Diagnosis and treatment planning in fixed partial dentures

1. Diagnosis and treatment planning in FPD Apurva Thampi

2. Contents • Introduction • Terminologies • Diagnosis and diagnostic aids • Intra oral examination • Radiographic examination • Vitality testing • Interocclusal records • Treatment planning • For single tooth restoration • Replacing multiple missing teeth • Conclusion • References

3. Introduction

4. Sequalae of tooth loss Aesthetics Speech Drifting and tilting Supra- erupted teeth Overloading of remaining teeth Loss of masticatory efficiency Loss of vertical dimension Mandibular deviation Loss of alveolar bone Combination syndrome

5. Conventional restorative treatment plan Loss of alveolar bone Edentulousness (lost occlusion) Major changes (impaired occlusion) Minor changes(intact occlusion) Healthy dentition Neglect Restorative care Prosthodontic intervention

6. What are the options available?? RPD RFP FPD Implants

7. Unhealthy unattractive dentition with poor function Predictable success Comfortable healthy occlusion Meticulous attention to every detail

8. Terminologies

9. 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 7/15/2017The Glossary of Prosthodontic terms - 9 (April 2017) 9

10. Fixed partial denture Any dental prosthesis that is luted, screwed, or mechanically attached or otherwise securely retained to natural teeth, tooth roots, and/or dental implants/abutments that furnish the primary support for the dental prosthesis and restoring teeth in a partially edentulous arch; it cannot be removed by the patient The Glossary of Prosthodontic terms - 9 (April 2017)

11. Parts of a fixed partial denture Abutment Retainer Pontic Connector

12. Diagnosis

13. Intraoral examination Tongue Floor of the mouth Vestibule Cheeks Hard and soft palates Objective indices rather than vague assessments to be used

14. Classification of ridge defects Class I • Buccolingual loss of tissue with normal ridge height in the apico- coronal direction Class II • Apico-coronal loss of tissue with normal ridge width in bucco-lingual direction Class III • Combination of buccolingual and apico-coronal loss of tissue resulting in loss of normal height and width Kazor CE, Al-Shammari K, Sarment DP, Misch CE, Wang HL. Implant plastic surgery: a review and rationale. Journal of Oral Implantology. 2004 Aug;30(4):240-54. Seibert in 1983

15. Classification of ridge defects

16. Periodontal examination Gingiva Periodontium Clinical attachment level All existing periodontal conditions to be corrected before definitive prosthodontic treatment

17. Periodontal examination – Gingiva Normal • Pink, stippled • firmly bound to the underlying connective tissue. • Free gingival margin, sharply pointed gingiva How to examine? • Lightly dried • Colour, texture, size contour, consistency, position • Palpate – exudate

18. Periodontal examination – Gingiva Width of band of attached gingiva Measure band of keratinized tissue in A-C direction – subtract sulcus depth Depress marginal gingiva with side of periodontal probe Inject anesthetic solution into non keratinized mucosa

19. Periodontal examination - Periodontium One of the most reliable and useful diagnostic tools Probe is inserted parallel to tooth and “walked” circumferentially through the sulcus – firm but gentle steps Others: • Tooth mobility • Open contact areas • Inconsistent marginal ridge heights • Missing or impacted teeth • Inadequate attached gingiva • Recession • Furcation involvements

20. Periodontal examination – Clinical attachment level Attachment level Inference At the CEJ – Free Gingival Margin on the clinical crown No loss of attachment On the root structure – Free Ginigival Margin at the CEJ Attachment loss=probing depth ; recession is 0 Severe recession Attachment loss = probing depth + recession Determines the amount of periodontal destruction  periodontitis (diagnostic gold standard)

21. Dental charting

22. Occlusal examination Initial tooth contact General alignment Lateral and protrusive contacts Jaw maneuverability

23. Occlusal examination – Initial tooth contacts Checked in both centric relation and maximum intercuspation If all teeth come in contact together at the end of terminal hinge closure – CR=MI If any teeth come in contact first – feather-light – direction of movement observed upon closure  slide from CR to MI

24. Occlusal examination – General alignment • Crowding, rotations, eruptions, spacing, malocclusion, vertical and horizontal overlap

25. Occlusal examination – Lateral and Protrusive contacts Unguided protrusive movement amount of posterior disocclusion Guided in to lateral excursive movements Presence or absence of contacts noted “Fremitus test” For teeth subjected to excessive loading

26. Radiographic examination Degree of bone loss impacted teeth, residual roots Root morphology, crown- root ratio Presence of apical disease Caries Calculus pulp chambers & canals Periodontal ligament and surrounding bone existing restorations (marginal fit, contour)

27. Panaromic radiographs Presence or absence of teeth Assessing third molars impactions, Evaluating the bone before implant placement. Screening edentulous arches for buried root tips

28. Special radiographs for TML disorders • Transcranial exposure-reveal the lateral third of the mandibular condyle and can be used to detect structural and positional changes 52 Tomography CT scanning Arthrotomography MRI

29. Vitality testing PERCUSSION THERMAL STIMULATION TEST CAVITY

30. Vitality testing Assess only afferent Nerve supply Misdiagnosis may occur Careful inspection of radiographs is also required as an adjunt

31. Diagnostic casts Articulated diagnostic casts are essential Accurate reproductions of the maxillary and mandibular arches made from distortion free alginate impressions.

32. Diagnostic casts - Advantages an unobstructed view of the edentulous spaces Length of the abutment teeth The true inclination of the abutment teeth Mesio-distal drifting Teeth – size and location Diagnostic situations where pontic designs need to decided

33. Differential diagnosis Consist of the most likely causes of the observed condition Definitive diagnosis is made only after all the evidence is gathered

34. Prognosis • Important for patient management and satisfaction • Influenced by general and local factors A forecast as to the probable result of a disease or a course of therapy – GPT 9 General factors • Age and overall health • Occlusal forces • Understanding and comprehension • History and success or previous dental treatment Local factors • Malocclusions • Crowding of teeth • Tooth mobility • Root angulation • Crown root ratios

35. Prosthodontic diagnostic index (PDI) Location and extent of edentulous area Condition of abutment teeth Occlusal scheme Residual ridge McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

36. PDI – Location and extent of edentulous areas Minimally compromised • Antr missing span not exceeding 2 missing teeth • Antr mandibular span not exceeding 4 missing teeth • Postr maxillary or mandibular not exceeding 2 PM or 1 PM and 1 M Moderately compromised • Antr maxillary not exceeding 2 missing incisiors • Antr mandibular not missing more than 4 • Postr maxillary or mandibular not exceeding 2 PM or 1 PM and 1 M • Missing canine Substantially compromised • Postr > 3 missing teeeht or 2 molars • Antr or postr more than 3 missing • Treatment requires high level of compliance McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

37. PDI – Condition of abutment teeth Minimally compromised • No preprosthetic therapy required Moderately compromised • Insufficient tooth structure in one or 2 sextants • Abutments require localized adjunctive therapy Substantially compromised • Insufficient tooth structure • Abutments require extensive adjunctive therapy • Abutments have guarded prognosis McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

38. PDI – Occlusal scheme Minimally compromised • No preprosthetic therapy required • Class 1 Molar realtion Moderately compromised • Requires localized adjunctive therapy • Class 1 molar and jaw realtionships Substantially compromised • Entire occlusal scheme requires management • Class II moalr and jaw relations Severely compromised • Decreased vertical dimension • Class II div 2 or class molar and jaw relations McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

39. PDI – Class I Ideal location and extent of edentulous space • Confined to a single arch • Does not compromise the support offered by abutments Ideal abutment condition Ideal occlusion Residual ridge morphology of completely edentulism McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

40. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

41. PDI – Class II Location and extent moderately compromised • Edentulous areas on one or both arches Abutments are moderately compromised • 1 or 2 sextants have sufficient tooth structure • Require localized adjuctive therapy Occlusion is moderately compromised Residual ridge - class II McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

43. PDI – Class III Location and extent of edentulous area is substantially compromised Condition of abutments is moderately compromised Occlusion is substantially compromised Residual ridge – class III McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

45. PDI – Class IV Location and extent of edentulous area is severely compromised Abutments are severely compromised Occlusion is severely compromised Residual ridge – class IV McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

47. Treatment plan

48. Treatment Planning Single-Tooth Restorations The selection of the material The selection design of the restoration Replacement of Missing Teeth Removable Partial Denture Implant- Supported Fixed Partial Denture Conventional Tooth- Supported Fixed Partial Denture Resin-Bonded Tooth- Supported

49. Identification of patient needs Correction of existing disease Prevention of future disease Restoration of function Improvement in appearance

50. Available materials and techniques Materials • Plastic materials • Cast metal • Metal ceramic • Resin-veneered • Fibre-reinforced • All ceramic Techniques • Fixed dental prosthesis • Implant supported prosthesis • Partial removable dental prosthesis • Complete dentures Contemporary fixed prosthodontics Rosenstiel 4th Ed

51. 12 restoration types Intracoronal • Glass ionomer • Composite resin • Simple amalgam • Complex amalgam • Metal inlay • Ceramic inlay • MOD onlay Extracoronal • Partial vneer crown • Full metal crown • Metal ceramic crown • All ceramic crown • Ceramic veneer fundamenals of fixed prosthodontics Shillingberg

52. Factors for decision making Destruction of tooth structure Esthetics Plaque control Financial considerations Retention

53. For single tooth restorations

54. Restoration longevity Cast restorations survive longer in the mouth than amalgam which in turn will last longer than composite restorations Bentley C, Drake CW. Longevity of restorations in a dental school clinic. Journal of Dental Education. 1986 Oct 1;50(10):594-600.

55. For replacement of multiple missing teeth

56. Abutment evaluation • Ideally vital tooth • Radiographically sound RC treated tooth can also be used • Should not be mobile • Teeth in which pulp capping has been done should not be done

57. Abutment evaluation Crown root ratio Root configuration Periodontal ligament area

58. Abutment evaluation – Crown root ratio • Measure of the length of tooth occlusal to the alveolar crest of bone compared with the length of root embedded in the bone

59. Abutment evaluation – Root configuration Broader LABIOLINGULLAY than MESIODISTALLY. Multirooted posterior teeth with widely separated roots. Conical roots can be used -for short span. A single rooted tooth with evidence of irregular configuration or with some curvature in the tooth that has a nearly taper

60. Abutment evaluation – Periodontal ligament area • Larger teeth have a greater surface area and better able to bear added stress. • ANTE’S LAW - the root surface area of the abutment teeth had to equal or surpassed that of the teeth being replaced with pontics.

61. Biomechanical considerations In addition to the increased load placed on the pdl by a long span FPD. Longer spans are less rigid. Bending or deflection varies directly with the cube of the length and inversely with cube of the occlusogingivally thickness of the pontic

62. Biomechanical considerations How to minimize these forces? Greater occlusogingival dimension Nickel chromium Double abutment Multiple grooves Arch curvature ( minimize additional retention from opposite arch)

63. Special considerations Pier abutments Third molar abutments Canine replacement Cantilever fixed partial denture

64. Special consideration – Pier abutments Non rigid connector Restrict to short span FPD key way -distal contours of pier a abutment key - mesial side of the distal pontic

65. Special consideration – Third molar abutment • Mild encroaching- restoring and recontouring • Tilting is severe –corrective measures

66. Special considerations – Canine replacement • No FPD replacing a canine should replace more than one additional tooth. • Best restored with Implants

67. Special considerations – Cantilever fixed partial denture Length roots with favourable configuration. Long clinical crowns. Good crown root ratios and healthy periodontium. Should replace only one tooth and have atleast two abutments. Pontic should posses maximum occlusogingival height to ensure a rigid prosthesis

68. Special considerations – Cantilever fixed partial denture

69. Conclusion It is critical to develop a through understanding of special patient concerns relating to previous care and expectations about future treatment.

70. Bibliogrphy • Contemporary fixed prosthodontic; Stephen.F. Rosenstiel –4th edition. • Fundamentals of fixed prosthodontic; Herbert.T. Shillingburg –3rd edition • The Glossary of Prosthodontic terms - 9 (April 2017) • McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Arbree NS. Classification system for partial edentulism. Journal of Prosthodontics. 2002 Sep 1;11(3):181-93. • Bentley C, Drake CW. Longevity of restorations in a dental school clinic. Journal of Dental Education. 1986 Oct 1;50(10):594-600.

71. Thank you and have a pleasant day ahead!!

Diagnosis and treatment planning in fixed partial dentures

You are reading a preview.

Check these out next

Diagnosis and treatment planning in fixed partial dentures

More Related Content

Slideshows for you (20)

Similar to Diagnosis and treatment planning in fixed partial dentures (20)

More from Apurva Thampi (13)

Recently uploaded (20)