Clinical Evaluation of Chairside Computer Assisted Design/Computer Assisted Machining (CAD/CAM) Lithium Disilicate Fixed Partial Dentures (FPD)
Phase: NA
Conditions: Missing Tooth
Sponsor: University of Michigan

 
 
 
 
CLINICAL EVALUATION OF  
CHAIRSIDE CAD/CAM LITHIUM 
DISILICATE FIXED PARTIAL DENTURES 
 
NCT 03036566 
Last IRB review: 23 May 2022 
 

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
Page 1  
 
 
 
 
 
Clinical Evaluation of  
Chairside CAD/CAM Lithium Disilicate  
Fixed Partial Dentures 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Copyright 2013: This Clinical Investigation Protocol, or any part thereof, may neither be passed 
on to third parties nor may it be reproduced, stored in a retrieval system, or transmitted, in any 
form or by any means; electronic, mechanical, photocopying, recording, or otherwise, without 
prior permission of Dr. Dennis J. Fasbinder, University of Michigan, USA. 

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
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1 Investigation Title 
 
Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate Fixed Partial Dentures 
 
2 Investigators 
Dennis J. Fasbinder, DDS 
Clinical Professor 
 
Gisele F. Neiva, DDS, MS 
Clinical Associate Professor 
 
Donald Heys, DDS, MS 
Professor of Dentistry 
 
Joseph B. Dennison, DDs, MS 
Professor Emeritus of Dentistry 
 
Ronald Heys, DDS, MS 
Associate Professor of Dentistry 
 
Department of Cariology, Restorative Sciences, and Endodontics 
School of Dentistry University of Michigan 
1011 N. University, Ann Arbor, Michigan  48109-1078  U.S.A. 
 
Phone: (734) 647-4450 e-mail: Dr. Fasbinder = djfas@umich.edu  
Fax: (734) 936-1597 
 
  
3 Sponsor 
Ivoclar Vivadent, USA 
 
4 Summary of Objectives and Design 
 
 
This investigation will be a longitudinal clinical trial to study the clinical performance of 
lithium disilicate (emaxCAD/Ivoclar) for in-office, CAD/CAM generated, full contour fixed 
partial dentures (FPDs).  The fixed partial dentures will be evaluated for clinical performance 
over a period of three years with an option to extend the study to five years. 
 
5 Specific Aims 
The specific aims of this project are: 
 
Evaluate the longitudinal clinical performance of lithium disilicate (emaxCAD) in-office 
CAD/CAM full contour, fixed partial dentures over five years of clinical service.   

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
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Evaluate the clinical workflow for fabricating in-office CAD/CAM FPDs. 
 
6 Significance of the Clinical Investigation 
 
 
Lithium disilicate (emaxCAD/Ivoclar) has had well documented, long-term success for 
chairside CAD/CAM full contour single crown applications.1,2  It has been routinely used for 
clinical situations requiring high strength and is available in millable block form for single tooth 
restorations for both the E4D (D4D Technologies) and CEREC (Sirona Dental) chairside 
CAD/CAM systems.  As the CAD/CAM software for the CEREC OmniCam has evolved, full 
contour, multi-unit restorations are now possible using lithium disilicate. 
 
 
Pressable lithium disilicate (emax Press/Ivoclar) has been used in dental laboratories to 
fabricate 3 or 4 unit fixed partial dentures (FPD).  Limited published long term results have been 
favorable.3  Lithium disilicate FPDs have been limited to replacing premolar or anterior teeth.  
Multi-unit emaxCAD blocks have been available for laboratory use for stack milling but 
unavailable for in-office use until recently.  The coincidental development of the software 
capability for full contour FPDs and extended size millable blocks of emaxCAD make the in-
office fabrication of full contour FPDs possible. 
 
 
This three year, optionally five year, longitudinal clinical evaluation will evaluate the 
clinical effectiveness of using emaxCAD to fabricate in-office, full contour, fixed partial 
dentures. 
 
 
Research Plan: Methods and Materials 
 
7.1 Subjects 
 
 
The patient population will be selected from current patients under clinical treatment at 
the University of Michigan Dental Clinics.  Patients will be over 18 years of age, of either 
gender, and of any ethnic background.  Each patient should have at least one missing premolar or 
anterior tooth that is appropriate for replacement with a fixed partial denture.  The second 
premolar teeth will be the most distal tooth acceptable for inclusion in the study.  Abutment teeth 
will have healthy periodontal status with at least a 1:1 crown:root ratio.  Both abutment teeth 
must be asymptomatic prior to treatment.  Endodontically treated teeth will be acceptable for 
abutments as long as nonmetallic cores can be placed to retain the FPD since the lithium 
disilicate will be bonded to the abutments. 

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
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No more than one FPD will be placed per patient.  If a patient presents with more than 
one missing teeth acceptable for the study, premolar teeth will be included prior to anterior teeth.  
Each FPD will be three units and include only one missing tooth. 
Exclusion criteria will include: 
 
Sensitive teeth 
 
Teeth with a history of direct or indirect pulp capping procedures 
 
Patients with significant untreated dental disease to include periodontitis and rampant caries 
 
Pregnant or lactating women 
 
Patients with allergies to any of the materials to be used in the study 
 
Patients unable to return for recall appointments 
 
 
7.2 Ethics Approval and Informed Consent 
 
 
The Health Sciences Institutional Review Board of the University of Michigan must 
review and approve the investigation protocol prior to initiating the study.  Patients can be 
enrolled in the study as soon as the contract is completed and funding is provided.  Patients who 
are eligible for the study will be screened by one or more of the investigators and the Clinical 
Research Coordinator and fully informed of the nature of the study and the need for long-term 
availability.  Each patient who participates in the study will sign an informed consent agreement 
and the originals will remain at the University.  Patients will be charged $650 for each FPD.  
This will fund an incentive fund for patient recalls.  As an incentive for patients to be available 
for the recall examinations, patients will receive $50 for every yearly recall that they return to be 
examined as well as free parking.  Patients will also receive free bitewing radiographs at the two-
year (and optionally the five year) recall appointments. 
 
After admission to the study a subject may withdraw at any time for any reason. The right 
of each subject to withdraw and the right of each subject to confidential treatment of personal 
data will be respected at all times. The PI will record any subject’s withdrawal and the reason(s). 
 
 
7.3 Study Size 
 
 
The study will include 30 patients each requiring a single FPD replacing a premolar or 
anterior tooth. 
 

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
Page 5  
 
 
7.4 Baseline - Restoration Placement 
 
 
Every patient will be evaluated with a clinical examination and periapical radiographs of 
the teeth to be included in the FPD.   Once the patient is accepted into the study, a series of 
appointments will be made to complete the FPD. 
 
 
1st Restorative Appointment 
 
A pre-operative questionnaire will be completed jointly by the patient, Clinical Research 
Coordinator, and treating doctor (copy enclosed in Appendix).  This will establish the baseline 
information from which to compare the responses at subsequent recall examinations.  Abutment 
teeth to be restored will be tested subjectively as described in the Data Collections section to 
follow.  The level of sensitivity will be recorded using a criterion-referenced rating scale.  The 
use of the scale will be explained to the patient prior to beginning the evaluation.  A Caries Risk 
Assessment will be completed for each patient at baseline based on the number of restorations 
the patient reports having received in the previous 12 months as well as the number of caries 
teeth planned to be restored over the next 6 months.  Low Caries Risk will be scored for patients 
having 0 or 1 restoration placed in the previous 12 months or planned to be replaced due to 
caries.  Moderate Caries Risk will be scored for patients having 2 or 3 restorations placed in the 
previous 12 months or planned to be replaced due to caries.  And High Caries Risk will be 
scored for patients having 4 or more restorations placed in the previous 12 months or planned to 
be replaced due to caries.  High caries risk patients will not qualify for the study due to the 
degree of uncontrolled dental disease that is present.  The shade of the teeth to be restored will be 
determined prior to tooth preparation.  A Classic Shade guide (Vita) will be used to determine 
the pre-treatment shade.  Digital photographs of the dentition with the selected shade tab(s) will 
be taken and used as an aid in matching the desired tooth shade.  Pre-treatment full arch 
diagnostic impressions may be made for case evaluation and as an aid in fabricating the 
temporary FPD should the need arise.   
 
 
2nd Restorative Appointment - Preparation 
 
 
All restorative procedures will be performed under standard local anesthesia with no 
increased risks incurred by patients participating in the study beyond those involved in routine 
dental treatment.  An Isolite2 System (Isolite) will be used to isolate the teeth for cavity 

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
Page 6  
preparation, optical imaging, and cementation of the restorations.  The abutment preparation will 
be consistent with the principles for an all-ceramic crown.   The crown preparation will be 
tapered 6-8 degrees towards the occlusal.   Occlusal reduction will be 2.0 mm over functional 
cusps and at least 1.5 mm over nonfunctional cusps and the central fissure area.  And the margin 
will be a rounded internal shoulder design of at least 1.2 mm axial depth without a bevel.  The 
crown margins will be placed at the free gingival margin unless prior restoration, caries, or tooth 
fracture dictates margin placement subgingivally.  If sufficient tooth loss is present to necessitate 
a core, a composite resin (Multi-core/Ivoclar) will be used.  If in the judgment of the operator, 
less than 1 mm of dentin thickness remains over the pulp, a glass ionomer base may be 
selectively placed prior to completing the preparation.  
 
 
FPD Fabrication 
 
 
After the abutment crown preparations have been completed, gingival retraction will be 
achieved with a combination of retraction cord, hemostatic agent, and a diode laser as required 
for the case.  The quadrant will be isolated from moisture using an Isolite 2 unit.  The CEREC 
OmniCam (Sirona Dental) will be used to record the preparation quadrant, opposing quadrant, 
and facial bite registration.  
 
 
If the case requires a temporary FPD, a bisacrylic material (Telio C&B/Ivoclar) will be 
used to fabricate a temporary FPD that will be cemented with a eugenol-free temporary cement.  
The digital impression will be used in the CEREC 4.21 software program for the full contour 
design of the FPD.  The designed FPD will be milled in a MCXL milling unit (Sirona Dental) at 
fast milling speed. 
 
 
The milled emaxCAD FPD will be tried in using silicon fit checking material (Fit 
Checker/GC Amer) and adjusted for delivery.  Alternatively, the milled FPD will be tried-in on a 
replica model of the preparations and adjusted for delivery.  The FPD will be crystallized in a 
porcelain oven under vacuum firing following Ivoclar’s recommendations.  Esthetic 
characterization and/or glazing of the FPD will also be done simultaneous with the 
crystallization process as the esthetic needs of the case dictates.  Surface polishing post-
crystallization will be done with diamond impregnated polishers, brushes, and diamond polishing 
paste.  Both proximal connectors will be measured in the faciolingual and occlusocervical 
directions and recorded.  Each connector should be no less than 16 mm2. 
 

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
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3rd Restorative Appointment - FPD Delivery  
 
 
Once the FPD is ready is for cementation, the internal surface of all abutment crowns will 
be etched for 20 seconds with 4.9% HFl acid (Ceramic etchant/Ivoclar), rinsed thoroughly, and 
dried.  A silane coupler will be applied for 60 seconds (Monobond Plus/Ivoclar) and gently 
dried.  All FPDs will be cemented with the most current formulation of a self-etching, dual-cure 
resin cement (MultiLink Automix/Ivoclar) following the manufacturer’s instructions. The FPD 
will be inserted and the excess cement will be removed.  Each abutment of the FPD will be light 
cured for 20 seconds from the facial, lingual and occlusal for a total cure of 2 minutes. 
 
 
Finishing and polishing will be initiated after visible light curing of the luting agent.  A 
series of diamond finishing burs, rubber abrasive points and cups, finishing strips, and diamond 
polishing paste will be used for removal of excess cement and final adjustment of the occlusion. 
 
 
Data Collection 
 
8.1 Post-Operative Sensitivity 
 
 
All patients will be asymptomatic prior to initiating the abutment preparations so the 
baseline is “no sensitivity”.  To evaluate the immediate post-operative sensitivity, patients will be 
contacted by telephone once a week after the initial appointment for four weeks or until the FPD 
is reported asymptomatic.  A criterion-referenced rating scale will be used to measure sensitivity.  
The phone interview will be used as a follow-up procedure to minimize recall loss as the patient 
is not required to return to the clinic.  During the phone interview a criterion-referenced rating 
will be made of functional tooth sensitivity using the following scale.  Patients will only be asked 
to return for an evaluation if they are having continued discomfort or any indication of premature 
occlusal contact. 
 
Sensitivity Criteria: 
1=  No sensitivity is experienced at anytime 
2=  Slight sensitivity is experienced occasionally but it is not uncomfortable 
3=  Moderate sensitivity is experienced intermittently and it is noticeably uncomfortable 
4=  Severe discomfort is noted routinely with cold or pressure stimulation 
 

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
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8.2 Clinical Evaluation 
 
 
Two independent evaluators will examine all FPDs in the study.  Clinical evaluations will 
be made at baseline (the appointment the FPD is cemented), six months, one year, two years, 
three years, and optionally at four years, and five years using written criteria based on modified 
USPHS criteria for margin discoloration, margin adaptation, proximal contact, recurrent caries, 
surface finish, connector fracture, and crown fracture (see Appendix for criteria description).  
Disagreements in evaluations will be discussed between the evaluators and a consensus judgment 
will be reached and recorded for every criteria.  Gingival health adjacent to the abutments and 
control teeth will be evaluated with a Gingival Score (Loe & Silness Index, 1963) and a Plaque 
Score (Silness & Loe Index, 1964). 
 
 
Intraoral digital color images at a 1:1.5 magnification will be taken to document pre-
operative, tooth preparation, and post-operative conditions.  Facial and occlusal views of the 
tooth will be documented for both the pre-operative and post-operative conditions.   
 
 
A postcementation quadrant impression will be made of the midfacial margin of each 
abutment and the opposing teeth in a polyvinyl siloxane material and casts will be poured in an 
enhanced stone.  Casts will be made at the baseline, 6 months, 1 year, 2 year, and 3 year, and 
optionally at the 4 year, and 5 year recall visits.  Bite-wing radiographs and periapical 
radiographs of each test tooth will be available preoperatively and at the two year and optionally 
at the five year recall.  
 
 
8.3  Data Management 
 
 
Case Report Form (CRF) 
 
 
Data will be entered in the Case Report Form (CRF) by the investigator or prior assigned 
persons at the study center. The entries will be made with blue ball-point pen.  In case of 
necessary corrections, the wrong entry will be crossed out and the new entry will be written 
beside it.  No erasure is allowed for corrections.  Changes or corrections will be dated and 
initialized by the investigator or assigned person(s).  The documentation of each patient visit 
(baseline and recalls) must be signed and dated by the conducting investigator. 
 
 
Copies of the completed CRFs and Adverse Events/Incident Reports will be retained 
together with the investigator’s study file for a period of 10 years after completion of the study at 

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
Page 9  
the study center.   Data entry will be done by the Clinic Study Coordinator of the Cariology, 
Restorative Sciences Clinical Research Unit. 
 
9 Statistical Analysis 
 
 
After the clinical evaluation data is collected for baseline and each recall, the clinical 
ratings will be entered into a statistical management program and appropriate non-parametric 
tests will be run to verify significant differences.  A Wilcoxon Sign Rank test will be used to 
determine significant differences in the change of ratings from baseline to a given time period.  
Each criterion-referenced category will be analyzed independently.  At any given time period, 
significant differences in clinical evaluation ratings will be determined. 
 
10 Project Time Line 
 
 
The recruitment of patients and clinical placement of restorations will begin immediately 
upon approval and funding of the project.  It is anticipated to take 8-10 months to recruit and 
place the restorations required for the study. 
 
11 Equipment 
 
 
All instrumentation required for placement and clinical evaluation of the restorations is 
available through the Research Clinic of the Department of Cariology, Restorative Sciences, and 
Endodontics at the University of Michigan School of Dentistry.  Additional measurement 
instrumentation to include measuring microscopes, scanning electron microscope, computer 
analysis, and intraoral imaging equipment is available within the School of Dentistry. 
 
12 Facilities 
 
 
The Graduate General Dentistry Clinic maintains a two chair Clinical Research Unit for 
clinical research within the department.  A full time Clinical Research Coordinator is dedicated 
to the Clinical Research Unit as well.  She will coordinate and schedule all patient appointments, 
maintain recall schedules, and collate data collected.  A Certified Dental Assistant is also 
available to provide clinical support.  Additional dental materials and instruments as well as 
personnel support will be provided by the Graduate General Dentistry Clinic as needed. 
 

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
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13 Additional Sponsorships: 
 
 
No other sponsorships are presently available or will be applied to this project. 
 
14 Bibliography 
1.  Fasbinder DJ, Dennison JB, Heys D, Neiva GF. A clinical evaluation of chairside lithium 
disilicate CAD/CAM crowns. JADA 2010 141(6 suppl): 10s-14s. 
 
2.  Fasbinder DJ, Dennison JB, Heys D, Neiva GF. Clinical evaluation of lithium disilicate 
chairside CAD/CAM crowns at 4 years. J Dent Res 91(Spec Issue A): abstract #645, 
2012. 
 
3.  Wolfart S, Eschbach S, Scherrer S, and Kern M. Clinical outcome of three-unit lithium-
disilicate glass-ceramic fixed dental prostheses: up to 8 years results. Dental materials 
2009 25:63-71. 
 
 
 
 
 
 
Appendix 
Initial Questionnaire 
Clinical Evaluation Criteria 
 
 
 
 
 

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
Page 11  
 
INITIAL QUESTIONNAIRE 
Patient: 
 
 
Date:  
 
 
1.  Birthdate (month-day-year)   
 
 
2.  Gender: male 
 
 
female  
 
 
3. Caries Risk Assessment 
 
Low 
 
 
 
0-1 carious lesions in the last 24 months 
 
Moderate 
 
 
2-4 carious lesions in the last 24 month 
 
High  
 
 
4+ carious lesions in the last 24 month (disqualifies) 
 
4. Teeth to be restored  
 
Anterior abutment:  
 
 
 
Posterior abutment:   
 
  
 
5. Pre-operative vitality; verify with cold test:    
 
Abutment tooth:  
  Vital       Devital    (circle one) 
 
Abutment tooth:  
  Vital       Devital    (circle one) 
 
6. Verify pre-operative PAXR for test teeth; less than 6 months old.  
 (initials) 
7. 
Occlusion – at least one centric stop per tooth. 
 
 (initials) 
 
lateral guidance location:   
 
 
 
8. 
Informed Consent and HIPPA form signed. 
 
 (initials) 
9. 
Pre-operative Shade:  
 
 
   (photograph shade tab/s with control tooth) 
 
shade details:   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
10. Opposing Tooth: (photograph opposing teeth; with and without occlusal contacts marked) 
Restorative material present:  
 
 
 
 
 
 
Evidence of wear facets:  yes          no    
Evidence of lateral interferences:   
 
 
 
  
 
 
 
 
 

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
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CLINICAL EVALUATION CRITERIA 
Gingival Index 
Gingival score (visual) for gingival area nearest to the crown margin; evaluate without disclosing. 
(Gingival scores will be based upon the standard Loe & Silness Index, 1963)  
 
score 0 = normal gingiva  
score 1 = mild inflammation - slight change in color, slight edema, no bleeding  
score 2 = moderate inflammation - redness, edema and glazing, bleeding on probing  
score 3 = severe inflammation - marked redness and edema, ulceration, spontaneous bleeding  
 
Plaque Index 
Plaque score (visual) for facial gingival area nearest to the crown margin; evaluate without disclosing. 
(Plaque scores will be based upon the standard Silness & Loe Index, 1964)  
 
score 0 = no plaque detectable in the gingival area 
score 1 = plaque recognized only by running tip of probe across tooth surface at gingival crest  
score 2 = moderate accumulation of plaque visible along gingival margin and adjacent tooth  
score 3 = abundance of plaque visible along gingival margin and adjacent tooth 
 
Color Match (with control tooth, indirect lighting, without magnification) 
Rating  
 
Tooth and restoration have an ideal color match; can distinguish restoration with some difficulty 
Alpha 
 
Readily perceptible mismatch in color; general match 
Bravo 
 
Obvious mismatch in color between tooth and restoration; unacceptable for cementation 
Charlie 
 
Margin Adaptation (margin integrity) 
 
No visible evidence of crevice formation along cavosurface margin 
 
 
explorer does not catch when drawn across the margin 
Alpha-1 
 
No visible evidence of crevice formation along cavosurface margin 
 
 
Margin is detectable along less than 50% of cavosurface margin; and less than 1 mm in depth  
Alpha-2 
 
No visible evidence of crevice formation along cavosurface margin 
 
 
Margin is detectable along more than 50% of cavosurface margin; and less than 1 mm in depth Alpha-3 
 
Evidence of crevice formation (penetrable) along less than 50% of the cavosurface margin;  
 
 
greater than 1 mm in depth 
Bravo-1 
 
Evidence of crevice formation (penetrable) along greater than 50% of the cavosurface margin;  
 
 
greater than 1 mm in depth 
Bravo-2 
 
Evidence of crevice formation exposing dentin to the axial or pulpal floor 
Charlie 
 
Margin Discoloration (evaluated with tooth dry) 
  
 
No evidence of margin discoloration 
Alpha 
 
Surface stain along less than 50% of exposed margin 
Bravo-1 
 
Surface stain along greater than 50% of exposed margin 
Bravo-2 
 
Penetrating discoloration of exposed margin 
Charlie 
 
Surface Finish (surface of the restoration as viewed under magnification) 
 
Smooth, highly polished to finely granular  
Alpha 
 
Gritty, moderate rough but uniform texture 
Bravo 
 
Rough or pitted, visible evidence of significant pits and voids 
Charlie 
 
Evidence of surface crazing with no loss of ceramic or mobile pieces 
Delta 
 
Caries 
 
No evidence of caries 
Alpha 
 
Evidence of recurrent caries at crown margin; repairable without compromise to crown 
Bravo 
 
Evidence of recurrent caries at crown margin; not repairable, crown requires replacement 
Charlie 
 
 

Clinical Evaluation of Chairside CAD/CAM Lithium Disilicate FPDs 
PI: Dr. Dennis J. Fasbinder 
Protocol 01  
23 May 2022 
 
 
 
 
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Abutment Fracture 
 
No evidence of abutment crown fracture 
Alpha 
 
Evidence of restoration fracture with no missing piece or mobility in the pieces 
Bravo 
 
Evidence of restoration fracture with a missing piece considered polishable or repairable 
Charlie 
 
Fracture of the restoration requiring replacement 
Delta 
 
Connector Fracture 
 
No evidence of connector fracture 
Alpha 
 
Evidence of connector fracture with no missing piece or mobility in the pieces 
Bravo 
 
Evidence of connector fracture with a missing piece considered polishable or repairable 
Charlie 
 
Fracture of the connector requiring replacement 
Delta 
 
Proximal Contact 
 
Firm resistance to passage of floss with ideal breadth of contact area 
Alpha 
 
Light resistance to passage of floss or notable variance in breadth of contact area;  
Bravo 
 
 
shim stock will pass through contact 
 
Contact visibly open with passage of one thickness of articulating paper (blue) 
Charlie 
 
Pontic Fracture 
 
No evidence of pontic fracture 
Alpha 
 
Evidence of pontic fracture without loss of material 
Bravo 
 
Pontic fracture with loss of material but repairable or does not require replacement 
Charlie 
 
Complete pontic fracture requiring replacement of the crown 
Delta 
 
Sensitivity 
 
No sensitivity is experienced at any time 
Alpha 
 
Slight sensitivity is experienced occasionally but is not uncomfortable 
Bravo 
 
Moderate sensitivity is experienced intermittently and is noticeably uncomfortable 
Charlie 
 
Severe discomfort is noted routinely with cold or pressure stimulation 
Delta