diagnosis and treatment planning in fpd.pptx

DIAGNOSIS AND TREATMENT PLANNING
IN
FIXED PARTIAL DENTURE
2

CONTENT
 Introduction
 Definitions
 Chief complaint
 Personal details
 History
 Examination
 Diagnosis and Prognosis
 Prosthodontic Diagnostic
Index 3
 Identification of patient
needs
 Treatment for tooth loss
 Selection of abutment
 Indications
 Treatment sequence
 Follow up

INTRODUCTION
The scope of fixed prosthodontics treatment can range
from the restoration of a single tooth to the
rehabilitation of the entire occlusion.
Mitchell DL, Sather DA, Wilson Jr EL, Shillingburg Jr HT, Kessler JC, Cain JR, Blanco LJ.
Fundamentals of Fixed Prosthodontics Fourth Edition. 4

DEFINITIONS
 DIAGNOSIS:
The determination of the nature of a disease -GPT-9
 TREATMENT PLAN
It is the sequence of procedures planned for the treatment
of a patient after diagnosis.-GPT-9
 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.- GPT-9
5

 A thorough diagnosis of the patient’s dental condition must be
correlated with the individual’s overall physical health and
psychologic needs.
 Using the gathered diagnostic information, it is then possible to
formulate a treatment plan.
6
Fundamentals of Fixed Prosthodontics Fourth Edition.

Full-mouth
radiographs
Diagnostic
casts
Intraoral
examination
TMJ and occlusal
evaluation
Health
history
5 ELEMENTS
TO GOOD
DIAGNOSTIC
WORK-UP
Mitchell DL, Sather DA, Wilson Jr EL, Shillingburg Jr HT, Kessler JC, Cain JR,
Blanco LJ. Fundamentals of Fixed Prosthodontics Fourth Edition.
7

8
HISTORY
All pertinent information concerning the reasons for
seeking treatment, along with any personal information,
including relevant previous medical and dental
experiences.
Rosenstiel SF, Land MF, editors. Contemporary fixed prosthodontics. Elsevier Health Sciences; 2015 Jul 28.

CHIEF COMPLAINT
9
COMFORT
FUNCTION
SOCIAL
APPEARANCE

PERSONAL DETAILS
Name Address
Phone
number
Gender
Occupation
Work
schedule
Marital
status
Budgetary
flexibility
10

MEDICAL HISTORY
Any medications the patient is taking and all relevant
medical conditions.
11
Conditions affecting treatment methods
Conditions affecting treatment plan
Systemic conditions with oral manifestations
Possible risks to the dentist & auxiliary personnel
CLASSIFICATION

12
MEDICAL DISORDERS AND FIXED
PROSTHODONTICS
CARDIOVASCULAR
DISORDERS
METABOLIC
DISORDERS
NEUROLOGICAL
DISORDERS
HEMATOLOGICAL
DISORDERS
BONE DISORDERS XEROSTOMIA BRUXISM
INFECTIOUS
DISORDERS
Gade D, Mahule D, Trivedi D, Shaikh D. Prosthodontic Management of Patients with Systemic Disorders.
European Journal of Molecular & Clinical Medicine. 2021 Mar 23;8(3):1439-51.

13
CARDIOVASCULAR DISORDERS
Hypertension

14
• Epinephrine in local anesthetic is NOT ABSOLUTELY
contraindicated for patients with severe cardiovascular
disease.
• Retraction cord containing epinephrine is
contraindicated.
• Epinephrine is known to cause adverse cardiovascular
problems or other symptoms such as anxiety, increased
respiratory rate, tachycardia, and, in rare instances,
death.
Baba NZ, Goodacre CJ, Jekki R, Won J. Gingival displacement for impression making in fixed prosthodontics:
contemporary principles, materials, and techniques. Dental Clinics. 2014 Jan 1;58(1):45-68.
The maximum dose of epinephrine in local anaesthesia for a
healthy subject is 0.2 mg, though this can be lowered to 0.04 mg if
patient has severe cardiovascular disease (ASA III and IV)

15
Most likely to experience hemorrhagic problems during dental
treatment.
They may be taking anticoagulants for a variety of reasons:
• prosthetic heart valves
• myocardial infarction (MI)
• stroke (cerebrovascular accident [CVA])
• atrial fibrillation (AF)
• deep venous thrombosis (DVT)
• unstable angina
ORAL ANTICOAGULANT THERAPY

16
American Heart Association (AHA) :
2.0 to 3.0 in every situation mentioned previously, except for
prosthetic heart valves, for which the INR range should be 2.5 to
3.5.
The INR for artificial heart valves should not exceed 4.0.
Physician may recommend stopping anticoagulant therapy 2 to 3
days prior to treatment, which is the traditional management of
patients on anticoagulants

17
Shikdar S, Bhattacharya PT. International normalized ratio (INR).
INTERNATIONAL NORMALIZED RATIO (INR)

18
Antibiotic prophylaxis for dental procedures now is
recommended:
• Prosthetic heart valve
• Previous IE
• Congenital heart disease (CHD)
• Unrepaired cyanotic CHD
• Cardiac transplants that develop valvulopathy
INFECTIVE ENDOCARDITIS
For patients with these conditions, prophylaxis is recommended for
all dental procedures that involve the gingiva, the periapical region of
the teeth, or perforation of oral mucosa.

19
Antibiotic regimen
• Single 2-g oral dose of amoxicillin for adults who are not allergic
to penicillin, 30 to 60 minutes before the procedure.
• If the patient is allergic to penicillin, 600 mg clindamycin or 500
mg azithromycin or clarithromycin may be substituted.

20
Natasha Stavreva. “Considerations of Oral Manifestations and Prosthodontic Management of Patients
with Diabetes Mellitus.” IOSR Journal of Dental and Medical Sciences, vol. 18, no. 8, 2019, pp 21-23.
METABOLIC DISORDERS
According to American diabetic association (ADA):
Fasting blood sugar (FBS) > 126 mg/dl
Or
Post random blood sugar (PRBS) >200mg/dl.
In the absence of these classic symptoms, glucose intolerance may
exist as impaired fasting glucose (IFG) when FBS is between 100 -
125 mg/dl.
Plasma glucose of 140 – 199 mg/dl  IGT
DIABETES
MELLITUS

21
Rahman B. Prosthodontic concerns in a diabetic patient. Int J Health Sci Res. 2013;3(10):117-120
• A narrow occlusal table, group function or mutually protected
occlusal scheme is better choice for periodontally
compromised teeth.
• Compromised periodontal condition restrains the tooth from
serving as an abutment for fixed prosthesis.
• Adversely affected by the stress of dental appointment
• Finish-line should be placed supragingival

22
XEROSTOMIA
• Conducive to greater carious activity
• Extremely hostile to the margins of cast metal or
ceramic restorations

23
When fixed partial dentures are given they should have:
• full coverage retainers
• easily cleaned pontics.
• margins of retainers should be supragingival.

24
• Silicone impression materials are the best tolerated and least traumatic to
the mucosa.
• Zinc oxide eugenol paste will adhere to and burn the mouth
• Plaster of paris will adhere to the mucosa and abrade it.
• Alginate sticks to teeth if the teeth are too dry. As the impression is
removed, tearing of the alginate occurs.
Miller and Grasso Removable partial denture 2nd ed 4
105

25
SIALORRHEA
Identification-
 Typically the floor of mouth will fill with saliva during examination
 This will not increase the retention but will cause problem during
impression making.
 Produces pits and voids in the impression.

26
BONE DISORDERS
• Bisphosphonate-related osteonecrosis of the jaws
• Scully et al  bisphosphonate therapy is a contraindication for
dental endosseous implants
• Marx et al  strongly discourage implant placement in patients
taking bisphosphonates.
OSTEORADIONECROSIS

27
• Compromised bone density & may be contraindicated for dental
implant surgery.
• With proper professional consultation with the patient’s physician
benefits of fixed prostheses can be provided to these patients.
PAGET’S DISEASE

28
HEMATOLOGICAL DISORDERS
• Bone maturation and development are often impaired
• Preoperative and postoperative antibiotics needs to be carefully
administered
• Disrupted and delayed healing pattern
ANEMIA

29
• Fixed partial dentures with supra-gingival finish lines
• Digital impression techniques are recommended to prevent any
injuries to the gingiva.
• Severe bleeding, delayed healing, increased risk of secondary
infection and post-operative discomfort contra-indicates the
implant placement.
LEUKEMIA

30
• Dental management requires a multidisciplinary approach with
medical supervision to prevent any complication that might affect the
patient’s medical condition and the success of dental treatment.
• PFM fixed restorations cemented with GIC were successfully used to
restore anterior and posterior dentition.
Abuelenain DA. Oral rehabilitation of patient with sickle cell anemia and dental anomaly: case report. Egyptian
dental journal. 2017 jan 1;63:919-23.

31
NEUROLOGICAL DISORDERS
PARKINSONS’S
DISEASE
• Semi-reclined 45-degree position during impression
procedure should be used to avoid excessive saliva pooling
and the risk of choking.
• Record impressions with quick-setting impression materials
Ajay Mootha MD, Jaiswal SS, Dugal R. Prosthodontic Treatment in Parkinson’s Disease Patients: Literature
Review. Journa. 2018 Nov;46(11):691.

32
• Margins of the prepared teeth kept supragingival or equigingival.
• Full coverage design
• The contacts and contours of the pontic and retainers should be self
cleansing.
• Resin cement should be used for cementation for metal copings
and fixed partial dentures  reduces the microleakage.
• All the restorations should be finished with flat occlusal morphology.
Ajay Mootha MD, Jaiswal SS, Dugal R. Prosthodontic Treatment in Parkinson’s Disease Patients: Literature
Review. Journa. 2018 Nov;46(11):691.

33
Karolyhazy K, Kivovics P, Fejerdy P, Aranyi Z. Prosthodontic status and recommended care of patients with
epilepsy. The Journal of prosthetic dentistry. 2005 Feb 1;93(2):177-82.
• For occlusal restorations, the use of ceramic inlays is best
avoided; complete metal-ceramic crowns are recommended
instead.
• Generally, fixed rather than removable prostheses are
preferred.
• For fixed partial dentures, the use of additional abutments may
be advisable for more stability.
EPILEPSY

34
Karolyhazy K, Kivovics P, Fejerdy P, Aranyi Z. Prosthodontic status and recommended care of patients with
epilepsy. The Journal of prosthetic dentistry. 2005 Feb 1;93(2):177-82.

35
ALZHEIMER’S
DISEASE
• Dental appointments and instructions are usually forgotten.
• Progressive neglect of oral health
• Treatment plans should be designed with minimal changes to the
oral cavity
• Not involve complete rehabilitation

36
BRUXISM
• Metal seem to be the safest choice
• Zirconia restorations are contraindicated specifically when
opposing natural teeth are present
• Single crowns should be constructed whenever possible and
short span FPDs should be given.
• Boxes, grooves or parallel pins can be used in the preparation

37
Universal precautions practiced for each patients
Possible route for transmission is direct contact, saliva, blood and
respiration
HIV
HEPATITIS B & C
SYPHILIS
HERPES
VARICELLA ZOSTER
INFECTIOUS DISEASES
Nagaraj KR, Savadi R. Prosthodontic management of HIV/AIDS subjects: An overview. The Journal of
Indian Prosthodontic Society. 2013 Dec 1;13(4):393-9.

38
General Measures:
1. Create safe and empathetic environment.
2. Maintain confidentiality of patients’ information.
3. Use standard precautions.
4. Provide unbiased treatment.
5. Advise regular dental visits.
6. Identify and manage oral manifestations of HIV/AIDS.
HIV/AIDS

39
Measures in Particular to Prosthodontics:
7. Evaluation of periodontal status of existing dentition during
construction of removable and fixed dentures.
8. Evaluation and management of xerostomia.
9. Increased maintenance of dentures for prevention of
candidiasis.
10. Evaluation of temporomandibular joint disorders.
11. Precautions during pre-prosthetic and implant surgeries.

40
• Use of high risk design FPD is beneficial and adherence to strict
plaque control by the doctors and patients before and after
treatment is indispensible.
• Use of a combination of both fixed and removable prostheses to
rehabilitate partially edentulous patients is advantageous.

41
COVID -19
Rokaya D. COVID-19: Prosthodontic challenges and opportunities in dental practice.

42
Rokaya D. COVID-19: Prosthodontic challenges and opportunities in dental practice.

43
• The patient is advised to safely keep the dislodged crown, FPD
or implant prosthesis in a box with butadiene solution.
• Patient is also advised to send a picture of the dislodged
prosthesis via email or whatsApp.
• If it is urgent & patient is healthy, appointment is fixed.
• In case of ill fitting prosthesis, the patient provide with a
temporary prosthesis which can be fabricated chair side or sent
to the lab as deemed necessary.
Sekhsaria S, Sharma A, Tiwari B, Sharma A, Mahajan T. Changing paradigm in prosthodontics practice post
COVID-19 outbreak. IP Ann Prosthodont Restor Dent 2020;6(2):71-76

Periodontal
history
Restorative
history
Orthodontic
history
Endodontic
history
Removable
prosthodontic
history Oral surgical
history
Radiographic
history
Myofascial pain &
temporomandibula
r dysfunction
history

46
EXAMINATION
General examination
General
appearan
ce
Gait
Weight
Skin
colour
Vital
signs

48
TMJ AND OCCLUSAL ADJUSTMENT
Prior to the start of fixed prosthodontics procedures, the patient’s
occlusion and TMJs must be evaluated to determine if they are
healthy enough to allow the fabrication of restorations.

49
PAPLTATION:
TMJ is palpated by
INTRAAURICULAR
method or the
EXTRAAURICULAR
method

C. With the mouth fully open, the
finger
is moved behind the condyle to
palpate the posterior aspect of the
A. Lateral aspect of the joint
with the mouth
closed.
B. Lateral aspect
of the joint during
opening and
closing.
Management of Temporomandibular Disorders and Occlusion, Jeffrey P. Okeson 7th edition

51
AUSCULTATION:
With stethoscope
clicking & crepitus in
joint is diagnosed
during anteroposterior
& eccentric
movements

52
Click- single explosive noise of short duration
Crepitus- continuous grafting sound
associated with osteoarthritic changes of
articular surfaces of joint

54
Masseter muscles are
palpated extraorally by
placing the fingers
over the lateral
surfaces of the rami of
the mandible.
Fingers are placed
over the patient’s
temples to feel the
temporalis muscles
Index finger is used to
touch the medial
pterygoid muscle on
the
inner surface of the
ramus
Mitchell DL, Sather DA, Wilson Jr EL, Shillingburg Jr HT, Kessler JC, Cain JR, Blanco LJ. Fundamentals
of Fixed Prosthodontics Fourth Edition.
Placing finger near
third molar to reach
maxillary tuberosity-
for lateral pterygoid
muscle

55
Trapezius muscle is felt
at the base of the skull,
high on the neck.
Sternocleidomastoid
muscle is grasped
between the thumb &
forefingers on the side
of the neck.

56
Average
opening of
more than
50 mm
Lateral
movement of
approximately
12 mm
A restricted mouth opening is considered to be any
distance less than 40 mm. If mouth opening is restricted
it is helpful to test the end feel.

57
If pressure by operator’s
fingers on the jaw can
further open the mouth it
is called “soft end feel”. It
suggests muscle induced
restriction.
If no further opening is
elicited upon exerting
pressure then it is
probably an intracapsular
disorder and is called “
hard end feel”.

The patient is observed for tooth visibility during normal
and exaggerated smiling.
58

60
• The intraoral examination reveal 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.

61
Evaluate the status of bacterial accumulation, the response of
the host tissues, and the degree of reversible and irreversible
damage.
Long-term periodontal health is prerequisite for successful
fixed prosthodontics

62
A healthy periodontium is a prerequisite for success with fixed
prosthodontic treatment.
Without a strong interdisciplinary relationship between
periodontics and prosthodontics, the esthetic, functional and/or
biological outcome may be compromised and necessitate
extensive and expensive retreatment.
Abduo J, Lyons KM. Interdisciplinary interface between fixed prosthodontics and periodontics. Periodontology
2000. 2017 Jun;74(1):40-62.

63
Pink, stippled, knife
edge free gingival
margin, sharply pointed
papillae
Enlarged and bulbous,
stippling lost, blunted
papillae, bleeding
GINGIVA

64
PERIODONTIUM
Probe is inserted
parallel to the tooth
“walked”
circumferentially
through the sulcus in
firm but gentle steps

65
CLINICAL ATTACHMENT LEVEL
Distance between the apical extent of the probing depth and
a fixed reference point on the tooth, most commonly either
the apical extent of a restoration or CEJ.

66

67
INITIAL TOOTH CONTACT
Centric relation Maximum intercuspation
If yes: restorative
treatment is often
straightforward…
If not: corrective
occlusal therapy may
be necessary prior…
If initial contact occurs between two posterior teeth, the
subsequent movement from the initial contact to the MI
position is carefully observed and its direction noted.

68
LATERAL & PROTRUSIVE CONTACTS
Fremitus (movement on palpation)
indicates tooth contact during
lateral excursions
Thin Mylar strip can be used
to test eccentric tooth
contact

Full-mouth
radiographs
Diagnostic
casts
Intraoral
examination
TMJ and occlusal
evaluation
Health
history
5 ELEMENTS
TO GOOD
DIAGNOSTIC
WORK-UP
Mitchell DL, Sather DA, Wilson Jr EL, Shillingburg Jr HT, Kessler JC, Cain JR,
69

 Integral part of the diagnostic
procedures
 Casts must be accurate
reproductions of the maxillary and
mandibular arches
 To derive maximum benefit 
mounted on a semi-adjustable
articulator.
70
DIAGNOSTIC CASTS

ADVANTAGES
 Great deal of information for diagnosing & arriving at a treatment
plan
 Allows unobstructed view of the edentulous spaces & accurate
assessment of the span length as well as the occlusogingival
dimension
 Length of abutment teeth can be accurately gauged
 Mesiodistal drifting, rotation, and faciolingual displacement of
prospective abutment teeth can be seen.
71
 Occlusal discrepancies, presence of centric relation prematurities
or excursive interferences can be determined.
 Changes in contour plus widening or narrowing of an abutment
tooth can also be tried and evaluated .
 The diagnostic wax-up, done in ivory wax, allows the patient to see
all of the compromises.

72
DIAGNOSTIC MOUNTING
Accurate diagnostic casts transferred to a semiadjustable
articulator are essential in planning fixed prosthodontic treatment

73
Accurate
impressions of
both dental arches
are required
IMPRESSION MAKING

ARTICULATOR SELECTION
74
Instrument selection depends on the type and complexity of
treatment needs, the demands for procedural accuracy, and
general expediency.

75
SMALL NON ADJUSTABLE ARTICULATOR
• Their use often leads to
restorations with occlusal
discrepancies.
• Some discrepancies can be
corrected intraorally, but this is
often time consuming & leads to
increased inaccuracy.
• The distance between the hinge and
the tooth to be restored is significantly
less on most nonadjustable
articulators than in the patient
• Restorations may have premature
tooth contacts because cusp position
is affected.

76
The radius of the arc
of closure affects the
likelihood of
interferences.

77
SEMIADJUSTABLE ARTICULATOR
• For most routine fixed prostheses, the use of a
semiadjustable articulator is a practical approach.
• They are about the same size as the anatomic structures
they represent.
• Therefore, the articulated casts can be positioned with
sufficient accuracy so that arcing errors are minimal and
usually of minimal clinical significance .

ARCON V/S NON ARCON
ARCON NON ARCON
Condylar guidance Upper member Lower member
Condyle of Articulator Lower member Upper member
Movements Anatomic function
of patient
Opposite to natural
anatomy
Adjustability Semi or fully Semi
Condylar Inclination Remains same when
open and closed
Changes
(8 degrees)
Condylar guidance pathways Curved and straight Only straight

79
ARCON
ARTICULATO
R
NON-ARCON
ARTICULATO
R
Condylar
inclination of
the mechanical
fossae is at a
fixed angle to
the maxillary
OP.
Angle changes
as the
articulator is
opened 
errors when
protrusive
record is being
used to
program.

80
• The mechanical fossae can be adjusted to mimic the
movements of the patient through the use of interocclusal
records.
• Error is introduced when nonarcon articulators are set with
protrusive wax records.
• As the protrusive record used to adjust the instrument is
removed from the arcon articulator, the maxillary OP and the
condylar inclination become more parallel.

81
FULLY ADJUSTABLE ARTICULATOR

82
The accuracy of reproduction of movement depends on:
• care and skill of the operator
• errors inherent in the articulator & recording device
• any malalignments resulting from slight flexing of the
mandible and the nonrigid nature of the TMJ.
Series of special pantographic tracings are used to record
the patient’s border movements.

83

84
FACEBOW TRANSFER
TRANSVERSE HORIZONTAL AXIS
• The mandibular hinging movement around the transverse
horizontal axis is repeatable.
• Facebows are used to record the anteroposterior and
mediolateral spatial position of the maxillary occlusal surfaces irt
this transverse opening and closing axis of the patient’s
mandible.

85

86
KINEMATIC HINGE AXIS FACEBOW

87

88
ARBITRARY HINGE AXIS FACEBOW

89

MOUNTING OF MAXILLARY CAST

91

92
CENTRIC RELATION RECORD
• Provides the orientation of mandibular to maxillary teeth in CR in the
terminal hinge position, in which opening and closing are purely
rotational movements.
• This position is independent of tooth contact.

93
Centric relation (CR) recording technique with hard pink
baseplate wax

94

95
An anterior programming device is used to facilitate
centric relation recording.

96
Thermoplastic
material can
be used
Plastic leaf
gauge maybe
used

97
CR recording
technique -
Reinforced
Aluwax Record

98
Elastomeric material
is used for CR
recording.

99
CR recording
technique with
preformed wax
wafer and leaf
gauge

MOUNTING THE MANDIBULAR CAST

101

102
Diagnostic waxing procedure

103
• A well defined, complete mouth radiographic series is essential.
• TMJ radiographs may be indicated for patients with joint
dysfunction and a panoramic radiograph can also be helpful.
• Radiographs provide information that cannot be determined
clinically.
RADIOGRAPHS IN FPD

104
Radiographs used in FPD are :
1. Full mouth intra-oral periapical radiographs
2. Panoramic radiographs
3. TMJ radiographs
4. Bitewing radiograph

 Remaining bone support
 Root number and morphology
 Quality of supporting bone
trabacular patterns and reaction
to functional charges.
 Width of the periodontal
ligament spaces and evidence of
traum from occlusion
106
FULL MOUTH RADIOGRAPHS
 Areas of vertical and horizontal
osseous resorption and furcation
invasions.
 Axial inclination of teeth
 Continuity and integrity of the
lamina dura.
 Pulpal morphology and previous
endodontic treatment with or
without post and cores.

107
 Presence of apical diseases, root resorption or root fractures.
 Retained root fragments, radiolucent areas, calcification, foreign
bodies, or impacted teeth
 Presence of carious lesions and restorations to the pulp and
alveolar crest.
 Proximity of carious lesions and restorations to the pulp and
alveolar crest
 Calculus deposits

108
Crown – root ratio
 This ratio is a measure of the length of tooth occlusal to the alveolar
crest of bone compared with the length of root embedded in the
bone.
 As the level of the alveolar bone moves apically, the level arm of that
portion out of the bone increases and the chance for harmful lateral
forces is increased.
 Optimum crown root ratio  2:3
 Minimum  1:1

109
Hölttä P, Nyström M, Evälahti M, Alaluusua S. Root–crown ratios of permanent teeth in a healthy Finnish population
assessed from panoramic radiographs. The European Journal of Orthodontics. 2004 Oct 1;26(5):491-7.

110
Lind’ s method
• Used previously to study relative amount of root shortening
(ratio of root length and crown height) of incisors using
intraoral radiographs
• Routinely used at treatment planning
Modified Lind’ s method
• Assessing relative root length can be used in objective
investigations of root shortening in different conditions causing
apical root resorption or affecting root development
• To study effect of childhood disease on R/C ratio

111
Panoramic radiographs
• Provide useful information as to the presence or absence of
teeth.
• Overall view about the dentition.
• Not provide detailed view for assessing bone support, root
morphology, or caries.

112
Sabarudin A, Tiau YJ. Image quality assessment in panoramic dental radiography: a comparative study
between conventional and digital systems. Quantitative imaging in medicine and surgery. 2013 Feb;3(1):43.

113
Special radiographs
• Assessment of TMJ disorders
• Trans-cranial exposure with the help of a positioning device , will
reveal the lateral third of the mandibular condyle and can be used
to detect structural and positional changes.
• Serial tomography, arthrography, CT scanning or magnetic
resonance imaging of the joints.

114
Purton DG, Ng BP, Chandler NP, Monteith BD. The bitewing radiograph as an assessment tool in fixed
prosthodontics. Journal of oral rehabilitation. 2004 Jun;31(6):562-7.
The use of bitewing radiographs to assess tooth and pulp morphology
when treatment planning for crowns on molars, especially in Asian
patients, may help to reduce these problems, and the possibility of
unexpected pulp exposures.

VITALITY TESTS
 Before any restorative treatment is begun, pulpal health must
be confirmed, usually by assessing the response to thermal
stimulation.
 Misdiagnosis can occur if the nerve supply is damaged but the
blood supply is intact.
116

History & examination
Differential diagnosis
Definitive diagnosis
118

The prognosis of dental disorders is influenced by :
 general factors (age of the patient, lowered resistance of the
oral environment)
 local factors (forces applied to a given tooth, access for oral
hygiene measures).
119

Ideal or
minimal
Moderately
compromised
Substantially
compromised
Severely
compromised
PROSTHODONTIC DIAGNOSTIC INDEX (PDI)
FOR PARTIALLY EDENTULOUS AND COMPLETELY
DENTATE PATIENTS
1. Location and extent of the edentulous area or areas
2. Condition of the abutment teeth
3. Occlusal scheme
4. Residual ridge
120

CLASS 1
121
Location and extent of
edentulous areas
Condition of
abutment
teeth
Occlusal
scheme
Residual
ridge
Confined to a single arch.
Does not compromise the
physiologic support of the
abutments.
May include any anterior
maxillary span that does not
exceed 2 incisors, any
anterior mandibular span
that does not exceed 4
missing incisors, or any
posterior span that does not
exceed 2 premolars or one
Ideal or
minimally
compromised
with no need
for pre
prosthetic
therapy
Ideal or
minimally
compromised,
with no need for
pre prosthetic
therapy
Maxillomandibula
r
relationship
consists of class
I molar and jaw
relationships.
Conforms
to class I
complete
edentulism

CLASS II
122
edentulous areas
Condition of
abutment
teeth
Occlusal
scheme
Residual
ridge
May exist in one or both
arches.
Does not compromise the
abutments.
May include any ant.
maxillary span that does not
exceed 2 incisors, any ant.
mandibular span that does
not exceed 4 missing
incisors, or any posterior
span that does not exceed 2
PM or 1PM &1 M
Moderately
compromised
Abutment is
1or 2 sextant
have
insufficient
tooth
structure.
Abutment in 1
or 2 sextant
necessitate
loc. Adjunctive
therapy.
Occlusal
correction
necessitates loc.
adjunctive
therapy.
Maxillomandibula
r relationship:
class 1 molar
and jaw
relationship.
Conforms
to class II
complete
edentulism

CLASS -III
123
edentulous areas
Condition of
abutment teeth
Occlusal
scheme
Residual
ridge
May exist in one or both
arches.
Compromise the
abutments.
May include any
posterior maxillary or
mandibular edentulous
area greater than 3 teeth
or 2 molars or anterior &
posterior edentulous
area of 3 or more teeth
Moderately
compromised
Abutment in 3
sextants have
insufficient tooth
structure.
Abutment in 3
sextants
necessitate more
substantially
localized
adjunctive
therapy.
Entire occlusal
scheme must be
reestablished
without change
in OVD
Maxillomandibula
r relationship:
class II molar
and jaw
relationship.
Conforms
to class III
complete
edentulism

CLASS IV
124
edentulous areas
Condition of
abutment teeth
Occlusal
scheme
Residual
ridge
Extensive & maybe
present in both arches .
Compromise the
abutments & prognosis is
guarded.
Includes acquired or
congenital maxillofacial
defects.
At least 1 edentulous
area with guarded
prognosis.
Severely
compromised
Abutment in 4 or
more sextants
have insufficient
tooth structure.
Abutment in 4 or
more sextants
necessitate more
substantially
localized
adjunctive
therapy.
Entire occlusal
scheme must be
reestablished
including change
in OVD
Maxillomandibula
r relationship:
class II molar, div
2 or class III
molar and jaw
relationship
Conforms
to class IV
complete
edentulism

126
Good
health
Optimal
appearance
Optimal
function

128
Prevention of
future disease
Corrections of
existing
disease
Improvement
of appearance
Restoration of
function

133
Treatment
planning
Single tooth
restoration
Replacement
of missing
teeth

134
TREATMENT PLANNING FOR SINGLE TOOTH
RESTORATIONS
Intracoronal
restoration
Extracoronal
restoration

135
INTRACORONAL RESTORATIONS
When sufficient coronal tooth structure exists to retain and
protect a restoration under the anticipated stresses of
mastication, an intracoronal restoration can be employed.

136
GLASS IONOMER
Mitchell DL, Sather DA, Wilson Jr EL, Shillingburg Jr HT, Kessler JC, Cain JR, Blanco LJ. Fundamentals of
Fixed Prosthodontics Fourth Edition.
COMPOSITE RESIN SIMPLE AMALGAM

137
COMPLEX
AMALGAM
Mitchell DL, Sather DA, Wilson Jr EL, Shillingburg Jr HT, Kessler JC, Cain JR, Blanco LJ. Fundamentals of
Fixed Prosthodontics Fourth Edition.
INLAY ONLAY

138
EXTRACORONAL RESTORATIONS
When insufficient coronal tooth structure
exists to retain the restoration within the
crown, an extracoronal resoration or crown is
needed.
 Partial coverage crown
 All metal crown
 Metal-ceramic crown
 All ceramic crown
 Ceramic veneer

139
PARTIAL COVERAGE CROWN
• Restore a tooth with 1 or
more intact axial surfaces
with half or more of the
coronal tooth structure
remaining.
• Moderate retention
• Retainer for short-span
FPD

140
PARTIAL VENEER CROWN
TYPES :
Posterior Teeth 
3/4th crown
Modified 3/4th
7/8th crown
Reverse 3/4th
Proximal ½ crown
Anterior teeth 
3/4th crown
Pin-ledges
Porcelain Laminates

141
ALL METAL CROWN
• Maximum retention with
no esthetic expectations
• Limited to 2nd molars,
some mandibular 1st
molars, & occasionally
mandibular 2nd PM

142
METAL CERAMIC CROWN
• Restore teeth with
multiple defective axial
surface
• Maximum retention with
high esthetic
requirements

143
ALL CERAMIC CROWN
• Full coverage &
maximum esthetics
combined
• Not resistant to fracture
as metal ceramic crowns
• Low to moderate stress

144
CERAMIC VENEER
• Severe staining or
developmental defects
restricted to the facial surface
• Moderate incisal chipping &
small proximal lesions
• Only minimal tooth
preparation

SELECTION OF MATERIAL AND DESIGN
 Destruction of tooth structure
 Esthetics
 Plaque control
 Financial considerations
 Retention
145

146
DESTRUCTION OF TOOTH STRUCTURE
Remaining tooth structure must gain strength and
protection from the restoration:
Cast metal or ceramic >>>>> amalgam or composite
resin

147
ESTHETICS
• Highly visible area
• Metal-ceramic crowns can be used for single-unit ant.
or post. crowns, as well as for FPD retainers.
• All-ceramic crowns are most commonly used on
incisors

148
PLAQUE CONTROL
• Cemented restoration demands a good plaque-control
program
• If extensive plaque, decalcification, and caries are present 
use of crowns should be carefully weighed.

151
RETENTION
• Full coverage crowns are unquestionably the most
retentive.
• Maximum retention is not nearly as important for
single-tooth restorations as it is for FPD retainers.

152
TREATMENT PLANNING FOR REPLACEMENT OF
MISSING TEETH
IMPLANT
SUPPORTED
D FPD
RESIN
BONDED
TOOTH
SUPPORTED
D FPD
CONVENTIO
NAL TOOTH
SUPPORTED
D FPD
REMOVABLE
E PARTIAL
DENTURE

153
Removable
partial denture
Conventional
Tooth
Supported FPD
Resin
tooth
supported
FPD
Implant
supported
FPD
SPAN
LENGTH
Posterior spans
longer than 2
teeth Anterior
spans longer
than 4 incisors
Canine + 2 or
more contiguous
teeth
Posterior span:
2 or fewer
Incisors: 4 or
fewer
Single
tooth
Possible for
2 incisors
Single
tooth
2- to 6-unit
span

154
RPD Conventional
FPD
Resin
bonded
tooth
supported
FPD
Implant
supported
FPD
SPAN
CONFIGUR
ATION
No distal
abutment
Multiple or
bilateral
edentulous
spaces
Usually has
distal abutment
but can be used
with short
cantilever pontic
Abutments
mesial and
distal to
pontic
No distal
abutment
Pier in 3+
pontic span

155
RPD Conventional
FPD
Resin
bonded
tooth
supported
FPD
Implant
supported FPD
ABUTMENT
ALIGNMENT
Tipped
abutment
s can be
tolerated
Widely
divergent
abutment
alignmen
Less than 25-
degree
inclination can
be
accommodated
by preparation
modification
Abutments
mesial and
distal to
pontic
Less than 15-
degree inclination
mesiodistally
Should be in
same faciolingual
plane
Preparations :not
easily modified
because of
minimal reduction

156
Removable
partial denture
Conventional
Tooth
Supported FPD
Resin
tooth
supported
FPD
Implant
supported
FPD
ABUTMENT
CONDITION
Short clinical
crowns
Insufficient
abutments
Good if
abutments need
crowns
Non vital teeth
can be used if
there is
sufficient
coronal tooth
structure
Defect free
abutments
Incisor,
premolars
replaceme
nt
Defect free
abutments
requiring
no
restoration

157
Removable
partial denture
Conventional
Tooth
Supported
FPD
Resin tooth
supported
FPD
Implant
supported
FPD
OCCLUSION More adaptable
to irregularities
in a healthy
opposing
natural dentition
Favourable
loading
Can not be
used for
incisor
replacement
in presence
of deep
vertical
overlap
Occlusal
forces must
be nearly
vertical as
possible to
prevent
unfav.
lateral
loading of
implants

158
Removable
partial denture
Conventional
Tooth Supported
Supported FPD
Resin tooth
tooth
supported
FPD
Implant
supportedF
FPD
PERIODONTA
AL
CONDITION
Can use
alternate
(secondary)
abutments
when primary
abutments are
weakened
Good alveolar
bone support
Crown root ratio
1:1 or better
No mobility
Favourable root
morphology
Provides rigid
stabilization
No mobility
Periodontal
splints
Dense
bone

159
Removable
partial denture
Conventional
Tooth Supported
Supported FPD
Resin tooth
tooth
supported
FPD
Implant
supportedF
FPD
RIDGE FORM Gross tissue loss
loss in residual
ridge
Moderate
resorption
No gross soft
tissue defects
Moderate
resorption
No gross
soft tissue
defects
Broad, flat
ridge

161
TREATMENT FOR TOOTH LOSS
Advantages Disadvantages
Decision to remove a tooth

162
Consequences of removal without
replacement
Over time, loss of
arch integrity
may result in
tooth movement.

SELECTION OF ABUTMENT
163
Replacement of a single missing
tooth:
Exception : replacing a
maxillary or mandibular
canine tooth
DOUBLE-ABUTTING

ABUTMENT EVALUATION
164
Endodontically
treated
abutments Unrestored
abutments

ENDODONTICALLY TREATED ABUTMENTS
165
Can serve well as
an abutment with
a post and core
foundation for
retention and
strength.
Maxillary buccal
cusp fracture has
a better prognosis
than does a
patient presenting
with a lingual
cusp fracture

UNRESTORED ABUTMENTS
166
An unrestored,
caries-free tooth
is an ideal
abutment.

THE ROOTS AND THEIR SUPPORTING TISSUES SHOULD BE
EVALUATED FOR THREE FACTORS:
167
Crown root ratio
Root
configuration
Periodontal
ligament area

CROWN-ROOT RATIO
 ‘The physical relationship between the portion of the tooth within
the alveolar bone compared with the portion not within the alveolar
bone, as determined radiographically.’’- GPT-9
 CRR represents the biomechanical concept of Class I lever for
evaluating abutment teeth.
168
Grossmann Y, Sadan A. The prosthodontic concept of crown-to-root ratio: a review of the literature. The
Journal of prosthetic dentistry. 2005 Jun 1;93(6):559-62.

CROWN-ROOT RATIO
169
Optimum
crown-root
ratio is 2:3
Maximum
acceptable
crown-root ratio
is 1:1

170
Greater faciolingual
dimension, makes it a
superior abutment to whose
root is essentially circular in
cross section.
ROOT CONFIGURATION

171
Molar with divergent roots
better abutment tooth than
one whose roots are fused
ROOT CONFIGURATION

ROOT SURFACE AREA
177
ANTE’S LAW
Johnston et al root surface area of the abutment teeth had
to equal or surpass that of the teeth being replaced with
pontics

178
Combined root surface area
of the second premolar and
the second molar (a2p +
a2m) is greater than that of
the first molar being replaced
(a1m).

181
There will be eight times as much deflection (8x) if the
thickness is decreased by one-half (t/2).

182
The deflection will be
eight times as great (8x) if
the span length is
doubled (2p).
The deflection will be 27
times as great (27x) if the
span length is tripled (3p)
Bending or deflection varies directly with cube of
length and inversely with cube of occlugingival
thickness of pontics.

PERIODONTAL DISEASES
185
After horizontal bone
loss, the PDL–
supported root surface
area can be
dramatically reduced.
The forces applied
to the supporting
bone are magnified.

188
Seating
action
Unseating
action
Distal side of the
retainermovement in a mesial
direction will seat the key into the
keyway
Mesial side of the middle abutment
mesially directed movement will
unseat the key.

189
Akulwar RS, Kodgi A. Non-rigid connector for managing pier abutment in FPD: A case report. Journal of
clinical and diagnostic research: JCDR. 2014 Jul;8(7):ZD12.
• The size, shape and type of connectors play important role in
future success of a FPD.
• The selection of proper connector is important step in treatment
planning of pier abutment.
• Thus, the design and passive fit of non-rigid connectors is
significant to success of a long span fixed partial denture.

191
CANINE REPLACEMENT FPD
• Difficult  canine often lies outside the interabutment
axis
• Prospective abutments :
 lateral incisor weakest tooth in the entire arch
 first premolar weakest posterior tooth.
• FPD replacing a maxillary canine is subjected to more
stresses than that replacing a mandibular

192
CANTILEVER FPD
Potentially
destructive design
No occlusal contact
on pontic in either
centric or lateral
excursions

TREATMENT
SEQUENCE
Treatment of
symptoms
Stabilization of
deteriorating
conditions
Definitive
therapy
Follow-up
care

The relief of discomfort accompanying an acute condition is a priority
in planning treatment.
195
TREATMENT OF SYMPTOMS

196
STABILIZATION OF DETERIORATING CONDITIONS
DENTAL CARIES PERIODONTAL
DISEASES

DENTAL CARIES
197
Treatment of carious lesions is
approached in a conventional
manner, and may serve as a
foundation for FDPs.
Definitive crowns are best
avoided in a patient with active
caries

PERIODONTAL DISEASE
Replacement of defective restorations
Removal of carious lesions
Recontouring of overcontoured restorations
Proper oral hygiene instructions
198

199
DEFINITIVE THERAPY
Oral
surger
y
Periodontic
s
Endodontic
s
Orthodontic
s
Fixed
prosthodontic
s

200
Principle of
Treatment simplification

OCCLUSAL RESHAPING
Reduce neuromuscular pathology
Orthopedic stability
201

202
ANTERIOR RESTORATIONS:
If both anterior and posterior teeth are to be restored, the anterior
teeth are usually restored first.
POSTERIOR RESTORATIONS:
Restoring opposing posterior segments at the same time is often
advantageous.

COMPLEX PROSTHODONTICS:
Carefully planned treatment sequencing is critically important in the
planning of complex prosthodontic treatments involving alteration of
the vertical dimension or a combination of FDPs and partial RDPs
203

204
FOLLOW UP
Monitor dental health
Identify newly developed signs of disease early
Initiate corrective measures

CONCLUSION
 The basis of logical treatment planning consists of identifying the
patient’s needs, eliciting his or her expectations and wishes, and
comparing these with the available and feasible corrective
materials and techniques.
 Then a rational sequence of treatment may be initiated for
symptomatic relief, stabilization, definitive therapy, and follow-up
care.
205

206
• Rosenstiel SF, Land MF, editors. Contemporary fixed prosthodontics. Elsevier Health
Sciences; 2015 Jul 28.
• Mitchell DL, Sather DA, Wilson Jr EL, Shillingburg Jr HT, Kessler JC, Cain JR,
• Abduo J, Lyons KM. Interdisciplinary interface between fixed prosthodontics and
periodontics. Periodontology 2000. 2017 Jun;74(1):40-62.
• Balevi B. Ante's law is not evidence based. The Journal of the American Dental
Association. 2012 Sep 1;143(9):1011-2.
• Rudel K, Dent M, Wöstmann B, Dent DM. Long-span fixed dental prostheses not
meeting Ante’s law: A retrospective analysis.
• Akulwar RS, Kodgi A. Non-rigid connector for managing pier abutment in FPD: A
case report. Journal of clinical and diagnostic research: JCDR. 2014 Jul;8(7):ZD12.
• Management of Temporomandibular Disorders and Occlusion, Jeffrey P. Okeson 7th
edition
• Grossmann Y, Sadan A. The prosthodontic concept of crown-to-root ratio: a review of
the literature. The Journal of prosthetic dentistry. 2005 Jun 1;93(6):559-62.

207
• Rahman B. Prosthodontic concerns in a diabetic patient. Int J Health Sci Res.
2013;3(10):117-120
• Karolyhazy K, Kivovics P, Fejerdy P, Aranyi Z. Prosthodontic status and recommended
care of patients with epilepsy. The Journal of prosthetic dentistry. 2005 Feb
1;93(2):177-82.
• Baba NZ, Goodacre CJ, Jekki R, Won J. Gingival displacement for impression making
in fixed prosthodontics: contemporary principles, materials, and techniques. Dental
Clinics. 2014 Jan 1;58(1):45-68.
• Nagaraj KR, Savadi R. Prosthodontic management of HIV/AIDS subjects: An overview.
The Journal of Indian Prosthodontic Society. 2013 Dec 1;13(4):393-9.
• Rokaya D. COVID-19: Prosthodontic challenges and opportunities in dental practice.
• Sekhsaria S, Sharma A, Tiwari B, Sharma A, Mahajan T. Changing paradigm in
prosthodontics practice post COVID-19 outbreak. IP Ann Prosthodont Restor Dent
2020;6(2):71-76
• Ajay Mootha MD, Jaiswal SS, Dugal R. Prosthodontic Treatment in Parkinson’s Disease
Patients: Literature Review. Journa. 2018 Nov;46(11):691.

208
• Holt RA, Nordquist RE. Effect of resin/fluoride and holmium:YAG laser irradiation on
the resistance to the formation of caries-like lesions. J Prosthodont 1997;6:11–19.
• Shikdar S, Bhattacharya PT. International normalized ratio (INR).
• Chan C, Weber H. Plaque retention on teeth restored with full-ceramic crowns: a
comparative study. The Journal of prosthetic dentistry. 1986 Dec 1;56(6):666-71
• Natasha Stavreva. “Considerations of Oral Manifestations and Prosthodontic
Management of Patients with Diabetes Mellitus.” IOSR Journal of Dental and Medical
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