Diagnosis & Treatment Planning in FPD

DIAGNOSIS & TREATMENT
PLANNING
IN
FIXED PARTIAL DENTURE
PRESENTED BY:
Dr. Anshul Sahu
2nd Year
PG Student

CONTENTS:
 Introduction
 Definitions
 Diagnostic aids
• Personal information
• Patient evaluation
• History
• Medical
• Past Dental
• Examination
• General Examination
• Extra Oral examination
• Intra Oral examination
• Radiographic examination

 Treatment planning
• Single – tooth restoration
• Replacement of missing teeth
• Selection of the type of prosthesis
• Abutment evaluation
• Biomechanical considerations
• Special problems
 Conclusion
 References

INTRODUCTION
• Fixed prosthodontic treatment can offer exceptional satisfaction for both
patient and the dentist.
• Fixed Prosthodontics can transform an unhealthy, unattractive dentition with
poor function into a comfortable, healthy occlusion capable of giving years
of further service while greatly enhancing esthetics.
• Nothing is more important in the construction of fixed partial dentures than
an adequate diagnosis and a well-devised treatment plan. Although these
two subjects are usually considered together. Astute dentists must recognize
their subtle differences.
• Diagnosis is an evaluation of the condition of the patient when he presents
for treatment. Treatment planning concerns the treatment procedures by
which the dentist will restore the patient to an optimum state of dental
health.

DEFINITIONS
(Glossary of Prosthodontic Term 9)
 DIAGNOSIS: The determination of the nature of a disease.
 PROGNOSIS: A forecast as to the probable result of a disease or a course of
therapy.
 TREATMENT PLAN: The sequence of procedures planned for the treatment
of a patient after diagnosis.
 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.

DIAGNOSTIC AIDS
PERSONAL INFORMATION:
 Name
 Age
 Sex
 Address
 Contact No.
 Family history
 Socio-economic status

CHIEF COMPLANT:
 The accuracy and significance of the patient’s primary reason or
reasons for seeking treatment should be analyzed first.
 Four categories:
• COMFORT (pain, sensitivity, swelling)
• FUNCTION (difficulty in mastication or speech)
• SOCIAL (bad taste or odor )
• APPEAREANCE (fractured or unattractive teeth or restorations,
discoloration

HISTORY:
A patient's history should include all necessary information concerning the
reasons for seeking treatment, along with any personal details and past
medical and dental experiences that are pertinent. A screening
questionnaire is useful for history taking.

MEDICAL HISTORY:
An accurate and current general medical history should include any
medication the patient is taking as well as all relevant medical conditions.
 Any disorders that necessitate the use of antibiotic premedication, any use
of steroids or anticoagulants and any previous allergic responses to
medication or dental materials should be recorded.
 Any conditions affecting the treatment plan e.g.: various radiation therapy,
hemorrhagic disorders etc. should be recorded.
 Possible risk factors to the dentist and auxiliary personnel, e.g. carriers of
Hepatitis B, Aids or Syphilis are recorded so that adequate measures can be
followed when treating known carriers.

PAST DENTAL HISTORY
DENTAL
HISTORY
Periodontal
History
Restorative
History
Endodontic
History
Orthodontic
History
Removable
Prosthodontic
History
Oral Surgical
History
Radiographic
History
TMJ
Dysfunction
History

 PERIODONTAL HISTORY:
 The patients oral hygiene is assessed, current plaque control measures are
discussed, as are previously received oral hygiene instructions.
 The frequency of any previous debridement should be recorded.
 Nature of any previous periodontal surgery should be noted.

 RESTORATIVE HISTORY:
 Simple composites resin or dental amalgam fillings or may involve crowns
and extensive fixed partial dentures.
 The age of previous existing restorations can help the prognosis and
probable longevity of any future fixed prosthesis.

 ENDODONTIC HISTORY:
 The findings should be reviewed periodically so that peri-apical health can
be monitored, any recurring lesions promptly detected.

 ORTHODONTIC HISTORY:
 Apical root resorption subsequent to orthodontic treatment.
 As the crown/root ratio is affected, future prosthodontic treatment
and its prognosis may also be affected

 REMOVABLE PROSTHODONTIC HISTORY:
 The patients experiences with removable prostheses must be
carefully evaluated.
 Listening to the patients comments about previously unsuccessful in
assessing whether future treatment will be more successful.

 ORAL SURGICAL HISTORY:
 Missing teeth and any complications that may have occurred during
tooth removal is obtained.
 Before any treatment is undertaken, the prosthodontic component
of the proposal treatment should be fully co-ordinated with surgical
component.

 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 a part of examination.

 TMJ DYSFUNCTION HISTORY:
 A history of pain or clicking in the TMJ or neuromuscular systems,
such as tenderness to palpation, may be due to TMJ DYSFUNCTION,
which should be normally be treated and resolved before fixed
prosthodontic treatment begins.

EXAMINATION:
 An examination consist of the clinician’s use of sight, touch and
hearing to detect conditions outside the normal range.
 It is critical to record what is actually observed rather than to make
diagnostic comments about the condition.

 GENERAL EXAMINATION:
 General appearance: Gait and weight are assessed.
 Skin color : Anemia or jaundice.
 Vital signs: Respiration, pulse, temperature and blood pressure are
measured and recorded.
 Vital signs outside normal ranges should be referred for a
comprehensive medical evaluation

 EXTRAORAL EXAMINATION:
 Facial Asymmetry
 Cervical Lymph nodes
 Tmj
 Muscles Of Mastication
 Mouth opening
 Lips

 TEMPOROMANDIBULAR JOINTS:
 The TMJ is palpated bilaterally just anterior to the auricular tragic
while having the patient open and close his lower jaw.
 Tenderness, clicking or pain on movement is noted and can be
indicative of inflammatory changes in the retrodiscal tissues , which
are highly vascular and innervated.

 MUSCLES OF MASTICATION:
 A brief palpation of masseter, temporalis, medial pterygoid, lateral
pteregoid muscles may reveal tenderness.
 Palpation is best accomplished bilaterally and simultaneously.
 This allows the patient to compare and report any differences
between the left and right sides.

 MASSETER MUSCLE:
 The patient is asked to clench their teeth and, using both hands, the
practitioner palpates the masseter muscles on both sides extra
orally, making sure that the patient continues to clench during the
procedure.
 Palpate the origin of the masseter bilaterally along the zygomatic
arch and continue to palpate down the body of the mandible where
the masseter is attached.

 TEMPORALIS MUSCLE:
 The muscle is divided into three functional areas and therefore each area is
independently palpated.
 To locate the muscle, have the patient clench.
 The anterior region is palpated above the zygomatic arch and anterior to the
TMJ.
 The middle region is palpated directly above the TMJ and superior to
the zygomatic arch.
 The posterior region is palpated above and behind the ear.

 LATERAL PTERYGOID MUSCLE:
 Placing the forefinger, or the little finger, over the buccal area of the
maxillary third molar region and exerting pressure in a posterior, superior,
and medial direction behind the maxillary tuberosity.

 MEDIAL PTERYGOID MUSCLE:
 It can be palpated by placing the finger on the lateral aspect of the
pharyngeal wall of the throat, this palpation is difficult and sometimes
uncomfortable for the patient.
 Functional manipulation is done when the muscle becomes fatigued and
symptomatic.
 The muscle contracts as the teeth are coming in contact.
 Also stretches when the mouth is open wide.

 MOUTH OPENING:
 Average opening > 50mm
 Restricted opening < 35mm (intracapsular changes in the joints)
 Any deviation from the midline is also recorded. Maximum lateral
movement can be measured (normal is about 12mm).

 LIPS:
 Next, the patient is observed for tooth exposure during normal and
exaggerated smiling.
 This may be critical in treatment planning and particularly for margin
placement of metal-ceramic crowns.
 “NEGATIVE SPACE”:- The space between maxillary and mandibular anteriors
during normal smile.
 Missing teeth, diastemas and fractured or poorly restored teeth affect
negative space and require correction.

INTRA ORAL EXAMINATION
 Condition of the soft tissues , teeth and supporting structures.
 Lips, tongue, floor of the mouth, gingiva, vestibule, cheeks, hard and soft
palate.
 Any abnormalities of the soft tissues should be noted and the patient
informed

 GINGIVAL & PERIODONTAL EXAMINATION:
 First the patient's general oral hygiene is observed.
 The presence or absence of inflammation should be noted along with
gingival architecture and stippling. The existence of pockets should be
entered in the record and their location and depth chartered.
 The presence and amount of tooth mobility should be recorded with
special attention paid to any relationship with occlusal prematurities and
to potential abutment teeth.
 Check for a band of attached gingiva around all the teeth.

 EXAMINATION OF TOOTH STRUCTURE:
 The presence and location of caries is noted. The amount and
location of caries, coupled with an evaluation of plaque retention,
can offer some prognosis for new restorations that will be placed.
 It will also help the preparation designs to be used.

 OCCLUSAL EXAMINATION:
 The initial clinical examination starts with the clinician asking the
patient to make a few simple opening and closing movements while
carefully observing the opening and closing strokes.
 Special attention is given to;
 Initial tooth contact
 Tooth alignment
 Eccentric contacts

 GENERAL ALIGNMENT:
 Crowding, rotation, supra-eruption, 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.

 RADIOGRAPHIC EXAMINATION:
Can help to evaluate the following areas:
 Degree of bone loss
 Impacted teeth, residual roots
 Root morphology, crown-root ratio
 Presence of apical disease
 Caries
 Pulp chambers & canals
 Periodontal ligament and surrounding bone
 Existing restorations (marginal fit, contour)

 PANOROMIC RADIOGRAPHS:
 Presence or absence of teeth
 Assessing third molars impactions
 Evaluating the bone before implant placement
 Screening edentulous arches for buried root tips

 SPECIAL RADIOGRAPH’S FOR TMJ DISORDERS:
 Transcranial exposure-reveal the lateral third of the mandibular condyle and
can be used to detect structural and positional changes
 More information can be obtained from:
 Tomography
 Arthrography
 C T scanning
 Magnetic resonance imaging

 VITALITY TESTING:
 Prior to any restorative treatment, pulpal health must be assessed, usually
by measuring the response to percussion and thermal and electrical
stimulation. A diagnosis of non-vitality can be confirmed by preparing a test
cavity before the administration of local anesthetic.

 DIAGNOSTIC CASTS:
 A life size reproduction of the parts of the oral cavity and or facial structures
for the purpose of study and treatment planning.
 Articulated diagnostic casts are essential in planning fixed prosthodontic
treatment.
 To accomplish their intended goal, they must be accurate reproductions of
the maxillary and mandibular arches made from distortion free alginate
impressions.
 The diagnostic casts should be mounted on a semidjustable articulator with
a face bow.

 ADVANTAGES OF DIAGNOSTIC CASTS:
 For diagnosing problems and arriving at a treatment plan.
 Allow an unobstructed view of the edentulous spaces and an accurate
assessment of the span length, as well as occlusogingival dimension.
 Curvature of the arch in the edentulous region can be determined so
that it will be possible to predict whether the pontic/pontics will act as
a lever arm on the abutment teeth.
 Length of the abutment teeth can be accurately gauged to determine
which preparation designs will provide adequate retention and
resistance.
 The true inclination of the abutment teeth will also became evident, so
that the problems in a common path of insertion can be anticipated.

 Mesiodistal drifting, rotation and faciolingual displacement of
prospective abutment teeth can be clearly seen.
 A thorough evaluation of wear facets — their number, size and location
is possible.
 Discrepancies in the occlusal plane become very apparent on the
articulated casts.
 Occlusal discrepancies can be evaluated and the presence of centric
prematurities or excursive interferences can be determined.
 Teeth that have supraerupted into the opposing edentulous spaces are
easily spotted and the amount of correction needed can be
determined.
 Diagnostic wax-up can be carried out

 MOUTH PREPARATION:
 Mouth preparation refers to the dental procedure that need to be
accomplished before fixed Prosthodontics can be properly undertaken.
 As a general plan , the following sequence of treatment procedures in
advance of fixed prosthodontic should be adhered to;
• Relief of symptoms (chief complaint)
• Removal of etiological factors (eg; excavation of caries removal of
deposits)
• Repair of damage .
• Maintenance of dental health.

 The following list describes the sequence in the treatment of a patient with
extensive dental disease including missing teeth , retained roots , caries and
defective restorations:
 Preliminary assessment
 Emergency treatment of presenting symptoms
 Oral surgery
 caries control and replacement of existing restorations
 Definitive periodontal treatment
 Orthodontic treatment
 Definitive occlusal treatment
 Fixed Prosthodontics
 Follow up care

 A logical TREATMENT SEQUENCE should be planned before
beginning any fixed prosthodontic intervention. Such planning will
normally multidisciplinary.

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

 TREATMENT PLANNING FOR SINGLE TOOTH
RESTORATIONS
 The selection of the material and design of the restoration is based on
several factors:
 Destruction of tooth structure
 Esthetics
 Plaque control
 Financial considerations
 Retention

 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.

 ESTHETICS:
 PARTIAL VENEER restoration can be used to restore in highly visible area.
 The use of ceramic in some can be used as FULL VENEER.
METAL CERAMIC CROWNS
• Single unit anterior
• Posterior crowns
• Fixed partial denture

 PLAQUE CONTROL:
 The use of cemented restoration demands the institution and maintenance
of good plaque-control program to increase the changes for success of the
restoration. Many teeth are seemingly prime candidates for cast metal or
ceramic restorations, based solely on amount of tooth destruction that has
previously occurred. However, when these teeth are evaluated from the oral
environment, they may in fact be poor risks for cemented restorations.

 RETENTION:
 Full veneer crowns are unquestionably the most retentive. However,
maximum retention is not nearly as important for single-tooth restorations
as it is for fixed partial denture retainers. It does become a special concern
for short teeth and removable partial denture abutments.

 FINANCIAL CONSIDERATIONS:
 Selection should not be less than optimum just because the patient cannot
afford.
 Sound alternative to the preferred treatment plan and not apply pressure.

INTRA CORONAL RESTORATION:
 When sufficient coronal tooth structure exists to retain and protect a
restoration under the anticipated stresses of mastication, an intracoronal
restoration can be employed.
 Here the restoration itself is dependent on the strength of the remaining
tooth structure for structural integrity.

 GLASS IONOMER CEMENT:
 Where extensions can be kept minimal.
 Preparation retention will be minimal .
 Class 5 lesions
 Incipient lesions
 Root caries in geriatric patients.
 Interim treatment restoration to assist in the control of a mouth with
rampant caries.

 COMPOSITE RESIN:
 In minor to moderate-lesions in esthetically critical areas.
 Due to polymerization shrinkage and insufficient abrasion resistance, its use
on posteriors should be restricted to small occlusal and mesio-occlusal
restorations on first molars

 SIMPLE SILVER AMALGAM:
• Simple amalgam, without pins or other auxiliary retention is widely used for
one-to-three-surface restoration of minor to moderate sized lesions in
esthetically non-critical areas.
• They are best used when more than half of coronal dentin is intact.

 COMPLEX AMALGAM:
 Moderate to severe lesions with amalgam augmented by pins.
 As a final restoration when a crown is contraindicated .
 Missing cusps or endodontically premolars and molars.
 Teeth that ordinarily would be restored with mesio-occulsal onlays or other
extracoronal restorations.

 METAL INLAY:
 Minor to moderate lesions where esthetic require low .
 Etchable base metal alloys if a bonding effect is desired.
 Restoration of MOD on molars.

 CERAMIC INLAY:
 Minor to moderate sized lesion where esthetic demand is high.
 B’coz this type of restoration can be etched to enhance bonding
the structural integrity of tooth cusps may be stabilized by bonding .

 MOD ONLAY:
 Moderately large lesions on premolars and molars with intact facial and
lingual surfaces.
 It will accommodate a wide isthmus and upto one missing cusp on molar.

EXTRA CORONAL RESTORATION:
 Insufficient coronal tooth.
 Deflective axial tooth structure.
 Modify contours to refine occlusion or improve esthetics

 PARTIAL VENEER CROWN:
 To restore a tooth with one or more intact axial surfaces with half or more of
the coronal tooth structure remaining.
 It will provide moderate retention and can be used as a retainer for short
span fixed partial dentures.
 If tooth destruction is not extensive.

 FULL METAL:
 Restore teeth with multiple defective axial surfaces.
 Restricted to situation where there are no esthetic expectations.

 METAL CERAMIC CROWN:
 Multiple defective axial surfaces
 Fixed partial dentures retainer where full coverage and good cosmetic
results must be obtained

 ALL CERAMIC CROWN:
 Full coverage and maximum esthetics.
 Restricted to situation likely to produce low moderate stress .
 Usually used on incisors

 CERAMIC VEENERS:
 Produces good cosmetic result on otherwise intact anterior teeth that are
marred by severe staining or developmental defects restricted to facial
surface of the tooth.
 Moderate incisal clipping and proximal lesions.

TREATMENT PLANNING FOR THE REPLACEMENT OF
MISSING TEETH
 Several factors must be weighed when choosing the type of prosthesis to be
used in any given situation. Important ones are:
• Biomechanical factors
• Periodontal factors
• Esthetics
• Financial factors
• Patient‘s wishes

 ABUTMENT EVALUATION:
 Abutment teeth are called upon to withstand the forces normally directed
to the missing teeth, in addition to those usually applied to the abutments.
 Whenever possible an abutment should be a vital tooth.
 The roots and their supporting tissues should be evaluated for 3 factors:
 Crown-root ratio
 Root configuration
 Periodontal ligament area

 CROWN ROOT RATIO:
 It is a measure of the length of the tooth occlusal to the alveolar crest of
bone compared with the length of the root embedded in the bone.
 Optimum -2:3
 Minimum -1:1 (acceptable)

 ROOT CONFIGURATION:
 Roots that are broader labiolingually are preferable to roots that are round
in cross section.
 Multirooted posterior teeth with widely separated roots will offer better
periodontal support than roots that converge, fuse or generally present a
conical configuration.
 Conical roots can be used -for short span.
 A single rooted tooth with evidence of irregular configurations or with some
curvature in the apical third is preferable to the tooth that has a nearly
perfect taper.

 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.

BIOMECHANICAL CONSIDERATIONS:
 All fixed partial dentures, long or short spanned bend and flex.
 Bending or deflection varies directly with the cube of the length and
inversely with the cube of occlusogingival thickness of the pontic.
 Compared with a fixed partial denture having a single tooth pontic span, a
two tooth pontic span will bend 8 times as much. A three tooth pontic will
bend 27 times as much as a single pontic.

 TO OVERCOME THIS SITUATION:
 Greater occlusogingival dimension
 Nickel chromium
 Double abutment
 Multiple grooves

SPECIAL PROBLEMS:
 PIER ABUTMENTS:
 An edentulous space can occur on both sides of a tooth, creating a lone,
freestanding pier abutment. Physiologic tooth movement, arch position of
the abutments and a disparity in the retentive capacity of the retainers can
make a rigid 5-unit fixed partial denture as a less than ideal plan of
treatment.

 The retention on the smaller anterior tooth is usually less than that of the
posterior tooth because of its smaller dimensions.
 The use of a non-rigid connector has been recommended to reduce this
hazard.
 key way : Distal contours of pier a abutment
 Key: Mesial side of the distal pontic

 TILTED MOLAR ABUTMENTS:
 Common problem that occurs is the mandibular second molar abutment
that has tilted mesially into the space formerly occupied by the first molar.

 ADJUSTMENT FOR TILTED MOLAR:
 If the encroachment is slight, the problem can be remedied by restoring or
recontouring the mesial surface of the third molar with an overtapered
preparation on the second molar.
 If the tilting is severe, other corrective measure will have to be followed. The
treatment of choice is uprighting of the molar by orthodontic treatment.
 A proximal half crown can be used as a retainer on the distal abutment.

 CANINE – REPLACEMENT FIXED PARTIAL DENTURE:
 This is a problem because often the canine lies outside the interabutment
axis. The abutments are the lateral incisor, usually the weakest in the entire
arch and the first premolar, the weakest posterior tooth. A FPD replacing
maxillary canine is subjected to more stress than that replacing a mandibular
canine since forces are transmitted outward on the maxillary arch.
 So the support from secondary abutments will have to be considered.
 Edentulous spaces created by the loss of canine and any contiguous teeth is
best restored with Implants.

 CANTILEVER FPDs:
 Cantilever FPD is one that has an abutment or abutments at one end only,
with the other end of the pontic remaining unattached. This is a potentially
destructive design with the lever arm created by the pontic.
 Abutment teeth for cantilever FPDs should be evaluated for lengthy roots
with a favourable configuration, good crown root ratios and long clinical
crowns.
 Generally, cantilever FPDs should replace only one tooth and have at least 2
abutments.

CONCLUSION
 The scope of fixed prosthodontic treatment can range from the restoration
of a single tooth to the rehabilitation of the entire occlusion. Single teeth
can be restored to full function and improvement in cosmetic effect can be
achieved. Missing teeth can be replaced with fixed prosthesis that will
improve patient comfort and masticatory ability, maintain the health and
integrity of the dental arches, in many instances elevate the patient's self
image.
 It is also possible by the use of fixed restorations, to render supportive and
long range corrective measures for the treatment of problems related to the
temporomandibular joint and its neuromuscular system. On the other hand,
with improper treatment of the occlusion it is possible to create disharmony
and damage to the stomatognathic system.

REFERENCES
 Fundamentals of fixed prosthodontics- Shillingburg- 1st South Asia Edition
 Contemporary Fixed Prosthodontics-Rosenstiel- 3rd edition
 Tylmans theory and practice of fixed prosthodontics- 8th edition
 Diagnosis and treatment planning in fixed partial dentures, JPD, Dec 1973,
Vol 30, No.6


Diagnosis & Treatment Planning in FPD

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