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Indian Dental Academy: will be one of the most relevant and exciting training

center with best faculty and flexible training programs for dental

professionals who wish to advance in their dental practice,Offers certified

courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry,

Prosthetic Dentistry, Periodontics and General Dentistry.

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Abutmnt evaluation /orthodontics courses in india Presentation Transcript

  • 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2. ContentsContents  IntroductionIntroduction  Diagnostic recordDiagnostic record General informationGeneral information Medical historyMedical history Drug historyDrug history Dental historyDental history  Clinical examinationClinical examination Extra oralExtra oral Intra oralIntra oral  Radiographic examinationRadiographic examination  Pre treatment recordsPre treatment records  PrognosisPrognosis  Treatment planningTreatment planning  ConclusionConclusion www.indiandentalacademy.com
  • 3. INTRODUCTIONINTRODUCTION Successful fixed prosthodontic therapySuccessful fixed prosthodontic therapy begins with a thorough assessment of thebegins with a thorough assessment of the patient’s physical and psychologicalpatient’s physical and psychological condition and determining a treatment thatcondition and determining a treatment that will satisfy the expectations of the patient.will satisfy the expectations of the patient. www.indiandentalacademy.com
  • 4. Some key words used are :Some key words used are : • ExaminationExamination: Scrutiny or investigation for the purpose: Scrutiny or investigation for the purpose of making a diagnosis or assessment.of making a diagnosis or assessment. • Diagnosis:Diagnosis: It is translation of data gathered by clinicalIt is translation of data gathered by clinical and radiographic examination into an organized,and radiographic examination into an organized, classified definition of condition present.classified definition of condition present. • Treatment planningTreatment planning: Sequence of procedures planned: Sequence of procedures planned for the treatment of the patient.for the treatment of the patient. • PrognosisPrognosis: A forecast as to the probable result of a: A forecast as to the probable result of a disease or a cause of therapy.disease or a cause of therapy. www.indiandentalacademy.com
  • 5. To gain the necessary informationTo gain the necessary information about the patient, dentist should:about the patient, dentist should: (1) Conduct a thorough examination(1) Conduct a thorough examination (2) Listen to all the patient has to say(2) Listen to all the patient has to say (3) Be alert to things patient may leave unsaid(3) Be alert to things patient may leave unsaid (4) Record details of information in an logical(4) Record details of information in an logical sequencesequence www.indiandentalacademy.com
  • 6. Diagnostic record for the fixedDiagnostic record for the fixed partial denture patientpartial denture patient It includes:It includes: • General informationGeneral information • Visual examinationVisual examination • PalpationPalpation • Still photographyStill photography • Intraoral radiographyIntraoral radiography • MeasurementsMeasurements • Diagnostic castsDiagnostic casts www.indiandentalacademy.com
  • 7. • Diagnostic casts are an integral part of theDiagnostic casts are an integral part of the diagnostic procedures necessary to give thediagnostic procedures necessary to give the dentist as complete a perspective as possible ofdentist as complete a perspective as possible of the patient’s dental needs.the patient’s dental needs. • These casts are used to evaluate soft tissueThese casts are used to evaluate soft tissue contours, vestibular morphology frenalcontours, vestibular morphology frenal attachments, bony contours (eg Tori), crownattachments, bony contours (eg Tori), crown length, and morphology, teeth alignment andlength, and morphology, teeth alignment and paths of insertion, available pontic space,paths of insertion, available pontic space, existing restorations, esthetic factors and theexisting restorations, esthetic factors and the occlusion.occlusion. •    www.indiandentalacademy.com
  • 8. Data obtained must beData obtained must be • easily retrievableeasily retrievable • In a logical sequenceIn a logical sequence • And should be kept confidentialAnd should be kept confidential General information can be gathered by any of theGeneral information can be gathered by any of the following 3 ways:following 3 ways: I) Direct interrogation by the dentist:I) Direct interrogation by the dentist: - It offers greatest latitude- It offers greatest latitude - Questions asked are brief & general in nature- Questions asked are brief & general in nature -Can be probing & overlapping on points,-Can be probing & overlapping on points, dentist deems importantdentist deems important www.indiandentalacademy.com
  • 9. --Helps in developing rapport with patient and toHelps in developing rapport with patient and to evaluate patient attitude towards previous treatment.evaluate patient attitude towards previous treatment. DisadvantagesDisadvantages - Time consuming- Time consuming - Relies heavily on skill & experience of dentist.- Relies heavily on skill & experience of dentist. - It is easy to forget necessary questions to be posed.- It is easy to forget necessary questions to be posed. (ii)(ii) A comprehensive questionnaire:A comprehensive questionnaire: -It is quick & filled by patient in waiting room-It is quick & filled by patient in waiting room Disadvantages:Disadvantages: -Patient may not read it carefully-Patient may not read it carefully www.indiandentalacademy.com
  • 10. -May overlook important information-May overlook important information -May give it to companions to fill which lead to-May give it to companions to fill which lead to errors.errors. (iii)(iii) A combination of both:A combination of both: -- Gives added advantage of bothGives added advantage of both - Form filled by pt. can be verbally reviewed- Form filled by pt. can be verbally reviewed - Any +ve/-ve response may be noted &- Any +ve/-ve response may be noted & clarifiedclarified -- chance to correlate between examination,chance to correlate between examination, observation & pt.’s health historyobservation & pt.’s health history - Any conflicting information may be thoroughly- Any conflicting information may be thoroughly probedprobed www.indiandentalacademy.com
  • 11. • GENDER:GENDER: Female pts. are more conscious ofFemale pts. are more conscious of their appearance. Therefore importance given totheir appearance. Therefore importance given to details such as lip support, visibility of teeth,details such as lip support, visibility of teeth, cuspal contour, shade of teeth etc.cuspal contour, shade of teeth etc. www.indiandentalacademy.com
  • 12. -postmenopausal women also pose psychologicalpostmenopausal women also pose psychological problems with other problems like dry mouth, burningproblems with other problems like dry mouth, burning mouth syndrome & general vague pain.mouth syndrome & general vague pain. -- Male patientsMale patients tend to be more occupied with theirtend to be more occupied with their work & are less concernedwork & are less concerned -Expect comfort & functionExpect comfort & function OCCUPATION: influences the degree of importance of factors like esthetics, phonetics and general appearance. www.indiandentalacademy.com
  • 13. • For professionals, who are in intimate contact with people in their public life, appearance and retention of denture is more important than masticatory efficiency. • Public speakers, singers and musicians who play wind instrument require perfect retention and particular attention to shape and position of teeth and palatal form and thickness. In addition a question about the work hours will allow the dentist to fix appointments at time convenient for the patient.www.indiandentalacademy.com
  • 14. • SOCIAL SETTING:SOCIAL SETTING: Knowledge of patient’sKnowledge of patient’s social setting helps the dentist to understandsocial setting helps the dentist to understand patient expectationspatient expectations - It is also helpful to have patient identify close- It is also helpful to have patient identify close friends and relatives whose judgment they valuefriends and relatives whose judgment they value and if possible gain insight into their views.and if possible gain insight into their views. www.indiandentalacademy.com
  • 15. • Other questions to be asked:Other questions to be asked: - how the patient chose the particular dental office. -Was he referred by another dentist physician or by other means? - If referral is from another dentist, valuable background information and specific items like diagnostic casts / radiographs can be obtained. www.indiandentalacademy.com
  • 16. Medical historyMedical history A complete health history should include, (1) Name of patient’s physician, including data and reason for the last appointment. (2) A record of the status of all major body systems (3) A record of all medications the patient is currently taking and any change in that regime within last six months. www.indiandentalacademy.com
  • 17. (4) A record of any hospitalization (5) A record of any complication that was a result of previous dental treatment. (6) A record of patients opinion of his / her general health. (7) Space to update health history whenever patient is recalled.patient is recalled. www.indiandentalacademy.com
  • 18. • Many systemic diseases might or might not haveMany systemic diseases might or might not have local manifestations. But some have a directlocal manifestations. But some have a direct relation to FDP success. Few such conditionsrelation to FDP success. Few such conditions are:are: (1) Debilitating diseases(1) Debilitating diseases: Patient with known: Patient with known debilitating diseases like Diabetes, tuberculosis,debilitating diseases like Diabetes, tuberculosis, blood dyscrasias etc should be under medicalblood dyscrasias etc should be under medical control.control. www.indiandentalacademy.com
  • 19. • These patients require extra instructions in oralThese patients require extra instructions in oral hygiene, eating habits and tissue rest.hygiene, eating habits and tissue rest. (a) Diabetes:(a) Diabetes: An uncontrolled diabetic or poorlyAn uncontrolled diabetic or poorly controlled diabetics may pose problems of:controlled diabetics may pose problems of: (i) Bacterial, viral and fungal infections –(i) Bacterial, viral and fungal infections – including candidiasisincluding candidiasis www.indiandentalacademy.com
  • 20. (ii) Xerostomia: It causes dry, atrophic oral(ii) Xerostomia: It causes dry, atrophic oral mucosa accompanied by mucositis, ulcers,mucosa accompanied by mucositis, ulcers, desquamation and opportunistic infection.desquamation and opportunistic infection. • Inflammed depapillated, painful tongueInflammed depapillated, painful tongue • Difficulty in lubricating, masticating, andDifficulty in lubricating, masticating, and swallowing are the other complicationsswallowing are the other complications www.indiandentalacademy.com
  • 21. (iii) Poor wound healing(iii) Poor wound healing (iv) Burning mouth syndrome(iv) Burning mouth syndrome (v) Insulin reaction in patients treated with insult.(v) Insulin reaction in patients treated with insult. Precautions taken to prevent insulin shockPrecautions taken to prevent insulin shock during dental appointments are dietaryduring dental appointments are dietary instruction i.e. to eat normal meal, keepinstruction i.e. to eat normal meal, keep appointments as short as possible and source ofappointments as short as possible and source of sugar given to patient, in case of symptoms.sugar given to patient, in case of symptoms. www.indiandentalacademy.com
  • 22. (b) Tuberculosis:(b) Tuberculosis: - should find whether disease is active/ passive- should find whether disease is active/ passive - immunity is usually low- immunity is usually low - precaution to be taken while handling such- precaution to be taken while handling such patients like sterilization, protective gear etc.patients like sterilization, protective gear etc. (c) Blood dyscrasias:(c) Blood dyscrasias: - proper history should be taken- proper history should be taken - blood tests/ consultation prior to treatment- blood tests/ consultation prior to treatment - these patients get easily bruised, so care- these patients get easily bruised, so care should be taken while during crown preparationshould be taken while during crown preparation and impression making.and impression making. www.indiandentalacademy.com
  • 23. (2) Cardio vascular diseases: -Patient with history of Rheumatic fever and Rheumatic heart disease are susceptible to infective endocarditis. - Prophylactic antibiotic coverage for all dental procedures Artificial heart valves also warrant antibiotic prophylaxes to prevent prosthetic valve endocarditis. www.indiandentalacademy.com
  • 24. • Stress and anxiety related to dental visit may precipitate angina and sudden death due to cardiac arrhythmias and cardiac arrest. • The following points have to be noted to avoid emergencies in dental office: • (i) Detection of the condition through history & consultation with patient’s cardiologist. www.indiandentalacademy.com
  • 25. (ii) Making patient free to talk about fears and relieving them of the anxiety (iii) Convenient short morning appointment (iv) Premedication with diazepam 5-10 mg to reduce apprehension (v) Nitroglycerine tablets to be made available in dental office and given sublingually if pain starts. www.indiandentalacademy.com
  • 26. (3) Diseases of joints:  Particularly osteoarthritis presents a problem.  Under the age of 45, men and women are affected in the ratio of 2 : 1.  It affects the weight bearing joints like, hips, knee and spine and also the terminal joints of fingers, less frequently affected are second row of joints in fingers and TMJ. www.indiandentalacademy.com
  • 27. Prosthetic consideration: -When terminal joints fingers are arthritic it is difficult to maintain oral hygiene. - Osteoarthritis of TMJ presents problem in FDP construction as mandibular movements are painful and jaw relation records are difficult to record and repeat. www.indiandentalacademy.com
  • 28. (4) Diseases of skin:(4) Diseases of skin: DermatologicalDermatological conditions like pemphigus that are extremelyconditions like pemphigus that are extremely painful.painful. (5) Neurological disorders:(5) Neurological disorders: -Patient with Bell’s palsy and Parkinson’s-Patient with Bell’s palsy and Parkinson’s disease etc. need special prosthetic treatmentdisease etc. need special prosthetic treatment considerationsconsiderations www.indiandentalacademy.com
  • 29. (6) Radiation treated patients:(6) Radiation treated patients: Patients treatedPatients treated by radiation of head and neck tend to developby radiation of head and neck tend to develop problems likeproblems like i) Mucositisi) Mucositis ii) Xerostomiaii) Xerostomia iii) Loss of tasteiii) Loss of taste iv) Constricture of muscles (trismus)iv) Constricture of muscles (trismus) v) Secondary infections (Candidiasis)v) Secondary infections (Candidiasis) - Dentist detects most oral malignancies.- Dentist detects most oral malignancies. Malignancies are eradicated by surgery /Malignancies are eradicated by surgery / radiation and subsequent treatment handled byradiation and subsequent treatment handled by maxillofacial prosthodontist.maxillofacial prosthodontist. www.indiandentalacademy.com
  • 30. • Before radiation treatment is started:Before radiation treatment is started: 1) Infections are treated1) Infections are treated 2) Extraction of all remaining teeth if CD is2) Extraction of all remaining teeth if CD is plannedplanned 3) Xerostomia, mucositis and oral hygiene3) Xerostomia, mucositis and oral hygiene managed.managed. www.indiandentalacademy.com
  • 31. • Patient receiving chemotherapy for CancerPatient receiving chemotherapy for Cancer show:show: 1) Mucositis1) Mucositis 2) Extensive bleeding following minor trauma2) Extensive bleeding following minor trauma 3) Xerostomia3) Xerostomia 4) Infection4) Infection 5) Poor healing5) Poor healing • Oncologist consulted prior to any invasive dentalOncologist consulted prior to any invasive dental procedure. Symptomatic relief for mucositis andprocedure. Symptomatic relief for mucositis and xerostomia should be providedxerostomia should be provided www.indiandentalacademy.com
  • 32. (7) Menopause:(7) Menopause: Occurs at around 45 years ageOccurs at around 45 years age - Important changes in bodily function occurs.- Important changes in bodily function occurs. - Majority undergo bone changes, generalized- Majority undergo bone changes, generalized osteoporosis mental disturbances ranging fromosteoporosis mental disturbances ranging from mild irritability to complete nervous breakdown,mild irritability to complete nervous breakdown, hot flushes, burning palate, burning tongue,hot flushes, burning palate, burning tongue, inability to adjust and vague areas of pain.inability to adjust and vague areas of pain. www.indiandentalacademy.com
  • 33. (8) Hypo & Hyper thyroidism:(8) Hypo & Hyper thyroidism: HyperthyroidismHyperthyroidism – Thyrotoxic crisis precipitated by– Thyrotoxic crisis precipitated by stress, trauma, surgical procedures.stress, trauma, surgical procedures. - Osteoporosis might develop.- Osteoporosis might develop. HypothyroidsHypothyroids – may develop hypothyroid coma when– may develop hypothyroid coma when exposed to stressful conditions.exposed to stressful conditions. - Oral manifestations are increase tongue size and- Oral manifestations are increase tongue size and gingival edema.gingival edema. www.indiandentalacademy.com
  • 34. • (9) Allergies and Angionematic edema:(9) Allergies and Angionematic edema: - H/o of allergy to any drugs, most commonly to- H/o of allergy to any drugs, most commonly to lignocaine , allergy to nickel etclignocaine , allergy to nickel etc - Angioneurotic edema is a no emergency,- Angioneurotic edema is a no emergency, edematous swelling of lips, cheek etc afteredematous swelling of lips, cheek etc after contact with an antigen like acrylic / metal.contact with an antigen like acrylic / metal. - Emergency treatment :0.3 – 0.5 ml epinephrine- Emergency treatment :0.3 – 0.5 ml epinephrine 1 : 1000 1M, support respiration / obtain medical1 : 1000 1M, support respiration / obtain medical assistance.assistance. www.indiandentalacademy.com
  • 35. (10) Diseases of respiratory system: Asthma,(10) Diseases of respiratory system: Asthma, COPD, pneumonia,TB etc.COPD, pneumonia,TB etc. - usually patient is on medications, so physician- usually patient is on medications, so physician should be consulted.should be consulted. - short morning appointments- short morning appointments - avoid NSAIDS- avoid NSAIDS -Malaise in older patients is often indicative of an-Malaise in older patients is often indicative of an impeding health crisis and should not beimpeding health crisis and should not be ignored.ignored. In diseases like AIDS, Hepatitis B &C and otherIn diseases like AIDS, Hepatitis B &C and other communicable diseases universal precautionscommunicable diseases universal precautions should be taken to avoid cross infection.should be taken to avoid cross infection.www.indiandentalacademy.com
  • 36. Drug historyDrug history • Value of knowing what medication the patientValue of knowing what medication the patient takes is:takes is: -It can be an indication of a systemic disease-It can be an indication of a systemic disease and which could alter dental treatment.and which could alter dental treatment. -Compatibility of the drugs prescribed during the-Compatibility of the drugs prescribed during the course of dental treatment with those alreadycourse of dental treatment with those already being taken.being taken. • Dentists should be aware of the synergistic andDentists should be aware of the synergistic and antagonistic` effects of drugs.antagonistic` effects of drugs. • Effects of drugs that can influence the outcomeEffects of drugs that can influence the outcome of prosthodontic treatment are listed below:of prosthodontic treatment are listed below: www.indiandentalacademy.com
  • 37. (1) Xerostomia :(1) Xerostomia : (a) Antihistamines Diphenylhydramine (Benadryl)(a) Antihistamines Diphenylhydramine (Benadryl) (b) Glycopyrrolate, Propanthelin(b) Glycopyrrolate, Propanthelin (c) Antihypertensives(c) Antihypertensives (d) Nitroglycerin given in angina(d) Nitroglycerin given in angina (e) Antipsychotic drugs(e) Antipsychotic drugs (f) Antiparkinsonian agents(f) Antiparkinsonian agents (g) Anti arrhythmic agents(g) Anti arrhythmic agents (h) Tricyclic anti depressants – Imipramine,(h) Tricyclic anti depressants – Imipramine, amitriptylinamitriptylin (i) Antianxiety agents – diazepam, alprazolam(i) Antianxiety agents – diazepam, alprazolam www.indiandentalacademy.com
  • 38. (j) Antisialogogues – atropine(j) Antisialogogues – atropine (k) Decongestants – phenyl propanolamine(k) Decongestants – phenyl propanolamine (2) Sialorrehea(2) Sialorrehea – increase salivation– increase salivation (a) Adrenergic stimulating drugs – epinephrine(a) Adrenergic stimulating drugs – epinephrine (b) Sialogogues – Pilocarpine, neostigmine(b) Sialogogues – Pilocarpine, neostigmine (c) Cholinesterase inhibitors used in myasthenia(c) Cholinesterase inhibitors used in myasthenia gravisgravis (3) Dysphagia :(3) Dysphagia : - Tricyclic antidepressants- Tricyclic antidepressants - Antipsychotic drugs- Antipsychotic drugs - All those that cause xerostomia also cause- All those that cause xerostomia also cause dysphagiadysphagia www.indiandentalacademy.com
  • 39. (4) Mucosal changes: (a)Phenytoin – Edematous gingival tissues and hyperplasia (b) Digoxin (c) Adrenal corticosteroids – atrophy of mucosa / skin (5) Hypoglycemic shock- Insulin takers (6) Nausea, vomiting Aspirin – Used in Rheumatic conditions Narcotic analgesic – codein, propoxyphene Digitalis Estrogens – In postmenopausal women www.indiandentalacademy.com
  • 40. (7) Anti coagulants- Warfarin, Heparin (8) Drug induced Parkinson like syndrome with bizarre muscle movements including facial muscles (a) Antipsychotics – chlorpromazine, Haloperidol (b) Tricyclic antidepressants (c) Metoclopromide (9) Altered taste sensation Beta blockers – propanotol, Atenolol ACE inhibitors – captopril enalopril www.indiandentalacademy.com
  • 41. (10) Behavioural changes / confusion Adrenal corticosteroids • Antiparkinsonism agents – Procyclidine, Benztropine, trihexphenedryl tricyclic antidepressants, narcotic analgesics, central nervous system depressing drugs including alcohol – Patient acceptance of prosthesis could be affected. • The updating of health history is very important. • New medications, changes in treatment, and surgery can have a significant effect on dental treatment www.indiandentalacademy.com
  • 42. • Family history:Family history: - proper history can reveal inheritable diseases in- proper history can reveal inheritable diseases in the familythe family - it includes blood disorders, abnormality of- it includes blood disorders, abnormality of bones, teeth, diabetes, hypertension etc.bones, teeth, diabetes, hypertension etc. • Appraisal of General PhysicalAppraisal of General Physical Characteristics:Characteristics: The three main physical characteristics to beThe three main physical characteristics to be looked for are :looked for are : (1) The neuromuscular skills / motor skills(1) The neuromuscular skills / motor skills (2) The general appearance(2) The general appearance (3) The face(3) The face www.indiandentalacademy.com
  • 43. I) Neuromuscular skillsI) Neuromuscular skills: Degree of: Degree of coordination in a patient is the foremost factor tocoordination in a patient is the foremost factor to be looked for:be looked for: a) Facial movements:a) Facial movements: Bell’s palsy, nerveBell’s palsy, nerve blocks or trigeminal neuralgia will result inblocks or trigeminal neuralgia will result in hemiplegia / dyskinesia. Tremors or spasms arehemiplegia / dyskinesia. Tremors or spasms are indicative of Parkinson’s disease, nervous habitsindicative of Parkinson’s disease, nervous habits / possible drug induced Tardive dyskinesia./ possible drug induced Tardive dyskinesia. www.indiandentalacademy.com
  • 44. b) Speech:b) Speech: Fluency and quality of patient’sFluency and quality of patient’s speech is judged during casual conversation.speech is judged during casual conversation. II) Facial features:II) Facial features: An observation of patient’s face to note theAn observation of patient’s face to note the length, fullness, support of lips includinglength, fullness, support of lips including pihiltrum, nasolabial fold, labiomental fold, labialpihiltrum, nasolabial fold, labiomental fold, labial commisures and modiolus.commisures and modiolus. www.indiandentalacademy.com
  • 45. • General Appearance:General Appearance: A patient with pleasingA patient with pleasing countenance who has a zest for life is usually acountenance who has a zest for life is usually a better prosthodontic risk than one who is tensebetter prosthodontic risk than one who is tense and depressed about life in general.and depressed about life in general. • Mental Attitude:Mental Attitude: The international prosthodontic workshopThe international prosthodontic workshop identified certain factors that produce anidentified certain factors that produce an adaptive or maladaptive response.adaptive or maladaptive response. Factors which produce an adaptive response:Factors which produce an adaptive response: 1) The acceptance of the dentist & confidence in1) The acceptance of the dentist & confidence in the dentist.the dentist. 2) Previous favorable experience with authority2) Previous favorable experience with authority figures.figures. www.indiandentalacademy.com
  • 46. 3) The capacity to cope favorably with change.3) The capacity to cope favorably with change. 4) Favorable physical condition.4) Favorable physical condition. 5) Realistic expectations of the patient.5) Realistic expectations of the patient. 6) Good learning capacity.6) Good learning capacity. 7)Desire of the patient to please the doctor.7)Desire of the patient to please the doctor. 8) Recognition by the patient of the limitations to8) Recognition by the patient of the limitations to complete success.complete success. 9) Good physical coordination.9) Good physical coordination. 10) The therapeutic alliance of the patient with10) The therapeutic alliance of the patient with the doctor.the doctor. www.indiandentalacademy.com
  • 47. Factors which produce a maladaptive responseFactors which produce a maladaptive response toFDP:toFDP: 1) Lack of trust in the dentist.1) Lack of trust in the dentist. 2) Poor communication between the dentist & his2) Poor communication between the dentist & his patient.patient. 3) Negative previous experience.3) Negative previous experience. 4) Unrealistic expectations of the patient.4) Unrealistic expectations of the patient. 5) Resistance to change arising from severe5) Resistance to change arising from severe anxiety or depression or hopelessness.anxiety or depression or hopelessness. 6) Low tolerance level for anxiety or pain.6) Low tolerance level for anxiety or pain. 7) High level of anxiety on the part of the patient.7) High level of anxiety on the part of the patient. 8) Inadequate tissue tolerance.8) Inadequate tissue tolerance. 9) Muscle in coordination.9) Muscle in coordination. www.indiandentalacademy.com
  • 48. 10) Chronic dissatisfaction10) Chronic dissatisfaction 11) The wish to fail. The patient wants attention11) The wish to fail. The patient wants attention and needs a continuing relationship with theand needs a continuing relationship with the dentist.dentist. - Dr. Milus House classified mental attitude into 4- Dr. Milus House classified mental attitude into 4 types based on extensive clinical experience.types based on extensive clinical experience. a) Philosophical patienta) Philosophical patient b) Indifferent patientb) Indifferent patient c) Critical patientc) Critical patient d) Skeptical patientd) Skeptical patient www.indiandentalacademy.com
  • 49. Dental historyDental history • It includes:It includes: 1) Chief complaint:1) Chief complaint: It is a simple statement ofIt is a simple statement of what prompted the patient to seek care. Itwhat prompted the patient to seek care. It should be expressed clearly & concisely inshould be expressed clearly & concisely in patient’s own words.patient’s own words. 2) Symptoms & duration of problem:2) Symptoms & duration of problem: Information to be obtained.Information to be obtained. (1) Beginning and severity of dental disease.(1) Beginning and severity of dental disease. (2) Patients reaction to dental treatment(2) Patients reaction to dental treatment (3) Opinion of the dentists who have performed(3) Opinion of the dentists who have performed service for the patient.service for the patient.www.indiandentalacademy.com
  • 50. Detailed information obtained:Detailed information obtained: (1) Cause of loss of natural whether carious /(1) Cause of loss of natural whether carious / periodontalperiodontal (2) H/o difficult extraction – there might be more(2) H/o difficult extraction – there might be more bone loss at that site.bone loss at that site. (3) Order of tooth loss(3) Order of tooth loss (4) Length of time patient has been edentulous(4) Length of time patient has been edentulous (5) Any areas of jaw not healed might indicates(5) Any areas of jaw not healed might indicates (a) In sufficient healing time(a) In sufficient healing time (b) Incomplete elimination of pathological tissue(b) Incomplete elimination of pathological tissue (c) Health state not conducive to bone(c) Health state not conducive to bone regenerationregeneration www.indiandentalacademy.com
  • 51. Diet and NutritionDiet and Nutrition -The diet of the patient must be assessed-The diet of the patient must be assessed -Any deficiencies of nutrients and essential-Any deficiencies of nutrients and essential elements can have various manifestations e.g.elements can have various manifestations e.g. Vitamin B can cause angular chelitis.Vitamin B can cause angular chelitis. -Also seen in patient with decrease VD.-Also seen in patient with decrease VD. • Iron deficiency anemia, protein and calciumIron deficiency anemia, protein and calcium deficiency cause muscle weakness and bonedeficiency cause muscle weakness and bone resorption in postmenopausal women andresorption in postmenopausal women and elderly patients.elderly patients. www.indiandentalacademy.com
  • 52. • Patients advised on a balanced diet.Patients advised on a balanced diet. • Pt. should be asked about the habit of pan/betelPt. should be asked about the habit of pan/betel nut chewing, smoking, drinking & bruxism whichnut chewing, smoking, drinking & bruxism which have detrimental effect on health of oral tissues.have detrimental effect on health of oral tissues. www.indiandentalacademy.com
  • 53. CLINICAL EXAMINATION &CLINICAL EXAMINATION & EVALUATION:EVALUATION: (I) Extra oral examination:(I) Extra oral examination: • The head and neck region is examined for theThe head and neck region is examined for the presence of any pathological condition relatingpresence of any pathological condition relating to non dental or systemic conditionto non dental or systemic condition (a) Face form:(a) Face form: Classification of the shape / formClassification of the shape / form of the face put forward by Leon Williams is theof the face put forward by Leon Williams is the simplest and most useful guide though notsimplest and most useful guide though not scientifically correct.scientifically correct. • Williams claims that the shape of upper CentralWilliams claims that the shape of upper Central Incisor bears a definite relation with the shape ofIncisor bears a definite relation with the shape of the face.the face. www.indiandentalacademy.com
  • 54. Face formsFace forms www.indiandentalacademy.com
  • 55. Face profile:Face profile: Can be early indicator of patientsCan be early indicator of patients jaw classification – Normal, prognathic &jaw classification – Normal, prognathic & retrognathic. The labial surface of central incisorretrognathic. The labial surface of central incisor parallels the profile and vertical jaw relationsparallels the profile and vertical jaw relations (increase or decrease VD) can be accurately(increase or decrease VD) can be accurately determined.determined. www.indiandentalacademy.com
  • 56. Facial profileFacial profile www.indiandentalacademy.com
  • 57. Facial profilesFacial profiles www.indiandentalacademy.com
  • 58. b)b) Lips:Lips: It includesIt includes (1) Lip support(1) Lip support (2) Lip thickness(2) Lip thickness (3) Lip length(3) Lip length (4) Lip fullness(4) Lip fullness • Lips should be examined for cracking fissures atLips should be examined for cracking fissures at corners and ulceration. It may be due tocorners and ulceration. It may be due to candidal infection, vitamin deficiency, incompletecandidal infection, vitamin deficiency, incomplete or over closureor over closure www.indiandentalacademy.com
  • 59.  Lip support:Lip support: Lack of proper lip support can leadLack of proper lip support can lead to a collapsed appearance and wrinklingto a collapsed appearance and wrinkling  Lip thickness:Lip thickness: A thin lip presents specialA thin lip presents special problems as a slight change in labiolingual toothproblems as a slight change in labiolingual tooth position alters the drape of lip whereas a thick lipposition alters the drape of lip whereas a thick lip gives more freedom to the dentist beforegives more freedom to the dentist before obvious changes in lip contour manifest.obvious changes in lip contour manifest. www.indiandentalacademy.com
  • 60. Lip supportLip support BeforeBefore AfterAfter www.indiandentalacademy.com
  • 61.  Lip length:Lip length: Long lips tend to hide the teeth thusLong lips tend to hide the teeth thus presenting dentist with a temptation to restorepresenting dentist with a temptation to restore teeth too long to make them visible.teeth too long to make them visible. Short upper lip, will expose most of the toothShort upper lip, will expose most of the tooth surface and even the tooth restorationsurface and even the tooth restoration junction(margin of the restoration)junction(margin of the restoration) www.indiandentalacademy.com
  • 62. C)TMJ: TMJ should be healthy before FDP isC)TMJ: TMJ should be healthy before FDP is made.made. Patient presenting with one / more of thePatient presenting with one / more of the following symptoms are considered to befollowing symptoms are considered to be suffering from TMJ disorder.suffering from TMJ disorder. (1) Pain and tenderness in muscles of(1) Pain and tenderness in muscles of mastication and TMJ.mastication and TMJ. (2) Sounds during condylar movements(2) Sounds during condylar movements (3) Limitations of mandibular movements(3) Limitations of mandibular movements TMD can be either degenerative arthritisTMD can be either degenerative arthritis related TMD or nonarthritic TMD.related TMD or nonarthritic TMD. www.indiandentalacademy.com
  • 63. Reported by Patient Clinical findings 1) Joint noise (s) 1) Clicking, crepitation 2) Pain in face, jaw, ears, headache 2) Pain, tenderness with palpation of masticatory muscles and TMJ 3) Pain on mouth opening 3) TM arthralgia 4) Difficulty in opening wide and chewing 4) Impaired mandibular mobility irregularity or deviation of opening, locking of mandible www.indiandentalacademy.com
  • 64. • Health of TMJ can be estimated by a simpleHealth of TMJ can be estimated by a simple test:test: 1) Patient is asked to open mouth wide1) Patient is asked to open mouth wide and relax, move jaw to left and relax, moveand relax, move jaw to left and relax, move jaw to right and relax and finally move jawjaw to right and relax and finally move jaw forward and relax.forward and relax. 2) A fingertip is placed on face over each condyle2) A fingertip is placed on face over each condyle and patient instructed to open the mouthand patient instructed to open the mouth slightly and move jaw sideways, then to openslightly and move jaw sideways, then to open wide and close.wide and close. If clicking / crepitus in joints is detected byIf clicking / crepitus in joints is detected by finger and is accompanied by painful function,finger and is accompanied by painful function, TMD is likely to be present.TMD is likely to be present.www.indiandentalacademy.com
  • 65. • Prosthetic considerations:Prosthetic considerations:  Unhealthy TMJ complicates jaw relation records.Unhealthy TMJ complicates jaw relation records.  Centric relation depends on structural andCentric relation depends on structural and functional harmony of osseous structures, intrafunctional harmony of osseous structures, intra articular tissue and capsular ligaments. Difficultyarticular tissue and capsular ligaments. Difficulty to give correct & repeatable centric relation andto give correct & repeatable centric relation and centric occlusion.centric occlusion.  Occlusal corrections often needed.Occlusal corrections often needed. www.indiandentalacademy.com
  • 66. • Dentist’s treatment strategies will includeDentist’s treatment strategies will include (1) General emphasis on rest for masticatory(1) General emphasis on rest for masticatory systemsystem (2) Elimination of gross occlusal discrepancies(2) Elimination of gross occlusal discrepancies (3) Patient counseling regarding nature of TMD.(3) Patient counseling regarding nature of TMD. - Symptomatic treatment for pain- Symptomatic treatment for pain www.indiandentalacademy.com
  • 67. • Tone of facial muscles:Tone of facial muscles: Tone of facial tissueTone of facial tissue may indicate limitations on what might be donemay indicate limitations on what might be done to improve patient facial contour.to improve patient facial contour. Only the inadequate support from the intra oralOnly the inadequate support from the intra oral structures can be restored to the originalstructures can be restored to the original positions. Care is taken to see that tone of skinpositions. Care is taken to see that tone of skin is comparable through out the face.is comparable through out the face. www.indiandentalacademy.com
  • 68. • Valuable diagnostic information can be obtainedValuable diagnostic information can be obtained by means of:by means of: • TransilluminationTransillumination • PercussionPercussion • Pulpal vitality testsPulpal vitality tests • Laboratory testsLaboratory tests www.indiandentalacademy.com
  • 69. TRANSILLUMINATIONTRANSILLUMINATION:: • It is a fine adjunct in the oral examination. ItIt is a fine adjunct in the oral examination. It consists of the passage of light through tissuesconsists of the passage of light through tissues by interposing the object to be examinedby interposing the object to be examined between the light source and the examiner. Thebetween the light source and the examiner. The extent of sub gingival calcareous deposits,extent of sub gingival calcareous deposits, interproximal caries. The presence of opaqueinterproximal caries. The presence of opaque foreign objects embedded in soft tissues etc. canforeign objects embedded in soft tissues etc. can be evaluated.be evaluated. www.indiandentalacademy.com
  • 70. • PERCUSSIONPERCUSSION • Percussion is the tapping of teeth for indicationPercussion is the tapping of teeth for indication of pulpal and periapical inflammation, with theof pulpal and periapical inflammation, with the handle end of the mouth mirror.handle end of the mouth mirror. www.indiandentalacademy.com
  • 71. – PULPAL VITALITY TESTSPULPAL VITALITY TESTS:: • Vitality of abutment (J) should always beVitality of abutment (J) should always be checked for. Before any restorative treatment,checked for. Before any restorative treatment, pulpal health must be assessed usually bypulpal health must be assessed usually by measuring the response to percussion andmeasuring the response to percussion and thermal or electrical stimulation.thermal or electrical stimulation. • All suspected (J) are tested initially by percussionAll suspected (J) are tested initially by percussion and their vitality tests are run with an electricand their vitality tests are run with an electric vitalometer, ice and heat.vitalometer, ice and heat. • Ice is the most useful single aid to locate theIce is the most useful single aid to locate the offending (+) in early acute pulpitisoffending (+) in early acute pulpitis www.indiandentalacademy.com
  • 72. • A prospective abutment that lacks the necessaryA prospective abutment that lacks the necessary attached tissue is a very poor candidate to receiveattached tissue is a very poor candidate to receive a crown. Any presence or absence ofa crown. Any presence or absence of inflammation should be noted along withinflammation should be noted along with gingival architecture and stippling. The existencegingival architecture and stippling. The existence of pockets should be entered in record and theirof pockets should be entered in record and their location and depth noted with periodontal probe.location and depth noted with periodontal probe. The detection of bifurcation and trifurcationThe detection of bifurcation and trifurcation involvement are also noted. Before making useinvolvement are also noted. Before making use of a tooth with a furcation involvement as anof a tooth with a furcation involvement as an abutment, Ante’s law should be applied to assessabutment, Ante’s law should be applied to assess the remaining support of teeth.the remaining support of teeth. www.indiandentalacademy.com
  • 73.    • Occlusal examinationOcclusal examination:: • Finally, an evaluation should be made of theFinally, an evaluation should be made of the occlusion. Teeth should be checked for anyocclusion. Teeth should be checked for any wear facets, if present whether localized orwear facets, if present whether localized or widespread. Nonworking interferences are alsowidespread. Nonworking interferences are also looked for.looked for. • The amount of slide between the retrudedThe amount of slide between the retruded position and the position of maximumposition and the position of maximum intercuspation should be noted. (Is the slide theintercuspation should be noted. (Is the slide the straight one or does the mandible deviate to onestraight one or does the mandible deviate to one side or the other).side or the other). www.indiandentalacademy.com
  • 74. DIAGNOSIS ANDDIAGNOSIS AND TREATMENTTREATMENT PLANNING IN FDPPLANNING IN FDP part 2part 2 -DR. AZEEM A. KHOJA-DR. AZEEM A. KHOJA www.indiandentalacademy.com
  • 75. FULL MOUTH RADIOGRAPHS:FULL MOUTH RADIOGRAPHS: • complete mouth radiographic series (14 pericomplete mouth radiographic series (14 peri apical and 4 bite wing radiographs) is essential.apical and 4 bite wing radiographs) is essential. • TMJ radiographTMJ radiograph • Panoramic radiograph in patients with TMJPanoramic radiograph in patients with TMJ disorders.disorders. www.indiandentalacademy.com
  • 76. An Intraoral radiographic examination reveals:An Intraoral radiographic examination reveals: • Remaining bone supportRemaining bone support • Root number and morphologyRoot number and morphology • root proximityroot proximity • Quality of supporting bone, trabecular patternsQuality of supporting bone, trabecular patterns and furcational changesand furcational changes • Width of the periodontal ligament spaces andWidth of the periodontal ligament spaces and evidence of trauma from occlusionevidence of trauma from occlusion • Areas of vertical and horizontal resorptionAreas of vertical and horizontal resorption www.indiandentalacademy.com
  • 77. • Axial inclination of teethAxial inclination of teeth • Continuity and integrity of lamina duraContinuity and integrity of lamina dura • Pulpal morphology and previous endodonticPulpal morphology and previous endodontic treatment with or without post and cores.treatment with or without post and cores. • Presence of apical disease, root resorption orPresence of apical disease, root resorption or root fractures.root fractures. • Retained root fragments, radiolucent areas,Retained root fragments, radiolucent areas, calcifications, foreign bodies or impacted teethcalcifications, foreign bodies or impacted teeth • Presence of carious lesions, the conditions ofPresence of carious lesions, the conditions of existing restorations, and the proximity of cariesexisting restorations, and the proximity of caries and restorations to the dental pulpand restorations to the dental pulp www.indiandentalacademy.com
  • 78. • Calculus depositsCalculus deposits • Oral roentgenographic manifestations ofOral roentgenographic manifestations of systemic diseases.systemic diseases.   Radiographic modifications in case of periodontalRadiographic modifications in case of periodontal disease- ‘Thinning’ of radiograph.disease- ‘Thinning’ of radiograph. www.indiandentalacademy.com
  • 79. TREATMENT PLANNING:TREATMENT PLANNING: • A systematic design aimed at the completeA systematic design aimed at the complete medical or surgical care of a patient,medical or surgical care of a patient, • the institution of measures or giving ofthe institution of measures or giving of remedies designed to cure a disease.remedies designed to cure a disease. www.indiandentalacademy.com
  • 80. • formulating a logical sequenceformulating a logical sequence • restore the patient’s dentition to good healthrestore the patient’s dentition to good health • optimal function and appearanceoptimal function and appearance www.indiandentalacademy.com
  • 81. • appropriate planappropriate plan informs the patient about theinforms the patient about the present conditions,present conditions, • the extent of dental treatment proposed,the extent of dental treatment proposed, • the time and cost of treatment andthe time and cost of treatment and • the level of home care and professional followthe level of home care and professional follow up needed for successup needed for success www.indiandentalacademy.com
  • 82. OBJECTIVES OF TEATMENTOBJECTIVES OF TEATMENT PLANNINGPLANNING • Correction of existing diseaseCorrection of existing disease • Prevention of future diseasePrevention of future disease • Restoration of functionRestoration of function • Improvement of appearanceImprovement of appearance www.indiandentalacademy.com
  • 83. CONSIDERATIONS IN TREATMENTCONSIDERATIONS IN TREATMENT PLANNING:PLANNING: • PATIENTS DESIRES, EXPEPCTATIONSPATIENTS DESIRES, EXPEPCTATIONS AND NEEDSAND NEEDS • proper identification of the patient’s needs.proper identification of the patient’s needs. patient’s expectations must also be realistic.patient’s expectations must also be realistic. • Disappointment-result of poor communicationDisappointment-result of poor communication or lack of understanding or other limitations ofor lack of understanding or other limitations of treatment.treatment.   www.indiandentalacademy.com
  • 84. • AGE:AGE: between the ages of 20 and 55 years.between the ages of 20 and 55 years. • When partially edentulous conditions exist inWhen partially edentulous conditions exist in patients younger or older than this, seriouspatients younger or older than this, serious considerations should be given to some type ofconsiderations should be given to some type of restoration other than fixed.restoration other than fixed. • O.H. ROBERTS -based on over 1000 bridges,O.H. ROBERTS -based on over 1000 bridges, the younger the patient at the time the bridge isthe younger the patient at the time the bridge is cemented, the more likely it is to fail.cemented, the more likely it is to fail. www.indiandentalacademy.com
  • 85. Factors affecting the success of FDP inFactors affecting the success of FDP in relation to age:relation to age: • Length of clinical crownLength of clinical crown • The caries rateThe caries rate • Periodontal conditionPeriodontal condition www.indiandentalacademy.com
  • 86. Length of clinical crownLength of clinical crown:: • The younger the patient, the shorter is theThe younger the patient, the shorter is the crown and the greater is the convergence anglecrown and the greater is the convergence angle between the sides of the crown preparation (i.e.between the sides of the crown preparation (i.e. the less closely the preparation can be made tothe less closely the preparation can be made to approach the ideal of near parallel sides).approach the ideal of near parallel sides). • An inverse relationship between retention andAn inverse relationship between retention and convergence angle has been demonstrated byconvergence angle has been demonstrated by Jorgensen in 1955.Jorgensen in 1955. www.indiandentalacademy.com
  • 87.    2)2) Caries rateCaries rate:: • The caries rate is at its highest in those patientsThe caries rate is at its highest in those patients under 21 years of age and this factor mayunder 21 years of age and this factor may contribute to the high failure rate in this agecontribute to the high failure rate in this age group.group. • After 21 years of age, the caries rate in theAfter 21 years of age, the caries rate in the majority of patients gradually falls and is at amajority of patients gradually falls and is at a relatively low level by the age of 35.relatively low level by the age of 35.    www.indiandentalacademy.com
  • 88.    3)3) Periodontal conditionPeriodontal condition:: The relatively advanced periodontal diseaseThe relatively advanced periodontal disease involving tooth mobility most common in thoseinvolving tooth mobility most common in those patients over 45 years is probably the cause ofpatients over 45 years is probably the cause of the increased failure rate of FDP in the older agethe increased failure rate of FDP in the older age group.group.    www.indiandentalacademy.com
  • 89. Sex:Sex: • Although the quality of esthetics is desirable oneAlthough the quality of esthetics is desirable one in every fixed partial denture, it is more desirablein every fixed partial denture, it is more desirable when the appliance is placed for women,when the appliance is placed for women, particularly in the anterior part of the mouth.particularly in the anterior part of the mouth. www.indiandentalacademy.com
  • 90. • Maintainance of oral hygiene:Maintainance of oral hygiene: A removable prosthesis, since it can be cleanedA removable prosthesis, since it can be cleaned more quickly and more readily is preferred formore quickly and more readily is preferred for those patients who the dentist suspects won’t bethose patients who the dentist suspects won’t be diligent and careful in maintaining oral cleanliness.diligent and careful in maintaining oral cleanliness. www.indiandentalacademy.com
  • 91. • Occupation of the patientOccupation of the patient The occupation of a patient is a factor to beThe occupation of a patient is a factor to be considered, particularly when the prosthesis isconsidered, particularly when the prosthesis is planned for a patient who depends largely uponplanned for a patient who depends largely upon this personal appearance as a means of earningthis personal appearance as a means of earning his livelihood.his livelihood. www.indiandentalacademy.com
  • 92. Systemic and emotional health:Systemic and emotional health: • Elderly or debilitated patients unable to tolerateElderly or debilitated patients unable to tolerate the long appointments routinely required forthe long appointments routinely required for extensive fixed partial denture may be betterextensive fixed partial denture may be better served with more conservative care e.g.served with more conservative care e.g. removable prosthesis.removable prosthesis. • Patients requiring antibiotic prophylaxis shouldPatients requiring antibiotic prophylaxis should have as much treatment performed perhave as much treatment performed per appointment as possible to reduce the frequencyappointment as possible to reduce the frequency of dentist induced bacteremias.of dentist induced bacteremias. www.indiandentalacademy.com
  • 93. • Many medications commonly prescribed for aMany medications commonly prescribed for a number of systemic and emotional disorders cannumber of systemic and emotional disorders can result in significant xerostomia, which canresult in significant xerostomia, which can unfavorably affect the outcome of treatment.unfavorably affect the outcome of treatment. • Bruxism, common in emotionally tenseBruxism, common in emotionally tense individuals taxes the reparative capacities ofindividuals taxes the reparative capacities of periodontiumperiodontium www.indiandentalacademy.com
  • 94. • Periodontal factorsPeriodontal factors inflamationinflamation furcation involvementfurcation involvement margin placementmargin placement biologic widthbiologic width www.indiandentalacademy.com
  • 95. Inflamation:Inflamation: • goals of periodontal therapy-goals of periodontal therapy- - conversion of periodontal pocket depth- conversion of periodontal pocket depth to clinically normal sulcular depthsto clinically normal sulcular depths - establish physiologic gingival- establish physiologic gingival architrcturearchitrcture - provide adequate zone of attached- provide adequate zone of attached gingivagingiva www.indiandentalacademy.com
  • 96. Furcation invasions: Teeth with furcationFurcation invasions: Teeth with furcation invasion, require ‘special considerationinvasion, require ‘special consideration’’ www.indiandentalacademy.com
  • 97. MARGIN PLACEMENTMARGIN PLACEMENT www.indiandentalacademy.com
  • 98.   Margin placement:Margin placement: • The gingivae are healthiest when margins areThe gingivae are healthiest when margins are placed well above (i.e. 1-2 mm) the gingival crestplaced well above (i.e. 1-2 mm) the gingival crest intra crevicular margin placement- not theintra crevicular margin placement- not the universal solution to dental caries.universal solution to dental caries. • Indications for the intra crevicular gingivalIndications for the intra crevicular gingival margin - esthetics, retention requirements,margin - esthetics, retention requirements, location of caries or pre-existing restorations,location of caries or pre-existing restorations, root sensitivity and areas of cervical erosion orroot sensitivity and areas of cervical erosion or root fracture.root fracture. At the same time, the supra gingival margins mayAt the same time, the supra gingival margins may be more susceptible to cement dissolutionbe more susceptible to cement dissolutionwww.indiandentalacademy.com
  • 99. •Biologic width:Biologic width: A band of soft tissue attachment between the base ofA band of soft tissue attachment between the base of the gingival sulcus and the alveolar crest that isthe gingival sulcus and the alveolar crest that is composed of approximate 2 mm of junctionalcomposed of approximate 2 mm of junctional epithelium (attachment epithelium) and connectiveepithelium (attachment epithelium) and connective tissue fibers.tissue fibers. The dento gingival attachment, referred to as theThe dento gingival attachment, referred to as the ‘biologic width’ has significant implications in‘biologic width’ has significant implications in treatment planningtreatment planning.. www.indiandentalacademy.com
  • 100. • In the past, - gingival termination wasIn the past, - gingival termination was commonly prepared as sub gingival as possible.commonly prepared as sub gingival as possible. • The contemporary approach is to place theThe contemporary approach is to place the margin in the gingival crevice i.e. the intramargin in the gingival crevice i.e. the intra crevicular margin. To avoid encroaching on thecrevicular margin. To avoid encroaching on the biologic width, the tooth preparation mustbiologic width, the tooth preparation must terminate at least 2 mm coronal to the alveolarterminate at least 2 mm coronal to the alveolar crest.crest. • the presence of caries, fractured root structurethe presence of caries, fractured root structure or previous restorations apical to the gingivalor previous restorations apical to the gingival crest predispose to the violation of the biologiccrest predispose to the violation of the biologic width during tooth preparation.width during tooth preparation. www.indiandentalacademy.com
  • 101. • short clinical crown- may induce dentist toshort clinical crown- may induce dentist to overextend the preparation apically in anoverextend the preparation apically in an attempt to enhance retention.attempt to enhance retention. • Severing the natural dento gingival attachment -Severing the natural dento gingival attachment - chronic gingival inflammation, pocket formationchronic gingival inflammation, pocket formation and osseous defects in the bone.and osseous defects in the bone. • Fibrous connective tissue and epitheliumFibrous connective tissue and epithelium remodel in an attempt to reestablish aremodel in an attempt to reestablish a physiologic attachment.physiologic attachment. www.indiandentalacademy.com
  • 102. Periodontal treatment planPeriodontal treatment plan • Initial therapy:Initial therapy: -control of microbial plaque-control of microbial plaque -tooth brushing-tooth brushing -flossing-flossing -other aids-other aids -scaling and polishing-scaling and polishing -correction of defective (overhanging) restorations-correction of defective (overhanging) restorations -root planing-root planing -strategic tooth removal-strategic tooth removal -stabilization of mobile teeth-stabilization of mobile teeth -minor tooth movement-minor tooth movementwww.indiandentalacademy.com
  • 103. • Evaluation of initial therapyEvaluation of initial therapy • Surgical therapySurgical therapy --soft tissue proceduressoft tissue procedures gingivectomygingivectomy open debridementopen debridement mucosal repairmucosal repair -hard tissue procedures-hard tissue procedures bone inductionbone induction osseous resectionosseous resection -treatment of furcation involvement-treatment of furcation involvement odontoplasty –osteoplastyodontoplasty –osteoplasty root amputationroot amputation hemisectionhemisection www.indiandentalacademy.com
  • 104. provisionalisationprovisionalisation restorationrestoration • Evaluation of surgical therapyEvaluation of surgical therapy • Guided tissue regeneration( hard and soft tissueGuided tissue regeneration( hard and soft tissue procedures)procedures) • MaintenanceMaintenance • PrognosisPrognosis www.indiandentalacademy.com
  • 105. Occlusion:Occlusion: • Simultaneous equalized contacts of all teethSimultaneous equalized contacts of all teeth (anterior and posterior) in maximum inter(anterior and posterior) in maximum inter cuspation (centric occlusion) at a physiologiccuspation (centric occlusion) at a physiologic vertical dimension of occlusion.vertical dimension of occlusion. • A physiologic plane of occlusionA physiologic plane of occlusion • A functional anterior guidance, vertical andA functional anterior guidance, vertical and horizontal overlap of the anterior teeth that willhorizontal overlap of the anterior teeth that will protect the posterior teeth from interceptiveprotect the posterior teeth from interceptive occlusal contacts in eccentric portions.occlusal contacts in eccentric portions. www.indiandentalacademy.com
  • 106. • A comfortable, unlocked arrangement of cusps,A comfortable, unlocked arrangement of cusps, fossae, grooves and ridges that will not restrictfossae, grooves and ridges that will not restrict functional jaw movements.functional jaw movements. • Axial loading of all posterior teeth.Axial loading of all posterior teeth. • Anatomic forms to the cusps, fossae, marginalAnatomic forms to the cusps, fossae, marginal ridges that will minimize inter dental foodridges that will minimize inter dental food impaction and contribute to efficientimpaction and contribute to efficient comminution of food.comminution of food. • Occlusal and proximal tooth contacts that willOcclusal and proximal tooth contacts that will lend long term stability to the occlusal scheme.lend long term stability to the occlusal scheme. www.indiandentalacademy.com
  • 107. • An esthetic and phonetic relationship of theAn esthetic and phonetic relationship of the anterior teeth.anterior teeth. • Occlusal rests fabricated of a material that wearsOcclusal rests fabricated of a material that wears like natural enamel.like natural enamel. www.indiandentalacademy.com
  • 108. • Esthetic considerations:Esthetic considerations: An unfavorable anterior guidance or plane ofAn unfavorable anterior guidance or plane of occlusion will not only adversely affect occlusalocclusion will not only adversely affect occlusal function but will also produce an unnaturalfunction but will also produce an unnatural appearance.appearance. The long clinical crowns that commonly resultThe long clinical crowns that commonly result from surgical periodontics are particularlyfrom surgical periodontics are particularly troublesome to restore esthetically.troublesome to restore esthetically. www.indiandentalacademy.com
  • 109. • defect in the anterior edentulous ridge--restoreddefect in the anterior edentulous ridge--restored surgically with some form of ridge augmentationsurgically with some form of ridge augmentation followed by a conventional FPD. Prostheticfollowed by a conventional FPD. Prosthetic restoration may be employed using an FPD (i.e.restoration may be employed using an FPD (i.e. with gingival porcelain) or more commonly withwith gingival porcelain) or more commonly with a RPD.a RPD. www.indiandentalacademy.com
  • 110. • ANDREWS BRIDGE SYSTEMSANDREWS BRIDGE SYSTEMS www.indiandentalacademy.com
  • 111. Resin bonded bridgesResin bonded bridges www.indiandentalacademy.com
  • 112. • Bonded laminate veneers can be conservativeBonded laminate veneers can be conservative alternatives to esthetic veneer crowns.alternatives to esthetic veneer crowns. Laminates are recommended to restore estheticsLaminates are recommended to restore esthetics in blemished but sound anterior teeth and arein blemished but sound anterior teeth and are particularly useful with tetracycline stained teeth.particularly useful with tetracycline stained teeth. www.indiandentalacademy.com
  • 113. • ENDODONTIC CONSIDERATIONSENDODONTIC CONSIDERATIONS:: • An endodontically treated tooth is commonlyAn endodontically treated tooth is commonly restored with conservative tooth preparation andrestored with conservative tooth preparation and a cast restoration.a cast restoration. insufficient remaining tooth structure to supportinsufficient remaining tooth structure to support an extra coronal restoration- corono radicularan extra coronal restoration- corono radicular stabilization with post and core is indicated.stabilization with post and core is indicated. • Pulp less teeth can successfully function asPulp less teeth can successfully function as abutments to FPD or RPD but a post and coreabutments to FPD or RPD but a post and core is usually required for such teeth.is usually required for such teeth. www.indiandentalacademy.com
  • 114. www.indiandentalacademy.com
  • 115. • prognosis is poor for a pulp less tooth with anprognosis is poor for a pulp less tooth with an extremely short root or with a canal that cannotextremely short root or with a canal that cannot be negotiated to place a post be negotiated to place a post  Elective Endodontic TherapyElective Endodontic Therapy:: • Endodontic therapy may be necessary for aEndodontic therapy may be necessary for a supra erupted or malaligned tooth to improvesupra erupted or malaligned tooth to improve the arch relationship while facilitating fabricationthe arch relationship while facilitating fabrication of a cast restoration with a more favorable archof a cast restoration with a more favorable arch position and occlusion.position and occlusion. www.indiandentalacademy.com
  • 116. AbutmentAbutment • A tooth , portion of a tooth or that of a dentalA tooth , portion of a tooth or that of a dental implant that serves to support or retain aimplant that serves to support or retain a prosthesis.prosthesis. www.indiandentalacademy.com
  • 117. Ideal abutment:Ideal abutment: • Ideal crown root ratioIdeal crown root ratio • Adequate thickness of enamel and dentinAdequate thickness of enamel and dentin • Adequate bone supportAdequate bone support • Absence of periodontal diseaseAbsence of periodontal disease • Proper gingival contourProper gingival contour www.indiandentalacademy.com
  • 118. Abutment selectionAbutment selection • Crown : rootCrown : root • Root configurationRoot configuration • Periodontal surface areaPeriodontal surface area -Ante’s law: Ante in 1926 stated that the-Ante’s law: Ante in 1926 stated that the abutment should have a combined pericementalabutment should have a combined pericemental area equal to or greater than the tooth or teetharea equal to or greater than the tooth or teeth to be replaced and this recommendation hasto be replaced and this recommendation has been referred to as Ante’s law (term given bybeen referred to as Ante’s law (term given by Johnston et al).Johnston et al). www.indiandentalacademy.com
  • 119. • Factors modifying Ante’s law:Factors modifying Ante’s law: Increased abutments required:Increased abutments required: 1.1. Bone loss from periodontal diseaseBone loss from periodontal disease 2.2. Mesial or distal tipping or changes in axialMesial or distal tipping or changes in axial inclinationinclination 3.3. Migration (bodily movement) of abutment teethMigration (bodily movement) of abutment teeth 4.4. Less than favorable opposing arch relationshipsLess than favorable opposing arch relationships 5.5. Endodontically restored abutment tooth withEndodontically restored abutment tooth with root resectionsroot resections 6.6. Arch form situation creating greater leverageArch form situation creating greater leverage factorsfactors www.indiandentalacademy.com
  • 120. 7. Tooth mobility created after osseous surgery7. Tooth mobility created after osseous surgery (Splinting procedure)(Splinting procedure) • Root proximitiesRoot proximities • Long axis relationshipLong axis relationship • Arch form or arch curvatureArch form or arch curvature • RigidityRigidity • Margin locationMargin location • Span lengthSpan length • Occlusal anatomyOcclusal anatomy • Buccolingual dimension of teethBuccolingual dimension of teeth • Pontic - tissue contactPontic - tissue contact • Common path of insertionCommon path of insertionwww.indiandentalacademy.com
  • 121. Types of abutmentsTypes of abutments • Pier abutmentsPier abutments • Tilted molar abutmentsTilted molar abutments • Canine replacement FDPCanine replacement FDP • Cantilever FDPCantilever FDP • Extensively damaged abutmentsExtensively damaged abutments • Implant abutmentsImplant abutments • Unrestored abutmentsUnrestored abutments www.indiandentalacademy.com
  • 122. • Pier abutment is a lone, free standing abutmentPier abutment is a lone, free standing abutment with edentulous spaces on both sides.with edentulous spaces on both sides. • Physiologic tooth movement, arch position ofPhysiologic tooth movement, arch position of the abutments and a disparity in the retentivethe abutments and a disparity in the retentive capacity of the retainers - less than ideal plan ofcapacity of the retainers - less than ideal plan of treatment.treatment. www.indiandentalacademy.com
  • 123. • Because of the distance through whichBecause of the distance through which movement occurs, the independent directionmovement occurs, the independent direction and magnitude of movements of the abutmentand magnitude of movements of the abutment teeth and the tendency of the prosthesis to flex,teeth and the tendency of the prosthesis to flex, stress can be concentrated around the abutmentstress can be concentrated around the abutment teeth as well as between retainers and abutmentteeth as well as between retainers and abutment preparationspreparations www.indiandentalacademy.com
  • 124. • The Pier abutment can act as a fulcrum andThe Pier abutment can act as a fulcrum and transmits the forces on the terminal abutments,transmits the forces on the terminal abutments, leading to the failure of the weaker retainer. Theleading to the failure of the weaker retainer. The loosened casting will break around the marginsloosened casting will break around the margins and caries is likely to become extensive beforeand caries is likely to become extensive before discovery.discovery. www.indiandentalacademy.com
  • 125. The non-rigid connector has been suggested as a solution to this problem. In spite of the apparently close fit, the movement in the non rigid connector is enough to prevent the transfer of stress from the segment being loaded to the rest of FPD. www.indiandentalacademy.com
  • 126. Tilted molar abutmentsTilted molar abutments www.indiandentalacademy.com
  • 127. www.indiandentalacademy.com
  • 128. • Other means to correct this problem:Other means to correct this problem: 1.1. Proximal half crownProximal half crown 2.2. Telescopic crownTelescopic crown 3.3. Non-rigid connectorNon-rigid connector www.indiandentalacademy.com
  • 129. • Canine Replacement FPDCanine Replacement FPD • FPD replacing canines can be difficult becauseFPD replacing canines can be difficult because the canine often lies outside the inter abutmentthe canine often lies outside the inter abutment axis. The prospective abutments are the lateralaxis. The prospective abutments are the lateral incisor, usually the weakest tooth in the entireincisor, usually the weakest tooth in the entire arch and the 1arch and the 1stst premolar, the weakest posteriorpremolar, the weakest posterior tooth.tooth. www.indiandentalacademy.com
  • 130. • the forces are transmitted outward (labially) onthe forces are transmitted outward (labially) on the maxillary arch, against the inside of the curvethe maxillary arch, against the inside of the curve (its weakest point).(its weakest point). • On the Mandibular canine, the forces areOn the Mandibular canine, the forces are directed inward (lingually), against the outside ofdirected inward (lingually), against the outside of the curve (its strongest point)the curve (its strongest point) www.indiandentalacademy.com
  • 131. Cantilever Fixed Partial DenturesCantilever Fixed Partial Dentures:: • A cantilever FPD is one that has an abutment orA cantilever FPD is one that has an abutment or abutments at one end only, with the other endabutments at one end only, with the other end of the pontic remaining, unattached.of the pontic remaining, unattached. • This is potentially destructive design with theThis is potentially destructive design with the lever arm created by the pontic, and is frequentlylever arm created by the pontic, and is frequently misused. In a cantilever design, the pontic actsmisused. In a cantilever design, the pontic acts as a lever that tends to be depressed underas a lever that tends to be depressed under forces with a strong occlusal vector.forces with a strong occlusal vector. www.indiandentalacademy.com
  • 132. Implant abutmentsImplant abutments www.indiandentalacademy.com
  • 133. • INDICATIONS ANDINDICATIONS AND CONTRAINDICATINOS OF FDP:CONTRAINDICATINOS OF FDP: • INDICATIONSINDICATIONS GeneralGeneral LocalLocal www.indiandentalacademy.com
  • 134. GENERAL INDICATIONSGENERAL INDICATIONS • PsychologicalPsychological • Systemic diseasesSystemic diseases • Orthodontic considerationOrthodontic consideration • Periodontal ReasonsPeriodontal Reasons • SpeechSpeech   • Function and StabilityFunction and Stability www.indiandentalacademy.com
  • 135. LOCAL INDICATIONSLOCAL INDICATIONS • Lack of space for suitable replacementLack of space for suitable replacement • The morphology of the abutment teethThe morphology of the abutment teeth • Tilted teethTilted teeth • Teeth suitable for abutmentTeeth suitable for abutment which requirewhich require restorationrestoration www.indiandentalacademy.com
  • 136. CONTRAINDICATIONSCONTRAINDICATIONS • Inability of patient to cooperateInability of patient to cooperate • Age of patientAge of patient • High caries rateHigh caries rate • Gingival and periodontal considerationsGingival and periodontal considerations 1.1. Gingival hyperplasiaGingival hyperplasia 2.2. GingivitisGingivitis 3.3. Advanced periodontal diseaseAdvanced periodontal disease www.indiandentalacademy.com
  • 137. LOCAL FACTORS CONTRAINDICATINGLOCAL FACTORS CONTRAINDICATING A BRIDGEA BRIDGE:: • Prognosis of AbutmentPrognosis of Abutment • Ridge form and tissue lossRidge form and tissue loss • Unfavorable tilting or rotation of the teethUnfavorable tilting or rotation of the teeth • Maintenance and repairMaintenance and repair • RPD is indicatedRPD is indicated www.indiandentalacademy.com
  • 138. • PROGNOSIS:PROGNOSIS: An estimation of the likely course of the disease.An estimation of the likely course of the disease. • can be difficult to make, but its importance tocan be difficult to make, but its importance to patients understanding and successful treatmentpatients understanding and successful treatment must be recognizedmust be recognized Fixed prostheses function in a hostileFixed prostheses function in a hostile environment, the moist oral environment isenvironment, the moist oral environment is subject to constant changes in temperature andsubject to constant changes in temperature and acidity and considerable load fluctuation. Aacidity and considerable load fluctuation. A comprehensive clinical examination helpscomprehensive clinical examination helps identify the likely prognosis. All facts andidentify the likely prognosis. All facts and observations are first considered individuallyobservations are first considered individually and then correlated appropriately.and then correlated appropriately.www.indiandentalacademy.com
  • 139. CONCLUSIONCONCLUSION www.indiandentalacademy.com
  • 140. • The history and clinical examination mustThe history and clinical examination must provide sufficient data for the practitioner toprovide sufficient data for the practitioner to formulate a successful treatment plan.formulate a successful treatment plan. • If they are too hastily accomplished, details mayIf they are too hastily accomplished, details may be missed that can cause significant problemsbe missed that can cause significant problems during treatment, when it may be difficult orduring treatment, when it may be difficult or impossible to make correctionsimpossible to make corrections www.indiandentalacademy.com
  • 141. • Thus, to achieve predictable success in thisThus, to achieve predictable success in this technically exacting and demanding field, theretechnically exacting and demanding field, there must be meticulous attention to every detailmust be meticulous attention to every detail from the initial patient interview, diagnosis,from the initial patient interview, diagnosis, through the active treatment phases and tothrough the active treatment phases and to planned schedule of follow up care.planned schedule of follow up care. www.indiandentalacademy.com
  • 142. WELL BEGUNWELL BEGUN isis HALF DONEHALF DONE www.indiandentalacademy.com
  • 143. BIBLIOGRAPHYBIBLIOGRAPHY • Contemporary fixed prosthodontics- Rosensteil, Land andContemporary fixed prosthodontics- Rosensteil, Land and Fujimoto, 4Fujimoto, 4thth ed,ed, • Fundamentals of fixed prosthodontics- Shillingburg, Hobo,Fundamentals of fixed prosthodontics- Shillingburg, Hobo, Jacobi, 3Jacobi, 3rdrd ed.ed. • Tylman’sTheory and practice of fixed prosthodontics- Malone ,Tylman’sTheory and practice of fixed prosthodontics- Malone , Roth, 8Roth, 8thth ed.ed. • J. Prosthet Dent 1979; 42: 411 (force distribution for teeth whenJ. Prosthet Dent 1979; 42: 411 (force distribution for teeth when loaded singly and when used as FPD abutments).loaded singly and when used as FPD abutments). • J. Prosthet Dent 1996; 76: 424 (stress analysis of a cantileveredJ. Prosthet Dent 1996; 76: 424 (stress analysis of a cantilevered FPD with normal and decreased bone support).FPD with normal and decreased bone support). • limiting criteria for fixed bridge reconstruction (JPD – 1991, 65:limiting criteria for fixed bridge reconstruction (JPD – 1991, 65: 357-64).357-64). www.indiandentalacademy.com
  • 144. For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com