate a normal crown and root With emphasis on the cemento enamel junction Root can be
stained to simulate exposed dentin.
•
• The use of pink porcelain. With modified ridge lab pontic

• The use of removable partial dentures in cases of severe defects. Residual ridge contour
Ideally shaped ridge

MASK) The use of gingival mask (G-

• A gingival mask (also called removable artificial gingiva or gingival veneer) consists of a prosthesis
made of thermoactivated acrylic resin in a color similar to the gum tissue.
• - It is placed on the labial surface of the teeth. The veneer's function is to restore the
mucogingival contour and esthetics in areas where periodontal tissues are deficient.
• Indications:
• 1. To cover-exposed crown margins, exposed implant components and root surfaces and reduce the length of the
clinical crown.
• 2.To block out the black triangles between teeth in which gingival recession has occurred. To fill in the space between the crown and the soft tissue.
• 3. To prevent airflow through or beneath maxillary fixed restorations or through the spaces between the teeth and thus improving phonetics.
• 4. To provide increased lip and cheek support for those patients who require it.
• 5. It is also beneficial for patients with high lip lines and a gummy smile who have been treated with osseo integrated dental implants.
• Contraindications:
• 1. Patients with poor plaque control
• 2. Unstable periodontal health
• 3. High caries activity
• 4. Smoking 5. Known allergy to acrylic or silicone
• Retention forms:
• 1. Mechanically: with tiny extensions of the mask material slightly projecting between the roots of the natural teeth or the implants just above the gum
line
• 2. Natural capillary action created by the saliva
• 3. Pressure of the lips against the gingival prosthesis.

• In severe bone resorption:

• Removable partial denture is better indicated rather than fixed partial denture

• Residual ridge contour:

• The edentulous ridge’s contour and topography should be carefully evaluated during the treatment-planning phase
• The edentulous ridge’s contour and topography should be carefully evaluated during the treatment-planning phase

An ideally shaped ridge has

• A smooth, regular surface of attached gingiva, which facilitates maintenance of a plaque-free environment.
• Its height and width should allow placement of a pontic that appears to emerge from the ridge and mimics the appearance of
the neighboring teeth.
• Facially, it must be free of frenum attachment and be of adequate facial height to sustain the appearance of interdental
papillae.

26
Loss of residual ridge contour may lead to:
• Un esthetic open gingival embrasures (“black triangles”)
• Food impaction

• Percolation of saliva during speech

deformities into three categories: Siebert classified residual ridge

• Class I defects: faciolingual loss of tissue width with normal ridge height
• Class II defects: loss of ridge height with normal ridge width
• Class III defects: a combination of loss in both dimensions

The incidence of residual ridge deformity after anterior tooth loss is high (91%); in the majority of these patients, the deformities are class III defects. Because
many patients with class II and class III defects are dissatisfied with the esthetics of their FDPs ,pre prosthetic surgery to augment such residual ridges should
be carefully considered

Surgical modification:
• Although residual ridge width may be augmented with hard tissue grafts, this is usually not indicated unless the edentulous site is to receive an
implant
•
•
•
• Class I Defects:
•
• Soft tissue procedures have been advocated for improving the width of a class I defect; however, because class I defects are infrequent and are not
esthetically challenging,surgical augmentation of ridge width is uncommon.
• Soft tissue procedures used:
• I. Roll technique

27
 • II. Pouch technique
Steps of roll technique:
• Soft tissue from the lingual side of the edentulous site is used where its epithelium is removed
• 2) Flap is elevated creating a pouch on the vestibular surface
• 3) Flap is rolled back upon itself and into the pouch thickening the facial aspect of the ridge and enhancing its
width
Steps of pouch technique
• Split-thickness flap is reflected
• 2) Submucosal / subepithelial graft -harvested from the palate- is placed in the pouch
• 3) Flaps are sutured in place, thus increasing ridge width
Class II and Class III Defects:
• Soft tissue procedures used:
• I. Interpositional graft
• II. Onlay graft
pouch technique): Steps of interpositional graft ( variation of the
• 1) A wedge-shaped connective tissue graft is inserted into a pouch preparation on the facial aspect of the residual ridge
• 2) The epithelial portion of the wedge may be positioned coronally to the surrounding epithelium
if an increase of ridge height is desired
Onlay graft
• The onlay graft is designed to increase ridge height, but also contributes to ridge width, which
makes it useful for treating class III ridge defects.
• It is a thick “free gingival graft” harvested from partial- or full-thickness palatal donor sites.
• Because the amount of height augmentation can be only as thick as the graft, the procedure may have to be repeated several times to reestablish normal
residual ridge height.
Reference

International Journal of Dentistry Research 2019; 4(3): 108-111 Partial extraction therapies- A review Ankita V. Chitnis1 , Gaurang Mistry2 , Padmapriya •
Puppala3 , Omkar Shetty4 • Pontic Site Management Tarun KumarSudhindra ulkKarniUdatta Kher First Online: 03 January 2020 • A root submergence
technique for pontic site development in fixed dental prostheses in the maxillary anterior esthetic zone Sunyoung Choi, I. Yeo, +3 authors J. Han Published
2015 Medicine Journal of Periodontal & Implant Science • Kher, U., & Tunkiwala, A. (Eds.). (2020). Partial Extraction Therapy in Implant Dentistry. •
Predictability of a New Orthodontic Extrusion Technique for Implant Site Development: A Retrospective Consecutive Case-Series Study 25 Jan 2020 • Jul-Aug
1981;2(4):212-23. The edentulous ridge in fixed prosthodontics D A Garber, E S Rosenberg • Journal of Indian Society of Periodontology, 01 Jul 2014, Soft
tissue expansion before vertical ridge augmentation: Inflatable silicone balloons or self-filling osmotic tissue expanders? • Correction of anterior ridge defect
for conventional prosthesis January 2008The Journal of the Korean Academy of Periodontology • Gingival Architecture Preservation Last Updated on Thu, 18
Feb 2021 | Tooth Structure • Soft Tissue Volume Augmentation Using Connective Tissue Grafts via Apical Pouch: Technical Considerations and Case Reports. P.
Lin, L. Claman, H. Chien Published 2016 Medicine The International journal of periodontics & restorative • KNOW SELECTION CRITERIA FOR PONTIC AND
DESIGNS! sangeetaporiya.spDecember 20, 2019 • Posterior maxillary segmental osteotomy for management of insufficient intermaxillary vertical space and
intermolar width discrepancy: a case report,2016 • ,5th Contemporary Fixed Prosthodontics Edition Considerations for s

28
Considerations
affecting pontic design

By alaa sayed
Biological considerations:
1.Ridge contact

2.oral hygiene considerations

3. pontic material

4. porimal contact

5. buccal and lingual contours

29
6.occlusal forces

1. Ridge contact
1.Pin point pressure free Contact between the pontic and underlying tissues is indicated to prevent
any inflammation or ulceration of soft tissues

2. Contact should occur exclusively on keratinized attached tissues

3.Area of contact should be small and convex

4.If the tip of the pontic extends past the muco-gingival junction an ulcer will form there

5.when esthetics is not of prime concern as in posterior area where attention is paid to oral hygiene
and function, ridge contact can be totally avoided .

6. - any blanching of soft tissues is observed in try in, the pressure area should be identified with
disclosing medium (I. e pressure indicating paste) and the pontic is recontoured until tissue contact is
entirely passive .

-Blanching and positive ridge pressure may be due to excessive scraping in the ridge area on the
working cast in an attempt to improve appearance of ridge pontic relationship .

7.No junction between to different materials is allowed in tissue surface of the pontic

8.Evaluation of ridge pontic relationship should be done in try in stage.

9.pontic ridge relarionship varies according to pontic design and could be:

a. Sanitary and modified sanitary : no ridge contact

30
b.Ridge lap pontic : large concave tissue contact

c.Modified ridge lap pontic :pinpoint passive tissue contact should resemble letter T

d.Stein pontic :minimal passive convex tissue contact

e.conical pontic : one point of contact at the center of residual ridge

31
f.Ovate pontic and modified ovate pontic:

1- convex tissue contact

2 – 1 – 2 mmm mucosal extension

3- applying light pressure on gingiva, blanching of gingiva should disappear within 5 minutes, if not,
gingivoplasty is recommended

g.Step and flat pontic : passively contacting a wide area of ridge

h. E.pontic : It has flat surface on the tissue side of the pontic resembles

the anatomical cross-section of a tooth at the cementoenamel junction.

32
 2. oral hygiene

1.The shape of the gingival surface, its relation to the ridge, and the materials used in its fabrication
influence ultimate success.

- Gingival embrasures around the pontic should be wide enough to allow oral hygiene aids.

- Contact between pontic and tissue must allow passage of floss from one retainer to other

However, to prevent food entrapment, embrasures should not be opened excessively.

- Research makes it evident that plaque is the main predisposing factor for the onset of gingival and
Periodontal diseases as well as caries.

fixed prosthesis may make it more difficult to maintain dental hygiene, worsen plaque buildup, and
raise the risk of periodontitis and dental cavities. Higher plaque buildup and gingivitis has been found
to be present more frequently in areas in contact with the bridge pontic and subgingival margin of
bridge retainer.

33
Margins coronal to gingival attachment, proper marginal fit, proper emergence form, smooth pontic
faces, embrasure spacing and passive pressure on the mucosa underneath have all been suggested as
features in crown and bridge construction to minimize these concerns

design, structure, and hygiene specifications of the pontic have been researched and found to be
more important than the material on its own in preventing any inflammation in edentulous area

2.Normally, where tissue contact occurs, the gingival surface of a pontic is inaccessible to the bristles
of a toothbrush

Therefore, the patient must develop excellent hygiene habits. Devices such as proxy brushes, Oral-B
Super Floss (Oral-B, Procter & Gamble), and dental floss with a threader,waterpik flosser

- Floss Threaders: Threaders feature a flexible piece of plastic designed to help maneuver dental floss
around and between any dental work such as braces and bridges.

- Super Floss: The first part is stiffened-end dental floss. The spongy part (middle segment) of the
floss consists of cotton or nylon threads coated with wax. The end part is a simple wax-coated piece of
thread.

- The Waterpik® Water Flosser and Sonic-Fusion® makes flossing easier and more effective than the
alternatives. Clinical research confirms that the Waterpik® Water Flosser is significantly more effective
than string floss, interdental brushes, and air floss for reducing gingivitis and improving gum health.

34
 3.pontic material
Investigations into the biocompatibility of materials used to fabricate pontics have centered
on two factors:

(1)the effect of the materials and (2) the effects of surface adherence

The effect of materials

Materials used for pontic fabrication :

1 - Metal and metal alloys

I. HIGH-NOBLE ALLOYS:

II. GOLD-PLATINUM-PALLADIUM

III. GOLD-PALLADIUM-SILVER

35
IV. GOLD-PALLADIUM

II. NOBLE ALLOYS

1. PALLADIUM-SILVER

2. PALLADIUM-COPPER-GALLIUM:

palladium 79%, copper 7%, and gallium 6%

3. PALLADIUM-GALLIUM

III. PREDOMINANTLY BASE METAL ALLOYS:

1. NICKEL-CHROMIUM

2. COBALT-CHROMIUM

2. TITANIUM AND TITANIUM ALLOYS:

4 –Commercially pure titanium grade 4

Noble alloys

1.The corrosion resistance of the alloys is due to the high

thermodynamic stability of the gold in the alloys In simulated body
fluids and oral environments, gold alloy would not be prone to pitting
or crevice corrosion

2. Allergy to gold is improbable, although allergic reactions to gold

salts are well recognized. Previous authors have reported contact
sensitivity to gold.

36
3.the oral environment is moist and may permit slow dissolution of
elemental gold into gold salts capable of provoking a
reaction.Wiesenfeld, D., Ferguson, M. M., Forsyth, A., & MacDonald,
D. G. (2005, May 15).

Nickel chromium alloys

1.showed unstable galvanic corrosion behavior

2.some of the nickel-based alloys have been shown to be susceptible to pitting and/or crevice
corrosion

3.once the oxide film on the alloy has been disrupted, the alloys are difficult to re-passivate

4.beryllium-containing nickel alloy was susceptible to localized corrosion

Stainless-steel alloy
1.the coating which is formed by chromium oxides, is extremely thin and transparent

2.This protective layer does not form as easily in a solution containing chloride ions because
saliva contains high levels of chloride ions as the result from the presence of sodium chloride,
stainless-steel surfaces can be corroded in the mouth when they are scratched

Dental casting alloys

1.Numerous in vitro studies have documented that each metallic dental

restoration releases cations due to corrosion

2.Cu, Ni, Ag and Be have pronounced cytotoxic potency

3.Ni, Co, and Cr, can modulate the immune response

4.Local and systemic allergic reactions to many metals have been observed,
with Ni being the most frequent allergenic element

37
5.Laboratory technicians have a higher risk for fibrotic lung diseases due to dust
from metals and abrasives

Palladium
1.palladium based alloys have been reported as causative agents in cases of stomatitis, oral
lichenoid reactions, and disseminated urticaria.

2.Palladium allergy seems to occur in patients who are sensitive also to nickel.

3.Titanium allergy has a low prevalence rate of 0.6%

- consequences of tarnish and corrosion of materials used for pontic

fabrication :
1.metallic taste

2.discoloration of teeth

.3.galvanic pain

4.oral lesions :The released metallic ions from corrosion reactions can interact with the oral
tissues to generate, swelling, and infection. Oral lesions can then occurs

.5.change in dimension and mechanical properties thus altering fit and functionality of
restorations

6.Poor esthetics .

Dental ceramics :
Ceramics are biocompatible inert materials

Biological advantages :

38
1 - Low thermal conductivity: no thermal shock to the prepared tooth.

2. No electrolytic corrosion.

3. No metal preparation: no metal inhaled during metal finishing.

4. Resistant to degradation in oral fluids.

-An evaluation in human subjects conducted on commercially pure titanium and zirconium
oxide discs (Y-TZP) examined early bacterial adhesion to these surfaces. The authors reported
that the early adhesion/colonization of bacteria on zirconia surfaces was significantly less
compared to titanium surfaces

- Bremer et al investigated the formation of oral biofilm on various dental ceramics in

vivo and reported that zirconia ceramics were superior to lithium disilicate glass ceramics in
terms of inhibiting bacterial adhesion. In their study, the highest values of biofilm coating and
biofilm thickness were found on lithium disilicate glass ceramics.

Effect of surface adherence

1. Vita Enamic, Lava Ultimate, and Cerasmart .

Non-polished surfaces showed much higher surface roughness and

bacterial adhesion compared to polished surfaces

. Polishing processes affected the surface properties and bacterial

adhesion.

2.The degree of enamel wear associated with monolithic zirconia was

similar to conventional feldspathic porcelain. Smoothly polished

39
ceramic surfaces resulted in less wear of antagonistic enamel than
glazing.

3.polished zirconia caused significantly less wear to enamel than the

glazed zirconia.” it is also concluded, “the polished zirconia remained
unchanged, but the glazed zirconia showed significant loss of the glaze
layer.

4. the monolithic zirconia, significantly higher bacterial adhesion were

noted in the glazed than polished specimens .

5. in terms of improving flexural strength and restoring surface

roughness after grinding, polishing protocols can be considered the
best indication as post-processing treatment after YSZ ceramics
adjustments/grinding.

4 – proximal contacts

1.Anterior region: proximal embrasures are minimal for primary

esthetic

40
BUT should at least allow space to prevent papillary impingement

2.Posterior region : embrasures become wider

5.buccal and lingual contours

- Contours : pontics must be of natural contours in harmony with

adjacent retainers and natural teeth

- Overcontouring: leads to accumulation of dental plaque in the area

between the equator and Residual ridge

- Undertcontouring : mucosal injury and inflammation

.6 – Occlusal surface
A.BUCCOLINGUAL WIDTH :

Reducing the buccolingual width of occlusal table has been suggested

to lessen occlusal loads and improve chewing efficiency

However critical analysis reveals that :

41
1- forces decrease only when chewing food of uniform consistency

2- There is a little increase in chewing efficiency (12%) from 1/3

reduction in occlusal width

3 – narrowing occlusal table may preclude development of

harmonious stable occlusion

4 – narrowing occlusal table may not provide adequate cheek support

5- narrowing occlusal table may cause difficulties in plaque control

FOR THESE REASONS :Normal occlusal width is generally

recommended

Unless the residual alveolar ridge has been collapsed buccolingually

reducing the buccolingual contour will then be recommended to
facilitate plaque control

B.Height of occlusal table :

42
The same height as the missed tooth (it’s a matter of supra-eruption
of the opposing teeth)

Class 2 malocclusion may be associated with deep overbite and

decreased vertical dimension , in these situation the pontics may be
designed to increase the vertical dimension ( similar to the effect of
orthodontic extrusion)

C.Occlusal schemes: number and location of occlusal contacts has an

effect on loads transmitted to abutment teeth

If occlusion and TMJs are within normal limits then treatment should
be done to maintain the normal relationship

Care should be taken to avoid :

1 – contact on inclined planes of occlusal anatomy which transmits

Undesirable horizontal loads to abutment teeth.

43
2 – Posterior contact in eccentric movements

Mechanical considerations

1-occlusion and position of edentulous area

1.Locations of edentulous area determines Magnitude and direction of forces

directed towards the pontic

1. In posterior area : direction of forces is mainly towards the long axis.with

greater magnitude of forces

2. In anterior area : A- upper anteriors : direction of forces is palato-labial

B- lower anterior area : direction of forces is labiolingual

2.Restorations of posterior teeth are subjected mainly to compressive loading,

while those of anterior teeth are mainly subject to tensile loading.

44
3.Intensity of stresses and stress concentration increase significantly when load
applied us not along long axis of tooth

Buccal cusps of lower molars and palatal cusps of upper molars take up most of
compressive loading So, the occlusal design should be planned to reduce
Magnitude of stresses by providing points of contact not wide areas of contact
with opposing teeth

2.Dimensions of edentulous area

Mesiodistally : increasing the mesiodistal distance of pontic increase the

bending of restoration.

45
Edentulous area limitations for bridge construction :

1 – Maximum of 2 posterior missing teeth

2 – maximum of 4 anterior teeth

3- maximum of missing canine and 1 adjacent tooth

Why?

- has been reported that all FPD, long or short possesses a certain degree of
bending or flexing when subjected to a load, the longer the span , the greater
the flexing

- Bending varies directly with the cube of the length & inversely with the cube
of the occluso-gingival thickness of the pontic.

Clinical sequelae of bridge flexing

Excessive bending may lead to failure of a long span FPD

being manifested clinically as:

1- Fracture of porcelain veneer.

2- Connector breakage

46
3- Retainer loosening

4 - An unfavorable tissue response.

How to minimize bending?

1. In long span bridge we may add secondary retainer that extend distance from
the primary intra abutment axes equal to the distance that the pontic lever arm
extends in the opposite direction

2 - The bridge must be constructed from a material with high rigidity and high
modulus of rupture so that it can be cast in thin sections without permanent
deformation.(base metal alloys rather than noble)

3- increasing occlusogingival thickness of pontic

3 - Arch curvature

1.Arch form affects the amount of stresses falling on pontic :

In V shaped arch : anterior pontics lie outside interabutment axis act

as lever arm leading to torquing forces

- Abutments in straight Line resist movement in single direction only,

while those in curved path will resist buccolingual and mesiodistal
movements

47
 How to overcome?

Secondary retention (R) must extend a distance from primary

interabutment axis equal to the distance the pontic lever arm(P)
extends to the opposite side

Esthetic principles
(previously discussed)
1. patient related factors

2. incisogingival length variations

3. mesiodistal width variations

4. gingival considerations

5. lip line considerarions

48
References :

-mulla anam nagib, agarwal abhinav (2017) : all about dental pontics:
bridging the gap - a review. journal of science, 7(8): 294-298

- Factors Influencing Abutment Selection in Fixed

Partial Denture-A Review Volume 7, Issue 4, April – 2022

- Contemporary fixed prosthodontics 5th edition

-2Bremer F, Grade S, Kohorst P, et al: In vivo biofilm formation on

different dental ceramics. Quintessence Int 2016; 42: 565- 574

Özarslan, M., Bilgili Can, D., Avcioglu, N.H. et al. Effect of different
polishing techniques on surface properties and bacterial adhesion on
resin-ceramic CAD/CAM materials. Clin Oral Invest 26, 5289–5299
(2022)

Elshahawy, W., Watanabe, I. & Kramer, P.1(2011). In vitro cytotoxicity

evaluation of

elemental ions released from different prosthodontic materials.

Dental Materials,

Vol.25, No.12, (July 2009), pp. 1551-1555, ISSN 0109-

Relationship between Pontics and Residual Ridge Mucosa : A

systematic

Review April 2021 , ustafa F. Laxmidhar, Vilas V. Patel

49
, Jayanti R. Patel

Gomez-Meda, Ramon, and Jonathan Esquivel. "Perio-prosthodontic

pontic site management, part I: Pontic designs

and their current applications." Journal of Esthetic and Restorative

Dentistry (2023).

Digital pontic design

by Amr Islam(Implant group)

Introduction

-Dental digital scanning systems were initially envisioned by Duret in the 1970s
for digital scanning directly in the patient’s mouth or on a cast
-Mörmann et al. developed the first in-office optical capture and ceramic
machining system which allowed chairside milling of inlays from pre-fired ceramic
blocks after optical data acquisition directly in the patient’s mouth

50
 -The first optical impression of a cavity was obtained in
1982

-Scanning technologies evolved in the subsequent

decades and gradually led to wider application expanding
from the initial optical capture of inlay preparations,
onlays, veneers, and eventually to crowns and short-span partial fixed
dental prostheses.

Evolution of Digital scanning

-The market penetration of digital scanning technologies has advanced

considerably in the last decade because of patient comfort, and because the
captured data permit acceleration of certain steps in the laboratory
fabrication process.

-In a systematic review and meta-analysis published in 2021, it was

reported that the patients preferred digital scanning over conventional
impressions and digital scans were less time-consuming than conventional
impression technique

Applications of Intra-oral scanning in the field of

dentistry:

51
Intra-oral scanners have many different applications in the dental field. The
current clinical applications of IOS are extremely wide, as these devices can not
only be used in fixed prosthodontics to obtain the virtual models needed to
manufacture a whole range of prosthetic restorations (single crowns, fixed partial
dentures) on natural teeth and implants, but also in implantology for guided
surgery and in orthodontics.

Some of the applications of IOS include but are not limited to;

-3D models for diagnostic purposes and communication

-Impressions of preparations of natural teeth for fabricating a wide range of
prosthetic restorations
- frameworks and fixed partial dentures
- Capturing the 3D position of dental implants and fabricating implant-supported
single crowns, bridges, and bars can be successfully fabricated from optical
impressions.

Advantages of digital scanning over

conventional impressions:

-Less time consuming

-More predictable results
-No storage space needed
-Higher patient satisfaction

52
Disadvantages of Digital scanning:

-Difficulty detecting deep marginal lines of prepared

teeth
-Learning curve
-Purchasing and managing costs

Current literature states that conventional impressions still appear to be the best
solution currently for long-span restorations, such as fixed full arches on natural
teeth and implants (with a higher number of prosthetic abutments).

Concepts of scanning in Dentistry:

-Most Dental scanners in the market utilize optical technology in the form of light
that captures the rendered object by forming a 3 dimensional point cloud(STL
image).
-Sensors in the Scanner head can measure the distance and angulation of the
object by reading the reflected light off the object while sending it to the software
to design a virtual record of the area being scanned.

Different types of intra-oral scanners in the market

-CERECT PRIMESCAN from Dentsply

Sirona
-AORAL SCAN from Shining 3D

53
 -iTero Element 2 from Align
-Emerald S from Planmeca
-Medit i700 by Medit
-Trios 4 by 3Shape
-CS3600 by carestream Dental

Main Principles of Digital scanning

-Triangulation Technique(ex, cerec bluecam, omnicam)

-Conofocal Laser Scanning, (ex, Trios, I Tero)
-Active Wavefront Sampling(AWS), (ex, Lava cos)

Accuracy of different Intra-oral scanners

It is very difficult to compare the results (in terms of trueness and precision) of the studies comparing
the accuracy of IOS as scanners have different image-capturing technologies and may therefore require
different scanning techniques; unfortunately, little is known about the influence of scanning technique
on the final results, and the scientific literature should address this topic in the coming years.

54
Different features of commercially available Intra-oral
scanners

A whole series of elements differentiate IOS in terms of their clinical

use. These include;

-Necessity of opacization with powder or not

-Scanning speed
-Tip size
-Ability to detect in-color impressions
- Proprietary/closed or 3rd party/open software(ex; STL file)

What are the tools needed to carry on with the digital

impression technique?

-The scanner itself which can come with a cord or can be

cordless/wireless

-A computer with a screen on it the installed scanning

software.

-In case of a digital implant impression, a scan body is

needed and is sometimes placed on the implant using a Ti-
base. The scan body transfers the position, depth, and
angulation of the Implant.

55
Technicalities of scanning and factors taken in to
consideration

-Clinician and chair position during scanning: upper &lower arch scanning and
bite record.

While taking digital impression of patient’s upper arch,

clinician should be beside or behind the patient and patient
should be supine/semi-supine for ergonomic reasons.
In case of lower impression taking, the clinician should be in
front of the patient and the patient should be upright

-lllumination of the clinic and dental unit: Intensity of Led light of room and unit
may affect accuracy of scanning as scanning technology works on sensors that
perceive light.
Direct light of unit away from area being scanned to avoid
confusion and misinterpretation of area being scanned by the
scanner.

56
-Color cancellation of objects simulating the oral environment: Avoid gloves and
mirrors of white or pink color that may simulate the teeth and soft
tissue.

-Moisture control: area of interest to be scanned should be dry. Surrounding area

should be somewhat moist.

-Lustrous areas: metallic restorations (amalgam, metal crown, etc) produce

artifacts during scanning leading to inaccurate results. A
special spray(titanium oxide) is used to matt these surfaces.

-Scanning Depth: It is usually at 16mm. Can be decreased or increased according

to the area being scanned.

Scanning of palate may require high scanning depth(ex:21 mm)

while scanning of bite may require low scanning depth(ex:
11mm) if patients tongue is interfering with the details of the
scan

57
Digital Pontic design

Digital design of a pontic is significantly useful

when the fabrication of a definitive ovate pontic
is desired especially when esthetics are of
primary concern.
-The established tissue beneath an interim
ovate pontic may collapse when an interim FDP
is removed and an impression is made.

Drawbacks of ovate pontic design using the conventional

impression technique

-In cases where soft tissue tissue collapse occurs prior to conventional impression
taking, the produced stone cast would be inaccurate and would require
modifications
-To ensure positive contact between the definitive ovate pontic and the stone cast
in such cases; scrapping of the cast is usually necessary.
-However, reshaping or porcelain additions to a definitive pontic may be necessary
at the evaluation phase, because the scraping is done arbitrarily

58
Advantages of digital pontic design

-Digital scanning of an interim ovate pontic

and the sculptured/ contoured soft tissue is
an alternative method to the conventional impression technique
-It provides a faster more predictable outcome than the conventional
technique with far less possibility of errors.
-This can be accomplished by scanning the provisional restoration outside of
the mouth to record the subgingival part and its undersurface and
superimposing it with the master scan.

Procedural steps of definitive pontic design fabrication

using digital technique

1-After sculpting the soft tissue with an interim FDP, draw lines on the palatal
surface of the interim FDP
2-Scan the maxillary teeth and the interim FDP with an intraoral digital scanner
(Fig 2). Remove the interim FDP and grasp it with cotton pliers to fabricate an
extraoral impression. Rescan the pontic beginning from the palatal surface and
moving toward the apical part(Fig 3)

Figure 2, Intraoral digital Fig 3, Extraoral

impression of interim digital impression
fixed dental prosthesis of intaglio surface
and remaining teeth, of ovate pontic,
frontal view. apical view.
59
3-Scan the abutments(master cast) (Fig4). Capture the antagonist and
maxillomandibular relationship. Transmit the digitized data to a laboratory.
4-Use CAD software to design the definitive FDP within the confines of the interim
FDP (Fig 5). Export the completed design to a milling machine.

Fig5, A Virtually designed fixed dental

Fig4, Intraoral digital prosthesis, frontal view. B, Duplicated
impression of abutments and ovate pontic, apical view.
pontic site, occlusal view.

5-Finally, inspect the definitive FDP intraorally and lute it (Fig 6).

Fig6, A Comparison between interim fixed

dental prosthesis and definitive fixed dental
prosthesis. Note replicated contour. B,
Definitive fixed dental prosthesis in place

60
Conclusion

-It is important whenever possible to fabricate a pontic that is both hygienic and
esthetic. Special consideration are needed to create a design that combines easy
maintenance, natural appearance, and adequate mechanical strength

-The evolving technology of Digital scanning in the past decade has allowed the
introduction of novel dental procedures that can provide both accuracy and
reliability in the field of dentistry.

-The digital design of a pontic has shown that the integration of digital technology
in fixed prosthodontics and the dental field in general will significantly improve the
procedure and final desired outcome

61
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McLaren E. CAD/CAM dental technology. Compend Contin Educ Dent. 2011;32:73. 89./Mörmann WH. The
evolution of the CEREC system. J Am Dent Assoc. 2006;137(Suppl):7S.
Manicone PF, et al. Patient preference and clinical working time between digital scanning and conventional
impression making for implant-supported prostheses: a systematic review and metaanalysis. J Prosthet Dent. 2021
S0022-3913(20)30794-0. Online ahead of print

Aragón ML, Pontes LF, Bichara LM, Flores-Mir C, Normando D. Validity and reliability of intraoral scanners
compared to conventional gypsum models measurements: a systematic review. Eur J Orthod. 2016;38(4):429–434.
doi: 10.1093/ejo/cjw033. Berrendero S, Salido MP, Valverde A, Ferreiroa A, Pradíes G. Influence of conventional
and digital intraoral impressions on the fit of CAD/CAM-fabricated all-ceramic crowns. Clin Oral
Investig. 2016;20(9):2403–2410. doi: 10.1007/s00784-016-1714-6. Gherlone E, Mandelli F, Capparè P, Pantaleo G,
Traini T, Ferrini F. A 3 years retrospective study of survival for zirconia-based single crowns fabricated from
intraoral digital impressions. J Dent. 2014;42(9):1151–1155. doi: 10.1016/j.jdent.2014.06.002

Zimmermann M, Mehl A, Mörmann WH, Reich S. Intraoral scanning systems - a current overview. Int J Comput
Dent. 2015;18(2):101–129.

Goracci C, Franchi L, Vichi A, Ferrari M. Accuracy, reliability, and efficiency of intraoral scanners for full-arch
impressions: a systematic review of the clinical evidence. Eur J Orthod. 2016;38(4):422–428.
doi: 10.1093/ejo/cjv077

.Aragón ML, Pontes LF, Bichara LM, Flores-Mir C, Normando D. Validity and reliability of intraoral scanners
compared to conventional gypsum models measurements: a systematic review. Eur J Orthod. 2016;38(4):429–434.
doi: 10.1093/ejo/cjw033

Patterson M. Intraoral scanners In dentistry – an update on digital technology - Scottish Dental magazine.
www.sdmag.co.uk. Published 2018. Accessed September 20, 2022.https://www.sdmag.co.uk/2018/10/01/intraoral-
scanners-in-dentistry-an-update-on-digital-technology/

Rosenstiel SF, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 5th ed. St. Louis: Elsevier; 2016. p. 559-
60. 11. de Vasconcellos DK, Volpato CÂ, Zani IM, Bottino MA. Impression technique for ovate pontics. J Prosthet
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Raigrodski AJ, Schwedhelm ER, Chen YW. A simplified technique for recording an implant-supported ovate
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