for placement of fixed prosthesis, case history is important

1. PATIENT EVALUATION, DIAGNOSIS AND
TREATMENT PLANNING FOR FIXED PARTIAL
PROSTHESIS
Presented by-Dr. Vaishali Shrivastava.
Pg 2ND year student.
Dept. of prosthodontics ,crown & bridge & implantology.
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Contents-
1) Definitions
2) Diagnostic aids- personal information
patient evaluation
history – past medical and dental
3) Examination
general examination
extra oral examination
intraoral examination
radiographic examination
4) Treatment planning
5)Conclusion
6) references

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fixed prosthodontics - the branch of prosthodontics concerned with the replacement and/or restoration of
teeth by artificial substitutes that cannot be removed from the mouth by the patient (GPT9)
fixed dental prosthesis -the general term for any prosthesis that is securely fixed to a natural tooth or teeth, or
to one or more dental implants/implant abutments; it cannot be removed by the patient.(GPT9)
diagnosis(ca. 1861): the determination of the nature of a disease;(GPT9)

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Personal Details
• patient’s name
• Age/sex
• Address
• phone number
• Occupation
• work schedule
• marital and financial status

5. 5
CHIEF
COMPLAINTS
BELONG
TO
4
CATEGORIES
COMFORT(PAIN,SENSITIVITY,SWEELING)
Function (difficulty in mastication or
speech)
Social( bad taste or odour)
Appearance(fracture or unattractive
teeth or restorations, discoloration)
Chief Complaint-
The accuracy and significance of
the patient’s primary reason or
reasons for seeking treatment
should be analyzed first.

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Medical History
An accurate and current general medical history should include any medication the
patient is taking, as well as all relevant medical conditions
Possible risk
factors
Systemic
conditions
Conditions
affecting
the
treatment
plan
Conditions
affecting
the
treatment
method

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Dental History
Dental history
Periodontal
history
Restorative
history
Endodontic
history
Removable
prosthodontic
history
Oral
surgery
history
Radiographic
history
Orthodonti
c history
Tmj
dysfunction
history

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Periodontal history
• The patient’s oral hygiene is assessed, and current plaque-control
measures are discussed, as are previously received oral hygiene
instructions.
• The frequency of any previous débridement should be recorded
• Nature of any previous periodontal surgery should be noted.

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Restorative history
• The patient’s restorative history may include only simple composite resin or
dental amalgam fillings, or it may involve crowns and extensive fixed dental
prostheses.
• The age of existing restorations can help establish the prognosis and probable
longevity of any future fixed prostheses.

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Endodontic history
• Patients often forget which teeth have been
endodontically treated. These can be readily
identified with radiographs.
• The findings should be reviewed periodically so
that periapical health can be monitored and any
recurring lesions promptly detected
Defective endodontics has led to recurrence of
a periapical lesion. Re-treatment is required

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Apical root resorption after orthodont
treatment.
• root resorption (detected on radiographs) may
be attributable to previous orthodontic
treatment.
• As the crown/root ratio is affected, future
prosthodontic treatment and its prognosis
may also be affected.
Orthodontic history

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Removable prosthodontic history
The patient’s experiences with removable prostheses must be carefully
evaluated.
Listening to the patient’s comments about previously unsuccessful
removable prostheses can be very helpful in assessing whether future
treatment will be more successful

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Oral surgical history
• Information about missing teeth and any complications that may have occurred during tooth removal is
obtained.
• Before any treatment is undertaken, the prosthodontic component of the proposed treatment should be fully
coordinated with the surgical component.

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Radiographic history
• Previous radiographs may prove helpful in judging the progress of
dental disease.
• They should be obtained if possible, because it is generally better to
avoid exposing the patient to unnecessary ionizing radiation.
• In most instances, however, a current diagnostic radiographic series is
essential and should be obtained as part of the examination.

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Temporomandibular joint dysfunction history
• A history of pain or clicking in the TMJs or neuromuscular symptoms, such as
tenderness to palpation, may be caused by TMJ dysfunction, which should
normally be treated and resolved before fixed prosthodontic treatment
begins.
• A screening questionnaire efficiently identifies these problems.
• The patient should be questioned regarding any previous treatment for joint
dysfunction (e.g., occlusal devices, medications, biofeedback, or physical
therapy exercises).

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EXAMINATION
General Examination
• general appearance-gait, and weight
• Skin color-anemia or jaundice.
• Vital signs-respiration, pulse, temperature, and blood pressure,
are measured and recorded.

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Extraoral Examination
• facial asymmetry.
• Cervical lymph nodes
• TMJs
• the muscles of mastication
• Mouth opening

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palpating bilaterally just anterior to the auricular tragi
while the patient opens and closes the mouth.
Auricular palpation (Fig. 1-9) with light anterior pressure
helps identify potential disorders in the attachment of the
disk.
Temporomandibular joints

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Muscles of mastication
A brief palpation of masseter, temporalis, medial and
lateral pterygoid muscles may revel tenderness.
Palpation is best accomplished bilaterally and
simultaneously.

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Lips
The patient is observed for tooth visibility during normal and exaggerated
smiling.
Missing teeth, diastemas, and fractured or poorly restored teeth disrupt the
harmony of the negative space and often require correction

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24. 24
Intraoral Examination
The intraoral examination can reveal considerable information concerning the
condition of the soft tissues, teeth, and supporting structures.
The tongue, floor of the mouth, vestibule, cheeks, and hard and soft palates are
examined, and any abnormalities are noted.

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Periodontal Examination
GINGIVA

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Dental Charting
An accurate charting of the
state of the dentition reveals
important information
about the condition of the
teeth and facilitates
treatment planning.

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Occlusal examination
The initial clinical examination starts with the clinician’s asking the patient to make a few simple
opening and closing movements while the clinician carefully observes the opening and closing strokes.
Special attention is given to-
• initial contact
• tooth alignment
• eccentric contacts
• jaw maneuverability

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General alignment
• The teeth are evaluated for crowding, rotation,
supraeruption, spacing, malocclusion, and vertical and
horizontal overlap .
• Teeth adjacent to edentulous spaces often have shifted
position slightly.
• Small amounts of tooth movement can significantly affect
fixed prosthodontic treatment

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Radiographic Examination
It may help to evaluate following areas
• Impacted teeth. Residual roots
• Degree of bone loss
• Root morphology, crown root ratio
• Presence of apical disease
• Caries
• Pulp chambers & canals
• Periodontal ligament and surrounding bone
• Existing restoration

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Vitality Testing
Before any restorative treatment, pulpal health must be assessed, usually by measuring the
response to gentle tapping with an instrument, or percussion, and thermal or electrical
stimulation.
A diagnosis of nonvitality can be confirmed by preparing a test cavity without the administration of local
anesthetic.

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DIAGNOSIS AND PROGNOSIS
diagnosis can usually be developed after such supporting evidence has been assembled.
A typical diagnosis condenses the information obtained during the clinical history taking and
examination
The prognosis is an estimation of the likely course of a disease. It can be difficult to make, but its
importance to patient management and successful treatment planning must nevertheless be
recognized.

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Prosthodontic Diagnostic Index (PDI) for the Partially
Edentulous and the Completely Dentate Patient
American College of Prosthodontists (ACP) has developed diagnostic indices for partial edentulism24
and for the completely dentate patient25 on the basis of diagnostic findings that are summarized

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Each class is differentiated by specific diagnostic criteria (ideal or minimal, moderately
compromised, substantially compromised, or severely compromised) of the following
(for the partially edentulous):
1. Location and extent of the edentulous area or areas
2. Condition of the abutment teeth
3. Occlusal scheme
4. Residual ridge For the completely dentate patient, only tooth condition and
occlusal scheme are evaluated

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Location and Extent of the Edentulous Areas
In the ideal or minimally compromised edentulous area, the edentulous span is
confined to a single arch and one of the following:
• Any anterior maxillary span that does not exceed two missing incisors
• Any anterior mandibular span that does not exceed four missing incisors
• Any posterior maxillary or mandibular span that does not exceed two premolars or
one premolar and one molar

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In the moderately compromised edentulous area, the edentulous span is in both arches, and one
of the following conditions exists:
• The span includes any anterior maxillary span that does not exceed two missing incisors
• The span includes any anterior mandibular span that does not exceed four missing incisors
• The span includes any posterior maxillary or mandibular span that does not exceed two premolars
or one premolar and one molar
• The maxillary or mandibular canine is missing

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The substantially compromised edentulous area includes
• Any posterior maxillary or mandibular span that is greater than three missing
teeth or two molars
• Any edentulous span, including anterior and posterior areas of three or more
missing teeth The severely compromised edentulous area includes
• Any edentulous area or combination of edentulous areas whose care requires a
high level of patient compliance

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Condition of the Abutment Teeth (Tooth Condition for Completely
Dentate Patients)
Ideal or minimally compromised abutment teeth condition:
• No preprosthetic therapy is indicated
Moderately compromised abutment teeth condition
: • Tooth structure is insufficient to retain or support intracoronal restorations, in one or two
sextants
• Abutments require localized adjunctive therapy (i.e., periodontal, endodontic, or orthodontic
procedures in one or two sextants)

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Substantially compromised abutment teeth condition:
• Tooth structure is insufficient to retain or support intracoronal or extracoronal
restorations, in four or more sextants
• Abutments require extensive adjunctive therapy (i.e., periodontal, endodontic or
orthodontic procedures- in four or more sextants) Severely compromised abutment teeth
condition:
• Abutments have a guarded prognosis

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Diagnostic cast
Diagnostic cast allows assessment of
following
1)Dimensions of edentulous space
2)occlusal plane
3)Alignment and angulation of abutment
teeth
4) Centric relation and MIP

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Treatment planning for single tooth restoration
The selection of material and design of restoration is based on several factors
• destruction of tooth structure
• Esthetics
• Plaque control
• Financial consideration
• retention

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Destruction of tooth structure
If the amount of destruction previously suffered by the tooth is such that
the remaining tooth structure must gain strength and protection from the
restoration,cast metal or ceramic is indicated over amalgam or composite
resin

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Esthetics
Partial veneer restoration can be used to restore in highly visible area
Metal ceramic crowns
- Single unit anterior
- Posterior crowns

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Extracoronal restorations
An extracoronal cast metal restoration or
crown, encircles all or part of the remaining
tooth structure. As such, it can strengthen and
protect a tooth weakened by caries or trauma.

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Metal-Ceramic
Metal-ceramic restorations consist of a tooth-colored
layer of porcelain bonded to a cast metal substructure.
They are used when a complete crown is needed to restore
appearance as well as function.

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Complete Ceramic Crowns,
inlays, and laminate veneers made entirely of dental porcelain can
be the most esthetically pleasing of all fixed restorations
Drawbacks include a comparative lack of strength and the
difficulties associated with achieving an acceptable marginal fit.

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Resin-Veneered
Resin-veneered restorations were popular before the metal-ceramic
technique was fully developed, but problems with wear and discoloration
of the polymethyl methacrylate veneer limited their use to long-term
interim restorations.

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Fiber-Reinforced Resin
Advances in composite resin technology, especially the introduction of
glass and polyethylene fibers, have prompted the use of indirect
composite resin restorations for inlays, crowns, and FDPs

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SELECTION OF ABUTMENT TEETH
Abutment teeth are called upon to withstand the forces normally directed to
the missing teeth, in addition to those usually applied to abutments
The roots and their supporting tissues should be evaluated for 3 factors-
1) Crown root ratio
2) Root configuration
3) Periodontal ligament area

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CROWN ROOT RATIO-
It is a measure of length of tooth occlusal to the alveolar crest of bone
compared with the length of root embedded in bone
Ideal – 2:3
Minimum 1:1

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Root length and form
• Abutment teeth should possess adequate root
anchorage in the bone to effectively resist and
transmit the occlusal load.
• The length of the abutment root is directly
proportional to the stability and strength of the
prosthesis
• Roots with parallel sides and developmental grooves
are better able to resist additional occlusal force than
smooth sided conical roots.

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• Roots that are broad labiolingually are preferred over ones that are round in cross-section.
Multirooted teeth provide greater stability and resistance to force than single rooted teeth .
• A single-rooted tooth with irregular configuration or with some curvature in the apical third
of the root is preferred, than to the tooth that has a nearly perfect taper

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Ante’s law • Ante’s law states that ‘the
combined pericemental area of the abutment teeth
should be equal to or greater than the pericemental
area of the tooth or teeth to be replaced’.
• According to this law one missing tooth can be
successfully replaced by taking two abutments for
support. If two teeth are missing, they can be
replaced taking support of two abutments, but the
limit is being reached. It is unacceptable to replace
three teeth with two abutments

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Special considerations
Pier abutment Definition:
A natural tooth located between terminal abutments that serve to
support a fixed or a removable prosthesis (GPT9). It is also called
‘intermediate abutment’

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Canine replacement fixed partial dentures
• Replacing canine with a fixed partial denture is often difficult as the canine
lies outside the interabutment axis and as described earlier, the fulcrum line is
labial to the arch circumference. Hence, the abutments are subjected to
increased stresses

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Cantilever fixed partial dentures
Definition: A fixed dental prosthesis in which the pontic is cantilevered, i.e. is
retained and supported only on one end by one or more abutments (GPT9).
• In a conventional FPD supported by abutment on either side of edentulous space,
forces on the pontic are distributed evenly to both the abutments (

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The objectives of any successful treatment planning should begin with
identification of existing disease, the aetiology, pathogenesis and the ideal
treatment planning. The process of treatment should include prevention of
future disease, restoring function and improving appearance also. This
should be planned after identifying the patient’s needs which is very
important for the successful treatment or prognosis. Throughout, the extent
of treatment is modified by the attitude of and objectives for the patient
conclusion

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References-
Fundamentals of fixed prosthodontics- shillingburg 1st south asia edition
Contemporary fixed prosthodontics – Rosenstiel- 3rd edition
Diagnosis and treatment planning in FPD’s , JPD dec 1973,vol 30,no.6