ASSALAMU ALAIKUM WA RAHMATULLAHI WA BARAKATAHU
Treatment planning for the
replacement of missing teeth
DR TAJMULLA AHMED
Introduction
The reason for patients seeking
treatment should be analyzed first.
NEED
DEMAND
Careful examination will reveal
problems and disease of which
patient is unaware .
The demand for treatment can fall into one of
the 3 categories :
1. Appearance –missing, fractured teeth
discoloration , unaesthetic restorations
2. Function – difficulty in mastication or speech
3. Comfort – pain , sensitivity , swelling
Medical history
. Conditions affecting treatment plan
diabetes,
hypertension ,
rheumatic heart disease,
hemorrhagic disorders ,
any previous allergic responses,
previous radiation therapy ,
epilepsy ,
xerostomia
Medical history
2. Systemic conditions with oral manifestations –
periodontitis in; diabetes ,pregnancy ,
hyperplasia associated with anticonvulsant use ,
erosion of teeth in case of regurgitated stomach acid ,
drugs which reduce salivary flow, e.g. antihistamines,anticholenergic
3. Infectious diseases.hepatitis B
AIDS which are risk factors to the dentist and auxillary personnel
Dental history
Cause of tooth loss
Habits such as betal nut chewing ,clenching or bruxism
Periodontal history – any debridement and current plaque control
measures
Restorative history – age of exsisting restoration
Endodontic history –
Orthodontic history – occasionally root resorption occurs due to previous
orthodontic treatment
Oral surgery history – any complication during tooth removal
Periodontal examination
Existing periodontal disease should be corrected before any
definitive prosthodontic treatment.
Normal gingiva
Inflamed marginal gingiva
Inflamed papillary gingiva
Fibrous epulis
trauma from occlusion ,
It is not a vitality test
but it reveals
inflammation of the
PDL.
PERCUSSION
sinusitis ,
Any pain on
percussion may be
due to;
periodontal
inflammation or
extention of pulpal
disease into periodontal
ligament
PULP VITALITY TEST
Misdiagnosis can occur if the nerve supply is damaged but blood supply is intact
Can be done by thermal (hot /cold) or electric stimuli
Pulp vitality test responses
No response –
Mild to moderate degree pain for 1-2 sec
Strong painful response for 1-2 sec
Moderate to severe lingering painful
response
• Non vital pulp
• False negative
• Normal pulp health
• Reversible pulpitis
• irreversible pulpitis
Occlusion examination
Initial examination starts by asking the patient to make a few
simple opening and closing movements while carefully observing
the opening & closing strokes.
The objective is to assess:
• Initial tooth contact with
Centric Relation.
• Interferences
• Type of occlusion
INITIAL TOOTH CONTACT
The patient is guided into terminal hinge
closure by bimanual manipulation
If all the teeth come together
simultaneously at the end of terminal
hinge closure, the centric relation position
of the patient is said to coincide with the
maximum intercuspation .
TYPE OF OCCLUSION
•BILATERAL BALANCED OCCLUSION;
the bilateral, simultaneous anterior and posterior
occlusal contact of teeth in centric and eccentric
positions
•GROUP FUNCTION OCCLUSION;
multiple contact relations between the maxillary and
mandibular teeth in lateral movements on the
working side.
•MUTUALLY PROTECTED OCCLUSION;
posterior teeth prevent excessive contact of the
anterior teeth in maximum intercuspation, and the
anterior teeth disengage the posterior teeth in all
mandibular excursive movements.
•Canine guided occlusion is a type of mutually
protected occlusion.
INTERFERENCES
These are undesirable occlusal contacts that may
produce mandible deviation during closure to maximum
intercuspation or may hinder smooth passage to & from
the intercuspal position.
RADIOGRAPHIC EXAMINATION
Coronal portion of teeth
• -incipient caries ,proximal caries,
secondary caries
Pulp cavity
• – size , shape, presence of pulpal
pathology
Root anatomy
• – no. of roots , their inclination ,length,
shape ,completion of apical foramen.
Alveolar bone
• – periapical pathology ,furcation ,
trabeculae
Crown root ratio
Periodontal ligament space
Assessment of endodontic treatment
Unerupted teeth
DIAGNOSTIC CAST
Examined for;
crown length ,
crown contour,
contact ,
alignment of tooth in the arch (extruded,tilted)
wear facets
edentulous area,
curvature of the arch
Selection of the type of prosthesis
Missing teeth may be replaced by one
of three prosthesis types:
A removable partial denture
A tooth supported fixed partial denture
Implant supported fixed partial denture
No prosthetic treatment
Removable Partial Denture
Indications;
edentulous spaces
greater than two
posterior teeth,
Anterior spaces
greater than four
incisors or
Spaces that
include;
An edentulous
space with no distal
abutment
Canine, central incisor &
lateral incisor
canine or lateral incisor,
canine and first premolar or
canine and both premolars.
Conventional tooth supported fixed partial denture
There should be an abutment tooth on each end of the
edentulous space to support the prosthesis.
There should be no gross soft tissue defect in the edentulous
ridge.
Resin bonded tooth supported fixed partial denture
A conservative restoration for use on defect free abutments in
situations where there is a single missing tooth, usually an
incisor or premolar.
Implant supported fixed partial denture
Ideally suited;
when there are insufficient numbers of abutment teeth or
inadequate strength in the abutments to support a
conventional FPD,
No prosthetic treatment
If a patient presents with a long standing edentulous space with;
---little or no drifting or
---elongation of the adjacent or opposing teeth,
the replacement option should be left to the patient’s wishes.
Destruction of tooth
structure
Esthetics
The selection of material and
design of the restoration is based
on several factors:
Plaque control
Financial
considerations
Retention
Whenever possible an abutment
should be a vital tooth.
ABUTMENT
EVALUATION
An asymptomatic endodontically
treated tooth with radiographic
evidence of a good seal and
complete obturation of the canal
The roots and their supporting
tissues should be evaluated
for three factors:
Crown root
ratio
Root
configuration
Periodontal
ligament area
ABUTMENT EVALUATION
Crown root ratio
to be utilized as a
FPD abutment
Optimum crown root ratio;
2:3.
Minimum acceptable ratio
1:1.
Roots broader labio-lingually than mesio-distally preferred
to roots that are round in cross section.
Root
configuration
Multi-rooted posterior teeth with widely separated roots
offer better periodontal support than roots that converge,
fuse or with conical configuration.
It is the abutment teeth root surface area or the area of
periodontal ligament attachment of the root to the bone.
Periodontal
ligament area
Larger teeth, greater surface area and better bare added
stress.