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Company LogoDiagnosis and Treatment Planning in Fixed Partial Dentures
Presented by Dr.Abbasi Begum .MP.G Department of ProsthodonticsNarayana Dental College
ContentsContents1.Introduction2.Definitions and
terminologies3.Diagnostic aids– Personal information– Patient evaluation–Medical history– Past dental history Clinical examinationClinical examination• General examination • Extra oral examination • Intraoral examination– Radiographic
examination- Vitality testing
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4.Treatment plan Treatment planning for single – tooth restorations
Treatment planning for the replacement of missing teeth - Selection of the type of prosthesis - Abutment evaluation - Biomechanical considerations - Special problems
5.Conclusion 6.References
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Company LogoSequelae of tooth loss
MigrationUnilateral chewing
Alveolar bone lossOcclusal interference
Loss of proximal contact Overloading of anteriors
Loss of VDTMD
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The traditional restorative approach in prosthetic dentistry
Treatment options for missing teeth
Company LogoINTRODUCTIONINTRODUCTION
Fixed prosthodontics : The art and science of restoring damaged teeth
with cast metal, metal-ceramic,or all-ceramic restorations, and of replacing missing teeth with fixed prostheses.
Successful fixed prosth-odontic treat- ment
Company LogoDefinitions and terminologies
Fixed partial denture: A dental prosthesis that is luted,screwed or
mechanically attached or otherwise securely retained to
the natural teeth, tooth roots, and /or dental implant abutments that furnish primary support for the dental prosthesis.
Commonly referred to as BRIDGES95
DiagnosisDiagnosisDIAGNOSIS The determination of
the nature of a disease.
Glossary of Prosthodontic Glossary of Prosthodontic terms 8terms 8
TREATMENT PLAN The sequence of
procedures planned for the treatment of a patient after diagnosis.
Glossary of Prosthodontic Glossary of Prosthodontic terms 8terms 8
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“Nothing is more critical to success than beginning with all the necessary data.”
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Company Logo5 elements to a good diagnostic workup
1. History2. TMJ/occlusal evaluation3. Intraoral examination4. Diagnostic casts5. Full mouth radiographs
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Company LogoMEDICAL HISTORY-outlineAccurate and current general medical history should include
Medication.
As well as relevant medical conditions.
If necessary the patients physician(s) can be contacted for clarification.
Conditions affecting the treatment methods Conditions affecting treatment plan Systemic conditions with oral
manifestations Possible risk factors for the dental surgeon
and patient
Company LogoHistoryHistory
Any special precautions are necessary ?????? To premedicate some patients for certain
conditions or to avoid medication for others History of infectious diseases Serum Hepatitis AIDS previous reaction to a drug: an allergic reaction or syncope resulting from anxiety in the dental
chair
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A reaction to a dental material : nickel-containing alloys
Patients who present with a history of cardiovascular
problems may require special treatment Patient with uncontrolled hypertension should not be treated A systolic reading 160 mm of mercury or a diastolic reading 95 preempts dental treatment Refer the patient to his or her physician for
evaluation and treatment
Company Logo Hypertension or Coronary artery
disease…………….. epinephrme X since this drug has a
tendency heart rate elevate blood pressurePREMEDICATION
BASED ON 1991 GUIDELINES (AHA)
Amoxicillin in case of allergy
Prosthetic heart valve
Erythromycin OR History of previous bacterial endocarditis,
Clindamycin Congenital heart malformations,or mitral valve prolapse
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Previous radiation therapy, hemorrhagic disorders, extremes of age, and terminal illness
Expected to modify the patient's response the patient's response to dental treatment
affect the prognosisprognosis
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Systemic conditions with oral manifestations
Eg periodontitis modified by
diabetes, menopause, pregnancy, or the use of anticonvulsant drugs
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Epilepsy Diabetic patients Dental treatment for the diabetic should interfere as little as possible with the patient's
dietary routine, and the patient's stress level should
be reducedXerostomia: conductive to greater carious activity extremely hostile to the margins
of cast metal or ceramic restorations
DENTADENTAL L HISTOHISTORYRY
Company LogoPeriodontal HistoryPeriodontal History
The patients oral hygiene is assessed, current plaque control measures are discussed, as are previously received oral hygiene instructions.
The frequency of any previous debridement should be recorded
Nature of any previous periodontal surgery should be noted.
Company LogoRestorative HistoryRestorative History
Simple composite resin or dental amalgam fillings, or it may involve crowns and extensive fixed partial dentures
Prognosis and probable longevity of any future fixed prostheses
Endodontic HistoryEndodontic History Monitoring periapical health and Detecting recurring lesions promptly
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Company LogoOrthodontic HistoryOrthodontic HistoryApical root resorption subsequent to orthodontictreatment.
As the crown/root ratio is affected, future prosthodontic treatment and its prognosis may also be affected
Removable Removable Prosthodontic Prosthodontic HistoryHistory Helpful in assessing whether future treatment will be more successful
Company LogoOral Surgical HistoryOral Surgical History Missing teeth and any
complications that may have occurred during tooth removal is obtained
Before any treatment is undertaken,
the prosthodontic component of the proposal treatment should be fully co-ordinated with surgical component
Company LogoRadiographic HistoryRadiographic History
Judging the progress of dental disease A current diagnostic radiographic series is
essential and should be obtained as part of the examination.
Company LogoTMJ Dysfunction HistoryTMJ Dysfunction History
A history of pain or clicking in the TMJ or neuromuscular systems, such as tenderness to palpation, may be due to TMJ DYSFUNCTION, which should be normally be treated and resolved before fixed prosthodontic treatment begins
Company LogoEXAMINATION General Examination
Extraoral Examination Temporomandibular Joints Muscles of Mastication Lips
Intraoral Examination Periodontal Examination Gingiva Periodontium
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Occlusal Examination Initial Tooth Contact Lateral and Protrusive Contacts Jaw Maneuverability
Radiographic Examination Vitality Testing
Company LogoEXAMINATIONEXAMINATION
Clinician's use of Sight, Touch, And Hearing to detect conditions outside the
normal range It is critical to record what is actually observed
rather than to make diagnostic comments about the condition.
EX:- Gingival inflammation - swelling, redness, and bleeding on probing…
Company LogoGENERAL EXAMINATIONGENERAL EXAMINATION
General appearance, gait, and weightSkin color-signs of anemia or jaundiceVital signs-respiration, pulse,
temperature, and blood pressure vital signs outside normal ranges
should be referred for a comprehensive medical evaluation
Company LogoEXTRAORAL EXAMINATION
1. Facial symmetry: Special attention2. Cervical lymph nodes are palpate3. TMJ
This permits a comparison between relative timing of left and right condylar movements.Asynchronous movement – anterior disk displacement.
Company LogoAuricular palpationAuricular palpation
Light anterior pressure-Identify potential disorders
in the posterior attachment of the disk
Tenderness, or pain on movement- Inflammatory changes in the Retrodiscal tissues
Palpation at Angles of the mandible- Identify even a minimal click
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Company Logo4. Maximum mandibular 4. Maximum mandibular openingopeningNormal values to maximum opening
range from 45 to 55 mm < 35mm – restricted – intra capsular
changes.Midline deviation on opening and/or
closing is recorded The maximum lateral movements of the
patient can be measured(normal is about 12 mm)
EXAMINATION OF TEMPOROMANDIBULAR DISORDERSIN THE ORTHODONTIC PATIENT: A CLINICAL GUIDE, J Appl Oral Sci. 2007;15(1):77-82
Company LogoMuscles of Mastication.
Palpated for signs of tenderness.
Palpation is best accomplished bilaterally and simultaneously.
This allows the patient to compare and report any
differences between the left and right sides.
Temporalis
Masseter muscle Palpation Medial pterygoid
Lateral pterygoid
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Trapezius muscle is felt at the base of the skull, high on the neck
The sternocleidomastoid muscle is grasped between the thumb and forefingers on the side of the neck. The muscle will be accentuated by a slight turn of the patient's head
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A brief palpation of masseter, temporalis, medial pterygoid, lateral pteregoid, trapezius and sternocleido mastoid muscles may reveal tenderness.
Any difference – classify the discomfort as mild, moderate , severe.
Each palpation site is given a numerical score..
Treatment initiated – asses the response to treatment
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Company Logo5. LIPS :-5. LIPS :- Next, the patient is observed for tooth
exposure during normal and exaggerated smiling.
This may be critical in treatment planning and
particularly for margin placement of metal-ceramic crowns.
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Company LogoINTRA ORAL INTRA ORAL EXAMINATIONEXAMINATION Evaluate the condition of the
soft tissues, teeth, and supporting structures.
A) SOFT TISSUE
EXAMINATION:- Lips, tongue, floor of the mouth,
gingiva, vestibule, cheeks, hard and soft palate…
Any abnormalities of the soft tissues
should be noted and the patient informed
Company LogoClassification of Ridge Defects: Classification of Ridge Defects: Seibert 1983 classified the
various types of ridge loss into 3 classes [1]:
Class I: Buccolingual loss of Buccolingual loss of tissue with normal ridge height in tissue with normal ridge height in apicocoronal dimensionapicocoronal dimension
Class II: Apicocoronal loss of Apicocoronal loss of tissue with normal ridge tissue with normal ridge width in width in a Buccolingual dimensiona Buccolingual dimension
Class III: Combination Bucco - lingual and apico-coronal loss of tissue resulting in loss of normal height and width
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Later, Allen et al (1985) introduced severity as a
classification criterion in the evaluation of alveolar
deformities. Severity is classified as- Mild deformity < 3mm Moderate deformity 3 - 6mm Severe deformity > 6mm
Periodontal Plastic Surgery For Alveolar Ridge Augmentation: A Case Report, Ashish Agarwal et al, Indian Journal of Dental Sciences.June 2012 Issue:2, Vol.:4 61
Company LogoGingiva :-
Lightly dried before examination so that moisture does not obscure subtle changes.
Color, texture, size, contour, consistency and position are noted
carefully palpated to express any exudate or pus that may be present in the sulcular area
Company LogoPERIODONTAL EXAMINATION : Should include ; Assessment of the quality and quantity Of
Attached Gingiva Depth of Periodontal Pockets measured
with a periodontal probe Degree of tooth mobility Degree of recession
Company LogoPeriodontal Pockets And Attachment Levels In this examination the probe is inserted
essentially parallel to the tooth and is “walked” circumferentially through the sulcus in firm but gentle steps, determining the measurement when the probe is in contact with the apical portion of the sulcus .
Thus any sudden change in the attachment level can be detected.
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Examination of tooth structure: Carious lesions:- -determine Rate and Extent of carious lesions. The amount and location of caries, coupled with an evaluation of plaque retention, can
offer some prognosis for new restorations that will be
placed. It will also help to determine the preparation
designs to be used.57
Company LogoOcclusal Examination
Special attention is given to initial contact, tooth alignment, eccentric contacts, and jaw maneuverability.
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Company LogoGeneral Alignment :-
Crowding, rotation, supra-eruption, spacing, malocclusion, and vertical and horizontal overlap.
Teeth adjacent to edentulous spaces often have shifted position slightly.
Small amounts of tooth movement can significantly affect fixed prosthodontic treatment.
Company LogoAnalysis of occlusion
Any TMJ Pain, muscle spasm.
Ease or Difficulty with which the various excursions can be made voluntarily by the patient.
Any occlusal interferences.
Over erupted or tilted teeth interfering with the occlusion.
Company LogoRADIOGRAPHIC EXAMINATION
Can help to evaluate the following areas: - Degree of bone loss - Impacted teeth, residual roots - Root morphology, crown-root ratio - Presence of apical disease - Caries - calculus - pulp chambers & canals - Periodontal ligament and surrounding bone - existing restorations (marginal fit, contour)
Company Logo PANOROMIC RADIOGRAPHS
Presence or absence of teeth
Assessing third molars impactions,
Evaluating the bone before implant placement.
Screening edentulous arches for buried root tips
Company LogoSpecial Radiograph’s For TMJ Disorders Transcranial exposure-reveal the lateral
third of the mandibular condyle and can be used to detect structural and positional changes
More information can be obtained fromTomography
Arthrography
C T scanning
Magnetic resonance imaging 52
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Vitality Testing
Pulpal health must be measured before restorative treatment to
PERCUSSION and
THERMAL STIMULATION
TEST CAVITY-nonvitality without L.A
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VITALITY TEST asses only afferent Nerve supply.
MISDIAGNOSIS occurs if N S is damaged and blood supply intact .
Careful inspection of radiographs therefore provide an essential aid in the examination.
Company LogoDIAGNOSTIC CASTS
Articulated diagnostic casts are essential in planning fixed Prosthodontic treatment.
They must be accurate reproductions of the maxillary and mandibular arches made from distortion free alginate impressions.
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Company LogoAdvantages of Diagnostic Casts:- 1) Allow an unobstructed view of the
edentulous spaces and an accurate assessment of the span length, as well as occlusogingival dimension.
2) Length of the abutment teeth can be accurately gauged to determine which preparation designs will provide adequate retention and resistance.
3) The true inclination of the abutment teeth will also became evident, so that the problems in a common path of insertion can be anticipated. 48
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4) Mesiodistal drifting, rotation and faciolingual displacement of prospective abutment teeth
can be clearly seen.
5) A thorough evaluation of wear facets – their number, size and location is possible.
6) Diagnostic wax-up can be carried out in situations calling for the use of pontics which are wider or narrower than the teeth that would normally occupy the edentulous space
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Company Logo 7) Teeth that have supraerupted into the
opposing edentulous spaces are easily spotted and the amount of correction needed can be determined.
8) Occlusal discrepancies can be evaluated
and the presence of centric prematurities or excursive interferences can be determined.
9) Discrepancies in the occlusal plane become very apparent on the articulated casts.
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The selection of the material and design of the restoration is based on several factors:
1 Destruction of tooth structure2. Esthetics3. Plaque control4. Financial considerations5. Retention
Treatment Planning for Single-Tooth Restorations
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Company LogoDestruction of tooth structure:
If the amount of destruction is such that the remaining tooth structure must gain strength and protection from the restoration, cast metal or ceramic is indicated over amalgam or composite resin.
Esthetics All-ceramic crowns-incisors Metal-ceramic crowns can be used for Single-unit anterior or posterior crowns Fixed partial dentures.
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Company LogoPlaque controlPlaque control Use of a cemented restoration-
“A Good Plaque control program” If extensive plaque, decalcification, and caries are present
in a mouth, the use of crowns of any kind should be carefully weighed
Motivated to follow a regime of brushing, flossing and dietary regulation to control or eliminate the disease process responsible for destruction of tooth structure.
If these measures prove to be successfulcast metal, ceramic or metal ceramic restorations can be fabricated
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Company LogoFINANCIAL CONSIDERATIONS “SOME ONE” ?????????????????Government agencyA branch of militaryInsurance company
Selection should not be less than optimum just because the patient cannot afford
Sound alternative to the Sound alternative to the preferred treatment plan
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Company LogoRetention
Full veneer crowns are unquestionably the most retentive
Special concern for ; Short teeth Removable partial denture abutment.
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Company LogoTWELVE RESTORATION TYPES "plastic restoration" or a "cemented restoration ?????????INTRA CORONAL RESTORATION When sufficient coronal tooth structure exist to retain and
protect a restoration under the anticipated stresses of mastication an intracoronal restoration can be employed.
In this circumstance , the crown of the tooth and the restoration itself are dependent upon the strength of remaining tooth structure to provide structural integrity.
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Company LogoGLASS IONOMER
Where extensions can be kept minimal. Class V lesions Incipient lesions Root caries in geriatric patients &
periodontal patients Interim treatment restoration to assist in
the control of a mouth with rampant caries further enhanced by the release of fluoride by the material.
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Company LogoCOMPOSITE
Restoration of incisal angles assisted by acid
etching, a tooth that has received a class 4 resin
restoration ultimately will require a crown.
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Company LogoSILVER AMALGAM
Minor to moderate sized lesions in esthetically non critical areas.
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Company LogoCOMPLEX AMALGAM
Moderate to severe lesions - amalgam augmented by pins.
As a final restoration when a crown is contraindicated .
Missing cusps or endodontically treated premolars and molars.
Teeth that ordinarily would be restored with mesio-occulso-distal (MOD)onlays or other extracoronal
restorations.
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Company LogoMETAL INLAY
Minor to moderate lesions where esthetic requirements are low .
Usually made of softer gold alloys Etchable base metal alloys- if a bonding
effect is desired.
Restoration of MOD on molars.
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Company LogoCERAMIC INLAY
Minor to moderate sized lesion where esthetic demand is high.
B’coz this type of restoration can be etched to enhance bonding the structural integrity of tooth cusps may be stabilized by bonding
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Company LogoMOD ONLAY
Moderately large lesions on premolars and molars with intact facial and lingual surfaces.
It will accomodate a wide isthmus and upto one missing cusp on molar.
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Company LogoEXTRA CORONAL RESTORATION
Insufficient coronal tooth.
Deflective axial tooth structure.
Modify contours to refine occlusion or improve
esthetics.
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Company LogoPARTIAL VENEER CROWN
To restore a tooth with one or more intact axial surfaces with half or more of the coronal tooth structure remaining.
For short span fixed partial dentures.
If tooth destruction is not extensive.
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Company LogoFULL METAL
Restore teeth with multiple defective axial surfaces.
Restricted to situation where there are no esthetic
expectations.
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Company LogoMETAL CERAMIC CROWN
Multiple defective axial surfacesFixed partial dentures retainer
where full coverage and good cosmetic results must be obtained.
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Company LogoALL CERAMIC CROWN
Full coverage and maximum esthetics.
Restricted to situation likely to produce low
moderate stress .
Usually used on incisors.
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Company LogoCERAMIC VEENERS
Intact anterior tooth that are marred by severe staining or developmental defects restricted to facial surface of the tooth.
Moderate incisal clipping and proximal lesions.
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Company LogoTREATMENT PLANNING FOR THE REPLACEMENT OF MISSING TEETH
A REMOVAL PARTIAL DENTURE. A TOOTH SUPPORTED FIXED PARTIAL DENTURE
OR AN IMPLANT SUPPORTED FIXED PARTIAL
DENTURE
SELECTION OF THE TYPE OF THE POSTHESIS
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Company LogoFACTORS CONSIDERED
BIOMECHANICAL PERIODONTAL ESTHETIC FINANCIAL and PATIENTS WISHES.
It is not uncommon to combine two types in the same arch.
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Company LogoREMOVABLE PARTIAL DENTURE
Edentulous spaces greater than two posterior teeth.
Anterior space greater than four lncisors.
Edentulous space with no distal abutment.
Multiple edentulous spaces.
Tipped teeth adjoining edentulous spaces and prospect-ive abutments with divergent alignment.
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Periodontally weakened.
Teeth with short clinical crowns.
Insufficient number of abutments.
If there has been a severe loss of tissues in the edentulous ridge.
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Company LogoCONVENTIONAL TOOTH SUPPORTED FIXED PARTIAL DENTURE
Abutment teeth are periodontally sound.
Edentulous span is short and straight.
Expected to provide a longlife of function for the patient.
No gross soft tissue defect in the edentulous ridge.
Reserved for patients who are both highly motivated and able to afford.
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Company LogoRESIN BONDED TOOTH SUPPORTED FIXED PARTIAL DENTURE Defect free abutments where single
missing tooth.
A single molar (muscles are not well developed).
Mesial and distal abutment are present.
Moderate resorption and no gross soft tissue defects on edentulous ridges.
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Younger patients whose immature teeth with large pulps are poor risks for endodontic free abutment preparation.
Tilted tooth can be accommodated only if there is enough tooth structure to allow a change in the normal alligment of axial reduction.
Periodontal splints.
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Company LogoIMPLANT SUPPORTED FIXED PARTIAL DENTURE
Insufficient number of abutments.
Patient’s attitude and or a combination of intra oral factors make a removable partial denture or FPD a poor choice.
No distal abutment.
Alveolar bone with satisfactory density and thickness in a broad, flat ridges.
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Configuration that permit implant placement.
Single tooth where defect free adjacent teeth.
A span length of two or six teeth can be replaced by multiple implants.
Pier in an edentulous span (three or more teeth long).
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Company LogoNO PROSTHETIC TREATMENT
Long standing edentulous space into which there has been little or no drifting or elongation of the adjacent teeth.
If the patients percieves no functional , occlusal or esthetic impairement.
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Company LogoCASE PRESENTATION
In cases where the choice between a fixed partial denture and a removable partial denture is not clear cut, two or more treatment options should be presented to the patients along with their advantages and disadvantages.
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The prosthodontist is the best person to evaluate the physical and biological factors present , while the patients feelings should carry considerable weight on matters of esthetics & finances .
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Company LogoABUTMENT EVALUATION
The roots and their supporting tissues should be evaluated for three factors
Crown root ratio
Root configuration
Periodontal ligament area
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Company LogoCROWN ROOT RATIO
Optimum -2:3
Minimum -1:1 (acceptable)
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Company LogoROOT CONFIGERATION
Broader Labiolingullay than Mesiodistally.
Multirooted posterior teeth with widely separated roots.
Conical roots can be used -for short span.
A single rooted tooth with evidence of irregular configu- ration or with some curvature in the tooth –is preferable than that which has a nearly taper.
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Company LogoPERIODONTAL LIGAMENT AREA
Larger teeth have a greater surface area and better able to bear added stress.
“ ANTE’S LAW” the root surface area of the abutment teeth had to equal or surpassed that of the teeth being replaced with pontics.
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Company LogoBIOMECHANICAL CONSIDERATIONS
In addition to the increased load placed on the pdl by a long span FPD.
Longer spans are less rigid.
Bending or deflection varies directly with the cube of the length and inversely with cube of the occlusogingival thickness of the pontic .
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Greater occlusogingival dimension Nickel chromium Double abutment Multiple grooves
TO MINIMIZE –
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Company LogoSpecial Situations
Non rigid connector
Restrict to short span FPD
key way -distal contours of pier a abutment
key - mesial side of the distal pontic
PIER ABUTMENTS
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A Nonrigid connector on the middle abutment isolates force to that segment of the fixed partial denture to which it is applied
Company LogoTHIRD MOLAR ABUTMENTS
Mild encroaching- restoring and recontouring
Tilting is severe –corrective measures
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Orthodontic appliance for uprighting a tilted
molar
Proximal half crown as a retainer
Non rigid connector on distal aspect of premolar retainer
Company LogoCANINE – REPLACEMENT FIXED PARTIAL DENTURE
Fixed partial dentures replacing canines can be difficult because the canine often lies outside the interabutment axis.
FPD replacing a maxillary canine is subjected to morestresses than that replacing a mandibular canine
Edentulous spaces created by the loss of canine and any contiguous teeth is best restored with Implants.
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Company LogoCANTILEVER FIXED PARTIAL DENTURES
Lengthy roots with favourable configuration.
Long clinical crowns.
Good crown root ratios and healthy periodontium.
Should replace only one tooth and have atleast two abutments.
Pontic should posses maximum occlusogingival height to ensure a rigid prosthesis.
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Forces on the pontic of a cantilever fixed partial denture tend to tip the fixed partial denture or the abutment tooth
Cantilever fixed partial denture replacing maxillary lateral incisor, using the canine as the abutment
Cantilever pontics can be used to replace a 1st premolar, if full veneers are used on 2nd PM,and 1st molar
Company LogoCONCLUSION
The history and clinical examination must provide sufficient data for the practioner to formulate a successful treatment plan.
The overall prognosis is influenced by general and local factors
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Company LogoReferences
1. Fundamentals of fixed prosthodontics-3rd edition, Shillingburg
2. Contemporary Fixed Prosthodontics-Rosenstiel- 3rd edition
3. Examination Of Temporomandibular Disorders . A Clinical Guide, J Appl Oral Sci. 2007;15(1):77-82, Ana Claúdia de Castro Ferreira et al
4. Pocket Dentistry-Fastest Clinical Dentistry Insight Engine
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5.History of and Examination for Temporomandibular Disorders
6.Supplement the Base to Complement the Crown: Localized Ridge Augmentation using Connective Tissue Graft-
7. Hemini Shah et al, IJSS Case Reports & Reviews | April 2015 | Vol 1 | Issue 11
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