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Diagnosis and Treatment Planning
in Fixed Partial Dentures
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Presented by
Dr.Abbasi Begum .M
P.G Department of Prosthodontics
Narayana Dental College
Contents
1. Introduction
2. Definitions and terminologies
3.Diagnostic aids
– Personal information
– Patient evaluation
– Medical history
– Past dental history
 Clinical 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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Sequelae of tooth loss
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Migration
Unilateral chewing
Alveolar bone loss
Occlusal interference
Loss of proximal contact
Overloading of anteriors
Loss of VD
TMD
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The traditional restorative approach in
prosthetic dentistry
Treatment options for missing teeth
RPD
RemovableFixed
prosthesis
Missing
teeth
IMPLANT
S
FPD
INTRODUCTION
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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.
patient education
placement of
removable complete
or partial prostheses
and endodontic
treatment
Successful
fixed prosthodontic treatment
periodontal therapy,
operative skills,
occlusal
considerations,
prevention of further
dental disease
sound diagnosis
Definitions and terminologies
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
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 BRIDGES
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Diagnosis
 DIAGNOSIS

The determination of the
nature of a disease.
Glossary of Prosthodontic terms 8
 TREATMENT PLAN

The sequence of procedures
planned for the treatment of
a patient after diagnosis.
Glossary of Prosthodontic terms 8
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“Nothing
is more critical to
success than beginning with all
the necessary data.”
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5 elements to a good
diagnostic workup
1.
2.
3.
4.
5.
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History
TMJ/occlusal evaluation
Intraoral examination
Diagnostic casts
Full mouth radiographs
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HISTORY
MEDICAL
DENTAL
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MEDICAL HISTORY-outline
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Accurate and current general medical history should include
 Medication.
 As well as relevant medical conditions.
 If necessary the patients physician(s) can be cont
acted for clarification.
 Conditions affecting the treatment methods
 Conditions affecting treatment plan
 Systemic conditions with oral manifestations
 Possible risk factors for the dental surgeon and pa
tient
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History



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
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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
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
Hypertension or Coronary artery disease……………..
epinephrme X since this drug has a tendency
heart rate
elevate blood pressure
PREMEDICATION
BASED
Amoxicillin in case of
allergy
ON 1991 GUIDELINES
(AHA)
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 to dental
treatment
affect the prognosis
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Systemic conditions with oral manifestations
Eg periodontitis
modified by
diabetes, menopause, pregnancy, or the use of a
nticonvulsant drugs
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Epilepsy
 Diabetic patients
 Dental treatment for the diabetic should
interfere as little as possible with the patient's dieta
ry
routine, and the patient's stress level should be re
duced
Xerostomia: conductive to greater carious activity
extremely hostile to the margins of
cast metal or ceramic restorations

Periodontal
History
TMJ
Dysfunction
History
Radiographic
History
Restorative
History
DENTAL
HISTORY
Oral
Surgical
History
Endodontic
History
Orthodontic
History
Removable
Prosthodont
ic History
Periodontal History
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
The patients oral hygiene is assessed, current p
laque control measures are discussed, as are p
reviously
received oral hygiene instructions
.

The frequency of any previous debridement sho
uld be recorded

Nature of any previous periodontal surgery sho
uld be noted.
Restorative History


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Simple composite resin or dental amalgam fillings,
or it may involve crowns and extensive fixed partial
dentures
Prognosis and probable longevity of any future fix
ed
prostheses
Endodontic History


Monitoring periapical health and
Detecting recurring lesions promptly
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Orthodontic History
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Apical root resorption subsequent to orthodo
ntic
treatment.
As the crown/root ratio is affected, future pro
sthodontic treatment and its prognosis may
also be
affected
Removable Prosthodontic
History
Helpful in assessing whether future treatment will be more
successful
Oral Surgical History

Missing teeth and any complicatio
ns that may have occurred durin
g tooth removal is obtained
Before any treatment is undertake
n,
the prosthodontic component of th
e
proposal treatment should b
e fully
co-ordinated with surgi
cal component

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Radiographic History


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Judging the progress of dental disease
A current diagnostic radiographic series is esse
ntial and should be obtained as part of the exa
mination.
TMJ Dysfunction History
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 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 treate
d and resolved before fixed prosthodontic treatment begins
EXAMINATION

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
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EXAMINATION






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Clinician's use of
Sight,
Touch, And
Hearing to detect conditions outside the normal r
ange
It is critical to record what is actually observed rat
her
than to make diagnostic comments about t
he condition.
EX:- Gingival inflammation - swelling, redness, a
nd bleeding on probing…
GENERAL EXAMINATION
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General appearance, gait, and weight
 Skin color-signs of anemia or jaundice
 Vital signs-respiration, pulse, temperature,
and blood pressure
 vital signs outside normal ranges should b
e
referred for a comprehensive medic
al evaluation

EXTRAORAL EXAMINATION
1. Facial symmetry: Special attention
2. Cervical lymph nodes are palpate
3. TMJ
This permits a compariso
n between relative timin
g of left and right condyl
ar
movements.
Asynchronous movem
ent – anterior disk displa
cement.
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Auricular palpation
Light anterior pressure
-Identify potential disorders i
n the posterior attachme
nt of the disk
 Tenderness, or pain on mo
vement- Inflammatory cha
nges in the Retrodiscal tis
sues
 Palpation at Angles of the
mandible- Identify even a
minimal click
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4. Maximum mandibular opening
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Normal values to maximum opening range
from 45 to 55 mm
 < 35mm – restricted – intra capsular chan
ges.
 Midline deviation on opening and/or closin
g is recorded
 The maximum lateral movements of the pa
tient can be measured
 (normal is about 12 mm)
EXAMINATION OF TEMPOROMANDIBULAR DISORDERS

IN THE ORTHODONTIC PATIENT: A CLINICAL GUIDE, J Appl Oral Sci. 2007;15(1):
Muscles of Mastication.
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
Palpated for signs of tenderness.

Palpation is best accomplished bilaterally and
simultaneously.

This allows the patient to compare and report an
y
differences between the left and right sides.
Masseter muscle Palpation
Temporalis
Medial pterygoid
Lateral pterygoid
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Trapezius muscle is fe
lt at the base of the sk
ull, high on the neck
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The sternocleidomastoid muscle is grasp
ed
between the thumb and forefingers on the
side
of the neck.
The muscle will be accentuated by a slig
ht
turn of the patient's head
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A brief palpation of masseter, temporalis,
medial pterygoid, lateral pteregoid, trapezius an
d
sternocleido mastoid muscles may reveal tende
rness.
Any difference – classify the discomfort as mild,
moderate , severe.
Each palpation site is given a numerical score..
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Treatment initiated – asses the response to treat
5. LIPS :

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Next, the patient is observed for tooth exposure d
uring normal and exaggerated smiling.
This may be critical in treatment planning and
particularly for margin placement of metal-cera
mic
crowns.
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INTRA ORAL EXAMINATION

Evaluate the condition of the soft tis
sues, teeth, and supporting structure
s.
A) SOFT TISSUE EXAMINATION:
Lips, tongue, floor of the mouth, gingi
va, vestibule, cheeks, hard and soft
palate…

Any abnormalities of the soft tissues
should be noted and the patient
informed
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Classification of Ridge Defects:




Seibert 1983 classified the
various types of ridge loss i
nto 3 classes [1]:
Class I: Buccolingual loss of
tissue with normal ridge hei
ght in apicocoronal dimensi
on
Class II: Apicocoronal loss
of tissue with normal ridge
width in a Buccolingual dim
ension
Class III: Combination Bucc
o - lingual and apico-corona
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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 Repo
rt, Ashish Agarwal et al, Indian Journal of Dental Sciences.
June 2012 Issue:2, Vol.:4
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Gingiva :


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Lightly dried before examination so that moisture
does not obscure subtle changes.
Color, texture, size, contour, consistency and posi
tion are noted
carefully palpated to express any exudate or pus t
hat
may be present in the sulcular area
PERIODONTAL EXAMINATION :
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Should include ;
 Assessment of the quality and quantity Of Att
ached Gingiva
 Depth of Periodontal Pockets measured with a
periodontal probe
 Degree of tooth mobility
 Degree of recession
Periodontal Pockets And AttachmentLogo
L
evels
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
In this examination the probe is inserted essential
ly
parallel to the tooth and is “walked” circumf
erentially through the sulcus in firm but gentle
steps, determining the measurement when the pr
obe is in contact with the apical portion of the su
lcus .

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 s
ome
prognosis for new restorations that will be placed.
It will also help to determine the preparation desig
ns to be used.
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Occlusal Examination


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Special attention is given to
initial contact,
tooth alignment,
eccentric contacts,
and jaw maneuverability.
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General Alignment :


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Crowding, rotation, supra-eruption, spacing,
malocclusion, and vertical and horizontal overlap.
Teeth adjacent to edentulous spaces often have shi
fted
position slightly.
Small amounts of tooth movement can significantly
affect fixed prosthodontic treatment.
Analysis of occlusion
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
Any TMJ Pain, muscle spasm.

Ease or Difficulty with which the various excursio
ns can be made voluntarily by the patient.

Any occlusal interferences.

Over erupted or tilted teeth interfering with the
occlusion.

RADIOGRAPHIC EXAMINATION Logo
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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)

PANOROMIC RADIOGRAPHS
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Presence or absence of teeth
Assessing third molars impactions,
Evaluating the bone before implant placement.
Screening edentulous arches for buried root tips
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Special Radiograph’s For TMJ
Disorders


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Transcranial exposure-reveal the lateral third of t
he mandibular condyle and can be used to det
ect
structural and positional changes
More information can be obtained from
Tomography
Arthrography
C T scanning
Magnetic resonance
imaging
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Vitality Testing
Pulpal health must be measured before restorativ
e
treatment to

PERCUSSION and

THERMAL STIMULATION

TEST CAVITY-nonvitality without L.A
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VITALITY TEST asses only afferent Nerve suppl
y.
MISDIAGNOSIS occurs if N S is damaged and b
lood supply intact .
Careful inspection of radiographs therefore provi
de an
essential aid in the examination.
DIAGNOSTIC CASTS
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
Articulated diagnostic
casts are essential in
planning fixed
Prosthodontic treatment.

They must be accurate reproductions of the maxilla
ry and mandibular arches made from distortion free
alginate
impressions.
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Advantages of Diagnostic Casts:-
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1) Allow an unobstructed view of the edentulou
s spaces and an accurate assessment of the span
length, as well as occlusogingival dimension.
2) Length of the abutment teeth can be accuratel
y gauged to determine which preparation designs
will provide
adequate retention and resistanc
e.
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.
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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 num
ber, size and location is possible.
6) Diagnostic wax-up can be carried out in situatio
ns
calling for the use of pontics which are wid
er or narrower
than the teeth that would norma
47
lly occupy the edentulous
space
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7) Teeth that have supraerupted into the opposing e
dentulous spaces are easily spotted and the amount o
f correction
needed can be determined.
8) Occlusal discrepancies can be evaluated and the p
resence of centric prematurities or excursive interfe
rences can be
determined.
9) Discrepancies in the occlusal plane become very
apparent on the articulated casts.
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Treatment
Planning
Replacement
of Missing
Teeth
Single-Tooth
Restorations
The selection
of the
material
The selection
design of the
restoration
???????
Removable
Partial
Denture
ImplantSupported
Fixed Partial
Denture
Conventional
ToothSupported
Fixed Partial
Denture
Resin-Bonded
ToothSupported
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Treatment Planning for Single-Tooth Restorati
ons
The selection of the material and design of the rest
oration is based on several factors:
1 Destruction of tooth structure
2. Esthetics
3. Plaque control
4. Financial considerations
5. Retention
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Destruction of tooth structure:

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If the amount of destruction is such that the rem
aining tooth structure must gain strength and pro
tection from the restoration, cast metal or cerami
c 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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Plaque control
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
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 caref
ully weighed

Motivated to follow a regime of brushing, flossing and diet

ary
regulation to control or eliminate the disease proces
s responsible for destruction of tooth structure.

If these measures prove to be successful
cast metal, ceramic or metal ceramic restorations can be
fabricated
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FINANCIAL CONSIDERATIONS
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 “SOME ONE” ?????????????
????
Government agency
A branch of military
Insurance company
 Selection should not be less than optimum just
because the patient cannot afford
 Sound alternative to the preferred treatment 41
plan
Retention
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
Full veneer crowns are unquestionably the most ret
entive

Special concern for ;

Short teeth

Removable partial denture abutment.
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TWELVE RESTORATION TYPES
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"plastic restoration" or a "cemented
restoration ?????????
INTRA CORONAL RESTORATION


When sufficient coronal tooth structure exist to retain and pr
otect a restoration under the anticipated stresses of mastica
tion an
intracoronal restoration can be employed.

In this circumstance , the crown of the tooth and the resto
ration
itself are dependent upon the strength of remai
ning tooth structure
to provide structural integrity.
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GLASS IONOMER
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Where extensions can be kept minimal.
 Class V lesions
 Incipient lesions
 Root caries in geriatric patients & periodontal pat
ients
 Interim treatment restoration to assist in the cont
rol of a mouth with rampant caries
further
enhanced by the release of fluoride
by the material.

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COMPOSITE
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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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SILVER AMALGAM

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Minor to moderate sized lesions in esthetic
ally non critical areas.
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COMPLEX AMALGAM
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
Moderate to severe lesions - amalgam augmente
d by pins.

As a final restoration when a crown is contraindic
ated .

Missing cusps or endodontically treated premolar
s and molars.

Teeth that ordinarily would be restored with mesi
o-occulso-distal (MOD)onlays or other extracoro
nal
restorations.
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METAL INLAY




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Minor to moderate lesions where esthetic requirem
ents are low .
Usually made of softer gold alloys
Etchable base metal alloys- if a bonding effect is d
esired.
Restoration of MOD on molars.
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CERAMIC INLAY
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
Minor to moderate sized lesion where esthetic demand is
high.

B’coz this type of restoration can be etched to enhance b
onding
the structural integrity of too
th cusps may be
stabilize
d by bonding
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MOD ONLAY
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
Moderately large lesions on premolars and molars with
intact facial and lingual surfaces.

It will accomodate a wide isthmus and upto one missin
g cusp on molar.
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EXTRA CORONAL RESTORATION
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
Insufficient coronal tooth.

Deflective axial tooth structure.

Modify contours to refine occlusion or improve esthetic
s.
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PARTIAL VENEER CROWN

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To restore a tooth with one or more intact axial surface
s with half or more of the coronal tooth structure remai
ning.

For short span fixed partial dentures.

If tooth destruction is not extensive.
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FULL METAL
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
Restore teeth with multiple defective axial surfac
es.

Restricted to situation where there are no estheti
c
expectations.
METAL CERAMIC CROWN
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
Multiple defective axial surfaces

Fixed partial dentures retainer where
full coverage and good cosmetic resu
lts must be obtained.
ALL CERAMIC CROWN
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
Full coverage and maximum esthetics.

Restricted to situation likely to produce low
moderate stress .

Usually used on incisors.
CERAMIC VEENERS
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
Intact anterior tooth that are marred by sev
ere staining or developmental defects re
stricted to facial surface of the tooth.

Moderate incisal clipping and proximal lesi
ons.
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TREATMENT PLANNING FOR THE REPLACEMEN
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T OF MISSING TEETH
SELECTION OF THE TYPE OF THE POSTHES
IS

A REMOVAL PARTIAL DENTURE.

A TOOTH SUPPORTED FIXED PARTIAL DENTURE
OR

AN IMPLANT SUPPORTED FIXED PARTIAL DENTU
RE
25
FACTORS CONSIDERED

BIOMECHANICAL

PERIODONTAL

ESTHETIC

FINANCIAL and

PATIENTS WISHES.
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It is not uncommon to combine two types in the sam
e arch.
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REMOVABLE PARTIAL DENTURE
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
Edentulous spaces greater than two posterior te
eth.

Anterior space greater than four lncisors.

Edentulous space with no distal abutment.

Multiple edentulous spaces.

Tipped teeth adjoining edentulous spaces and pr
ospect-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 i
n the edentulous ridge.
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CONVENTIONAL TOOTH SUPPORTED
FIXE
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D
PARTIAL DENTURE

Abutment teeth are periodontally sound.

Edentulous span is short and straight.

Expected to provide a longlife of function for the pati
ent.

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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RESIN BONDED TOOTH SUPPORTED
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FIXED PARTIAL DENTURE

Defect free abutments where single missing toot
h.

A single molar (muscles are not well developed).

Mesial and distal abutment are present.

Moderate resorption and no gross soft tissue def
ects on edentulous ridges.
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
Younger patients whose immature teeth with lar
ge
pulps are poor risks for endodontic free a
butment
preparation.

Tilted tooth can be accommodated only if there i
s
enough tooth structure to allow a change i
n the normal alligment of axial reduction.

Periodontal splints.
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IMPLANT SUPPORTED FIXED PARTIAL
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DENTURE

Insufficient number of abutments.

Patient’s attitude and or a combination of i
ntra 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 teet
h.

A span length of two or six teeth can be re
placed by multiple implants.

Pier in an edentulous span (three or more t
eeth
long).
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NO PROSTHETIC TREATMENT
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
Long standing edentulous space into which
there has been little or no drifting or elongat
ion of the adjacent teeth.

If the patients percieves no functional , occl
usal or esthetic impairement.
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CASE PRESENTATION
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In cases where the choice between a fixed
partial denture and a removable partial den
ture is not
clear cut, two or more treatme
nt options should be presented to the patie
nts along with their
sadvantages.
advantages and di
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The prosthodontist is the best person to ev
aluate the physical and biological factors p
resent , while the patients feelings shou
ld carry
considerable weight on
matters of esthetics & finances .
14
ABUTMENT EVALUATION
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The roots and their supporting tissues sho
uld be evaluated for three factors

Crown root ratio

Root configuration

Periodontal ligament area
13
CROWN ROOT RATIO

Optimum -2:3

Minimum -1:1 (acceptable)
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ROOT CONFIGERATION
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
Broader Labiolingullay than Mesiodistally.

Multirooted posterior teeth with widely separated ro
ots.

Conical roots can be used -for short span.

A single rooted tooth with evidence of irregular con
figu- ration or with some curvature in the tooth –is
preferable than that which has a nearly taper.
PERIODONTAL LIGAMENT AREA
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
Larger teeth have a greater surface area a
nd
better able to bear added stress.

“ ANTE’S LAW” the root surface area of th
e abutment teeth had to equal or surpas
sed that of
the teeth being replaced wit
h pontics.
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10
BIOMECHANICAL CONSIDERATIONS
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
In addition to the increased load placed on the p
dl by a long span FPD.

Longer spans are less rigid.

Bending or deflection varies directly with the cub
e of the length and inversely with cube of the oc
clusogingival thickness of the pontic .
9
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8
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TO MINIMIZE –

Greater occlusogingival dimension

Nickel chromium

Double abutment

Multiple grooves
7
Special Situations
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
PIER ABUTMENTS
Non rigid connector

Restrict to short span FPD

key way -distal contours of pier a abutment

key - mesial side of the distal pontic
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6
Company
A Nonrigid connector on the
middle abutment isolates
force to that segment of the
fixed partial denture to which
it is applied
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THIRD MOLAR ABUTMENTS
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
Mild encroaching- restoring and recontouring

Tilting is severe –corrective measures
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5
Company

Orthodontic appliance for
uprighting a tilted molar

Proximal half crown as a retainer
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Non rigid connector on distal aspect of premolar ret
ainer
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CANINE – REPLACEMENT FIXED PARTI
AL 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 more
stresses than that replacing a mandibular canine

Edentulous spaces created by the loss of canine and any contiguous
teeth is best restored with Implants.
4
CANTILEVER FIXED PARTIAL DENTURES
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
Lengthy roots with favourable configuratio
n.

Long clinical crowns.

Good crown root ratios and healthy
periodontium.

Should replace only one tooth and have atl
east two abutments.

Pontic should posses maximum occlusogi
ngival height to ensure a rigid prosthesis.
3
Company
Forces on the pontic of a cantilever fixed pa
rtial denture tend to tip the fixed partial dent
ure or the abutment tooth
Cantilever fixed partial denture replacing maxil
lary lateral incisor, using the canine as the abu
tment
Cantilever pontics can be used to replace
a 1st premolar, if full veneers are used on
2nd PM,and 1st molar
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CONCLUSION
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The history and clinical examination must provide sufficient d
ata for the practioner to formulate a successful treatment plan.
The overall prognosis is influenced by general and local facto
rs
1
References
1.
2.
3.
4.
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Fundamentals of fixed prosthodontics-3rd editio
n,
Shillingburg
Contemporary Fixed Prosthodontics-Rosenstiel3rd edition
Examination Of Temporomandibular Disorders .
A Clinical Guide, J Appl Oral Sci. 2007;15(1):77
-82, Ana Claúdia de Castro Ferreira et al
Pocket Dentistry-Fastest Clinical Dentistry Insig
ht Engine
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5.History of and Examination for Temporomandibul
ar Disorders
6.Supplement the Base to Complement the Crown:
Localized
Ridge Augmentation using Connec
tive Tissue Graft7. Hemini Shah et al, IJSS Case Reports & Revie
ws | April 2015 | Vol 1 | Issue 11
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