Diagnosis And Treatment Planning in Fixed Prosthodontics.pptx

The treatment planning is based on the identification of the need of a patient, ascertaining expectations
and comparing these with the available techniques. Thereafter a sequence of treatment may be initiated
for therapy, symptomatic relief, stabilization, and follow up. This paper focuses on the importance of
properly sequenced treatment planning for fixed partial denture cases.

1. Diagnosis And Treatment Planning in Fixed Prosthodontics Presented by Dr Abhidha Tripathi

2. Contents Introduction History Chief complaint Medical history Dental history General examination Intraoral examination Diagnostic aids Treatment planning for single tooth restoration Treatment planning for missing teeth 01 02 03 04 05 06 07 08 09 10

3. Introduction 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. - GPT 10

4. 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

5. Problems encountered during or after treatment can often be traced to errors and omissions during history taking and initial examination. And thus making the correct diagnosis is prerequisite for formulating an appropriate treatment plan.

6. History 01. Chief Complaint 02. Personal History 03. Medical History 04. Dental History

7. Chief Complaint Comfort (pain, sensitivity, swelling) 01 02 03 Function (difficulty in mastication or speech) Appearance (fractured or unattractive teeth or restorations, discoloration 04 Social (bad taste or odor) The accuracy and significance of the patient’s primary reason or reasons for seeking treatment should be analyzed first

8. Personal Details Establishing rapport and developing a basis on which the patient can trust the dentist have considerable influence in establishing a correct diagnosis, prognosis, and treatment plan. Name Age Gender Address Contact No Occupation Marital Status Socio economic status

9. Medications and relevant medical conditions If necessary, patient's physicians can be contacted for clarification. Following classification maybe helpful: Medical History

10. A, Extensive damage caused by self-induced acid regurgitation. Note that the lingual surfaces are bare of enamel except for a narrow band at the gingival margin. B, Teeth prepared for partial-coverage restorations. C and D, The completed restoration Severe gingival hyperplasia associated with anticonvulsant drug use

11. Dental History Clinicians should complete a thorough examination before establishing a diagnosis. With adequate experience, a clinician can often assess preliminary treatment needs during the initial appointment. Following things should be noted:

12. Examination In an examination, the clinician uses sight, touch, and hearing to detect abnormal conditions Thorough examination and data collection are needed for prospective patients who desire fixed prosthodontic treatment, and more detailed protocols for this effort can be obtained from various textbooks of oral diagnosis.

13. General Examination General appearance : Gait and weight are assessed. Skin colour : Anaemia or jaundice Vital signs : Respiration, pulse temperature and blood pressure are measured and recorded

14. Extraoral Examination

15. Temporomandibular Joints Palpating the TMJ bilaterally enables a comparison between the relative timing of left and right condylar movements during the opening stroke. Asynchronous movement may indicate a disk displacement that prevents one of the condyles from making a normal translatory movement. Auricular palpation with light anterior pressure helps identify potential disorders in the posterior attachment of the disk. Auricular palpation of the posterior aspects of the TMJ.

16. Mouth Opening Average opening: >50mm Restricted opening: <35mm (intracapsular changes in the joints) Midline deviation : normal is 12mm A. The distance between the maxillary and mmandibular incisor is measured when the patient is instructed to opem “all the way”. B. If the patient can only open partially or opens very slowly, the cause should be determined.

17. Muscles of Mastication Classify the discomfort as Bilaterally and simultaneously with light pressure Allows the patient to compare and report any differences between the left and right sides

18. The masseter muscles palpated by placing the fingers over the lateral surfaces of the rami of the mandible. The fingers are placed over the patient’s temples to feel the temporalis muscles. The index finger is used to touch the medial pterygoid muscle on the inner surface of the ramus. The trapezius muscle is felt at the base of the skull, high on the neck

19. Each palpation site is given a numerical score based on the patient’s response

20. Lips Patient is observed for tooth visibility during normal and exaggerated smiling. The extent of the smile depends on the length and mobility of the upper lip and the length of the alveolar process. Negative Space : When the patient laughs, the jaws open slightly and a dark space is often visible between the maxillary and mandibular teeth

21. Some patients show only their maxillary teeth during smiling. More than 25% do not show the gingival third of the maxillary central incisors during an exaggerated smile. The extent of the smile depends on the length and mobility of the upper lip and the length of the alveolar process. Smile analysis is an important part of the examination, particularly when anterior crowns or FPDs are being considered. A. Some individuals show considerable gingival tissue during an exaggerated smile. B. Others may not show the gingival margins of even the central incisors.

22. Intraoral Examination 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. This information can be evaluated properly during treatment planning only if objective indices, rather than vague assessments, are used.

23. Periodontal Examination 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. Existing periodontal disease must be corrected before any definitive prosthodontic treatment is undertaken

24. Gingiva The gingiva is dried for the examination so that moisture does not obscure subtle changes or detail. Color , texture, size, contour, consistency, and position are noted. The gingiva is carefully palpated to express any exudate present in the sulcular area

25. Dental Charting

26. Initial tooth contact The relationship of teeth in both centric relation and the maximum intercuspation should be evaluated. If all teeth come together simultaneously at the end of terminal hinge closure, the centric relation (CR) position of the patient is said to coincide with the maximum intercuspation (MI). The patient is guided into a terminal hinge closure to detect where initial tooth contact occurs. The clinician should ask the patient to “close featherlight” until any of the teeth touch and to have the patient help identify where that initial contact occurs by asking him or her to point at the location

27. Lateral and Protrusive Contacts The degree of vertical and horizontal overlap of the teeth is noted. When asked, most patients are capable of making an unguided protrusive movement. During this movement, the degree of posterior disocclusion that results from the overlaps of the anterior teeth is observed. Excursive contacts on posterior teeth may be undesirable. The patient is then guided into lateral excursive movements, and the presence or absence of contacts on the nonworking side and then the working side is note. Such tooth contact in eccentric movements can be verified with a thin Mylar strip (shim stock).

28. Fremitus (movement on palpation) indicates tooth contact during lateral excursions

29. Jaw Maneuverability The ease with which the patient moves the jaw and the way the mandible can be guided through hinge closure and excursive movements should be evaluated because this information is useful for assessing neuromuscular and masticatory function. If the patient has developed a pattern of protective reflexes, manipulating the jaw in a reproducible hinge movement can be difficult or impossible. Any restriction in maneuverability is recorded. A patient may move relatively freely in one lateral excursion but have difficulty moving to the contralateral side.

30. Diagnostic Aids Radiographs Vitality tests Diagnostic casts Periodontal Probe

31. 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 and canals Periodontal ligament and surrounding bone Existing restorations

32. Panoramic Radiographs Presence or absence of teeth Assessing third molars impactions Evaluating the bone before implant placement Screening edentulous arches for buried root tips

33. SPECIAL RADIOGRAPHS’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 CT scan MRI

34. 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. 4. Length of the abutment teeth can be accurately gauged to determine which preparation designs will provide adequate retention and resistance.

35. Diagnostic Casts 5) The true inclination of the abutment teeth will also became evident, so that the problems in a common path of insertion can be anticipated. 6) Mesiodistal drifting, rotation and faciolingual displacement of prospective abutment teeth can be clearly seen. 7) A thorough evaluation of wear facets – their number, size and location is possible. 8) Discrepancies in the occlusal plane become very apparent on the articulated casts.

36. Diagnostic Casts 9) Occlusal discrepancies can be evaluated and the presence of centric prematurities or excursive interferences can be determined. 10) Teeth that have supraerupted into the opposing edentulous spaces are easily spotted and the amount of correction needed can be determined. 11) Diagnostic wax-up can be carried out in situations calling for the use of pontics which are wider or narrower than the teeth that would normally occupy the edentulous space.

37. Prosthodontic Diagnostic Index (PDI) for Partially Edentulous and Completely Dentate Patients For each index, four categories, class I to class IV, are defined; class I represents an uncomplicated clinical situation and class IV represents a complex clinical situation. Each class is differentiated by specific diagnostic criteria (ideal or minimal, moderately compromised, substantially compromised, or severely compromised) of the following (for partially edentulous patients): 1. Location and extent of the edentulous area or areas 2. Condition of the abutment teeth 3. Occlusal scheme 4. Residual ridge

38. Treatment Planning for Replacement Of Missing Teeth Several factors must be weighed when choosing the type of prosthesis to be used in any given situation. Biomechanical factors Periodontal factors Esthetics Financial factors Patient’s wishes

39. 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

40. Summary A comprehensive history and a thorough clinical examination provide sufficient data for the practitioner to formulate a successful treatment plan it is crucial to develop a thorough understanding of each patient’s special concerns relating to previous care and his or her expectations about future treatment. Many problems encountered during fixed prosthodontic treatment are directly traceable to factors overlooked during the initial examination and data collection

41. References Dykema RW : Modern practice in crown and bridge prosthodontics; 3 rd edition. Rosenstiel:Contemporary Fixed Prosthodontics ;3 rd edition. Shillingberg HT: Fundamentals of Prosthodontics;3 rd edition. Tylman SD : Theory and practice in crown and fixed partial prosthodontics; 6 th edition.